NOTICES
DEPARTMENT OF HUMAN SERVICES
Income Limits and Co-payments for the Subsidized Child Care Program
[45 Pa.B. 2192]
[Saturday, May 2, 2015]This notice increases the income limits codified at 55 Pa. Code Chapter 3041, Appendix B (relating to co-payment chart family co-payment scale (based on the 2015 Federal Poverty Income Guidelines)) under 55 Pa. Code § 3041.107(b) (relating to availability and use of the Federal Poverty Income Guidelines). This increase is effective May 4, 2015.
Section 3041.107(b) of 55 Pa. Code requires the Department of Human Services to update the co-payment schedule in 55 Pa. Code Chapter 3041, Appendix B to reflect changes in the Federal Poverty Income Guidelines (FPIG). Effective May 4, 2015, the income guidelines for the Subsidized Child Care Program are increased due to increases in the FPIG. Under section 408.3 of the Public Welfare Code (62 P. S. § 408.3), the co-payment schedule is adjusted to reflect the increases. Chapter 3041, Appendix B of 55 Pa. Code also establishes the family co-payment levels according to the family's computed annual income and lists the weekly family co-payment based on the annual family income.
THEODORE DALLAS,
Acting SecretaryFiscal Note: 14-NOT-948. No fiscal impact; (8) recommends adoption.
CO-PAYMENT CHART
FAMILY CO-PAYMENT SCALE EFFECTIVE MAY 4, 2015
(BASED ON THE 2015 FEDERAL POVERTY INCOME GUIDELINES)
Weekly Family Size: 1 Weekly Family Size: 2 Weekly Family Size: 3 Co-pay Annual Income Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $9,770 $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $9,770.01 $11,770 $10.00 $8,660.01 $13,000 $10.00 $8,660.01 $14,090 $15.00 $11,770.01 $13,770 $16.00 $13,000.01 $13,930 $17.00 $14,090.01 $16,090 $20.00 $13,770.01 $15,770 $21.00 $13,930.01 $15,930 $22.00 $16,090.01 $18,090 $25.00 $15,770.01 $17,770 $25.00 $15,930.01 $17,930 $27.00 $18,090.01 $20,090 $30.00 $17,770.01 $19,770 $29.00 $17,930.01 $19,930 $31.00 $20,090.01 $22,090 $35.00 $19,770.01 $21,770 $33.00 $19,930.01 $21,930 $35.00 $22,090.01 $24,090 $40.00 $21,770.01 $23,770 $38.00 $21,930.01 $23,930 $39.00 $24,090.01 $26,090 $45.00 $23,770.01 $25,770 $43.00 $23,930.01 $25,930 $43.00 $26,090.01 $28,090 $50.00 $25,770.01 $27,660 $48.00 $25,930.01 $27,930 $48.00 $28,090.01 $30,090 $53.00 $27,930.01 $29,930 $53.00 $30,090.01 $32,090 $58.00 $29,930.01 $31,930 $58.00 $32,090.01 $34,090 $64.00 $31,930.01 $33,930 $63.00 $34,090.01 $36,090 $70.00 $33,930.01 $35,930 $68.00 $36,090.01 $38,090 $75.00 $35,930.01 $37,436 $73.00 $38,090.01 $40,090 $79.00 $40,090.01 $42,090 $85.00 $42,090.01 $44,090 $91.00 $44,090.01 $46,090 $97.00 $46,090.01 $47,212 200% FPIG $23,540 200% FPIG $31,860 200% FPIG $40,180
Weekly Family Size: 4 Weekly Family Size: 5 Weekly Family Size: 6 Co-pay Annual Income Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $15,930 $10.00 $8,660.01 $16,000 $10.00 $8,660.01 $18,180 $19.00 $15,930.01 $18,000 $19.00 $16,000.01 $18,410 $20.00 $18,180.01 $20,200 $24.00 $18,000.01 $20,000 $23.00 $18,410.01 $20,410 $24.00 $20,200.01 $22,200 $28.00 $20,000.01 $22,000 $27.00 $20,410.01 $22,410 $28.00 $22,200.01 $24,200 $33.00 $22,000.01 $24,250 $31.00 $22,410.01 $24,410 $32.00 $24,200.01 $26,200 $37.00 $24,250.01 $26,250 $35.00 $24,410.01 $26,410 $36.00 $26,200.01 $28,200 $41.00 $26,250.01 $28,250 $40.00 $26,410.01 $28,410 $41.00 $28,200.01 $30,200 $45.00 $28,250.01 $30,250 $44.00 $28,410.01 $30,000 $46.00 $30,200.01 $32,570 $49.00 $30,250.01 $32,250 $47.00 $30,000.01 $32,000 $50.00 $32,570.01 $34,570 $53.00 $32,250.01 $34,250 $51.00 $32,000.01 $34,000 $54.00 $34,570.01 $36,570 $58.00 $34,250.01 $36,250 $55.00 $34,000.01 $36,000 $58.00 $36,570.01 $38,570 $63.00 $36,250.01 $38,250 $59.00 $36,000.01 $38,000 $62.00 $38,570.01 $40,570 $68.00 $38,250.01 $40,250 $63.00 $38,000.01 $40,000 $66.00 $40,570.01 $42,570 $73.00 $40,250.01 $42,250 $68.00 $40,000.01 $42,000 $70.00 $42,570.01 $44,570 $78.00 $42,250.01 $44,250 $73.00 $42,000.01 $44,000 $75.00 $44,570.01 $46,570 $83.00 $44,250.01 $46,250 $78.00 $44,000.01 $46,000 $80.00 $46,570.01 $48,570 $89.00 $46,250.01 $48,250 $83.00 $46,000.01 $48,000 $85.00 $48,570.01 $50,570 $95.00 $48,250.01 $50,250 $88.00 $48,000.01 $50,000 $90.00 $50,570.01 $52,570 $101.00 $50,250.01 $52,250 $93.00 $50,000.01 $52,000 $95.00 $52,570.01 $54,570 $107.00 $52,250.01 $54,250 $98.00 $52,000.01 $54,000 $100.00 $54,570.01 $56,570 $113.00 $54,250.01 $56,250 $103.00 $54,000.01 $56,000 $105.00 $56,570.01 $58,570 $118.00 $56,250.01 $56,988 $109.00 $56,000.01 $58,000 $110.00 $58,570.01 $60,570 $115.00 $58,000.01 $60,000 $115.00 $60,570.01 $62,570 $121.00 $60,000.01 $62,000 $121.00 $62,570.01 $64,570 $127.00 $62,000.01 $64,000 $127.00 $64,570.01 $66,570 $134.00 $64,000.01 $66,000 $133.00 $66,570.01 $68,570 $139.00 $68,570.01 $70,570 $145.00 $70,570.01 $72,570 $151.00 $72,570.01 $74,570 $156.00 $74,570.01 $76,540 200% FPIG $48,500 200% FPIG $56,820 200% FPIG $65,140
Weekly Family Size: 7 Weekly Family Size: 8 Weekly Family Size: 9 Co-pay Annual Income Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $17,600 $10.00 $8,660.01 $19,000 $10.00 $8,660.01 $19,850 $21.00 $17,600.01 $20,000 $22.00 $19,000.01 $22,190 $23.00 $19,850.01 $24,050 $24.00 $20,000.01 $22,200 $26.00 $22,190.01 $24,590 $28.00 $24,050.01 $26,050 $27.00 $22,200.01 $24,030 $29.00 $24,590.01 $26,890 $31.00 $26,050.01 $29,050 $30.00 $24,030.01 $26,030 $33.00 $26,890.01 $28,890 $35.00 $29,050.01 $31,050 $34.00 $26,030.01 $28,030 $37.00 $28,890.01 $30,890 $39.00 $31,050.01 $33,050 $38.00 $28,030.01 $30,030 $41.00 $30,890.01 $32,890 $43.00 $33,050.01 $35,050 $42.00 $30,030.01 $32,730 $45.00 $32,890.01 $34,890 $47.00 $35,050.01 $37,050 $48.00 $32,730.01 $34,730 $49.00 $34,890.01 $36,890 $51.00 $37,050.01 $39,050 $53.00 $34,730.01 $36,730 $54.00 $36,890.01 $38,890 $55.00 $39,050.01 $41,050 $57.00 $36,730.01 $38,230 $59.00 $38,890.01 $40,890 $60.00 $41,050.01 $43,050 $60.00 $38,230.01 $40,230 $63.00 $40,890.01 $42,490 $65.00 $43,050.01 $45,050 $64.00 $40,230.01 $42,230 $66.00 $42,490.01 $44,490 $69.00 $45,050.01 $47,050 $68.00 $42,230.01 $44,230 $70.00 $44,490.01 $46,490 $73.00 $47,050.01 $49,050 $72.00 $44,230.01 $46,230 $74.00 $46,490.01 $48,490 $77.00 $49,050.01 $51,050 $76.00 $46,230.01 $48,230 $78.00 $48,490.01 $50,490 $81.00 $51,050.01 $53,050 $80.00 $48,230.01 $50,230 $82.00 $50,490.01 $52,490 $85.00 $53,050.01 $55,050 $85.00 $50,230.01 $52,230 $86.00 $52,490.01 $54,490 $89.00 $55,050.01 $57,050 $90.00 $52,230.01 $54,230 $90.00 $54,490.01 $56,490 $93.00 $57,050.01 $59,050 $95.00 $54,230.01 $56,230 $95.00 $56,490.01 $58,490 $97.00 $59,050.01 $61,050 $100.00 $56,230.01 $58,230 $100.00 $58,490.01 $60,490 $101.00 $61,050.01 $63,050 $105.00 $58,230.01 $60,230 $105.00 $60,490.01 $62,490 $106.00 $63,050.01 $65,050 $110.00 $60,230.01 $62,230 $110.00 $62,490.01 $64,490 $111.00 $65,050.01 $67,050 $115.00 $62,230.01 $64,230 $115.00 $64,490.01 $66,490 $116.00 $67,050.01 $69,050 $120.00 $64,230.01 $66,230 $120.00 $66,490.01 $68,490 $121.00 $69,050.01 $71,050 $125.00 $66,230.01 $68,230 $125.00 $68,490.01 $70,490 $126.00 $71,050.01 $73,050 $130.00 $68,230.01 $70,230 $130.00 $70,490.01 $72,490 $131.00 $73,050.01 $75,050 $136.00 $70,230.01 $72,230 $135.00 $72,490.01 $74,490 $136.00 $75,050.01 $77,050 $142.00 $72,230.01 $74,230 $140.00 $74,490.01 $76,490 $141.00 $77,050.01 $79,050 $148.00 $74,230.01 $76,230 $145.00 $76,490.01 $78,490 $146.00 $79,050.01 $81,050 $154.00 $76,230.01 $78,230 $151.00 $78,490.01 $80,490 $151.00 $81,050.01 $83,050 $160.00 $78,230.01 $80,230 $157.00 $80,490.01 $82,490 $156.00 $83,050.01 $85,050 $166.00 $80,230.01 $82,230 $163.00 $82,490.01 $84,490 $161.00 $85,050.01 $87,050 $172.00 $82,230.01 $86,316 $169.00 $84,490.01 $86,490 $167.00 $87,050.01 $89,050 $175.00 $86,490.01 $88,490 $173.00 $89,050.01 $91,050 $181.00 $88,490.01 $90,490 $179.00 $91,050.01 $93,050 $187.00 $90,490.01 $92,490 $185.00 $93,050.01 $95,050 $193.00 $92,490.01 $94,490 $191.00 $95,050.01 $97,050 $198.00 $94,490.01 $96,092 $197.00 $97,050.01 $99,050 $203.00 $99,050.01 $101,050 $209.00 $101,050.01 $103,050 $216.00 $103,050.01 $105,050 200% FPIG $73,460 200% FPIG $81,780 200% FPIG $90,100
