Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 635 - FAMILY PLANNING SERVICES CODE › Appendix B - A Guide to Cost Analysis Developing Cost Based Fees and Sliding Fee Scale

Current through Register Vol. 48, No. 28, July 12, 2024
Illinois Department of Public Health
A Guide to Cost Analysis
Developing Cost Based Fees
and
Sliding Fee Scale
Revised 11/89
A. B.A.
TABLE OF CONTENTS
INTRODUCTION.............................................................................................................................
APPROACH......................................................................................................................................
FUNCTIONAL
				AREAS.....................................................................................................................
DETERMINATION OF COST PER
				PROCEDURE............................................................................
PREPARE A COST OF SERVICE/FEE DETERMINATION
WORKSHEET FOR EACH COST
				CENTER..........................................................................
EXPENSE ALLOCATIONS FOR THE
				BCRR...................................................................................
RELATIVE
				VALUES........................................................................................................................
OPTIONAL REVENUE
				ANALYSIS.................................................................................................
CALCULATING THE SCHEDULE OF
				DISCOUNTS.......................................................................
DEVELOPMENT OF A SLIDING FEE
				SCALE.................................................................................
ATTACHMENTS
ATTACHMENT A:SAMPLES OF ADMINISTRATIVE
				COSTS......................................................
ATTACHMENT B:MEDICAL COST CENTER
				WORKSHEET.......................................................
ATTACHMENT C:LABORATORY COST CENTER
				WORKSHEET..............................................
ATTACHMENT D:PHARMACY COST CENTER
				WORKSHEET..................................................
ATTACHMENT E:EDUCATION/COUNSELING COST CENTER
				WORKSHEET.........................
ATTACHMENT F:POVERTY INCOME GUIDELINES - CLIENT
				FEE DISCOUNT CATEGORIES
ATTACHMENT G:SLIDING FEE
				SCALE......................................................................................
LIST OF EXAMPLES
ALLOCATION OF MONIES FOR
				BCRR.........................................................................................
COMPLETED BCRR FROM ABOVE
				ALLOCATIONS....................................................................
DETERMINATION OF COST PER
				PROCEDURE............................................................................
FEE DETERMINATION
				WORKSHEETS.........................................................................................
Medical...........................................................................................................
Laboratory......................................................................................................
Pharmacy........................................................................................................
Education and
				Counseling..............................................................................
POVERTY INCOME GUIDELINES - CLIENT FEE DISCOUNT
				CATEGORIES.............................
SAMPLE SLIDING FEE
				SCALE.......................................................................................................
COST BASED FEES
INTRODUCTION
Federal regulations require that each family planning project
				have a schedule of fees for the services it provides. You must develop
				realistic fees which reflect the cost of operation, yet are competitive to the
				local market. There must be a corresponding schedule of discounts which will be
				used by individuals based on their ability to pay.
It is now necessary for family planning providers to
				concentrate on management plans which will provide them with the information to
				develop, implement and analyze their efficiency, thus controlling costs. Only
				agencies with a sound financial management plan will remain financially
				viable.
The object of this manual is to help you determine the cost of
				providing services and setting the fees to be charged using Bureau of Community
				Health Services Common Reporting Requirements (BCRR) data with some
				modifications and utilization data provided by your CVR's.
Costs will come from using the financial information you
				reported in the various cost centers of your BCRR, Table 6, Column g. We would
				suggest completing the expense allocations pages to check the accuracy of your
				allocations on the BCRR and to insure accurate fees.
Utilization figures must be collected over the same period as
				the reported costs. Specific procedure data, not encounter data, must be used,
				since the purpose is to derive a cost per procedure. An actual count of your
				procedures over a specific time period may be obtained from your population
				profile as reported from your CVR's or you may use a daily log of clinic
				activity.
APPROACH
Rates charged for each service should reflect both direct and
				indirect costs. Direct costs include expenses associated with providing patient
				care (i.e., physician, nursing, supplies, etc.) plus an amount of overhead or
				indirect costs which are expended to support direct patient care (i.e.,
				administration, housekeeping, rent, etc.). In order to arrive at a true cost
				you must include the value of donated goods and services. You have allocated
				your overhead or indirect costs to the various cost centers on Table 6,
				worksheets A and B (administration, facility costs and fringe benefits) so that
				the amount on Table 6, column g in each cost center represents your total
				costs. Examples of administrative and facility costs are Attachment A.
There are seven steps in the development of cost based
				fee:
1. Identify the functional cost centers.
2. Identify services provided in each cost center.
3. Collect utilization data on services provided.
4. Collect direct cost data for each functional cost
				center.
5. Allocate overhead costs to functional cost centers.
6. Determine total units of service provided.
7. Determine cost of each service.
FUNCTIONAL AREAS
The health care functional areas within a family planning
				program represent a separation of functions within the program. A typical
				family planning program will provide services within four functional
				areas:
A. MEDICAL (CLINIC) OPERATIONS
Medical services delivered in providing a family
				planning method of a patient, and the diagnosis and treatment of related
				problems; excludes x-ray, laboratory and pharmacy services.
B. LABORATORY
Laboratory services provided by the family planning
				program including specimen collection and preparation for referral to outside
				laboratories.
C. PHARMACY
Services provided in the dispensing of
				contraceptives and medications to the family planning patient.
D. HEALTH EDUCATION/COUNSELING
Services provided to the client or prospective
				client for family planning related problem resolution or information. Includes
				tubal ligation counseling, fertility awareness and similar services.
DETERMINATION OF COST PER PROCEDURE
The purpose of this step is to distribute health care costs to
				particular procedures to derive the unit cost of each procedure. The cost per
				procedure should be computed for all procedures. The cost per procedure
				information is useful for managers in establishing charges and for analyzing
				the benefit of continuing to provide specific services. There may be some cases
				in which the cost per procedure requires a charge so far above the competitive
				rate (what other providers in the area would charge for that service) that the
				charge is prohibitive. This should be a signal to management that steps must be
				taken to lower costs in the future or consideration should be given to phasing
				out that service and making alternative arrangements.
In order to determine the cost you must define the specific
				procedures performed in each cost center and determine how many times or
				frequency the procedure is performed. We have assigned relative values to
				procedures.
Prepare a Cost of Service/Fee Determination Worksheet for each
				cost center. See Attachment B, C, D and E.
MEDICAL COST CENTER
Attachment B
1.
Column A
-
List procedure
2.
Column B
-
List Service Utilization/Frequency of Procedure.
3.
Column C
-
List Relative Value for Procedure.
4.
Column D
-
Column B X Column C. Total Column D.
5.
Column E
-
Cost center amount from BCRR Table 6, Column G, line
						  1.
6.
Column F
-
Total Column E divided by total Column D. This gives
						  you your average cost/service unit which is listed for each line item.
7.
Column G
-
The dollar amount in Column F times each RVS of Column
						  C. This amount represents the cost for each specific service.
8.
Column H
-
Cost of living allowance (COLA). Use the most recent
						  consumer price index provided by IDPH.
9.
Column I
-
Adjusted cost equal's cost/service in Column G times
						  Column H, cost of living allowance (COLA) % plus 100%.
Example:
$10.00 X 105% = $10.50
10.
Column J
-
The full fee to be charged and should approximate
						  Column K. For convenience round up to nearest dollar.
LABORATORY COST CENTER
Attachment C
1.
Column A
-
List lab services provided.
2.
Column B
-
List Service Utilization/Frequency of Procedure.
3.
Column C
-
List Relative Value for Procedure.
4.
Column D
Column B X Column C. Total Column D.
5.
Column E
-
Cost center amount from BCRR Table 6, Column G, line 2,
						  minus the cost of PURCHASED OUTSIDE LABORATORY TESTS equals adjusted total
						  cost/cost center. OUTSIDE LABORATORY TESTS ARE THOSE TESTS NOT PERFORMED BY THE
						  AGENCY. This does not include collection of specimens.
6.
Column F
-
Total adjusted cost center, Column E, divided by total
						  service units, Column D, equals Column F, the average cost/service unit.
7.
Column G
-
Adjusted cost/service equals the dollar amount in
						  Column F times each relative value of Column C. This amount represents the cost
						  for each specific service. Column F X Column C.
8.
Column H
-
Enter the per unit purchase expense of OUTSIDE
						  LABORATORY TESTS on the appropriate line or lines. This additional purchase
						  expense applies only to designated tests. For nondesignated test, Column H
						  equals ZERO.
9.
Column I
-
Total base cost equals adjusted cost/service plus per
						  unit purchase expenses. Column G + Column H.
10.
Column J
-
Cost of living allowance (COLA). Use the most recent
						  consumer price index provided by IDPH.
11.
Column K
-
Adjusted cost equals total base cost in Column I times
						  Column J, cost of living allowance (COLA) % plus 100%.
Example:
$4.60 X 105% = $4.83
12.
Column L
-
The full fee to be charged and should approximate
						  Column K. Cor convenience round up to nearest dollar.
PHARMACY COST CENTER
Attachment D
1.
Column A
-
List pharmaceuticals provided.
2.
Column B
-
List Service Utilization.
3.
Column C
-
List Relative Value for Pharmaceuticals.
4.
Column D
-
Column B X Column C. Total Column D.
5.
Column E
-
Cost center amount from BCRR Table 6, Column G, line 4,
						  minus the cost of consumed pharmaceuticals equals adjusted total cost/cost
						  center.
6.
Column F
-
Total adjusted cost center, Column E, divided by total
						  service units, Column D, equals Column F, the average cost/service unit.
7.
Column G
-
Adjusted cost/service equals the dollar amount in
						  Column F, times each relative value of Column C. This amount represents the
						  cost for each specific service. Column F x Column C.
8.
Column H
-
Equals the purchase expense per pharmaceutical unit. To
						  arrive at an average per unit purchase expense, for Attachment D, Column H,
						  when several brands of a pharmaceutical are purchased at different prices you
						  will divide the total dollar value of those pharmaceuticals consumed during
						  that period by the total number of units of those pharmaceuticals consumed
						  during the same reporting period.
9.
Column I
-
Total base cost equals adjusted cost/service plus per
						  unit purchase expense. Column G + Column H.
10.
Column J
-
Cost of living allowance (COLA). Use the most recent
						  consumer price index provided by IDPH.
11.
Column K
-
Adjusted cost equals total base cost in Column I times
						  Column J, cost of living allowance (COLA) % plus 100%.
