ABILITY-TO-PAY FEE SCHEDULE

DEPARTMENT OF STATE HEALTH SERVICES
MONTHLY ABILITY-TO-PAY FEE SCHEDULE

Integral Care charges a maximum monthly fee for services based on a client’s income and family size. To determine their maximum monthly fee, Integral Care clients must provide all required documents and complete a Financial Assessment. Failure to complete a Financial Assessment will result in the client being charged the full price of services received. Clients covered by Medicare, Medicaid, CHIP, or any other insurance must authorize payments to Integral Care. Clients covered by private insurance are responsible for paying all co-pays and deductibles. Integral Care clients should be prepared to show proof of insurance upon check-in and pay all fees, co-pays, and deductibles for services at every visit. Effective March 1, 2022.

MAXIMUM MONTHLY FEE BY FAMILY SIZE

Annual Gross IncomeMonthly Gross Income123456789+% monthly income family size 1
15,0601,255000000000
22,5901,88347000000002.50%
25,2802,10756000000002.66%
27,9702,33166000000002.82%
30,6602,555764700000002.98%
33,3502,779875600000003.14%
36,0403,003996600000003.30%
38,7303,22811276470000003.46%
41,4203,45212587560000003.62%
44,1103,67613999660000003.78%
46,8003,9001541127647000003.94%
49,4904,1241691258756000004.10%
52,1804,3481851399966000004.26%
54,8704,573202154112764700004.42%
57,5604,797220169125875600004.58%
60,2505,021238185139996600004.74%
62,9405,24525720215411276470004.90%
65,6305,46927722016912587560005.06%
68,3205,69329723818513999660005.22%
71,0105,9183182572021541127647005.38%
73,7006,1423402772201691258756005.54%
76,3906,3663632972381851399966005.70%
79,0806,590386318257202154112764705.86%
81,7706,814410340277220169125875606.02%
84,4607,038435363297238185139996606.18%
87,1507,26346038631825720215411276476.34%
89,8407,48748741034027722016912587566.50%
92,5307,71151443536329723818513999666.66%
95,2207,935541460386318257202154112766.82%
97,9108,159570487410340277220169125876.98%
100,6008,383599514435363297238185139997.14%
103,2908,6086285414603863182572021541127.30%
105,9808,8326595704874103402772201691257.46%
108,6709,0566905995144353632972381851397.62%
111,3609,2807226285414603863182572021547.78%
114,0509,5047556595704874103402772201697.94%
116,7409,7287886905995144353632972381858.10%
119,4309,9538227226285414603863182572028.26%
122,12010,1778577556595704874103402772208.42%
124,81010,4018927886905995144353632972388.58%
127,50010,6259298227226285414603863182578.74%
130,19010,8499668577556595704874103402778.90%
132,88011,0731,0038927886905995144353632979.06%
135,57011,2981,0429298227226285414603863189.22%
138,26011,5221,0819668577556595704874103409.38%
140,95011,7461,1211,0038927886905995144353639.54%
143,64011,9701,1611,0429298227226285414603869.70%
146,33012,1941,2021,0819668577556595704874109.86%
149,02012,4181,2441,1211,00389278869059951443510.02%
151,71012,6431,2871,1611,04292982272262854146010.18%
154,40012,8671,3301,2021,08196685775565957048710.34%
157,09013,0911,3751,2441,1211,00389278869059951410.50%
159,78013,3151,4191,2871,1611,04292982272262854110.66%
162,47013,5391,4651,3301,2021,08196685775565957010.82%
165,16013,7631,5111,3751,2441,1211,00389278869059910.98%
167,85013,9881,5581,4191,2871,1611,04292982272262811.14%
170,54014,2121,6061,4651,3301,2021,08196685775565911.30%
Top