Form 0285-3 Income Analysis Form

OMB No.: 0915-0285. Expiration Date: 08/31/2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FORM 3 - INCOME ANALYSIS FORM

YEAR 1  YEAR 2 (Existing Grantees only) 

FOR HRSA USE ONLY

Grantee Name

Grant Number

Application Tracking Number

PART 1: NON FEDERAL SHARE, PROGRAM INCOME

Payor Category

Number Of
Visits

Average
Charge
Per Visit

Gross
Charges
(a * b)=(c)

Average Adjustment Per Visit

Net Charges
(Amount Billed)
[c-(a*d)]

Collection Rate (%)

Projected Income
(e * f)

Actual Accrued Income Past 12 Months

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

PROJECTED FEE FOR SERVICE INCOME

1a. Medicaid: Medical

1b. Medicaid: EPSDT (if different from medical rate)

1c. Medicaid: Dental

1d. Medicaid: BH/SA

1e. Medicaid: other fee for Service

1.	Subtotal: Medicaid

2a. Medicare: all inclusive FQHC rate

2b. Medicare: other Fee for Service

2.	Subtotal: Medicare

3a. Private Insurance (Medical)

3b. Private Insurance (Dental)

3c. Private Insurance (BH/SA)

3.	Subtotal: Private

4a. Self-Pay: 100% charge, no discount (Medical)

4b. Self-Pay: 0% - 99% of charge, Sliding discounts including full discount (Medical)

4c. Self-Pay: 100% charge, no discount (Dental)

4d. Self-Pay: 0% - 99% of charge, Sliding discounts including full discount (Dental)

4e. Self-Pay: 100% charge, no discount (BH/SA)

4f. Self-Pay: 0% - 99% of charge, sliding discount including full discount, (BH/SA)

4.	Subtotal: Self Pay

5.	Subtotal: Other Public

6.	TOTAL FEE FOR SERVICE

PROJECTED CAPITATED MANAGED CARE INCOME

TYPE OF PAYOR

Number of Member Months
(a)

Rate Per Member Month
(b)

Risk Pool Adjustment
(c)

FQHC and Other Adjustments
(d)

Projected Gross Income
(e)

7a. Medicaid:

7b. Medicare

7c. Commercial

7d. Other Public

7.	TOTAL CAPITATED MANAGED CARE

8.	Managed Care Charges

(a) Visits

(b) Average Charge Per Visit

(c) Total Charges

TOTAL PROGRAM INCOME [line 6, column g + line 7, column e] Matches line7 "Program Income" of SF 424A

PART 2: NON-FEDERAL SHARE, OTHER INCOME

Total Other Income by Source

9. Applicant

10. State Funds

11. Local Funds

Other Support

12a. Other Federal Grants

12b. Contributions and Fundraising

12c. Foundation Grants

12d. Other___________(please list)

12.	Subtotal Other Support

13.	TOTAL OTHER INCOME

TOTAL NON-FEDERAL SHARE
[line6, row (g) + line 7, row (e) + line 13] Matches line 5, column f, "Non Federal" Totals of SF 424A

Comments/Explanatory Notes for Income Analysis Form (if applicable):