HomeMy WebLinkAboutfinal-appendix-b-healthpac-fpl-and-liability-schedule-2025-v1-1-26 APPENDIX B: HEALTH PROGRAM OF ALAMEDA COUNTY FEDERAL POVERTY LEVEL AND LIABILITY SCHEDULE
LEVEL
Emergency
Co-Pay
Inpatient
Co-Pay
Outpatient
Co-Pay
Pharmacy
Co-Pay1
Special
Procedure2
Co-Pay
1 2 3 4 5 6 7 8 9 10 ADD'L
MEMBER
ADD:
0-138%$0 $0 $0 $0 $0 1,836 2,490 3,143 3,795 4,450 5,102 5,755 6,409 7,062 7,715 655
138.01 - 150%$35 $100 $10 $5 $100 1,995 2,706 3,416 4,125 4,836 5,546 6,255 6,966 7,676 8,385 711
150.01 - 200%$50 $100 $15 $5 $100 2,660 3,608 4,554 5,500 6,448 7,394 8,340 9,288 10,234 11,180 948
Over 200%
1Pharmacy charge $5 per prescription drug with $50 per visit maximum.
myelography
cat scans nuclear med
thoracoscopy
colonoscopy venous/arterial catheter placement
endoscopy
pacemakers
stimulators or other devices
IV infusion/chemotherapy (co-pay to cover duration of treatment plan)
laparoscopy
MRI (Magnetic Resonance Imaging)
3An urgent care visit is charged the same as an outpatient visit.
Routine labs and x-rays are not accessed a co-pay.
HealthPAC CO-PAYMENT ***MAXIMUM GROSS MONTHLY INCOME (IN US DOLLARS) PER FAMILY SIZE***
HEALTH PROGRAM OF ALAMEDA COUNTY (HealthPAC) FEDERAL POVERTY LEVEL AND LIABILITY SCHEDULE
Effective January 1, 2026
PATIENTS WHOSE GROSS MONTHLY INCOME IS OVER 200% OF THE FEDERAL POVERTY INCOME GUIDELINES ARE NOT ELIGIBLE FOR HEALTHPAC AND SHALL BE
CONSIDERED SELF PAY.
hysteroscopy
2
Holter monitor