ࡱ > %` bjbj 7z ̟ ̟ "= "= "= 8 Z= $ ~= d BL > > > > > ? ? ? K K K K K K K $ .M h O K A ? ? A A K > > K E E E A > > K E A K E E E > > Q "= B E F L 0 BL E BP B BP E BP E ? v ?@ T E @ D @ ? ? ? K K WE j ? ? ? BL A A A A d : ># : ># Maryland Cancer Fund
Attachment B: SAMPLE Non-MHIP Treatment Plan and Budget Template for Paying Fee-for-Service
Name of Organization/Entity applying for Grant: ___________Dorchester County Health Department: _________________
Patient Name: ______Jane Doe____________________________ Date of Birth: __________01/01/1943__________
Diagnosis: _________Colorectal Cancer________________________ Date of Diagnosis: ______02/07/2008___________
Comments: Client screened under CRF program. Found to have Stage II colorectal cancer. Needs surgery and chemotherapy.
___________________________________________________________________________________________
Treatment Plan for (date) _2/2008_____ to (date) ___10/2008 Primary Treating Physicians Name: _______________________
Procedure and frequency of TreatmentDate AnticipatedCPT Codes
Anticipated (if applicable)Estimated CostsBasis for costs
(Medicaid or HSCRC-regulated rate for each procedure)CT of AbdomenFebruary,200874170$226Medical AssistanceHospitalization for colon resection with reanastamosisFebruary, 2008See below Surgeon44140$426Medical Assistance Anesthesiologist44140-30$142Medical Assistance In-patient PharmacyVarious
(list if known)$500HSCRC if regulated; Medical Assistance otherwise In-patient Laboratory, EKG, blood tests, etc.Various$1,000HSCRC if regulated; Medical Assistance otherwise In-patient Pathology88309$236HSCRC if regulated; Medical Assistance otherwise Hospital room fee, 7 daysUB927 x 1500 =$10,500HSCRCOperating room fees44140$3250HSCRCInitial surgeon visitin patient992221 x $ 24.50Medical AssistanceSurgeon visits x 7in patient992327 x $ 16= $112Medical AssistanceSurgical out patient visits x 4February-April, 2008992133 x 51.92=$155.76Medical AssistanceOncologist out patient visits x 16March-September, 200899204
992121 x 136.30=$136.30
15 x 37.00 =$555Medical AssistanceOut-patient pharmacyMarch-September, 2008Various (or list if known)$5,000Medical AssistanceOut-patient laboratory$500Medical AssistanceSub Total$22,763.56Indirect (7% of $20,000 max.)
(Maximum of 7% of total for Local Health Departments,
10% for non-LHD applicants)$1400Total Requested$21,400
Maryland Cancer Fund
Attachment C: Sample Treatment Plan and Budget Template using Maryland Health Insurance Plan
Name of Organization/Entity applying for Grant: ________Somerset County Health Department________________________
Patient Name: __________John Sample________________________________ Date of Birth: _________3/3/1930____________
Diagnosis: _____________Prostate Cancer____________________________ Date of Diagnosis: ______1/2/2008__________
Comments: __________Diagnosed at hospital; no source of funds for treatment. Surgery recommended.
__________________________________________________________________________________________________________
Treatment Plan for (date) __4/2008___ to (date) ____6/2008__ Primary Treating Physicians Name: _______________________
Procedure and frequency of TreatmentDate AnticipatedCPT Codes
Anticipated (if applicable)Estimated Costs Basis for costs
(MHIP rates)Maryland Health Insurance Plan (MHIP)
$1000 PPO planApril 2008September 2008N/A$370 x 6 months=$2220MHIP+ $500, PPO Plan 3MHIP Buy Down for preexisting conditionApril 2008September 2008N/A$37 x 6 months = $22210% of premiumMHIP deductible and co-paymentsApril 2008September 2008N/A$3000MHIP maximum out of pocket expensesSub Total for Treatment$5442Indirect costs
(Maximum of 7% of total for Local Health Departments,
10% for non-LHD applicants)$410Total Requested
(Treatment + Indirect)$5852
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