NOTICES

DEPARTMENT OF
HUMAN SERVICES

Income Limits and Co-payments for the Subsidized Child Care Program

[51 Pa.B. 2451]
[Saturday, May 1, 2021]

 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 2021 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 3, 2021.

 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 3, 2021, the income guidelines for the subsidized child care program are being raised due to increases in the FPIG. Under section 408.3 of the Human Services 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.

MEG SNEAD, 
Acting Secretary

 Fiscal Note: 14-NOT-1434. No fiscal impact; (8) recommends adoption.

CO-PAYMENT CHART
FAMILY CO-PAYMENT SCALE EFFECTIVE MAY 3, 2021
(BASED ON THE 2021 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	Less than:	$6,054	$5	Less than:	$6,141	$5	Less than:	$7,741
$6	$6,054.01	$6,810	$6	$6,141.01	$7,164	$7	$7,741.01	$9,031
$7	$6,810.01	$7,567	$7	$7,164.01	$8,187	$9	$9,031.01	$10,321
$8	$7,567.01	$8,324	$8	$8,187.01	$9,211	$10	$10,321.01	$11,611
$10	$8,324.01	$9,080	$10	$9,211.01	$10,234	$12	$11,611.01	$12,902
$11	$9,080.01	$9,837	$11	$10,234.01	$11,258	$14	$12,902.01	$14,192
$12	$9,837.01	$10,594	$13	$11,258.01	$12,281	$16	$14,192.01	$15,482
$14	$10,594.01	$11,351	$15	$12,281.01	$13,305	$19	$15,482.01	$16,772
$16	$11,351.01	$12,107	$17	$13,305.01	$14,328	$21	$16,772.01	$18,062
$17	$12,107.01	$12,864	$19	$14,328.01	$15,351	$24	$18,062.01	$19,352
$19	$12,864.01	$13,621	$21	$15,351.01	$16,375	$27	$19,352.01	$20,642
$21	$13,621.01	$14,377	$23	$16,375.01	$17,398	$29	$20,642.01	$21,933
$22	$14,377.01	$15,134	$26	$17,398.01	$18,422	$32	$21,933.01	$23,223
$24	$15,134.01	$15,891	$28	$18,422.01	$19,445	$35	$23,223.01	$24,513
$25	$15,891.01	$16,647	$30	$19,445.01	$20,469	$38	$24,513.01	$25,803
$27	$16,647.01	$17,404	$32	$20,469.01	$21,492	$40	$25,803.01	$27,093
$29	$17,404.01	$18,161	$34	$21,492.01	$22,515	$43	$27,093.01	$28,383
$30	$18,161.01	$18,918	$36	$22,515.01	$23,539	$46	$28,383.01	$29,673
$32	$18,918.01	$19,674	$39	$23,539.01	$24,562	$49	$29,673.01	$30,964
$34	$19,674.01	$20,431	$41	$24,562.01	$25,586	$52	$30,964.01	$32,254
$36	$20,431.01	$21,188	$43	$25,586.01	$26,609	$55	$32,254.01	$33,544
$37	$21,188.01	$21,944	$46	$26,609.01	$27,632	$58	$33,544.01	$34,834
$39	$21,944.01	$22,701	$48	$27,632.01	$28,656	$61	$34,834.01	$36,124
$41	$22,701.01	$23,458	$51	$28,656.01	$29,679	$64	$36,124.01	$37,414
$43	$23,458.01	$24,214	$53	$29,679.01	$30,703	$67	$37,414.01	$38,705
$45	$24,214.01	$24,971	$56	$30,703.01	$31,726	$71	$38,705.01	$39,995
$47	$24,971.01	$25,728	$59	$31,726.01	$32,750	$74	$39,995.01	$41,285
$50	$25,728.01	$26,485	$61	$32,750.01	$33,773	$77	$41,285.01	$42,575
$52	$26,485.01	$27,241	$64	$33,773.01	$34,796	$81	$42,575.01	$43,865
$54	$27,241.01	$27,998	$67	$34,796.01	$35,820	$85	$43,865.01	$45,155
$56	$27,998.01	$28,755	$70	$35,820.01	$36,843	$88	$45,155.01	$46,445
$58	$28,755.01	$29,511	$73	$36,843.01	$37,867	$92	$46,445.01	$47,736
$61	$29,511.01	$30,268	$76	$37,867.01	$38,890	$96	$47,736.01	$49,026
	200% FPIG	$25,760	$79	$38,890.01	$39,914	$100	$49,026.01	$50,316
			$82	$39,914.01	$40,937	$104	$50,316.01	$51,606
				200% FPIG	$34,840		200% FPIG	$43,920

