Sliding Fee Schedule Template Please enter your sliding fee scale rates in the yellow cells below for as many sites as you are including in your application. The site number (#1-5 below) should correspond with the number you give to each site in the Organization Information Attachment A. The weekly copay amount you enter for each Federal Poverty Level must meet or be less than and shall not exceed the maximum copay rate, which is shown below and also highlighted in yellow in the SACC Sliding Fee Schedule on the next page. For reference, the weekly copay amount is equivalent to the fee charged to families per unit of service. A unit of service is defined as 4+ hours of service. Federal Poverty Level 100% 101% 110% 119% 128% 137% 146% 155% 164% 173% 182% OR thru thru thru thru thru thru thru thru thru thru UNDER 109% 118% 127% 136% 145% 154% 163% 172% 181% 190% MAX. $0.00 $1.00 $2.00 $3.00 $4.00 $5.00 $6.00 $7.00 $8.00 $9.00 $10.00 COPAY Weekly Copay $ $ $ $ $ $ $ $ $ $ $ $ Site 1 Weekly Copay $ $ $ $ $ $ $ $ $ $ $ $ Site 2 Weekly Copay $ $ $ $ $ $ $ $ $ $ $ $ Site 3 Weekly Copay $ $ $ $ $ $ $ $ $ $ $ $ Site 4 Weekly Copay $ $ $ $ $ $ $ $ $ $ $ $ Site 5 NOTES: Income amounts reflect gross monthly income. Values in RED indicate the federal poverty level has MET the Maximum 85% of the State Median Income. Poverty Rates based on Federal Poverty Guidelines for 2017 (Jan.) & State Median Income Guidelines for 2018 (Aug.)
Sliding Fee Schedule Template Please enter your sliding fee scale rates in the yellow cells below for as many sites as you are including in your application. The site number (#1-5 below) should correspond with the number you give to each site in the Organization Information Attachment A. The weekly copay amount you enter for each Federal Poverty Level must meet or be less than and shall not exceed the maximum copay rate, which is shown below and also highlighted in yellow in the SACC Sliding Fee Schedule on the next page. For reference, the weekly copay amount is equivalent to the fee charged to families per unit of service. A unit of service is defined as 4+ hours of service. Federal Poverty Level 100% OR UNDER 101% thru 109% 110% thru 118% 119% thru 127% 128% thru 136% 137% thru 145% 146% thru 154% 155% thru 163% 164% thru 172% 173% thru 181% 182% thru 190% MAX. COPAY $0.00 $1.00 $2.00 $3.00 $4.00 $5.00 $6.00 $7.00 $8.00 $9.00 $10.00 Weekly Copay $ Site 1 $ $ $ $ $ $ $ $ $ $ $ Weekly Copay $ Site 2 $ $ $ $ $ $ $ $ $ $ $ Weekly Copay $ Site 3 $ $ $ $ $ $ $ $ $ $ $ Weekly Copay $ Site 4 $ $ $ $ $ $ $ $ $ $ $ Weekly Copay $ Site 5 $ $ $ $ $ $ $ $ $ $ $ NOTES: Income amounts reflect gross monthly income. Values in RED indicate the federal poverty level has MET the Maximum 85% of the State Median Income. Poverty Rates based on Federal Poverty Guidelines for 2017 (Jan.) & State Median Income Guidelines for 2018 (Aug.)
OECOSL_RFF_19-001-Att%20F.docx