Financial Assistance & Billing 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 $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 NotesFamily 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