BOH Agenda 082620 - Laserfiche WebLink

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ORANGE COUNTY HEALTH DEPARTMENT Board of Health Policy and Procedures Manual Section I: Board Adopted Policies Policy B: Fee and Eligibility Policy Reviewed by: Financial Review Committee,Health Director Approved by: Board of Health,Health Director the health department uses the 101%-250%Federal Poverty Level sliding scale. Determination of Sliding Fee percentage is based on gross income and family size. 4. Verification of income is required at time of enrollment for services, at the annual financial interview,or if there is a change in the work status in the family unit for clients to be eligible for the sliding fee scale. a. An annual gross income statement is preferred for evaluation. i. Gross income is defined as the total of all cash income before deductions for income taxes, employee social security taxes, insurance premiums,bonds, etc. For self-employed applicants,net income after business expenses. Gross income does NOT include money earned by children for babysitting, lawn mowing and other tasks. ii. In engross income includes: salary,wages,commissions,fees,tips, overtime pay,unemployment compensation,public assistance money, alimony and child support payments, Social Security benefits,VA benefits, Supplemental Security Income(SSI)benefits,retirement&pension payments,worker's compensation,bonuses,prize winnings and other sources of cash income except those specifically excluded. B. Sources 1. Sources of income verification may include,but are not limited to: a. Current pay stub b. Self-employment accounting records c. Letter documenting current employment and wages from employer d. Recent income tax return e. Unemployment or workers compensation receipt f. Public assistance letter g. Prior income verification through enrollment in other Health Department programs 2. If an individual claims"no income"(except for minors consenting to specific services under G.S. 90-21.5), a signed"Verification of Income and/or Residency" form(Attachment A)indicating financial support from another party must be submitted. 3. Failure to provide verification within 30 days or less of date of service will result in charges being assessed at 100%of sliding fee scale. The client will receive notification of required income verification at the time the initial appointment is made. 4. The client must read, sign and understand the"Determination of Eligibility Payment Plan for Clinical Services"and"Statement of Financial Responsibility Payment Plan"form(Attachment B)at their initial visit and annual financial reviews. C. Environmental Health Persons seeking Environmental Health services must obtain and properly complete an application for service and pay the corresponding fee for service(all applicants pay at the 100%pay status)before an appointment for a field visit will be scheduled. Sometimes Page 2 of 8 Original Effective Date:January 25,2001 Revision Dates:, 4/2016,9/2018,10/2019,10/2020