Weekly Family Size: 10 Weekly Family Size: 11 Weekly Family Size: 12 Co-pay Annual Income Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $21,610 $10.00 $8,660.01 $22,470 $10.00 $8,660.01 $23,370 $25.00 $21,610.01 $25,910 $26.00 $22,470.01 $25,000 $27.00 $23,370.01 $31,130 $30.00 $25,910.01 $29,010 $29.00 $25,000.01 $28,370 $36.00 $31,130.01 $34,530 $34.00 $29,010.01 $31,010 $33.00 $28,370.01 $30,370 $41.00 $34,530.01 $36,530 $37.00 $31,010.01 $33,010 $36.00 $30,370.01 $32,370 $45.00 $36,530.01 $38,530 $41.00 $33,010.01 $35,010 $39.00 $32,370.01 $34,370 $49.00 $38,530.01 $40,530 $45.00 $35,010.01 $37,010 $43.00 $34,370.01 $36,370 $53.00 $40,530.01 $42,530 $49.00 $37,010.01 $39,010 $47.00 $36,370.01 $38,370 $57.00 $42,530.01 $44,530 $53.00 $39,010.01 $41,010 $51.00 $38,370.01 $40,370 $61.00 $44,530.01 $46,530 $57.00 $41,010.01 $43,010 $55.00 $40,370.01 $42,370 $65.00 $46,530.01 $48,530 $61.00 $43,010.01 $45,010 $59.00 $42,370.01 $44,370 $69.00 $48,530.01 $50,530 $66.00 $45,010.01 $47,010 $63.00 $44,370.01 $46,370 $73.00 $50,530.01 $52,530 $71.00 $47,010.01 $49,210 $67.00 $46,370.01 $48,370 $78.00 $52,530.01 $54,530 $75.00 $49,210.01 $50,810 $72.00 $48,370.01 $50,370 $83.00 $54,530.01 $57,530 $78.00 $50,810.01 $52,810 $77.00 $50,370.01 $53,370 $88.00 $57,530.01 $59,530 $82.00 $52,810.01 $54,810 $82.00 $53,370.01 $55,370 $92.00 $59,530.01 $61,530 $86.00 $54,810.01 $56,810 $86.00 $55,370.01 $57,370 $96.00 $61,530.01 $63,530 $90.00 $56,810.01 $58,810 $90.00 $57,370.01 $59,370 $100.00 $63,530.01 $65,530 $94.00 $58,810.01 $60,810 $94.00 $59,370.01 $61,370 $104.00 $65,530.01 $67,530 $98.00 $60,810.01 $62,810 $98.00 $61,370.01 $63,370 $108.00 $67,530.01 $69,530 $102.00 $62,810.01 $64,810 $102.00 $63,370.01 $65,370 $112.00 $69,530.01 $71,530 $106.00 $64,810.01 $66,810 $106.00 $65,370.01 $67,370 $116.00 $71,530.01 $73,530 $111.00 $66,810.01 $68,810 $110.00 $67,370.01 $69,370 $120.00 $73,530.01 $75,530 $116.00 $68,810.01 $70,810 $114.00 $69,370.01 $71,370 $124.00 $75,530.01 $77,530 $121.00 $70,810.01 $72,810 $119.00 $71,370.01 $73,370 $128.00 $77,530.01 $79,530 $126.00 $72,810.01 $74,810 $124.00 $73,370.01 $75,370 $133.00 $79,530.01 $81,530 $131.00 $74,810.01 $76,810 $129.00 $75,370.01 $77,370 $138.00 $81,530.01 $83,530 $136.00 $76,810.01 $78,810 $134.00 $77,370.01 $79,370 $143.00 $83,530.01 $85,530 $141.00 $78,810.01 $80,810 $139.00 $79,370.01 $81,370 $148.00 $85,530.01 $87,530 $146.00 $80,810.01 $82,810 $144.00 $81,370.01 $83,370 $153.00 $87,530.01 $89,530 $151.00 $82,810.01 $84,810 $149.00 $83,370.01 $85,370 $158.00 $89,530.01 $91,530 $156.00 $84,810.01 $86,810 $154.00 $85,370.01 $87,370 $163.00 $91,530.01 $93,530 $161.00 $86,810.01 $88,810 $159.00 $87,370.01 $89,370 $168.00 $93,530.01 $95,530 $166.00 $88,810.01 $90,810 $164.00 $89,370.01 $91,370 $173.00 $95,530.01 $97,530 $171.00 $90,810.01 $92,810 $169.00 $91,370.01 $93,370 $178.00 $97,530.01 $99,530 $177.00 $92,810.01 $94,810 $174.00 $93,370.01 $95,370 $183.00 $99,530.01 $101,530 $183.00 $94,810.01 $96,810 $179.00 $95,370.01 $97,370 $188.00 $101,530.01 $103,530 $189.00 $96,810.01 $98,810 $184.00 $97,370.01 $99,370 $193.00 $103,530.01 $105,530 $195.00 $98,810.01 $100,810 $189.00 $99,370.01 $101,370 $198.00 $105,530.01 $107,530 $201.00 $100,810.01 $102,810 $195.00 $101,370.01 $103,370 $203.00 $107,530.01 $109,530 $207.00 $102,810.01 $104,810 $201.00 $103,370.01 $105,370 $209.00 $109,530.01 $111,530 $213.00 $104,810.01 $106,810 $207.00 $105,370.01 $107,370 $215.00 $111,530.01 $113,530 $219.00 $106,810.01 $108,810 $213.00 $107,370.01 $109,370 $221.00 $113,530.01 $115,530 $225.00 $108,810.01 $110,810 $219.00 $109,370.01 $111,370 $227.00 $115,530.01 $117,530 $232.00 $110,810.01 $115,644 $225.00 $111,370.01 $113,370 $233.00 $117,530.01 $119,530 $231.00 $113,370.01 $115,370 $239.00 $119,530.01 $121,530 $237.00 $115,370.01 $117,370 $245.00 $121,530.01 $123,530 $243.00 $117,370.01 $119,370 $251.00 $123,530.01 $125,530 $249.00 $119,370.01 $121,370 $257.00 $125,530.01 $127,530 $255.00 $121,370.01 $123,370 $263.00 $127,530.01 $129,530 $261.00 $123,370.01 $125,370 $269.00 $129,530.01 $131,530 $275.00 $131,530.01 $133,530 $280.00 $133,530.01 $135,196 200% FPIG $98,420 200% FPIG $106,740 200% FPIG $115,060
Weekly Family Size: 13 Weekly Family Size: 14 Weekly Family Size: 15 Co-pay Annual Income Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $25,110 $10.00 $8,660.01 $25,110 $10.00 $8,660.01 $29,410 $29.00 $25,110.01 $31,110 $29.00 $25,110.01 $31,150 $34.00 $29,410.01 $37,110 $36.00 $31,110.01 $34,690 $36.00 $31,150.01 $36,550 $43.00 $37,110.01 $39,110 $41.00 $34,690.01 $36,690 $43.00 $36,550.01 $38,550 $46.00 $39,110.01 $41,110 $44.00 $36,690.01 $38,690 $46.00 $38,550.01 $40,550 $49.00 $41,110.01 $43,110 $47.00 $38,690.01 $40,690 $49.00 $40,550.01 $42,550 $52.00 $43,110.01 $45,110 $51.00 $40,690.01 $42,690 $53.00 $42,550.01 $44,550 $56.00 $45,110.01 $47,110 $55.00 $42,690.01 $44,690 $57.00 $44,550.01 $46,550 $60.00 $47,110.01 $49,110 $59.00 $44,690.01 $46,690 $61.00 $46,550.01 $48,550 $64.00 $49,110.01 $51,110 $63.00 $46,690.01 $48,690 $65.00 $48,550.01 $50,550 $68.00 $51,110.01 $53,110 $67.00 $48,690.01 $50,690 $69.00 $50,550.01 $52,550 $72.00 $53,110.01 $55,110 $71.00 $50,690.01 $52,690 $73.00 $52,550.01 $54,550 $76.00 $55,110.01 $57,110 $75.00 $52,690.01 $54,690 $77.00 $54,550.01 $56,550 $80.00 $57,110.01 $59,110 $79.00 $54,690.01 $56,690 $81.00 $56,550.01 $58,550 $84.00 $59,110.01 $61,110 $84.00 $56,690.01 $58,690 $85.00 $58,550.01 $60,550 $88.00 $61,110.01 $63,110 $89.00 $58,690.01 $61,690 $90.00 $60,550.01 $62,850 $92.00 $63,110.01 $65,110 $94.00 $61,690.01 $63,690 $95.00 $62,850.01 $65,850 $97.00 $65,110.01 $67,110 $98.00 $63,690.01 $65,690 $100.00 $65,850.01 $67,850 $102.00 $67,110.01 $70,010 $102.00 $65,690.01 $67,690 $104.00 $67,850.01 $69,850 $107.00 $70,010.01 $71,510 $106.00 $67,690.01 $69,690 $108.00 $69,850.01 $71,850 $110.00 $71,510.01 $73,510 $110.00 $69,690.01 $71,690 $112.00 $71,850.01 $73,850 $114.00 $73,510.01 $75,510 $114.00 $71,690.01 $73,690 $116.00 $73,850.01 $75,850 $118.00 $75,510.01 $77,510 $118.00 $73,690.01 $75,690 $120.00 $75,850.01 $77,850 $122.00 $77,510.01 $79,510 $122.00 $75,690.01 $77,690 $124.00 $77,850.01 $79,850 $126.00 $79,510.01 $81,510 $126.00 $77,690.01 $79,690 $128.00 $79,850.01 $81,850 $130.00 $81,510.01 $83,510 $130.00 $79,690.01 $81,690 $132.00 $81,850.01 $83,850 $134.00 $83,510.01 $85,510 $134.00 $81,690.01 $83,690 $136.00 $83,850.01 $85,850 $138.00 $85,510.01 $87,510 $138.00 $83,690.01 $85,690 $140.00 $85,850.01 $87,850 $142.00 $87,510.01 $89,510 $143.00 $85,690.01 $87,690 $144.00 $87,850.01 $89,850 $146.00 $89,510.01 $91,510 $148.00 $87,690.01 $89,690 $149.00 $89,850.01 $91,850 $150.00 $91,510.01 $93,510 $153.00 $89,690.01 $91,690 $154.00 $91,850.01 $93,850 $154.00 $93,510.01 $95,510 $158.00 $91,690.01 $93,690 $159.00 $93,850.01 $95,850 $159.00 $95,510.01 $97,510 $163.00 $93,690.01 $95,690 $164.00 $95,850.01 $97,850 $164.00 $97,510.01 $99,510 $168.00 $95,690.01 $97,690 $169.00 $97,850.01 $99,850 $169.00 $99,510.01 $101,510 $173.00 $97,690.01 $99,690 $174.00 $99,850.01 $101,850 $174.00 $101,510.01 $103,510 $178.00 $99,690.01 $101,690 $179.00 $101,850.01 $103,850 $179.00 $103,510.01 $105,510 $183.00 $101,690.01 $103,690 $184.00 $103,850.01 $105,850 $184.00 $105,510.01 $107,510 $188.00 $103,690.01 $105,690 $189.00 $105,850.01 $107,850 $189.00 $107,510.01 $109,510 $193.00 $105,690.01 $107,690 $194.00 $107,850.01 $109,850 $194.00 $109,510.01 $111,510 $198.00 $107,690.01 $109,690 $199.00 $109,850.01 $111,850 $199.00 $111,510.01 $113,510 $203.00 $109,690.01 $111,690 $204.00 $111,850.01 $113,850 $204.00 $113,510.01 $115,510 $208.00 $111,690.01 $113,690 $209.00 $113,850.01 $115,850 $209.00 $115,510.01 $117,510 $213.00 $113,690.01 $115,690 $214.00 $115,850.01 $117,850 $214.00 $117,510.01 $119,510 $218.00 $115,690.01 $117,690 $219.00 $117,850.01 $119,850 $219.00 $119,510.01 $121,510 $224.00 $117,690.01 $119,690 $224.00 $119,850.01 $121,850 $224.00 $121,510.01 $123,510 $230.00 $119,690.01 $121,690 $229.00 $121,850.01 $123,850 $229.00 $123,510.01 $125,510 $236.00 $121,690.01 $123,690 $235.00 $123,850.01 $125,850 $234.00 $125,510.01 $127,510 $242.00 $123,690.01 $125,690 $241.00 $125,850.01 $127,850 $239.00 $127,510.01 $129,510 $248.00 $125,690.01 $127,690 $247.00 $127,850.01 $129,850 $244.00 $129,510.01 $131,510 $254.00 $127,690.01 $129,690 $253.00 $129,850.01 $131,850 $250.00 $131,510.01 $133,510 $260.00 $129,690.01 $131,690 $259.00 $131,850.01 $133,850 $256.00 $133,510.01 $135,510 $266.00 $131,690.01 $133,690 $265.00 $133,850.01 $135,850 $262.00 $135,510.01 $137,510 $272.00 $133,690.01 $135,690 $271.00 $135,850.01 $137,850 $268.00 $137,510.01 $139,510 $278.00 $135,690.01 $137,690 $277.00 $137,850.01 $139,850 $274.00 $139,510.01 $141,510 $284.00 $137,690.01 $139,690 $283.00 $139,850.01 $141,850 $280.00 $141,510.01 $143,510 $290.00 $139,690.01 $141,690 $289.00 $141,850.01 $143,850 $286.00 $143,510.01 $145,510 $297.00 $141,690.01 $143,690 $295.00 $143,850.01 $145,850 $292.00 $145,510.01 $147,510 $301.00 $145,850.01 $147,850 $298.00 $147,510.01 $149,510 $307.00 $147,850.01 $149,850 $304.00 $149,510.01 $151,510 $314.00 $149,850.01 $154,748 $310.00 $151,510.01 $153,510 $316.00 $153,510.01 $155,510 $322.00 $155,510.01 $157,510 $328.00 $157,510.01 $159,510 $334.00 $159,510.01 $161,510 $339.00 $161,510.01 $163,510 200% FPIG $123,380 200% FPIG $131,700 200% FPIG $140,020
Weekly Family Size: 16 Weekly Family Size: 17 Weekly Family Size: 18 Co-pay Annual Income Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $29,430 $10.00 $8,660.01 $29,410 $10.00 $8,660.01 $30,000 $34.00 $29,430.01 $38,070 $34.00 $29,410.01 $37,000 $35.00 $30,000.01 $38,500 $44.00 $38,070.01 $43,170 $43.00 $37,000.01 $46,330 $45.00 $38,500.01 $47,490 $50.00 $43,170.01 $45,170 $54.00 $46,330.01 $48,330 $56.00 $47,490.01 $49,490 $53.00 $45,170.01 $47,170 $57.00 $48,330.01 $50,330 $59.00 $49,490.01 $51,490 $57.00 $47,170.01 $49,170 $61.00 $50,330.01 $52,330 $62.00 $51,490.01 $53,490 $61.00 $49,170.01 $51,170 $65.00 $52,330.01 $54,330 $66.00 $53,490.01 $55,490 $65.00 $51,170.01 $53,170 $69.00 $54,330.01 $56,330 $70.00 $55,490.01 $57,490 $69.00 $53,170.01 $55,170 $73.00 $56,330.01 $58,330 $74.00 $57,490.01 $59,490 $73.00 $55,170.01 $57,170 $77.00 $58,330.01 $60,330 $78.00 $59,490.01 $61,490 $77.00 $57,170.01 $59,170 $81.00 $60,330.01 $62,330 $82.00 $61,490.01 $63,490 $81.00 $59,170.01 $61,170 $85.00 $62,330.01 $64,330 $86.00 $63,490.01 $65,490 $85.00 $61,170.01 $63,170 $89.00 $64,330.01 $66,330 $90.00 $65,490.01 $67,490 $89.00 $63,170.01 $65,170 $93.00 $66,330.01 $68,330 $94.00 $67,490.01 $69,490 $93.00 $65,170.01 $67,170 $97.00 $68,330.01 $70,330 $98.00 $69,490.01 $71,490 $98.00 $67,170.01 $69,170 $101.00 $70,330.01 $72,330 $102.00 $71,490.01 $73,490 $103.00 $69,170.01 $71,170 $106.00 $72,330.01 $74,330 $106.00 $73,490.01 $75,490 $108.00 $71,170.01 $74,170 $111.00 $74,330.01 $76,330 $111.00 $75,490.01 $77,490 $113.00 $74,170.01 $76,170 $116.00 $76,330.01 $78,330 $116.00 $77,490.01 $79,490 $117.00 $76,170.01 $77,570 $120.00 $78,330.01 $80,330 $121.00 $79,490.01 $82,490 $120.00 $77,570.01 $79,570 $124.00 $80,330.01 $82,330 $126.00 $82,490.01 $83,490 $124.00 $79,570.01 $81,570 $128.00 $82,330.01 $84,330 $128.00 $83,490.01 $85,490 $128.00 $81,570.01 $83,570 $132.00 $84,330.01 $86,330 $132.00 $85,490.01 $87,490 $132.00 $83,570.01 $85,570 $136.00 $86,330.01 $88,330 $136.00 $87,490.01 $89,490 $136.00 $85,570.01 $87,570 $140.00 $88,330.01 $90,330 $140.00 $89,490.01 $91,490 $140.00 $87,570.01 $89,570 $144.00 $90,330.01 $92,330 $144.00 $91,490.01 $93,490 $144.00 $89,570.01 $91,570 $148.00 $92,330.01 $94,330 $148.00 $93,490.01 $95,490 $148.00 $91,570.01 $93,570 $152.00 $94,330.01 $96,330 $152.00 $95,490.01 $97,490 $152.00 $93,570.01 $95,570 $156.00 $96,330.01 $98,330 $156.00 $97,490.01 $99,490 $156.00 $95,570.01 $97,570 $160.00 $98,330.01 $100,330 $160.00 $99,490.01 $101,490 $160.00 $97,570.01 $99,570 $164.00 $100,330.01 $102,330 $164.00 $101,490.01 $103,490 $164.00 $99,570.01 $101,570 $168.00 $102,330.01 $104,330 $168.00 $103,490.01 $105,490 $169.00 $101,570.01 $103,570 $173.00 $104,330.01 $106,330 $172.00 $105,490.01 $107,490 $174.00 $103,570.01 $105,570 $178.00 $106,330.01 $108,330 $176.00 $107,490.01 $109,490 $179.00 $105,570.01 $107,570 $183.00 $108,330.01 $110,330 $180.00 $109,490.01 $111,490 $184.00 $107,570.01 $109,570 $188.00 $110,330.01 $112,330 $185.00 $111,490.01 $113,490 $189.00 $109,570.01 $111,570 $193.00 $112,330.01 $114,330 $190.00 $113,490.01 $115,490 $194.00 $111,570.01 $113,570 $198.00 $114,330.01 $116,330 $195.00 $115,490.01 $117,490 $199.00 $113,570.01 $115,570 $203.00 $116,330.01 $118,330 $200.00 $117,490.01 $119,490 $204.00 $115,570.01 $117,570 $208.00 $118,330.01 $120,330 $205.00 $119,490.01 $121,490 $209.00 $117,570.01 $119,570 $213.00 $120,330.01 $122,330 $210.00 $121,490.01 $123,490 $214.00 $119,570.01 $121,570 $218.00 $122,330.01 $124,330 $215.00 $123,490.01 $125,490 $219.00 $121,570.01 $123,570 $223.00 $124,330.01 $126,330 $220.00 $125,490.01 $127,490 $224.00 $123,570.01 $125,570 $228.00 $126,330.01 $128,330 $225.00 $127,490.01 $129,490 $229.00 $125,570.01 $127,570 $233.00 $128,330.01 $130,330 $230.00 $129,490.01 $131,490 $234.00 $127,570.01 $129,570 $238.00 $130,330.01 $132,330 $235.00 $131,490.01 $133,490 $239.00 $129,570.01 $131,570 $243.00 $132,330.01 $134,330 $240.00 $133,490.01 $135,490 $244.00 $131,570.01 $133,570 $248.00 $134,330.01 $136,330 $245.00 $135,490.01 $137,490 $249.00 $133,570.01 $135,570 $253.00 $136,330.01 $138,330 $250.00 $137,490.01 $139,490 $254.00 $135,570.01 $137,570 $258.00 $138,330.01 $140,330 $255.00 $139,490.01 $141,490 $259.00 $137,570.01 $139,570 $263.00 $140,330.01 $142,330 $260.00 $141,490.01 $143,490 $264.00 $139,570.01 $141,570 $268.00 $142,330.01 $144,330 $265.00 $143,490.01 $145,490 $270.00 $141,570.01 $143,570 $273.00 $144,330.01 $146,330 $270.00 $145,490.01 $147,490 $276.00 $143,570.01 $145,570 $278.00 $146,330.01 $148,330 $275.00 $147,490.01 $149,490 $282.00 $145,570.01 $147,570 $284.00 $148,330.01 $150,330 $280.00 $149,490.01 $151,490 $288.00 $147,570.01 $149,570 $290.00 $150,330.01 $152,330 $285.00 $151,490.01 $153,490 $294.00 $149,570.01 $151,570 $296.00 $152,330.01 $154,330 $290.00 $153,490.01 $155,490 $300.00 $151,570.01 $153,570 $302.00 $154,330.01 $156,330 $296.00 $155,490.01 $157,490 $306.00 $153,570.01 $155,570 $308.00 $156,330.01 $158,330 $302.00 $157,490.01 $159,490 $312.00 $155,570.01 $157,570 $314.00 $158,330.01 $160,330 $308.00 $159,490.01 $161,490 $318.00 $157,570.01 $159,570 $320.00 $160,330.01 $162,330 $314.00 $161,490.01 $163,490 $324.00 $159,570.01 $161,570 $326.00 $162,330.01 $164,330 $320.00 $163,490.01 $165,490 $330.00 $161,570.01 $163,570 $332.00 $164,330.01 $166,330 $326.00 $165,490.01 $167,490 $336.00 $163,570.01 $165,570 $338.00 $166,330.01 $168,330 $332.00 $167,490.01 $169,490 $342.00 $165,570.01 $167,570 $344.00 $168,330.01 $170,330 $338.00 $169,490.01 $171,490 $348.00 $167,570.01 $169,570 $350.00 $170,330.01 $172,330 $344.00 $171,490.01 $173,490 $355.00 $169,570.01 $171,570 $356.00 $172,330.01 $174,330 $350.00 $173,490.01 $175,490 $362.00 $174,330.01 $176,330 $356.00 $175,490.01 $177,490 $368.00 $176,330.01 $178,330 $362.00 $177,490.01 $179,490 $374.00 $178,330.01 $184,076 $368.00 $179,490.01 $181,490 $374.00 $181,490.01 $183,490 $380.00 $183,490.01 $185,490 $386.00 $185,490.01 $187,490 $392.00 $187,490.01 $189,490 $397.00 $189,490.01 $191,490 200% FPIG $148,340 200% FPIG $156,660 200% FPIG $164,980
