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.

MAXIMUM MONTHLY FEE BY FAMILY SIZE

Annual Gross IncomeMonthly Gross Income123456789+
12,140 1,012 000000000
18,210 1,518 3800000000
20,370 1,698 4500000000
22,530 1,878 5300000000
24,690 2,058 61380000000
26,850 2,238 70450000000
29,010 2,418 80530000000
31,170 2,598 906138000000
33,330 2,778 1017045000000
35,490 2,958 1128053000000
37,650 3,138 12490613800000
39,810 3,318 136101704500000
41,970 3,498 149112805300000
44,130 3,678 1631249061380000
46,290 3,858 17713610170450000
48,450 4,038 19114911280530000
50,610 4,218 207163124906138000
52,770 4,398 2231771361017045000
54,930 4,578 2391911491128053000
57,090 4,758 25620716312490613800
59,250 4,938 274223177136101704500
61,410 5,118 292239191149112805300
63,570 5,298 3102562071631249061380
65,730 5,478 33027422317713610170450
67,890 5,658 35029223919114911280530
70,050 5,838 370310256207163124906138
72,210 6,018 3913302742231771361017045
74,370 6,198 4133502922391911491128053
76,530 6,378 4353703102562071631249061
78,690 6,558 45839133027422317713610170
80,850 6,738 48141335029223919114911280
83,010 6,918 50543537031025620716312490
85,170 7,098 529458391330274223177136101
87,330 7,278 555481413350292239191149112
89,490 7,458 580505435370310256207163124
91,650 7,638 606529458391330274223177136
93,810 7,818 633555481413350292239191149
95,970 7,998 661580505435370310256207163
98,130 8,178 689606529458391330274223177
100,290 8,358 717633555481413350292239191
102,450 8,538 746661580505435370310256207
104,610 8,718 776689606529458391330274223
106,770 8,898 806717633555481413350292239
108,930 9,078 837746661580505435370310256
111,090 9,258 868776689606529458391330274
113,250 9,438 900806717633555481413350292
115,410 9,618 933837746661580505435370310
117,570 9,798 966868776689606529458391330
119,730 9,978 1,000 900806717633555481413350
121,890 10,158 1,034 933837746661580505435370
124,050 10,338 1,069 966868776689606529458391
126,210 10,518 1,104 1,000 900806717633555481413
128,370 10,698 1,140 1,034 933837746661580505435
130,530 10,878 1,177 1,069 966868776689606529458
132,690 11,058 1,214 1,104 1,000 900806717633555481
134,850 11,238 1,252 1,140 1,034 933837746661580505
137,010 11,418 1,290 1,177 1,069 966868776689606529
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