Kingsbrook Jewish Medical Center

For Patients & Visitors

Sliding Scale Qualification Guidelines

Financial Assistance

Revised for March 2018
Family 100 % Federal 200% 225% 250% 275% 300%
Size Level A B C D E
1 $12,140 $24,280 $27,315 $30,350 $33,385 $36,420
2 $16,460 $32,920 $37,035 $41,150 $45,265 $49,380
3 $20,780 $41,560 $46,755 $51,950 $57,145 $62,340
4 $25,100 $50,200 $56,475 $57,625 $69,025 $75,300
5 $29,420 $58,840 $66,195 $73,550 $80,905 $88,260
6 $33,740 $67,480 $75,915 $84,350 $92,785 $101,220
7 $38,060 $76,120 $85,635 $95,150 $104,665 $114,180
8 $42,380 $84,760 $95,355 $105,950 $116,545 $127,140
For each additional person, add $4,060.00. $4,320 $8,640 $9,720 $10,800 $11,880 $12,960
POVERTY LEVEL PATIENT RESPONSIBILITY
A LESS THAN 200% 0% OF CHARGES
B 200% TO 225% 20% OF CHARGES
C 225% TO 250% 40% OF CHARGES
D 250% TO 275% 60% OF CHARGES
E 275% TO 300% 80% OF CHARGES
OVER 300% 100% OF CHARGES
CLINIC HOSPITAL SLIDING SCALE FEE
VISIT CHARGE Excludes the NYS HCRA Surcharge of 9.63%
A B C D E
LEVEL 1 $232.00 $0.00 $46.40 $92.80 $139.20 $185.60
LEVEL 2 $278.00 $0.00 $55.60 $111.20 $166.80 $222.40
LEVEL 3 $355.00 $0.00 $71.00 $142.00 $213.00 $284.00
LEVEL 4 $452.00 $0.00 $90.40 $180.80 $271.20 $361.60
LEVEL 5 $665.00 $0.00 $133.00 $266.00 $399.00 $532.00

The FAP eligible individual will not be charged more than the amounts generally billed to people who have insurance.

Kingsbrook Jewish Medical Center's Financial Assistance Program is based upon up to 300% of the 2012 Department of Health & Human Services Federal Poverty Guidelines, as published in the January 29, 2012 Federal Register.