Example:
$4.60 X 105% = $4.83
12.
Column L
-
The full fee to be charged and should approximate
						  Column K. For convenience round up to nearest dollar.
EDUCATION/COUNSELING COST CENTER
Attachment E
1.
Column A
-
List procedure.
2.
Column B
-
List Service Utilization/Frequency of Procedure.
3.
Column C
-
List Relative Value for Procedure.
4.
Column D
-
Column B X Column C. Total Column D.
5.
Column E
-
Cost center amount from BCRR, Table 6, Column G, line
						  7.
6.
Column F
-
Total Column E divided by total Column D. This gives
						  you your average cost/service unit which is listed for each line item.
7.
Column G
-
The dollar amount in Column F times each RVS of Column
						  C. This amount represents the cost for each specific service.
8.
Column H
-
Cost of living allowance (COLA). Use the most recent
						  consumer price index provided by IDPH.
9.
Column I
-
Adjusted cost equals cost/service in Column G times
						  Column H, cost of living allowance (COLA)% plus 100%.
Example:
$10.00 X 105% = $10.50
10.
Column J
The full fee to be charged and should approximate
						  Column K. For convenience round up to nearest dollar.
MEDICAL COST CENTER
CLIENT EXAMINATION DIRECT EXPENSES SALARIES AND
						  WAGES
(Include only those staff who perform or assist in
						  performing client examinations.)
1.
Physician
1.
$
.00
2.
Physician Assistants
2.
$
.00
3.
Nurse Practitioners
3.
$
.00
4.
Nurse Midwives
4.
$
.00
5.
Other Nurses
5.
$
.00
MEDICAL SUPPORT
6.
Medical Appointment Secretary
6.
$
.00
_________
7.
Portion of Client Records Clerk
7.
$
.00
8.
Total Salaries
8.
$
.00
Total on line 8 is equal to BCRR Table 6, worksheet A,
						  column E, line 1.
OTHER CLIENT EXAMINATION EXPENSES
9.
Contractual Examiners Fees
9.
$
.00
10.
Client Examination Equipment Lease or Rental
10.
$
.00
11.
Client Examination Equipment Depreciation
11.
$
.00
12.
Client Examination Equipment Depreciation
						  Expense
12.
$
.00
13.
Client Examination Supplies Expense
13.
$
.00
14.
Client Examination Staff Travel Expense
14.
$
.00
15.
Malpractice Insurance
15.
$
.00
16.
Other Client Examination Expenses
16.
$
.00
17.
Total Other Client Examination Expenses
17.
$
.00
(Sum of lines 9 through 16)
Total on line 17 is equal to BCRR Table 6, worksheet A,
						  Column I, line 1.
DONATED MEDICAL EXPENSES
18.
Value of Physician's Donated Time
18.
$
.00
19.
Value of Nurse Midwife/N.P.'s Donated Time
19.
$
.00
20.
Value of R.N.'s Donated Time
20.
$
.00
21.
Value of LPN's Donated Time
21.
$
.00
22.
Value of other Donated Medical Expenses
22.
$
.00
23.
Total Donated Services and Materials
23.
$
.00
(Sum of lines 18 through 22)
Total on line 23 is equal to BCRR Table 6, worksheet A,
						  Column j, line 1.
PATIENT EXAM INDIRECT COSTS
24.
Medical Fringe Benefits
24.
$
.00
(Worksheet A - Column g, line 1)
25.
Medical Facility Costs
25.
$
.00
(Worksheet B - Column d, line 1)
26.
Administrative Costs
26.
$
.00
(Worksheet B - Column g, line 1)
To arrive at the total medical costs you will add
						  salary and wages (8), other costs (17) and donated services and materials (23)
						  to the fringe benefits (24), facility costs (25) and administrative costs
						  (26).
27.
Total Medical Costs
27.
$
.00
This total equals BCRR Table 6, Column g, line
						  1.
LABORATORY COST CENTER
LABORATORY SERVICES DIRECT EXPENSES
28.
Salaries and Wages (include only those staff who
perform tests, assist in tests or prepare
						  specimens)
28.
$
.00
29.
Total
29.
$
.00
Total on line 29 is equal to BCRR Table 6, worksheet A,
						  Column E, line 2.
OTHER LABORATORY EXPENSES
30.
Laboratory Equipment Lease or Rental Expense
30.
$
.00
31.
Laboratory Equipment Depreciation Expense
Laboratory Equipment Maintenance and Repair
31.
$
.00
32.
Expense
32.
$
.00
33.
Laboratory Supplies Expense
33.
$
.00
34.
Purchased Outside Laboratory Services Expense
34.
$
.00
35.
Other Laboratory Expenses
35.
$
.00
36.
Total Other Laboratory Services Direct Expenses
36.
$
.00
(Sum of lines 30 through 35)
Total on line 36 is equal to BCRR Table 6, worksheet A,
						  Column I, line 2.
DONATED LABORATORY EXPENSES
37.
Value of Lab Technician's Donated Time
37.
$
.00
38.
Value of Donated Lab Supplies
38.
$
.00
39.
Value of Donated Lab Tests
39.
$
.00
40.
Value of other Donated Lab Expenses
40.
$
.00
41.
Total Donated Laboratory Services and Materials
41.
$
.00
(Sum of lines 37 through 40)
Total on line 41 is equal to BCRR Table 6, worksheet A,
						  Column j, line 2.
LABORATORY SERVICES INDIRECT EXPENSES
42.
Laboratory Fringe Benefits
42.
$
.00
(Worksheet A - Column g, line 2)
43.
Laboratory Facility Costs
43.
$
.00
(Worksheet B - Column d, line 2)
44.
Laboratory Administration Costs
44.
$
.00
(Worksheet B - Column g, line 2)
To arrive at the total laboratory expenses you will add
						  salary and wages (29), other costs (36) and donated services and materials (41)
						  to the fringe benefits (42), facility costs (43) and administrative costs
						  (44).
45.
Total Laboratory Costs
45.
$
.00
This total equals BCRR Table 6, Column g, line
						  2.
OUTSIDE LABORATORY TESTS:
Any laboratory test completed by an outside
						  incorporated entity. An invoice and payment to the entity for services must
						  exist.
If you have "purchased outside laboratory fees" which
						  will be included in total laboratory expenses for you BCRR information, you
						  must now subtract the dollar amount of those purchases from your BCRR total on
						  Table 6, Column G, line 2 to arrive at the dollar amount to be used in your
						  total adjusted cost/center of Attachment C, Column E. You WILL NOT use the
						  amount from you BCRR Table 6, Column G, line 2 for this amount.
OUTSIDE LABORATORY COST AREA
Type of Supply
Your Cost/Unit x Number Used = Total
						  Expense*
46.
VDRL/RPR
$
x
$
.00
47.
Pap Smear
$
x
47.
$
.00
48.
Gonorrhea Culture
$
x
48.
$
.00
49.
Miscellaneous Culture
$
x
49.
$
.00
50.
Sickle Cell
$
x
50.
$
.00
51.
PP Blood Glucose
$
x
51.
$
.00
52.
Cholesterol Level
$
x
52.
$
.00
53.
SMA 12
$
x
53.
$
.00
54.
Colposcopy
$
x
54.
$
.00
55.
Colposcopy and Biopsy
$
x
55.
$
.00
56.
Chlamydia
$
x
56.
$
.00
57.
Total Outside Laboratory Fees
57.
$
.00
*Round to the nearest dollar amount.
58.
Adjusted total cost/center:
58.
$
.00
Line 45, subtract Line 67, equals amount on Line 58.
						  This is the amount to be used in the Adjusted Total Cost/Center, Attachment C,
						  Column E.
PHARMACY COST CENTER
Supplies Consumed During Reporting Period:
Type of Supply
Your Cost/Unit x Number Used = Total
						  Expense*
59.
Oral Contraceptives
x
59.
$
.00
60.
Cream
x
60.
$
.00
61.
Jelly
x
61.
$
.00
62.
Suppository (each)
x
62.
$
.00
63.
Foam
x
63.
$
.00
64.
Diaphragm
x
64.
$
.00
65.
IUD
x
65.
$
.00
66.
Basal T & C
x
66.
$
.00
67.
Sponges (each)
x
67.
$
.00
68.
Condoms (each)
x
68.
$
.00
69.
Meds/Vag. Inf.
x
69.
$
.00
70.
Meds/Std Rx
x
70.
$
.00
71.
Contraceptive Film
x
71.
$
.00
*The number used for each type of supply will come from
						  your inventory sheets.
72.
Total (Sum of lines 59 through 71)
72.
$
.00
PROVISION OF CONTGRACEPTIVE DRUGS/SUPPLIES DIRECT
						  EXPENSES
73.
Salaries and Wages for Staff Who Dispense or
Assist in Providing Contraceptive Drugs and
						  Supplies
73.
$
.00
74.
Total
74.
$
.00
Total on line 74 is equal to BCRR Table 6, worksheet A,
						  Column E, line 4.
OTHER PHARMACY EXPENSES
75.
Provision of Drugs and Supplies Equipment
Lease or Rental Expense
75.
$
.00
76.
Provision of Drugs and Supplies Depreciation
						  Expense
76.
$
.00
77.
Provision of Drugs and Supplies Equipment Maintenance
						  and Repair Expense
77.
$
.00
78.
Dispensing Supplies Expense
78.
$
.00
79.
Other Pharmacy Expenses
79.
$
.00
80.
Total (Sum of lines 75 through 79)
80.
$
.00
81.
Total All Pharmacy Expenses
81.
$
.00
(Sum of lines 72 and 80)
Total on line 81 is equal to BCRR Table 6, worksheet A,
						  Column I, line 4.
DONATED PHARMACY EXPENSES
82.
Value of Pharmacists' Donated Time
82.
$
.00
83.
Value of Donated Pharmacy Supplies
83.
$
.00
84.
Value of Donated Contraceptive Supplies
84.
$
.00
85.
Value of Other Donated Pharmacy Expenses
85.
$
.00
86.
Total Donated Pharmacy Services and Materials
86.
$
.00
(Sum of lines 82 through 85)
Total on line 86 is equal to BCRR Table 6, worksheet A,
						  Column j, line 4.
PHARMACY SERVICES INDIRECT EXPENSES
87.
Pharmacy Fringe Benefits
87.
$
.00
(Worksheet A - Column g, line 4)
88.
Pharmacy Facility Costs
88.
