Family income as % of FPL | Discount off of gross charges |
[GREATER THAN]y% - x% | 50%. |
[GREATER THAN]z% - y% | 75%. |
[LESS THAN EQUAL TO]z% | Free. |
Household income | Maximum amount individual will be responsible for paying |
[GREATER THAN]$b - $a | 40% of gross charges, up to the lesser of AGB or x% of household income. |
[GREATER THAN]$c - $b | 20% of gross charges, up to the lesser of AGB or y% of household income. |
[LESS THAN EQUAL TO]$c | $0 (free). |
Example. S is a hospital facility with a FAP that bases eligibility solely on an individual's household income. S's FAP provides that an individual may apply for financial assistance by completing and submitting S's FAP application form. S's FAP also describes how individuals can obtain copies of the FAP application form. S's FAP application form contains lines on which the applicant lists all items of household income received by the applicant's household over the last month and the names of the applicant's household members. The instructions to S's FAP application form tell applicants where to submit the application and provide that an applicant must attach to his or her FAP application form proof of household income in the form of payroll check stubs from the last month or, if last month's wages are not representative of the applicant's annual income, a copy of the applicant's most recent federal tax return. Alternatively, the instructions state that an applicant may provide documentation of his or her qualification for certain specified state means-tested programs. The instructions also state that if an applicant does not have any of the listed documents proving household income, he or she may call S's financial assistance office and discuss other evidence that may be provided to demonstrate eligibility. S does not deny financial assistance to FAP applicants based on a failure to submit any information or documentation not mentioned in the FAP application form or instructions. S's FAP application form instructions also provide the contact information of the hospital facility office that can provide an applicant with information about the FAP and assistance with the FAP application process. S's FAP satisfies the requirements of this paragraph (b)(3).
26 C.F.R. §1.501(r)-4