Weekly Family Size: 19 Weekly Family Size: 20 Weekly Family Size: 21 Co-pay Annual Income Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $30,300 $10.00 $8,660.01 $32,000 $10.00 $8,660.01 $34,640 $35.00 $30,300.01 $40,300 $37.00 $32,000.01 $41,330 $40.00 $34,640.01 $45,890 $47.00 $40,300.01 $48,750 $48.00 $41,330.01 $50,810 $53.00 $45,890.01 $53,640 $57.00 $48,750.01 $50,750 $59.00 $50,810.01 $52,810 $62.00 $53,640.01 $54,970 $60.00 $50,750.01 $52,750 $62.00 $52,810.01 $54,810 $64.00 $54,970.01 $56,970 $63.00 $52,750.01 $54,750 $65.00 $54,810.01 $56,810 $67.00 $56,970.01 $58,970 $66.00 $54,750.01 $56,750 $68.00 $56,810.01 $58,810 $70.00 $58,970.01 $60,970 $70.00 $56,750.01 $58,750 $72.00 $58,810.01 $60,810 $74.00 $60,970.01 $62,970 $74.00 $58,750.01 $60,750 $76.00 $60,810.01 $62,810 $78.00 $62,970.01 $64,970 $78.00 $60,750.01 $62,750 $80.00 $62,810.01 $64,810 $82.00 $64,970.01 $66,970 $82.00 $62,750.01 $64,750 $84.00 $64,810.01 $66,810 $86.00 $66,970.01 $68,970 $86.00 $64,750.01 $66,750 $88.00 $66,810.01 $68,810 $90.00 $68,970.01 $70,970 $90.00 $66,750.01 $68,750 $92.00 $68,810.01 $70,810 $94.00 $70,970.01 $72,970 $94.00 $68,750.01 $70,750 $96.00 $70,810.01 $72,810 $98.00 $72,970.01 $74,970 $98.00 $70,750.01 $72,750 $100.00 $72,810.01 $74,810 $102.00 $74,970.01 $76,970 $102.00 $72,750.01 $74,750 $104.00 $74,810.01 $76,810 $106.00 $76,970.01 $78,970 $106.00 $74,750.01 $76,750 $108.00 $76,810.01 $78,810 $110.00 $78,970.01 $80,970 $110.00 $76,750.01 $78,750 $112.00 $78,810.01 $80,810 $114.00 $80,970.01 $82,970 $114.00 $78,750.01 $80,750 $116.00 $80,810.01 $82,810 $118.00 $82,970.01 $84,970 $119.00 $80,750.01 $82,750 $120.00 $82,810.01 $84,810 $122.00 $84,970.01 $86,970 $124.00 $82,750.01 $84,750 $125.00 $84,810.01 $86,810 $126.00 $86,970.01 $88,970 $129.00 $84,750.01 $86,650 $130.00 $86,810.01 $88,810 $131.00 $88,970.01 $90,970 $133.00 $86,650.01 $88,750 $135.00 $88,810.01 $90,810 $136.00 $90,970.01 $92,970 $137.00 $88,750.01 $90,750 $139.00 $90,810.01 $92,810 $141.00 $92,970.01 $94,970 $141.00 $90,750.01 $92,750 $143.00 $92,810.01 $94,810 $145.00 $94,970.01 $96,970 $145.00 $92,750.01 $94,750 $147.00 $94,810.01 $96,810 $149.00 $96,970.01 $98,970 $149.00 $94,750.01 $96,750 $151.00 $96,810.01 $98,810 $153.00 $98,970.01 $100,970 $153.00 $96,750.01 $98,750 $155.00 $98,810.01 $100,810 $157.00 $100,970.01 $102,970 $157.00 $98,750.01 $100,750 $159.00 $100,810.01 $102,810 $161.00 $102,970.01 $104,970 $161.00 $100,750.01 $102,750 $163.00 $102,810.01 $104,810 $165.00 $104,970.01 $106,970 $165.00 $102,750.01 $104,750 $167.00 $104,810.01 $106,810 $169.00 $106,970.01 $108,970 $169.00 $104,750.01 $106,750 $171.00 $106,810.01 $108,810 $173.00 $108,970.01 $110,970 $173.00 $106,750.01 $108,750 $175.00 $108,810.01 $110,810 $177.00 $110,970.01 $112,970 $177.00 $108,750.01 $110,750 $179.00 $110,810.01 $112,810 $181.00 $112,970.01 $114,970 $181.00 $110,750.01 $112,750 $183.00 $112,810.01 $114,810 $185.00 $114,970.01 $116,970 $185.00 $112,750.01 $114,750 $187.00 $114,810.01 $116,810 $189.00 $116,970.01 $118,970 $189.00 $114,750.01 $116,750 $191.00 $116,810.01 $118,810 $193.00 $118,970.01 $120,970 $194.00 $116,750.01 $118,750 $195.00 $118,810.01 $120,810 $197.00 $120,970.01 $122,970 $199.00 $118,750.01 $120,750 $199.00 $120,810.01 $122,810 $201.00 $122,970.01 $124,970 $204.00 $120,750.01 $122,750 $204.00 $122,810.01 $124,810 $205.00 $124,970.01 $126,970 $209.00 $122,750.01 $124,750 $209.00 $124,810.01 $126,810 $210.00 $126,970.01 $128,970 $214.00 $124,750.01 $126,750 $214.00 $126,810.01 $128,810 $215.00 $128,970.01 $130,970 $219.00 $126,750.01 $128,750 $219.00 $128,810.01 $130,810 $220.00 $130,970.01 $132,970 $224.00 $128,750.01 $130,750 $224.00 $130,810.01 $132,810 $225.00 $132,970.01 $134,970 $229.00 $130,750.01 $132,750 $229.00 $132,810.01 $134,810 $230.00 $134,970.01 $136,970 $234.00 $132,750.01 $134,750 $234.00 $134,810.01 $136,810 $235.00 $136,970.01 $138,970 $239.00 $134,750.01 $136,750 $239.00 $136,810.01 $138,810 $240.00 $138,970.01 $140,970 $244.00 $136,750.01 $138,750 $244.00 $138,810.01 $140,810 $245.00 $140,970.01 $142,970 $249.00 $138,750.01 $140,750 $249.00 $140,810.01 $142,810 $250.00 $142,970.01 $144,970 $254.00 $140,750.01 $142,750 $254.00 $142,810.01 $144,810 $255.00 $144,970.01 $146,970 $259.00 $142,750.01 $144,750 $259.00 $144,810.01 $146,810 $260.00 $146,970.01 $148,970 $264.00 $144,750.01 $146,750 $264.00 $146,810.01 $148,810 $265.00 $148,970.01 $150,970 $269.00 $146,750.01 $148,750 $269.00 $148,810.01 $150,810 $270.00 $150,970.01 $152,970 $274.00 $148,750.01 $150,750 $274.00 $150,810.01 $152,810 $275.00 $152,970.01 $154,970 $279.00 $150,750.01 $152,750 $279.00 $152,810.01 $154,810 $280.00 $154,970.01 $156,970 $284.00 $152,750.01 $154,750 $284.00 $154,810.01 $156,810 $285.00 $156,970.01 $158,970 $289.00 $154,750.01 $156,750 $289.00 $156,810.01 $158,810 $290.00 $158,970.01 $160,970 $294.00 $156,750.01 $158,750 $294.00 $158,810.01 $160,810 $295.00 $160,970.01 $162,970 $299.00 $158,750.01 $160,750 $299.00 $160,810.01 $162,810 $300.00 $162,970.01 $164,970 $304.00 $160,750.01 $162,750 $304.00 $162,810.01 $164,810 $305.00 $164,970.01 $166,970 $309.00 $162,750.01 $164,750 $309.00 $164,810.01 $166,810 $310.00 $166,970.01 $168,970 $315.00 $164,750.01 $166,750 $314.00 $166,810.01 $168,810 $315.00 $168,970.01 $170,970 $321.00 $166,750.01 $168,750 $319.00 $168,810.01 $170,810 $320.00 $170,970.01 $172,970 $327.00 $168,750.01 $170,750 $324.00 $170,810.01 $172,810 $325.00 $172,970.01 $174,970 $333.00 $170,750.01 $172,750 $330.00 $172,810.01 $174,810 $330.00 $174,970.01 $176,970 $339.00 $172,750.01 $174,750 $336.00 $174,810.01 $176,810 $335.00 $176,970.01 $178,970 $345.00 $174,750.01 $176,750 $342.00 $176,810.01 $178,810 $341.00 $178,970.01 $180,970 $351.00 $176,750.01 $178,750 $348.00 $178,810.01 $180,810 $347.00 $180,970.01 $182,970 $357.00 $178,750.01 $180,750 $354.00 $180,810.01 $182,810 $353.00 $182,970.01 $184,970 $363.00 $180,750.01 $182,750 $360.00 $182,810.01 $184,810 $359.00 $184,970.01 $186,970 $369.00 $182,750.01 $184,750 $366.00 $184,810.01 $186,810 $365.00 $186,970.01 $188,970 $375.00 $184,750.01 $186,750 $372.00 $186,810.01 $188,810 $371.00 $188,970.01 $190,970 $381.00 $186,750.01 $188,750 $378.00 $188,810.01 $190,810 $377.00 $190,970.01 $192,970 $387.00 $188,750.01 $190,750 $384.00 $190,810.01 $192,810 $383.00 $192,970.01 $194,970 $393.00 $190,750.01 $192,750 $390.00 $192,810.01 $194,810 $389.00 $194,970.01 $196,970 $399.00 $192,750.01 $194,750 $396.00 $194,810.01 $196,810 $395.00 $196,970.01 $198,970 $405.00 $194,750.01 $196,750 $402.00 $196,810.01 $198,810 $401.00 $198,970.01 $200,970 $411.00 $196,750.01 $200,750 $408.00 $198,810.01 $200,810 $407.00 $200,970.01 $202,970 $421.00 $200,750.01 $203,000 $414.00 $200,810.01 $202,810 $413.00 $202,970.01 $204,970 $426.00 $203,000.01 $203,628 $420.00 $202,810.01 $204,810 $419.00 $204,970.01 $206,970 $426.00 $204,810.01 $206,810 $425.00 $206,970.01 $208,970 $432.00 $206,810.01 $208,810 $431.00 $208,970.01 $210,970 $438.00 $208,810.01 $210,810 $437.00 $210,970.01 $212,970 $443.00 $212,970.01 $214,970 $449.00 $214,970.01 $216,970 $455.00 $216,970.01 $223,180 200% FPIG $173,300 200% FPIG $181,620 200% FPIG $189,940
[Pa.B. Doc. No. 15-828. Filed for public inspection May 1, 2015, 9:00 a.m.]
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