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 $12,880 | 150% FPL $19,320 | 200% FPL $25,760 | 250% FPL $32,200 | 300% FPL $38,640 |
| Family Size 2 People | 100% FPL $17,420 | 150% FPL $26,130 | 200% FPL $34,840 | 250% FPL $43,550 | 300% FPL $52,260 |
| Family Size 3 People | 100% FPL $21,960 | 150% FPL $32,940 | 200% FPL $43,920 | 250% FPL $54,900 | 300% FPL $65,880 |
| Family Size 4 People | 100% FPL $26,500 | 150% FPL $39,750 | 200% FPL $53,000 | 250% FPL $66,250 | 300% FPL $79,500 |
| Family Size 5 People | 100% FPL $31,040 | 150% FPL $46,560 | 200% FPL $62,080 | 250% FPL $77,600 | 300% FPL $93,120 |
| Family Size 6 People | 100% FPL $35,580 | 150% FPL $53,370 | 200% FPL $71,160 | 250% FPL $88,950 | 300% FPL $106,740 |
| Family Size 7 People | 100% FPL $40,120 | 150% FPL $60,180 | 200% FPL $80,240 | 250% FPL $100,300 | 300% FPL $120,360 |
| Family Size 8 People | 100% FPL $44,660 | 150% FPL $66,990 | 200% FPL $89,320 | 250% FPL $111,650 | 300% FPL $133,980 |
Additional Notes
- Family Size: For each additional family member over eight members, add $4,420 to income. Patients with family income over $100,000 will not be eligible for Financial Assistance, regardless of family size.
- FPL: “Federal Poverty Level” is determined yearly by the U.S. Department of Health and Human Services. Updated annually – effective March 2019.
- CoxHealth may make a presumptive determination that a patient is eligible for Financial Assistance based on Medicaid eligibility.
Table II: Amount of Discount & Patient Responsibility
| Patient’s Household Income | 100% FPL or less | 101–150% FPL | 151–200% FPL | 201–250% FPL | HOSPITAL ONLY: 251–300% FPL |
| Patient’s Discount | 95% | 90% | 85% | 80% | 75% |
| Patient Pays | Co-Pay + 5% | Co-Pay + 10% | Co-Pay + 15% | Co-Pay + 20% | Co-Pay + 25% |
| Co-Pays: | |||||
|---|---|---|---|---|---|
| Co-Pays: Physician Office Co-pay | $35.00 | $40.00 | $45.00 | $50.00 | N/A |
| Co-Pays: Physician Hospital Services Co-pay | $60.00 | $65.00 | $70.00 | $75.00 | N/A |
| Co-Pays: Hospital Inpatient Co-pay | $300 per stay | $300 per stay | $300 per stay | $300 per stay | $300 per stay |
| Co-Pays: Hospital Outpatient Co-pay | $25 per visit | $25 per visit | $25 per visit | $25 per visit | $25 per visit |
| Co-Pays: Hospital Emergency Dept. Co-pay | $100 per visit | $100 per visit | $100 per visit | $100 per visit | $100 per visit |
| Co-Pays: Home Care Medical Equipment Co-pay | $50 per visit | $50 per visit | $50 per visit | $50 per visit | $50 per visit |
Updated 03/2021