$
.00
(Worksheet B - Column d, line 4)
89.
Pharmacy Administration Costs
89.
$
.00
(Worksheet B - Column g, line 4)
To arrive at the total Pharmacy costs you will add
						  salary and wages (74), other costs (81) and donated services and materials (86)
						  to fringe benefits (87), facility costs (88) and administrative costs
						  (89).
90
Total Pharmacy Costs
90.
$
.00
This total equals BCRR Table 6, Column g, line
						  4.
91.
Adjusted total cost center
91.
$
.00
To arrive at the total adjusted cost/center you must
						  subtract the dollar amount of consumed contraceptives, drugs/supplies, from you
						  BCRR total on Table 6, Column G, line 4, which is the amount on Line 90, minus
						  line 72, equals the amount on line 91. This is the amount to be used in the
						  adjusted Total cost/center, Attachment D, Column E.
COUNSELING AND EDUCATION COST
						  CENTER
FAMILY PLANNING COUNSELING AND EDUCATIONAL DIRECT
						  EXPENSES
92.
Salaries and Wages, Family Planning
92.
$
.00
Counselors, Educators and Assistants
93.
Portion of Client Records Clerk
93.
$
.00
94.
Total
94.
$
.00
Total on line 94 is equal to BCRR Table t, worksheet A,
						  Column E, line 7.
OTHER COUNSELING AND EDUCATION EXPENSES
95.
Counseling and Educational Services
95.
$
.00
Staff Travel Expense
96.
Counseling and Educational Services
96.
$
.00
Equipment Rental
97.
Counseling Expense or Lease Expense and
97.
$
.00
Educational Services Equipment Depreciation
98.
Counseling and Educational Services Equipment
98.
$
.00
Repair and Maintenance Expense
99.
Counseling and Educational Supplies Expense
99.
$
.00
100.
Other Counseling and Educational Expense
100.
$
.00
101.
Total Family Planning Counseling and Educational
						  Services Direct Expenses
101.
$
.00
Total on line 101 is equal to BCRR Table 6, worksheet
						  A, Column I, line 7.
DONATED EDUCATION AND COUNSELING EXPENSES
102.
Value of Counselors Donated Time
102.
$
.00
103.
Value of Other Donated Counseling and Educational
						  Services Expenses
103.
$
.00
104.
Total Donated Counseling and Educational Services
						  Expenses
104.
$
.00
(Sum of lines 102 and 103)
Total on line 104 is equal to BCRR Table 6, worksheet
						  A, Column j, line 7.
COUNSELING AND EDUCATIONAL INDIRECT EXPENSES
105.
Counseling and Education Fringe Benefits
105.
$
.00
(Worksheet A - Column g, line 7)
106.
Counseling and Education Facility Costs
106.
$
.00
(Worksheet B - Column d, line 7)
107.
Counseling and Education Administration Costs
107.
$
.00
(Worksheet B - Column g, line 7)
To arrive at the total Counseling and Education costs
						  you will add salary and wages (92), other costs (101) and Donated Counseling
						  and Educational Services (104) to fringe benefits (105), facility costs (106)
						  and administrative costs (107).
108.
Total Counseling and Education Costs
108.
$
.00
This total equals BCRR Table 6, Column g, line
						  7.
FAMILY PLANNING CLIENT VISIT RELATIVE
						  VALUES
SERVICES
RVS
MEDICAL SERVICES VISITS
Minimal Service
11.00
Brief/Intermediate Exam
18.00
Extended Exam
30.00
Insertion of IUD
30.00
Diaphragm Fit
15.00
Sonography/lost IUD
30.00
X-ray/lost IUD
24.00
LAB PROCEDURES
Hematocrit/Hemoglobin
3.00
U/A Dip Stick
4.00
Pregnancy Test
10.00
VDRL/RPR
6.00
Pap Smear
8.00
Gonorrhea Culture
6.00
Bacterial Smear/Wet Mount
5.00
Miscellaneous Culture
6.00
Sickle Cell
5.00
P.P. Blood Glucose
6.00
Triglycerides
6.00
SMA 12
16.00
Colposcopy
30.00
Colposcopy with Biopsy
40.00
Chlamydia
7.00
Miscellaneous Culture
3.00
Sickle Cell
4.00
P.P. Blood Glucose
10.00
Triglycerides
6.00
SMA 12
8.00
Colposcopy
6.00
Colposcopy with Biopsy
5.00
Chlamydia
6.00
CONTRACEPTIVE DRUGS/SUPPLIES
Orals
1.20
Creams
2.65
Jellies
2.65
Suppositories (each)
.15
Foams
3.00
Diaphragm
4.00
Basal T & C
10.00
IUD
50.00
Sponges (each)
1.50
Condoms (each)
.22
Meds/Vag. Inf.
5.00
Meds/STD
5.00
Contraceptive Film
2.00
EDUCATION AND COUNSELING
In-depth/1 hour
11.00
15 min. to 1 Hour
7.00
Revised
11/89
CALCULATING THE SCHEDULE OF DISCOUNTS
1.
Determine the number of payment categories.
Example:
For the purpose of this manual, we will use a six step
						  schedule.
2.
The income levels for the zero pay category will be the
						  poverty levels published annually in the Federal Register. (See Attachment
						  F)
Example:
The poverty level for a one person family is $5,980;
						  for a two person family the poverty level is $8,020, etc.
3.
The income levels for the full fee will be 250% of the
						  poverty level plus $1.00.
Example:
For Family Size of 1, 100% pay = $5,980 x 2.5 =
						  t$14,950 + $1 or $14,951
4.
To determine the income levels between 0% pay and 250%
						  pay, use the following formula:
The 250% income level minus the poverty level, divided
						  by the number of payment categories, minus 2.
The result of this computation is the dollar range for
						  each step.
Example:
Family Size 1 - $14,950 (full fee > 250%) minus
						  $5,980 (0%) = $8,970 divided by 4 (6 steps-2 steps) = $2,242.50 step
						  interval.
5.
The lower limit of each step is $1 more than the upper
						  limit of the preceding step.
Example:
Family Size 1, upper limit of 0% pay is $5,980, lower
						  limit of the next category (20%) is $5,981.
6.
The upper level for each step is computed by adding the
						  dollar interval computed in Step 4 to the upper limit of the preceding
						  step.
Example:
Family Size 1 - upper limit of 0% pay is $5,980; upper
						  limit of the next category is $5,981 + $2,243 or $8,224. See Attachment
						  F.
DEVELOPMENT OF A SLIDING FEE SCALE
Federal regulations require that we provide family planning
				services on a sliding fee scale to allow persons to receive services regardless
				of their income level and subsequent ability to pay. Client or family income
				level is the determining factor for what level or percentage of the full fee a
				client will be charged.
A fee system must be developed and reevaluated at least
				annually after completing a cost analysis. The sliding fee scale will be based
				on the most current Federal Poverty Income Guidelines (See Attachment F). All
				clients must update their financial status every 12 months.
A sliding fee scale must be simple to be useful. Any fee scale
				which is over burdensome to the cashier or person computing the fee loses its
				value as the time required to compute the fee increases. Fees must be
				reasonable, related to cost and not provide a barrier to care. In selecting the
				client fee discount categories, it is important to remember that too few
				categories may either classify many clients at the lower end, reducing income,
				or at the upper end, discouraging clients to seek care because of the cost,
				thereby also reducing income. Too many categories may be difficult to implement
				and administer. For the purpose of this manual, we will use a six step sliding
				fee scale. See Attachment G.
Attachment A
EXAMPLES OF ADMINISTRATIVE COSTS
1.
Project Director
2.
Administrative Secretary and Receptionist
3.
Bookkeeper
4.
Administrative supplies
5.
Administrative staff travel and per diem
6.
Vehicle rental or lease expense
7.
Auditing and accounting
8.
Legal fees
9.
Consultants expense
10.
Dues and subscriptions
11.
Advertising
12.
Postage
13.
Printing
14.
Purchased staff training
15.
Fidelity bonding
16.
Photo copy
17.
Equipment depreciation
EXAMPLES OF FACILITY COSTS
1.
Custodian or Janitorial Contractual Services
2.
Building rental
3.
Building depreciation
4.
Building and contents insurance
5.
Building maintenance and repair
6.
Security
7.
Utilities
8.
Telephone
9.
Janitorial supplies
Attachment B
COST OF SERVICE/FEE DETERMINATION
						  WORKSHEET
MEDICAL COST CENTER
(A)
SERVICE/PROCEDURE
(B)
SERVICE UTILIZATION (FREQUENCY)
(C)
RVS VALUE
(D)
TOTAL SERVICE UNITS
(E)
TOTAL COST/ COST/CENTER
(F)
AVERAGE COST/SERVICE UNIT
(G)
COST/ SERVICE
(H)
COST OF LIVING ALLOWANCE
(I)
ADJUSTED
COST
(J)
FEE
Minimal Service
11.00
////////////////////////////
Brief/Intermediate Exam
18.00
////////////////////////////
Extended Exam
30.00
////////////////////////////
IUD Insertion
30.00
////////////////////////////
Diaphragm Fit
15.00
////////////////////////////
Sonography/lost IUD
30.00
////////////////////////////
X-ray/lost IUD
24.00
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
TOTAL
//////////////////////////
////////////////
//////////////////////////////
///////////////////
/////////////////////////////////
/////////////////////////
///////////////////////////////////
NOTES
1.
D = B x C
5.
G = F x C
REVISED
03-NOV-89
2.
Total Column D
6.
M = Cost of Living Allowance (COLA)
3.
E = Column G, line 1 of BCRR Table 6
7.
I = G x (COLA % + 100%)
4.
F = Column E / Column D Total
8.
