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 $12,760 | 150% FPL $19,140 | 200% FPL $25,520 | 250% FPL $31,900 | 300% FPL $38,280 |
| Family Size 2 People | 100% FPL $17,240 | 150% FPL $25,860 | 200% FPL $34,480 | 250% FPL $43,100 | 300% FPL $51,720 |
| Family Size 3 People | 100% FPL $21,720 | 150% FPL $32,580 | 200% FPL $43,440 | 250% FPL $54,300 | 300% FPL $65,160 |
| Family Size 4 People | 100% FPL $26,200 | 150% FPL $39,300 | 200% FPL $52,400 | 250% FPL $65,500 | 300% FPL $78,600 |
| Family Size 5 People | 100% FPL $30,680 | 150% FPL $46,020 | 200% FPL $61,360 | 250% FPL $76,700 | 300% FPL $92,040 |
| Family Size 6 People | 100% FPL $35,160 | 150% FPL $52,740 | 200% FPL $70,320 | 250% FPL $87,900 | 300% FPL $105,480 |
| Family Size 7 People | 100% FPL $39,640 | 150% FPL $59,460 | 200% FPL $79,280 | 250% FPL $99,100 | 300% FPL $118,920 |
| Family Size 8 People | 100% FPL $44,120 | 150% FPL $66,180 | 200% FPL $88,240 | 250% FPL $110,300 | 300% FPL $132,360 |
- 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 08/2020