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

Yearly Income Before TaxesMonthly Income Before Taxes123456789+
12,8801,073000000000
19,3201,6104000000000
21,5901,7994800000000
23,8601,9885600000000
26,1302,17865400000000
28,4002,36774480000000
30,6702,55684560000000
32,9402,745956540000000
35,2102,9341067448000000
37,4803,1231188456000000
39,7503,31313195654000000
42,0203,502144106744800000
44,2903,691157118845600000
46,5603,8801711319565400000
48,8304,06918614410674480000
51,1004,25820215711883560000
53,3704,448218171131956540000
55,6404,6372351861441067448000
57,9104,8262522021571188456000
60,1805,01527021817113195654000
62,4505,204288235186144106744800
64,7205,393307252202157118845600
66,9905,5833272702181711319565400
69,2605,77234728823518614410674480
71,5305,96136830725220215711884560
73,8006,150390327270218171131956540
76,0706,3394123472882351861441067448
78,3406,5284353683072522021571188456
80,6106,7184583903272702181711319565
82,8806,90748241234728823518614410674
85,1507,09650743536830725220215711884
87,4207,28553245839032727021817113195
89,6907,474558482412347288235186144106
91,9607,663584507435368307252202157118
94,2307,853611532458390327270218171131
96,5008,042639558482412347288235186144
98,7708,231667584507435368307252202157
101,0408,420695611532458390327270218171
103,3108,609725639558482412347288235186
105,5808,798755667584507435368307252202
107,8508,988786695611532458390327270218
110, 1209,177817725639558482412347288235
112,3909,366849755667584507435368307252
114,6609,555881786695611532458390327270
116,9309,744914817725639558482412347288
119,2009,933948849755667584507435368307
121,47010,123982881786695611532458390327
123,74010,3121,017914817725639558482412347
126,01010,5011,052948849755667584507435368
128,28010,6901,088982881786695611532458390
130,55010,8791,1251,017914817725639558482412
132,82011,0681,1621,052948849755667584507435
135,09011,2581,2001,088982881786695611532458
137,36011,4471,2391,1251,017914817725639558482
139,63011,6361,2781,1621,052948849755667584507
141,90011,8251,3171,2001,088982881786695611532
144,17012,0141,3581,2391,1251,017914817725639558
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