J = Fee
Attachment C
COST OF SERVICE/FEE DETERMINATION
						  WORKSHEET
LABORATORY COST CENTER
(A)
SERVICE/PROCEDURE
(B)
SERVICE UTILIZATION (FREQUENCY)
(C)
RVS VALUE
(D)
TOTAL SERVICE UNITS
(E)
ADJUSTED TOTAL COST/ COST/CENTER
(F)
AVERAGE COST/SERVICE UNIT
(G)
COST/SERVICE ADJUSTED
(H)
PER UNIT PURCHASE EXPENSE
(I)
TOTAL BASE COST
(J)
COST OF LIVING ALLLOWANCE
(K)
ADJUSTED COST
(L)
FEE
HGB/HCT
3.00
//////////////////////////
Urinalysis
4.00
///////////////////////////
Pregnancy Test
10.00
////////////////////////////
VDRL/RPR
6.00
///////////////////////////
Pap Smear
8.00
///////////////////////////
Gonorrhea Culture
6.00
///////////////////////////
Miscellaneous Culture
6.00
//////////////////////////
Bacterial Smear/Wet Mount
5.00
//////////////////////////
Sickle Cell
5.00
//////////////////////////
P.P. Blood Glucose
6.00
//////////////////////////
Cholesterol Level
6.00
//////////////////////////
SMA - 12
16.00
//////////////////////////
Colposcopy
30.00
//////////////////////////
Colposcopy and Biopsy
40.00
//////////////////////////
Chlamydia
7.00
//////////////////////////
TOTAL
/////////////////////////
////////////////
////////////////////////
///////////////////
/////////////////////////
//////////////////
////////////////////
////////////////
/////////////////
NOTES:
1.
D = B x C
6.
H = Actual Per Unit Purchase Expense From Outside
						  Laboratory
REVISED
03-NOV-89
2.
Total Column D
7.
I = Total Cost G + H
3.
E = Column G, line 2 of BCRR Table 6,
8.
J = Cost of Living Allowance (COLA)
Minus the Cost of Purchased Outside Laboratory
						  Tests
9.
K = I x (COLA % + 100%)
4.
F = Column E / Column D Total
10.
L = Fee
5.
G = F x C
Attachment D
COST OF SERVICE/FEE DETERMINATION
						  WORKSHEET
PHARMACY
COST CENTER
(A)a
SERVICE/PROCEDURE
(B)
SERVICE UTILIZATION (FREQUENCY)
(C)
RVS VALUE
(D)
TOTAL SERVICE UNITS
(E)
ADJUSTED TOTAL COST/ COST/CENTER
(F)
AVERAGE COST/SERVICE UNIT
(G)
COST/ SERVICE ADJUSTED
(H)
PER UNIT PURCHASE EXPENSE
(I)
TOTAL BASE COST
(J)
COST OF LIVING ALLOWANCE
(K)
ADJUSTED COST
(L)
FEE
Orals
1.20
//////////////////////
Creams
2.65
//////////////////////
Jellies
2.65
///////////////////////
Suppositories (each)
0.15
///////////////////////
Foams
3.00
///////////////////////
Diaphragms
4.00
///////////////////////
IUDS
50.00
///////////////////////
Basal T & C
10.00
///////////////////////
Sponges (each)
1.50
///////////////////////
Condoms (each)
0.22
///////////////////////
Meds/Vag Inf
5.00
///////////////////////
Meds/STD
5.00
///////////////////////
Contraceptive Film
2.00
///////////////////////
///////////////////////
///////////////////////
TOTAL
/////////////////////////
//////////////
////////////////////////
//////////////////////
////////////////////
////////////////
/////////////////////
////////////////////
//////////////////////
NOTES:
1.
D = B x C
6.
H = Actual Per Unit Purchase Expense
REVISED
03-NOV-89
2.
Total Column D
7.
I = G + H
3.
E = Column G, line 4 of BCRR Table 6
8.
J = Cost of Living Allowance (COLA)
Minus the Cost of Consumed Pharmaceuticals
9.
K x (COLA % + 100%)
4.
F = Column E / Column D Total
10.
L = Fee
5.
G = F x C
Attachment E
COST OF SERVICE/FEE DETERMINATION
						  WORKSHEET
EDUCATION/COUNSELING COST CENTER
(A)
SERVIC/PROCEDURE
(B)
SERVICE UTILIZATION (FREQUENCY)
(C)
RVS VLAUE
(D)
TOTAL SERVICE UNITS
(E)
TOTAL COST/ COST/CENTER
(F)
AVERAGE COST/SERVICE UNIT
(G)
COST/ SERVICE
(H)
COST OF LIVING ALLOWANCE
(I)
ADJUSTED COST
(J)
FEE
Indepth 1 Hour
11.00
///////////////////
Counseling/15 Min to 1 Hr
7.00
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
TOTAL
////////////////////
///////////////
////////////////////
//////////////
//////////////////
/////////////////
//////////////
NOTES:
1.
D = B x C
5.
G = F x C
REVISED
03-NOV-89
2.
Total Column D
6.
H = Cost of Living Allowance (COLA)
3.
E = Column G, line 7 of BCRR Table 6
7.
I = G x (COLA % + 100%)
4.
F = Column E / Column D Total
8.
J = Fee
Attachment F
EXAMPLE
POVERTY INCOME GUIDELINES
CLIENT FEE DISCOUNT CATEGORIES
03/08/89
Family Planning Services
1989 Revised Guidelines as published in Federal
				Register, 2/16/89, Vol. 54, No. 31
FAMILY SIZE
0%
20%
40%
60%
80%
100%
A
B
C
D
E
F
G
H
I
J
K
1
0
-
5980
5981
-
8224
8225
-
10467
10468
-
12711
12712
-
14950
14951
2
0
-
8020
8021
-
11029
11030
-
14037
14038
-
17046
17047
-
20050
20051
3
0
-
10060
10061
-
13834
13835
-
17607
17608
-
21381
21382
-
25150
25151
4
0
-
12100
12101
-
16639
16640
-
21177
21178
-
25716
25717
-
30250
30251
5
0
-
14140
14141
-
19444
19445
-
24747
24748
-
30051
30052
-
35350
35351
6
0
-
16180
16181
-
22249
22250
-
28317
28318
-
34386
34387
-
40450
40451
7
0
-
18220
18221
-
25054
25055
-
31887
31888
-
38721
38722
-
45550
45551
8
0
-
20260
20261
-
27859
27860
-
35457
35458
-
43056
43057
-
50650
50651
*
FOR FAMILY UNITS WITH MORE THAN 8 MEMBERS, FOR EACH
						  ADDITIONAL MEMBER AND ADD TO COLUMN B; $2,040
**
POVERTY LEVEL
$5,980
B
=
Family size = 1 = Poverty Level
B
=
All other Family size = Previous Family size Poverty
						  Level plus $2,040
C
=
(B + 1)
D
(J - B) / 4 + C
E
(D + 1)
F
=
(J-B) / 4 + E
G
=
(F + 1)
H
=
(J-B) / 4 + G
I
=
(H + 1)
J
=
(B x 2.5)
K
=
(J + 1)
Attachment G
SLIDING FEE SCALE
**********************************************************************************************************
SERVICE/PROCEDURES
(a)
COST/ SERVICES
FEE
0%
20%
40%
60%
80%
100%
Minimal Services
________
________
________
________
________
________
________
________
Brief/Intermediate Exam
________
________
________
________
________
________
________
________
Extended Exam
________
________
________
________
________
________
________
________
IUD Insertion
________
________
________
________
________
________
________
________
Diaphragm Fit
________
________
________
________
________
________
________
________
Sonography/lost IUD
________
________
________
________
________
________
________
________
X-ray/lost IUD
________
________
________
________
________
________
________
________
HCT/HBG
________
________
________
________
________
________
________
________
Urinalysis
________
________
________
________
________
________
________
________
Pregnancy Test
________
________
________
________
________
________
________
________
VDRL/RPR
________
________
________
________
________
________
________
________
Pap Smear
________
________
________
________
________
________
________
________
Gonorrhea Culture
________
________
________
________
________
________
________
________
Miscellaneous Culture
________
________
________
________
________
________
________
________
Bacterial Smear/Wet Mount
________
________
________
________
________
________
________
________
Sickle Cell
________
________
________
________
________
________
________
________
PP Blood Glucose
________
________
________
________
________
________
________
________
Cholesterol Level
________
________
________
________
________
________
________
________
SMA-12
________
________
________
________
________
________
________
________
Colposcopy
________
________
________
________
________
________
________
________
Colposcopy and Biopsy
________
________
________
________
________
________
________
________
Chlamydia
________
________
________
________
________
________
________
________
Orals
________
________
________
________
________
________
________
________
Creams
________
________
________
________
________
________
________
________
Jellies
________
________
________
________
________
________
________
________
Suppositories (each)
________
________
________
________
________
________
________
________
Foams
________
________
________
________
________
________
________
________
Diaphragms
________
________
________
________
________
________
________
________
IUDS
________
________
________
________
________
________
________
________
Basal T & C
________
________
________
________
________
________
________
________
Sponges (each)
________
________
________
________
________
________
________
________
Condoms (each)
________
________
________
________
________
________
________
________
Meds/Vag Inf
________
________
________
________
________
________
________
________
Meds/STD
________
________
________
________
________
________
________
________
Contraceptive Film
________
________
________
________
________
________
________
________
In-depth 1 Hour
________
________
________
________
________
________
________
________
Counseling/15 Min. to 1 Hr.
________
________
________
________
________
________
________
________
**********************************************************************************************************
ALLOCATION OF MONIES FOR BCRR
SALARIES
EQUIPMENT DEPRECIATION
0.5
OB/GYN Physician
50,000
Medical
800
0.2
OB/GYN Nurse Practitioners
52,000
Laboratory
200
1.5
RN's
24,000
Patient Records
100
0.5
RN (Pharmacy)
8,000
Administration
900
0.2
LPN's
22,000
0.5
Medical Appt. Secy.
5,750
0.5
Client Records Clerk
5,750
INSURANCE
1.0
Health Educator
16,000
0.5
Laboratory Technician
7,000
Medical Malpractice
5,000
1.0
Project Director
20,000
Fidelity Bonding
100
1.0
Admin. Secy./Recept.
12,000
Facility (fire, flood)
1,000
1.0
Bookkeeper
12,000
0.2
Custodian
1,600
RENT
12,000
UTILITIES
1,800
TELEPHONE
740
FRINGE BENEFITS
27,300
PHOTO COPY
560
POSTAGE
375
ADMIN. TRAVEL
200
CONSULTANT & CONTRACT SERVICES
Nurse Practitioner
17,000
SQUARE FOOTAGE
Outside Laboratory
19,792
Account's Fee
800
Medical
1,600 sq'
Attorney's Fee
100
Laboratory
200
Security
2,000
Other Health
300
Administration
400
2,500 sq'
SUPPLIES
Medical
10,000
Laboratory
3,000
Health Education
500
Pharmacy
1,000
Patient Records
200
Administration
500
Housekeeping
100
DONATED MATERIALS
Volunteer R.N.'s
6,000
GC's done by State lab
1,200
Contraceptives from closing clinic
2,400
Volunteer Counselor
400
Administrator's time
700
Rent at 2nd
						  site
1,200
MEDICAL COST CENTER
CLIENT EXAMINATION DIRECT EXPENSES
SALARIES AND WAGES (Include only those staff who
						  perform or assist in performing client examinations.)
