Schedule 2: CoxHealth Financial Assistance Income and Discount Schedule

Table I: Family Income Ranges for Financial Assistance

Family Size	100% FPL	150% FPL	200% FPL	250% FPL	300% FPL
Family Size 1 Person	100% FPL $13,590	150% FPL $20,385	200% FPL $27,180	250% FPL $33,975	300% FPL $40,770
Family Size 2 People	100% FPL $18,310	150% FPL $27,465	200% FPL $36,620	250% FPL $45,775	300% FPL $54,930
Family Size 3 People	100% FPL $23,030	150% FPL $34,545	200% FPL $46,060	250% FPL $57,575	300% FPL $69,090
Family Size 4 People	100% FPL $27,750	150% FPL $41,625	200% FPL $55,500	250% FPL $69,375	300% FPL $83,250
Family Size 5 People	100% FPL $32,470	150% FPL $48,705	200% FPL $64,940	250% FPL $81,175	300% FPL $97,410
Family Size 6 People	100% FPL $37,190	150% FPL $55,785	200% FPL $74,380	250% FPL $92,975	300% FPL $100,000
Family Size 7 People	100% FPL $41,910	150% FPL $62,865	200% FPL $83,820	250% FPL $100,000	300% FPL $100,000
Family Size 8 People	100% FPL $46,630	150% FPL $69,945	200% FPL $93,260	250% FPL $100,000	300% FPL $100,000

CoxHealth may make a presumptive determination that a patient is eligible for financial assistance based on Medicaid eligibility.
FPL (Federal Poverty Level) is determined yearly by the U.S. Department of Health and Human Services.

FPL	100% or less	101-150%	151-200%	201-250%	251-300%
FPL NHSC Clinic Site Services	100% or less	101-150%	151-200%	201-250%	251-300%
FPL Nominal Fee	100% or less $35.00	101-150% n/a	151-200% n/a	201-250% n/a	251-300% n/a
FPL Copay	100% or less n/a	101-150% $40.00	151-200% $45.00	201-250% $50.00	251-300% n/a
FPL Cost Share %	100% or less 0%	101-150% 10%	151-200% 15%	201-250% 20%	251-300% n/a
FPL Discount	100% or less 100%	101-150% 90%	151-200% 85%	201-250% 80%	251-300% n/a

Non-NHSC Clinic Site
Non-NHSC Clinic Site Copay	$35.00	$40.00	$45.00	$50.00	n/a
Non-NHSC Clinic Site Cost Share %	5%	10%	15%	20%	n/a
Non-NHSC Clinic Site Discount	95%	90%	85%	80%	n/a

Home Care Medical Equipment
Home Care Medical Equipment Copay	$50.00	$40.00	$45.00	$50.00	n/a
Home Care Medical Equipment Cost Share %	5%	10%	15%	20%	n/a
Home Care Medical Equipment Discount	95%	90%	85%	80%	n/a

Hospital Services
Hospital Services Copay
Hospital Services Physician Services in Hospital Inpatient, ER or Outpatient	$60.00	$65.00	$70.00	$75.00	n/a
Hospital Services Inpatient Hospital	$300 per stay	$300 per stay	$300 per stay	$300 per stay	$300 per stay
Hospital Services Emergency Room	$100 per visit	$100 per visit	$100 per visit	$100 per visit	$100 per visit
Hospital Services Outpatient Hospital	$25 per visit	$25 per visit	$25 per visit	$25 per visit	$25 per visit
Hospital Services Cost Share %	5%	10%	15%	20%	25%
Hospital Services Discount	5%	90%	85%	80%	75%

Copay - Nominal fee due from the patient before a discount is applied
Cost Share % - Percentage of balance remaining for which patient is responsible after copay is applied
Discount - Percentage of balance discounted (written off) after the copay is applied
FPL - Federal Poverty Level - determined yearly by U.S. Department of Health and Human Services
NHSC Site - Clinic sites who participate in the National Health Service Corp program which supports funding for healthcare professionals in health professional shortage areas
Nominal Fee - Small fee due from patient in lieu of a copay and cost share %

Updated 02/2022