1. Physician
1.
$
50,000.00
2. Physician Assistants
2.
$
.00
3. Nurse Practitioners
3.
$
52,000.00
4. Nurse Midwives
4.
$
.00
5. Other Nurses
5.
$
46,000.00
Medical Support
6. Medical Appointment Secretary
6.
$
5,750.00
7. Portion of Client Records Clerk
7.
$
4,600.00
8. Total Salaries
8.
$
158,350.00
Total on line 8 is equal to BCRR Table 6, worksheet A,
						  Column E, line 1.
OTHER CLIENT EXAMINATION EXPENSES
9. Contractual Examiners Fee
9.
$
17,000.00
10. Client Examination Equipment Lease or Rental
10.
$
.00
11. Client Examination Equipment Depreciation
						  Expense
11.
$
800.00
12. Client Examination Equipment Repair &
						  Maintenance
12.
$
.00
13. Client Examination Supplies Expense
13.
$
10,000.00
14. Client Examination Staff Travel Expense
14.
$
.00
15. Malpractice Insurance
15.
$
5,000.00
16. Other Client Examination Expenses
16.
$
240.00
17. Total Other Client Examination Expenses
17.
$
33,040.00
(Sum of lines 9 through 16)
Total on line 17 is equal to BCRR Table 6, worksheet
						  A, Column I, line 1.
DONATED MEDICAL EXPENSES
18. Value of Physician's Donated Time
18.
$
.00
19. Value of Nurse Midwife/N.P.'s Donated Time
19.
$
.00
20. Value of R.N.'s Donated Time
20.
$
6,000.00
21. Value of LPN's Donated Time
21.
$
.00
22. Value of other Donated Medical Expenses
22.
$
.00
23. Total Donated Services and Materials
23.
$
6,000.00
(Sum of lines 18 through 22)
Total on line 23 is equal to BCRR Table 6, worksheet A,
						  Column j, line 1.
PATIENT EXAM INDIRECT COSTS
24. Medical Fringe Benefits
(Worksheet A - Column g, line 1)
24.
$
18,291.00
25. Medical Facility Costs
(Worksheet B - Column d, line 1)
25.
$
11,984.00
26. Administrative Costs
(Worksheet B - Column g, line 1)
26.
$
37,724.00
To arrive at the total medical costs you will add
						  salary and wages (8), other costs (17) and donated services and materials (23)
						  to the fringe benefits (24), facility costs (25) and administrative costs
						  (26).
27. Total Medical Costs
27.
$
265,389.00
This total equals BCRR Table 6, Column g, line
						  1.
LABORATORY COST CENTER
LABORATORY SERVICES DIRECT EXPENSES
28. Salaries and Wages (include only those staff who
						  perform tests, assist in tests or prepare specimens)
28.
$
7,000.00
29. Total
29.
$
7,000.00
Total on line 29 is equal to BCRR Table 6, worksheet A,
						  Column E, line 2.
OTHER LABORATORY EXPENSES
30. Laboratory Equipment Lease or Rental Expense
30.
$
.00
31. Laboratory Equipment Depreciation Expense
31.
$
200.00
32. Laboratory Equipment Maintenance and Repair
						  Expense
32.
$
.00
33. Laboratory Supplies Expense
33.
$
3,000.00
34. Purchased Outside Laboratory Services
						  Expense
See page 35.
34.
$
19,792.00
35. Other Laboratory Expenses
35.
$
.00
36. Total Other Laboratory Services Expenses
36.
$
22,992.00
(Sum of lines 30 through 35)
Total on line 36 is equal to BCRR Table 6, worksheet A,
						  Column I, line 2.
DONATED LABORATORY EXPENSES
37. Value of Lab Technician's Donated Time
37.
$
.00
38. Value of Donated Lab Supplies
38.
$
.00
39. Value of Donated Lab Tests
39.
$
1,200.00
40. Value of other Donated Lab Expenses
40.
$
.00
41. Total Donated Laboratory Services and
						  Materials
41.
$
1,200.00
(Sum of lines 37 through 40)
Total on line 41 is equal to BCRR Table 6, worksheet A,
						  Column j, line 2.
LABORATORY SERVICES INDIRECT EXPENSES
42. Laboratory Fringe Benefits
(Worksheet A - Column g, line 2)
42.
$
819.00
43. Laboratory Facility Costs
(Worksheet B - Column d, line 2)
43.
$
1,598.00
44. Laboratory Administration Cost
(Worksheet B - Column g, line 2)
44.
$
5,716.00
To arrive at the total laboratory expenses you will add
						  salary and wages (29), other costs (36) and donated services and materials (41)
						  to the fringe benefits (42), facility costs (43) and administrative costs
						  (44).
45. Total Laboratory Costs
45.
$
39,325.00
This total equals BCRR Table 6, Column g, line
						  2.
OUTSIDE LABORATORY TESTS:
Any laboratory test completed by an outside
						  incorporated entity. An invoice and payment to the entity for services must
						  exist.
If you have "purchased outside laboratory fees" which
						  will be included in total laboratory expenses for your BCRR information, you
						  must now subtract the dollar amount of those purchases from your BCRR total on
						  Table 6, Column G, line 2 to arrive at the dollar amount to be used in your
						  total adjusted cost/center of Attachment C, Column E. You WILL NOT use the
						  amount from your BCRR Table 6, Column G, line 2 for this amount.
OUTSIDE LABORATORY COST AREA
Type of Supply
Your Cost/Unit
x
Number Used
=
Total Expense*
46. VDRL/RPR
4.00
x
8
46.
$
32.00
47. Pap Smear
3.50
x
4,000
47.
$
14,000.00
48. Gonorrhea Culture
6.50
x
8
48.
$
52.00
49. Miscellaneous Culture
18.00
x
40
49.
$
720.00
50. Sickle Cell
5.00
x
100
50.
$
500.00
51. P.P. Blood Glucose
4.50
x
20
51.
$
90.00
52. Cholesterol Level
4.00
x
10
52.
$
40.00
53. SMA 12
6.75
x
10
53.
$
68.00
54. Colposcopy
40.00
x
4
54.
$
160.00
55. Colposcopy and Biopsy
50.00
x
1
55.
$
50.00
56. Chlamydia
8.00
x
510
56.
$
4,080.00
57. Total Outside Laboratory Fees
57.
$
19,792.00
58. Adjusted Total Cost Center:
58.
$
19,533.00
Line 45, subtract Line 57
*Round to the nearest dollar amount. equals amount on
						  Line 58.
This is the amount to be used in the Adjusted
						  Total
Cost/Center, Attachment C, Column E
PHARMACY COST CENTER
Supplies Consumed During Reporting Period:
Type of Supply
Your Cost/Unit
x
Number Used
=
Total Expense**
59. Oral Contraceptives
.70
x
58,500
59.
$
40,950.00
60. Cream
1.00
x
54
60.
$
54.00
61. Jelly
1.00
x
50
61.
$
50.00
62. Suppository (each)
.20
x
5
62.
$
1.00
63. Foam
.90
x
2,304
63.
$
2,074.00
64. Diaphragm
3.00
x
124
64.
$
372.00
65. IUD
36.00
x
24
65.
$
864.00
66. Basal T & C
16.50
x
2
66.
$
33.00
69. Meds/Vag. Inf.
4.70
x
540
69.
$
2,538.00
70. Meds/STD Rx
4.70
x
539
70.
$
2,533.00
71. Contraceptive Film
3.00
x
10
71.
$
30.00
72. Total (Sum of lines 59 through 71)
72.
$
50,500.00
* The number used for each type of supply will come
						  from your inventory sheets.
** Round to the nearest dollar amount
PROVISION OF CONTRACEPTIVE DRUGS/SUPPLIES DIRECT
						  EXPENSES
73. Salaries and Wages for Staff Who Dispense or Assist
						  in Providing Contraceptive Drugs and Supplies
73.
$
8,000.00
74. Total
74.
$
8,000.00
Total on line 74 is equal to BCRR Table 6, worksheet A,
						  Column E, line 4.
OTHER PHARMACY EXPENSES
75. Provision of Drugs
						and Supplies Equipment Lease or Rental Expense
75.
$
.00
76. Provision of Drugs and Supplies Depreciation
						  Expense
76.
$
.00
77. Provision of Drugs and Supplies Equipment
						  Maintenance and Repair Expense
77.
$
.00
78. Dispensing Supplies Expense
78.
$
.00
79. Other Pharmacy Expenses
79.
$
.00
80. Total (Sums of lines 75 through 79)
80.
$
-0- .00
81. Total All Pharmacy Expenses
81.
$
50,500.00
(Sum of lines 72 and 80)
Total on line 81 is equal to BCRR Table 6, worksheet A,
						  Column I, line 4.
DONATED PHARMACY EXPENSES
82. Value of Pharmacists' Donated Time
82.
$
.00
83. Value of Donated Pharmacy Supplies
83.
$
.00
84. Value of Donated Contraceptive
						  Supplies
84.
$
2,400.00
85. Value of Other Donated Pharmacy
						  Expenses
85.
$
.00
86. Total Donated Pharmacy Services and
						  Materials
86.
$
2,400.00
(Sum of lines 82 through 85),
Total on line 86 is equal to BCRR Table 6, worksheet A,
						  Column j, line 4.
PHARMACY SERVICES INDIRECT EXPENSES
87. Pharmacy Fringe Benefits
(Worksheet A - Column g, line
						  4)
87.
$
819.00
88. Pharmacy Facility Costs
(Worksheet B - Column d, line 4)
88.
$
1,198.00
89. Pharmacy Administration Cost
(Worksheet B - Column g, line 4)
89.
$
10,288.00
To arrive at the total Pharmacy cost you will add
						  salary and wages (74), other costs (81) and donated services and materials (86)
						  to fringe benefits (87), facility costs (88) and administrative costs
						  (89).
90. Total Pharmacy Cost
This total equals BCRR Table 6, Column g, line
						  4.
90.
$
73,205.00
91. Adjusted total costs center
91.
$
22,705.00
To arrive at the total adjusted cost/center you must
						  subtract the dollar amount of consumed contraceptives, drugs/supplies from your
						  BCRR total on Table 6, Column G, line 4, which is the amount on line 90, minus
						  line 72, equals the amount on line 91. This is the amount to be used in the
						  adjusted total cost/center, Attachment D, Column E.
COUNSELING AND EDUCATION COST
						  CENTER
FAMILY PLANNING COUNSELING AND EDUCATIONAL DIRECT
						  EXPENSES
92. Salaries and Wages, Family Planning Counselors,
						  Educators and Assistants
92.
$
16,000.00
93. Portion of Client Records Clerk
93.
$
1,150.00
94. Total
94.
$
17,150.00
Total on line 94 is equal to BCRR Table 6, worksheet A,
						  Column E, line 7.
OTHER COUNSELING AND EDUCATION EXPENSES
95. Counseling and Educational Services Staff Travel
						  Expense
95.
$
.00
96. Counseling and Educational Services Equipment
						  Rental
96.
$
.00
97. Counseling Expense or Lease Expense and
						  Educational Services Equipment Depreciation
97.
$
.00
98. Counseling and Educational Services Equipment
						  Repair and Maintenance Expense
98.
$
.00
99. Counseling and Educational Supplies
						  Expense
99.
$
500.00
100. Other Counseling and Educational
						  Expense
100.
$
60.00
101. Total Family Planning Counseling and Educational
						  Services Direct Expenses
101.
$
560.00
Total on line 101 is equal to BCRR Table 6, worksheet
						  A, Column I, line 7.
DONATED EDUCATION AND COUNSELING EXPENSES
102. Value of Counselors Donated Time
102.
$
400.00
103. Value of Other Donated Counseling and Educational
						  Services Expense
103.
$
.00
104. Total Donated Counseling and Educational Services
						  Expenses
104.
$
400.00
(Sum of lines 102 through 103)
Total on line 104 is equal to BCRR Table 6, worksheet
						  A, Column j, line 7.
COUNSELING AND EDUCATIONAL INDIRECT EXPENSES
105. Counseling and Education Fringe Benefits
(Worksheet A - Column g, line 7)
105.
$
1,911.00
106. Counseling and Education Facility Costs
(Worksheet B - Column d, line 7)
106.
$
2,197.00
107. Counseling and Education Administration
						  Costs
(Worksheet B - Column g, line 7)
107.
$
3,430.00
To arrive at the total Counseling and Education costs
						  you will add salary and wages (92), other costs (101) and Donated Counseling
						  and Educational Services (104) to fringe benefits (105), facility costs (106)
						  and administrative costs (107).
108. Total Counseling and Education Costs
This total equals BCRR Table 6, Column g,
						  line 7.
108.
$
25,648.00
WORKSHEET A - COLUMN E
Salaried Personnel Includes Column C (C + E =
				E)
1. Medical - line
$
158,350
.5 OB/GYN Physician
50,000
2.0 OB/GYN Nurse
						  Practitioners
52,000
1.5 RN's
24,000
2.0 LPN's
22,000
.5 Medical Appt. Sec'y.
5,750
Add Column C
.4 Patient Records Clerk
4,600
2. Laboratory - line 2
$
7,000
0.5 Lab Technician
7,000
4. Pharmacy - line 4
$
8,000
.5 R.N.
8,000
7. Other Health - line 7
$
17,150
1.0 Health Educator
16,000
Add Column C
Patient Record Clerk
1,150
12. Administration - line 12
$
44,000
Patient Record Clerk
20,000
1.0 Admin. Sec'y/Recept.
12,000
1.0 Bookkeeper
12,000
13. Facility - line 13
$
1,600
.2 Custodian
1,600
15. TOTAL - LINE 15
$
236,100
WORKSHEET A - COLUMN I
Other Costs Include Column D (D + I = I)
1. Medical - line
$
33,040
Contractual N.P.
17,000
Medical Supplies
10,000
Medical Equipment
						  Depreciation
800
Medical Malpractice
						  Insurance
5,000
Add Column D
Patient Records Cost
240
2. Laboratory - line 2
$
22,992
Outside Laboratory
19,792
Laboratory Supplies
3,000
Laboratory Depreciation
200
3. Pharmacy - line 4
$
50,500
Contraceptives Used
50,500
7. Other Health
$
560
Health Education Supplies
500
Add Column D
60
12. Administration - line 12
$
4,275
Accountant Fee
800
Attorney Fee
100
Administrative Supplies
500
Equipment Depreciation
900
Fidelity Bonding
100
Telephone
740
Photo Copy
560
Postage
375
Administrative Travel
200
13. Facility - line 13
$
16,900
Security
2,000
Housekeeping Supplies
100
Facility Insurance
1,000
Rent
12,000
Utilities
1,800
15. TOTAL - LINE 15
$
128,267
WORKSHEET A - COLUMN J
Value of Donated Materials and Services
1. Medical - line 1
Volunteer R.N.'s
$
6,000
2. Laboratory - line 2
Free gc's done by the State lab
1,200
4. Pharmacy - line 4
Contraceptives donated by a closing
						  clinic
2,400
7. Other Health - line 7
Volunteer counselor
400
12. Administrator's Time
700
13. Free rent at second site
1,200
15. TOTAL - LINE 15
11,900
Click here to view
				image
TABLE 6 WORKSHEET A: DISTRIBUTION OF PATIENT
				RECORDS COSTS AND FRINGE BENEFITS ACROSS FUNCTIONAL COST CENTERS
NOTE: If this Worksheet is used, it must be retained
				by the grantee.
It should not be submitted with TABLE 6.
FUNCTIONAL COST CENTERS
DISTRIBUTION OF PATIENT
RECORDS COSTS
DISTRUBTION OF FRINGE
BENEFITS COSTS
Number of Encounters
% of Total Encounters
Amount of Personnel Distrb. to Functions
Amount of Other Distrb. to Functions
Salaried Personnel Costs (inc. Col. C)
% of Total Salaries
Amount of Fringe Benefits Distrb. to Functions
Total Salaried Personnel Costs
Other Costs
Value of Donated Mat. & Svcs.
Total Before Distribution
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
HEALTH CARE FUNCTIONS:
12,000
80%
4,600
240
158,350
67%
18,291
176,641
33,040
6,000
215,681
1) Medical (A)
2) Laboratory - Medical (B)
7,000
3%
819
7,819
22,992
1,200
32,011
3) X-Ray - Medical (C)
4) Pharmacy - Medical & Dental (D)
8,000
3%
819
8,819
50,500
2,400
61,719
5) Dental (Lab & X-Ray) (E)
-0-
6) Inpatient (F)
7) Other Health (G)
3,000
20%
1,150
60
17,150
7%
1,911
19,061
560
400
20,021
8) Community Service (H)
9) Environmental (I)
10) Patient Transportation (J)
11) Patient Records
(5750)
(300)
CLINIC OVERHEAD FUNCTIONS
44,000
19%
5,187
49,187
4,275
700
54,162
12) Administration (K)
13) Facility (L)
1,600
1%
273
1,873
16,900
1,200
19,973
14) Fringe Benefits
(27300)
15) TOTAL (LINES 1 through 14)
15,000
100%
-0-
-0-
236,100
100%
-0-
263,400
128,267
11,900
403,567
TABLE 6 WORKSHEET B:
DISTRIBUTION OF CLINIC OVERHEAD COSTS ACROSS
				HEALTH CARE COST CENTERS
NOTE: If this Worksheet is used, it must be retained
				by the grantee.
It should not be submitted with TABLE 6
FUNCTIONAL COST CENTERS
Total before Distribution Worksheet A, Col (k)
DISTRIBUTION OF FACILITY COSTS
Total after Distrb. of Facility Costs (a+d)
DISTRIBUTION OF ADMINISTRATION
						  COSTS
Total after Final Distrb. of Clinic Overhead Costs (e
						  & g)
Square Feet of Space Used
% of Square Footage
Amount of Facility Distrib.. to Function
% of Health Care Cost Subtotal
Amount of Admin. Distrb. to Functions
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
HEALTH CARE FUNCTIONS:
215,681
1,600
60%
11,984
227,665
66%
37,724
265,389
1) Medical (A)
2) Laboratory - Medical (B)
32,011
200
8%
1,598
33,609
10%
5,716
39,325
3) X-Ray - Medical (C)
4) Pharmacy - Medical & Dental (D)
61,719
150
6%
1,198
62,917
18%
10,288
73,205
5) Dental (Lab & X-Ray) (E)
6) Inpatient (F)
7) Other Health (G)
20,021
300
11%
2,197
22,218
6%
3,430
25,648
8) Community Service (H)
9) Environmental (l)
10) Patient Transportation (J)
11) SUBTOTAL (LINES 1 through 10)
346,409
100%
CLINIC OVERHEAD FUNCTIONS:
54,162
400
15%
2,996
57,158
(57,158)
-0-
12) Administration (K)
13) Facility (L)
19,973
(9,973)
-0-
-0-
14) SUBTOTAL (LINES 12 x 13)
15) GRAND TOTAL
403,567
2,650
100%
-0-
403,567
-0-
403,567
CONSISTENCY CHECKS:
1. COL. (a) equals TABLE 6: COL. (e)
2. COL. (e) equals TABLE 6 COL. (f)
3. COL. (h) equals TABLE 6 COL. (g)
4. LINE 15, COL. (a), COL. (e), and COL. (h) should
				all be equal.
DETERMINATION OF COST PER PROCEDURE
The purpose of this step is to distribute health care costs to
				particular procedures to derive the unit cost of each procedures. The cost per
				procedure should be computed for all procedures. The cost per procedure
				information is useful for managers in establishing charges and for analyzing
				the benefit of continuing to provide specific services. There may be some cases
				in which the cost per procedure requires a charge so far above the competitive
				rate (what other providers in the area would charge for that service) that the
				charge is prohibitive. This should be a signal to management that steps must be
				taken to lower costs in the future or consideration should be given to phasing
				out that service and making alternative arrangements.
In order to determine the cost you must define the specific
				procedures performed in each cost center and determine how many times or
				frequency the procedure is performed. We have assigned relative values to
				procedures on page 18.
Prepare a Cost of Service/Fee Determination Worksheet for each
				cost center. See Attachments B, C, D and E.
MEDICAL COST CENTER
Attachment B
1.
Column A -
List procedure.
2.
Column B -
List Service Utilization/Frequency of Procedure.
3.
Column C -
List Relative Value for Procedure from Page 18.
4.
Column D -
Column B x Column C. Total Column D.
5.
Column E -
Cost center amount from BCRR Table 6, Column G, line
						  1.
6.
Column F -
Total Column E divided by total Column D. This gives
						  you your average cost/service unit which is listed for each line item.
7.
Column G -
The dollar amount in Column F times each RVS of Column
						  C. This amount represents the cost for each specific service.
8.
Column H -
Cost of living allowance (COLA). Use the most recent
						  consumer price index provided by IDPH.
9.
Column I -
Adjusted cost equals cost/service in Column G times
						  Column H, cost of living allowance (COLA)% plus 100%.
Example:
$10.00 X 105% = $10.50
10.
Column J -
The full fee to be charged and should approximate
						  Column K. For convenience round up to nearest dollar.
LABORATORY COST CENTER
Attachment C
1.
Column A -
List lab services provided.
2.
Column B -
List Service Utilization/Frequency of Procedure.
3.
Column C -
List Relative Value for Procedure from Page 18.
4.
Column D -
Column B X Column C. Total Column D.
5.
Column E -
Cost center amount from BCRR Table 6, Column G, line 2,
						  minus the cost of PURCHASED OUTSIDE LABORATORY TESTS equals adjusted total
						  cost/cost center. OUTSIDE LABORATORY TESTS ARE THOSE TESTS NOT PERFORMED BY THE
						  AGENCY. This does not include collection of specimens.
6.
Column F -
Total adjusted cost center, Column E, divided by total
						  service units, Column D, equals Column F, the average cost/service unit.
7.
Column G -
Adjusted cost/service equals the dollar amount in
						  Column F times each relative value of Column C. This amount represents the cost
						  for each specific service. Column F X Column C.
8.
Column H -
Enter the per unit purchase expense of OUTSIDE
						  LABORATORY TESTS on the appropriate line or lines. This additional purchase
						  expense applies only to designated tests. See designated list on page
						  35.
For nondesignated test, Column H equals ZERO.
9.
Column I -
Total base cost equals adjusted cost/service plus per
						  unit purchase expense. Column G + Column H.
10.
Column J -
Cost of living allowance (COLA). Use the most recent
						  consumer price index provided by IDPH.
11.
Column K -
Adjusted cost equals total base cost in Column I times
						  Column J, cost of living allowance (COLA)% plus 100%.
Example:
$4.60 X 105% = $4.83
12.
Column L -
The full fee to be charged and should approximate
						  Column K. For convenience round up to nearest dollar.
PHARMACY COST CENTER
Attachment D
1.
Column A -
List pharmaceuticals provided.
2.
Column B -
List Service Utilization.
3.
Column C -
List Relative Value for Pharmaceuticals from page
						  18.
4.
Column D -
Column B X Column C. Total Column D.
5.
Column E -
Cost center amount from BCRR Table 6, Column G, line 4,
						  minus the cost of consumed pharmaceuticals equals adjusted total cost/cost
						  center.
6.
Column F -
Total adjusted cost center, Column E, divided by total
						  service units, Column D, equals Column F, the average cost/service unit.
7.
Column G -
Adjusted cost/service equals the dollar amount in
						  Column F, times each relative value of Column C. This amount represents the
						  cost for each specific service. Column F x Column C.
8.
Column H -
Equals the purchase expense per pharmaceutical unit. To
						  arrive at an average per unit purchase expense, for Attachment D, Column H,
						  when several brands of a pharmaceutical are purchased at different prices you
						  will divide the total dollar value of those pharmaceuticals consumed during
						  that period by the total number of units of those pharmaceuticals consumed
						  during the same reporting period.
9.
Column I -
Total base cost equals adjusted cost/service plus per
						  unit purchase expense. Column G + Column H.
10.
Column J -
Cost of living allowance (COLA). Use the most recent
						  consumer price index provided by IDPH.
11.
Column K -
Adjusted cost equals total base cost in Column I times
						  Column J, cost of living allowance (COLA)% plus 100%.
Example:
$4.60 X 105% = $4.83
12.
Column L -
The full fee to be charged and should approximate
						  Column K. For convenience round up to nearest dollar.
EDUCATION/COUNSELING COST CENTER
Attachment E
1.
Column A -
List procedure.
2.
Column B -
List Service Utilization/Frequency of Procedure.
3.
Column C -
List Relative Value for Procedure from Page 18.
4.
Column D -
Column B X Column C. Total Column D.
5.
Column E -
Cost center amount from BCRR, Table 6, Column G, line
						  7.
6.
Column F -
Total Column E divided by total Column D. This gives
						  you your average cost/service unit which is listed for each line item.
7.
Column G -
The dollar amount in Column F times each RVS of Column
						  C. This amount represents the cost for each specific service.
8.
Column H -
Cost of living allowance (COLA). Use the most recent
						  consumer price index provided by IDPH.
9.
Column I -
Adjusted cost equals cost/service in Column G times
						  Column H, cost of living allowance (COLA)% plus 100%.
Example:
$10.00 X 105% = $10.50
10.
Column J -
The full fee to be charged and should approximate
						  Column K. For convenience round up to nearest dollar.
Attachment B
COST OF SERVICE/FEE DETERMINATION
						  WORKSHEET
EDICAL COST CENTER
(A)
SERVICE/PROCEDURE
(B)
SERVICE UTILIZATION (FREQUENCY)
(C)
RVS VALUE
(D)
TOTALSERVICE UNITS
(E)
TOTAL COST/ COST/CENTER
(F)
AVERAGE COST/SERVICE UNIT
(G)
COST/ SERVICE
(H)
COST OF LIVING ALLOWANCE
`(I)
ADJUSTED COST
(J)
FEE
Minimal Service
900
11.00
9,900
/////////////////
$1.21
$13.31
5%
$13.98
$14.00
Brief/Intermediate Exam
1,500
18.00
27,000
///////////////////
1.21
21.78
5%
22.87
23.00
Extended Exam
6,000
30.00
180,000
/////////////////
1.21
36.30
5%
38.12
39.00
IUD Insertion
24
30.00
720
/////////////////
1.21
36.30
5%
38.12
39.00
Diaphragm Fit
124
15.00
1,860
/////////////////
1.21
18.15
5%
19.06
20.00
Sonography/lost IUD
1
30.00
30
/////////////////
1.21
36.30
5%
38.12
39.00
X-ray/lost IUD
1
24.00
24
/////////////////
1.21
29.04
5%
30.49
31.00
////////////////
////////////////
////////////////
////////////////
////////////////
////////////////
////////////////
////////////////
TOTAL
////////////////////
////////////////
219,534
$265,389
///////////////////
///////////
///////////////////
/////////////////
///////////////
NOTES:
1. D = B x C
5. G = F x C
REVISED: 03-Nov-89
2. Total Column D
6. H = Cost of Living Allowance (COLA)
3. E = Column G, line 1 of BCRR Table 6
7. I = G x (COLA % + 100%)
4. F = Column E / Column D Total
8. J = Fee
Attachment C
COST OF SERVICE/FEE DETERMINATION
						  WORKSHEET
LABORATORY COST CENTER
(A)
SERVICE/PROCEDURE
(B)
SERVICE UTILIZATION (FREQUENCY)
(C)
RVS VALUE
(D)
TOTAL SERVIOCE UNITSS
(E)
ADJUSTED TOTAL COST/ \COST /CENTER
(F)
AVERAGE COST/SERVICE UNIT
(G)
COST/ SERVICE ADJUSTED
(H)
PER UNIT PURCHASE EXPENSE
(I)
TOTAL
BASE
COST
(J)
COST OF
LIVING
ALLOWANCE
(K)
ADJUSTED
COST
(L)
FEES
MGS/HCT
3,890
3.00
11,670
///////////////////////
$ .26
$ .78
-0-
$ .78
5%
$ .82
$ 1.00
Urinalysis
3,799
4.00
15,196
///////////////////////
.26
1.04
-0-
1.04
5%
1.09
2.00
Pregnancy Tex
1,025
10.00
10,250
///////////////////////
.26
2.60
-0-
2.60
5%
2.73
3.00
VDRL/RPR
8
6.00
48
///////////////////////
.26
1.56
4.00
5.56
5%
5.84
6.00
Pap Smear
4,000
8.00
32,000
///////////////////////
.26
2.08
3.50
5.58
5%
5.86
6.00
Gonorrhea Culture
8
8.00
48
///////////////////////
.26
1.56
6.50
8.06
5%
8.46
9.00
Miscellaneous Culture
40
8.00
240
///////////////////////
.26
1.56
18.00
19.56
5%
20.54
21.00
Bacterial Smear/Wet Mount
305
5.00
1,525
///////////////////////
.26
1.30
-0-
1.30
5%
1.37
2.00
Sickle Cell
100
5.00
500
///////////////////////
.26
1.30
5.00
6.30
5%
6.62
7.00
Blood Glucose
20
6.00
120
///////////////////////
.26
1.56
4.50
6.06
5%
6.36
7.00
Cholesterol Level
10
6.00
60
///////////////////////
.26
1.56
4.00
5.56
5%
5.84
6.00
SMA - 12
10
16.00
160
///////////////////////
.26
4.16
6.75
10.91
5%
11.46
12.00
Colposcopy
4
30.0
120
///////////////////////
.26
7.80
40.00
47.80
5%
50.19
51.00
Colposcopy and Biopsy
1
40.00
40
///////////////////////
.26
10.40
50.00
60.40
5%
63.42
64.00
Chlmaydia
510
7.00
3,570
///////////////////////
.26
1.82
8.00
9.82
5%
10.31
11.00
TOTAL
/////////////////////
////////////
75,547
19,533
////////////////////////
///////////////////
//////////////////
///////////////
////////////////////////////
///////////////////
///////////////////
NOTES:
1.
D = B x C
5.
G = F x C
REVISED: 21-Dec-89
2.
Total Column D
6.
H = Actual Perm Unit Purchase Expense From Outside
						  Laboratory
3.
E = Column G, line 2 of BCRR, Table 6, Minus the Cost
						  of Purchased Outside Laboratory Tests ($39,325 - $19,792=$19,533)
7.
I = Total Cost G+H
4.
F = Column E / Column D Total
8.
J = Cost of Living Allowance (COLA)
9.
K = Ix(COLA%=100%)
10.
L = Fee
Attachment D
COST OF SERVICE/FEE DETERMINATION WORKSHEET
PHARMACY
COST CENTER
(A)
SERVICE/PROCEDURE
(B)
SERVICE UTILIZATION (FREQUENCY)
(C)
RVS VALUE
(D)
TOTAL SERVIOCE UNITSS
(E)
ADJUSTED TOTAL COST/ COST /CENTER
(F)
AVERAGE COST/SERVICE UNIT
(G)
COST/ SERVICE ADJUSTED
(H)
PER UNIT PURCHASE EXPENSE
(I)
TOTAL BASE COST
(J)
COST OF LIVING ALLOWANCE
(K) ADJUSTED COST
(L)
FEE
Orals
58,500
1.20
70,200.00
///////////////////////////
.26
.31
.70
1.01
5%
1.06
2.00
Creams
54
2.65
143.10
///////////////////////////
.26
.69
1.00
1.69
5%
1.77
2.00
Jellies
50
2.65
132.50
///////////////////////////
.26
.69
1.00
1.69
5%
1.77
2.00
Suppositories (each)
5
0.15
.75
///////////////////////////
.26
.04
.20
.24
5%
.25
.25
Foams
2,304
3.00
6,912.00
///////////////////////////
.26
.78
.90
1.68
5%
1.76
2.00
Diaphragms
124
4.00
496.00
///////////////////////////
.26
1.04
3.00
4.04
5%
4.24
5.00
IUDS
24
50.00
1,200.00
///////////////////////////
.26
13.00
36.00
49.00
5%
51.45
52.00
Basal T&C
2
10.00
20.00
///////////////////////////
.26
2.60
16.50
19.10
5%
20.05
21.00
Sponges (each)
152
1.50
228.00
///////////////////////////
.26
.39
.50
.89
5%
.93
1.00
Condoms (each)
18,500
0.22
4,070.00
///////////////////////////
.26
.06
.05
.11
5%
..12
.25
Meds/Vag Inf
540
5.00
2,700.00
///////////////////////////
.26
1.30
4.70
6.00
5%
6.30
7.00
Meds/STD
539
5.00
2,695.00
///////////////////////////
.26
1.30
4.70
6.00
5%
6.30
7.00
Contraceptive Film
10
2.00
20.00
///////////////////////////
.26
.52
3.00
3.52
5%
3.70
4.00
///////////////////////////
///////////////////////////
TOTAL
////////////////////////
/////////////
88,817.35
$22,705
///////////////////////////
///////////////////////
/////////////////////
///////////////
/////////////////////////
/////////////////////
//////////////////////
NOTES:
1.
D = B x C
5.
G = F x C
REVISED: 21-Dec-89
2.
Total Column D
6.
H = Actual Perm Unit Purchase Expense
3.
E = Column G, line 2 of BCRR, Table Minus the Cost of
						  Consumed
7.
I = G + H
Pharmaceuticals (($73,205 - $50,50 0 = $22,705)
8.
J = Cost of Living Allowance (COLA)
4.
F = Column E / Column D Total
9.
K = I x (COLA% + 100%)
10.
L = Fee
Attachment E
COST OF SERVICE/FEE DETERMINATION
						  WORKSHEET
EDUCATION, COUNSELING
COST CENTER
(A)
SERVICE PROCEDURE
(B)
SERVICE UTILIZATION (FREQUENCY)
(C)
RVS VALUE
(D)
TOTAL SERVICE UNITS
(E)
TOTAL COST/ COST/CENTER
(F)
AVERAGE COST/SERVICE UNIT
(G)
COST/ SERVICE
(H)
COST OF LIVING ALLOWANCE
(I)
ADJUSTED COST
(J)
FEE
Indepth 1 Hour
301
11.00
3,311
//////////////////////
1.80
19.80
5%
20.79
$21.00
Counseling/15Min to 1 Hr
1,564
7.00
10,948
//////////////////////
1.80
12.60
5%
13.23
14.00
//////////////////////
//////////////////////
//////////////////////
//////////////////////
//////////////////////
//////////////////////
//////////////////////
//////////////////////
//////////////////////
//////////////////////
//////////////////////
//////////////////////
//////////////////////
TOTAL
/////////////////////
////////////////
14.259
$25,648
/////////////////////
///////////////////
/////////////////////
//////////////////
/////////////////////
NOTES:
1.
D = B x C
5.
G = F x C
REVISED: 03 Nov-89
2.
Total Column D
6.
H = Cost of Living Allowance (COLA)
3.
E = Column G, line 7 of BCRR Table 6
7.
I = G x (COLA % + 100%)
4.
F = Column E / Column D Total
8.
J = Fee
Attachment F
E X A M P L E
POVERTY INCOME GUIDELINES
CLIENT FEE DISCOUNT CATEGORIES
Family Planning Services
1989 Revised Guidelines as published in
						  Federal Register, 2/16/89, Vol. 54 No. 31
03/08/89
FAMILY SIZE
0%
20%
40%
60%
80%
100%
A
B
C
D
E
F
G
H
I
J
K
1
0
-
5980
5981
-
8224
8225
-
10467
10468
-
12711
12712
-
14950
14951
2
0
-
8020
8021
-
11029
11030
-
14037
14038
-
17046
17047
-
20050
20051
3
0
-
10060
10061
-
13834
13835
-
17607
17608
-
21381
21382
-
25150
25151
4
0
-
12100
12101
-
16639
16640
-
21177
21178
-
25716
25717
-
30250
30251
5
0
-
14140
14141
-
19444
19445
-
24747
24748
-
30051
30052
-
35350
35351
6
0
-
16180
16181
-
22249
22250
-
28317
28318
-
34386
34387
-
40450
40451
7
0
-
18220
18221
-
25054
25055
-
31887
31888
-
38721
38722
-
45550
45551
8
0
-
20260
20261
-
27859
27860
-
35457
35458
-
43056
43057
-
50650
50651
*
FOR FAMILY UNITS WITH MORE THAN 8 MEMBERS, FOR EACH
						  ADDITIONAL MEMBER ADD TO COLUMN B: $2,040
**
POVERTY LEVEL: $5,980
B
=
Family size = 1 = Poverty Level
B
=
All other Family size = Previous Family size Poverty
						  Level plus $2,040
C
=
(B+1)
D
=
(J-B)/4+C
E
=
(D+1)
F
=
(J-B)/4+E
G
=
(F+1)
H
=
(J-B)/4+G
I
=
(H+I)
J
=
(Bx2.5)
K
=
(J+1)
Attachment G
SLIDING FEE SCALE
SERVICE/PROCEDURES
COST/ SERVICES
FEE
0%
20%
40%
60%
80%
100%
(a)
Minimal Services
$13.98
$14.00
N.C.
2.80
5.60
8.40
11.20
14.00
Brief/Intermediate Exam
22.87
23.00
N.C.
4.60
9.20
13.80
18.40
23.00
Extended Exam
38.12
39.00
N.C.
7.80
15.60
23.40
31.20
39.00
IUD Insertion
38.12
39.00
N.C.
7.80
15.60
23.40
31.20
39.00
Diaphragm Fit
19.06
20.00
N.C.
4.00
8.00
12.00
16.00
20.00
Sonography/lost IUD
38.12
39.00
N.C.
7.80
15.60
23.40
31.20
39.00
X-ray/lost IUD
30.49
31.00
N.C.
6.20
12.40
18.60
24.80
31.00
HCT/HBG
.82
1.00
N.C.
.20
.40
.60
.80
1.00
Urinalysis
1.09
2.00
N.C.
.40
.80
1.20
1.60
2.00
Pregnancy Test
2.73
3.00
N.C.
.60
1.20
1.80
2.40
3.00
VDRL/RPR
5.84
6.00
N.C.
1.20
2.40
3.60
4.80
6.00
Pap Smear
5.86
6.00
N.C.
1.20
2.40
3.60
4.80
6.00
Gonorrhea Culture
8.46
9.00
N.C.
1.80
3.60
5.40
7.20
9.00
Miscellaneous Culture
20.54
21.00
N.C.
4.20
8.40
12.60
16.80
21.00
Bacterial Smear/Wet Mount
1.37
2.00
N.C.
.40
.80
1.20
1.60
2.00
Sickle Cell
6.62
7.00
N.C.
1.40
2.80
4.20
5.60
7.00
PP Blood Glucose
6.36
7.00
N.C.
1.40
2.80
4.20
5.60
7.00
Cholesterol Level
5.84
6.00
N.C.
1.20
2.40
3.60
4.80
6.00
SMA - 12
11.46
12.00
N.C.
2.40
4.80
7.20
9.60
12.00
Colposcopy
50.19
51.00
N.C.
10.20
20.40
30.60
40.80
51.00
Colposcopy and Biopsy
63.42
64.00
N.C.
12.80
25.60
38.40
51.20
64.00
Chlamydia
10.31
11.00
N.C.
2.20
4.40
6.60
8.80
11.00
Orals
1.06
2.00
N.C.
.40
.80
1.20
1.60
2.00
Creams
1.77
2.00
N.C.
.40
.80
1.20
1.60
2.00
Jellies
1.77
2.00
N.C.
.40
.80
1.20
1.60
2.00
Suppositories (each)
*
.25
.25
N.C.
.05
.10
.15
.20
.25
Foams
1.76
2.00
N.C.
.40
.80
1.20
1.60
2.00
Diaphragms
4.24
5.00
N.C.
1.00
2.00
3.00
4.00
5.00
IUDS
51.45
52.00
N.C.
10.40
20.80
31.20
41.60
52.00
Basal T & C
20.05
21.00
N.C
4.20
8.40
12.60
16.80
21.00
Sponges (each)
.93
1.00
N.C.
.20
.40
.60
.80
1.00
Condoms (each)
*
.12
.25
N.C.
.05
.10
.15
.20
.25
Meds/Vag Inf
6.30
7.00
N.C.
1.40
2.80
4.20
5.60
7.00
Meds/STD
6.30
7.00
N.C.
1.40
2.80
4.20
5.60
7.00
Contraceptive Film
3.70
4.00
N.C.
.80
1.60
2.40
3.20
4.00
In-depth 1 Hour
20.79
21.00
N.C.
4.20
8.40
12.60
16.80
21.00
Counseling/15 Min. to 1 Hr.
13.23
14.00
N.C.
2.80
5.60
8.40
11.20
14.00
*Round to nearest .25