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	Less than:	$7,784	$5	Less than:	$7,294	$5	Less than:	$8,361
$7	$7,784.01	$9,341	$6	$7,294.01	$9,118	$7	$8,361.01	$10,452
$8	$9,341.01	$10,898	$8	$9,118.01	$10,942	$9	$10,452.01	$12,542
$10	$10,898.01	$12,455	$10	$10,942.01	$12,765	$11	$12,542.01	$14,632
$12	$12,455.01	$14,012	$12	$12,765.01	$14,589	$14	$14,632.01	$16,723
$15	$14,012.01	$15,569	$15	$14,589.01	$16,412	$17	$16,723.01	$18,813
$17	$15,569.01	$17,126	$17	$16,412.01	$18,236	$20	$18,813.01	$20,903
$20	$17,126.01	$18,683	$20	$18,236.01	$20,060	$23	$20,903.01	$22,994
$23	$18,683.01	$20,239	$23	$20,060.01	$21,883	$27	$22,994.01	$25,084
$26	$20,239.01	$21,796	$27	$21,883.01	$23,707	$30	$25,084.01	$27,174
$29	$21,796.01	$23,353	$30	$23,707.01	$25,530	$34	$27,174.01	$29,265
$32	$23,353.01	$24,910	$34	$25,530.01	$27,354	$39	$29,265.01	$31,355
$36	$24,910.01	$26,467	$38	$27,354.01	$29,178	$43	$31,355.01	$33,445
$39	$26,467.01	$28,024	$42	$29,178.01	$31,001	$48	$33,445.01	$35,536
$42	$28,024.01	$29,581	$46	$31,001.01	$32,825	$53	$35,536.01	$37,626
$45	$29,581.01	$31,138	$49	$32,825.01	$34,648	$57	$37,626.01	$39,716
$49	$31,138.01	$32,694	$53	$34,648.01	$36,472	$61	$39,716.01	$41,807
$52	$32,694.01	$34,251	$57	$36,472.01	$38,296	$65	$41,807.01	$43,897
$55	$34,251.01	$35,808	$61	$38,296.01	$40,119	$70	$43,897.01	$45,987
$59	$35,808.01	$37,365	$65	$40,119.01	$41,943	$74	$45,987.01	$48,077
$62	$37,365.01	$38,922	$69	$41,943.01	$43,766	$79	$48,077.01	$50,168
$66	$38,922.01	$40,479	$73	$43,766.01	$45,590	$83	$50,168.01	$52,258
$69	$40,479.01	$42,036	$77	$45,590.01	$47,414	$88	$52,258.01	$54,348
$73	$42,036.01	$43,593	$81	$47,414.01	$49,237	$93	$54,348.01	$56,439
$77	$43,593.01	$45,149	$86	$49,237.01	$51,061	$98	$56,439.01	$58,529
$81	$45,149.01	$46,706	$90	$51,061.01	$52,884	$104	$58,529.01	$60,619
$85	$46,706.01	$48,263	$95	$52,884.01	$54,708	$109	$60,619.01	$62,710
$89	$48,263.01	$49,820	$100	$54,708.01	$56,532	$114	$62,710.01	$64,800
$93	$49,820.01	$51,377	$104	$56,532.01	$58,355	$120	$64,800.01	$66,890
$98	$51,377.01	$52,934	$109	$58,355.01	$60,179	$125	$66,890.01	$68,981
$102	$52,934.01	$54,491	$114	$60,179.01	$62,002	$131	$68,981.01	$71,071
$106	$54,491.01	$56,048	$119	$62,002.01	$63,826	$137	$71,071.01	$73,161
$111	$56,048.01	$57,604	$125	$63,826.01	$65,650	$143	$73,161.01	$75,252
$116	$57,604.01	$59,161	$130	$65,650.01	$67,473	$149	$75,252.01	$77,342
$120	$59,161.01	$60,718	$135	$67,473.01	$69,297	$155	$77,342.01	$79,432
$125	$60,718.01	$62,275	$141	$69,297.01	$71,120	$161	$79,432.01	$81,523
	200% FPIG	$53,000	$146	$71,120.01	$72,944	$168	$81,523.01	$83,613
				200% FPIG	$62,080		200% FPIG	$71,160

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	Less than:	$9,428	$5	Less than:	$7,871	$5	Less than:	$8,672
$7	$9,428.01	$11,785	$6	$7,871.01	$10,495	$6	$8,672.01	$11,562
$10	$11,785.01	$14,142	$8	$10,495.01	$13,119	$9	$11,562.01	$14,453
$13	$14,142.01	$16,499	$11	$13,119.01	$15,743	$12	$14,453.01	$17,343
$16	$16,499.01	$18,856	$14	$15,743.01	$18,366	$16	$17,343.01	$20,234
$19	$18,856.01	$21,213	$17	$18,366.01	$20,990	$19	$20,234.01	$23,124
$22	$21,213.01	$23,571	$21	$20,990.01	$23,614	$23	$23,124.01	$26,015
$26	$23,571.01	$25,928	$25	$23,614.01	$26,238	$27	$26,015.01	$28,905
$30	$25,928.01	$28,285	$29	$26,238.01	$28,862	$32	$28,905.01	$31,796
$34	$28,285.01	$30,642	$34	$28,862.01	$31,485	$37	$31,796.01	$34,686
$39	$30,642.01	$32,999	$38	$31,485.01	$34,109	$42	$34,686.01	$37,577
$44	$32,999.01	$35,356	$43	$34,109.01	$36,733	$48	$37,577.01	$40,467
$49	$35,356.01	$37,713	$49	$36,733.01	$39,357	$53	$40,467.01	$43,358
$54	$37,713.01	$40,070	$54	$39,357.01	$41,980	$60	$43,358.01	$46,248
$59	$40,070.01	$42,427	$60	$41,980.01	$44,604	$66	$46,248.01	$49,139
$64	$42,427.01	$44,784	$66	$44,604.01	$47,228	$73	$49,139.01	$52,029
$69	$44,784.01	$47,141	$71	$47,228.01	$49,852	$78	$52,029.01	$54,920
$74	$47,141.01	$49,498	$76	$49,852.01	$52,476	$84	$54,920.01	$57,810
$78	$49,498.01	$51,855	$82	$52,476.01	$55,099	$90	$57,810.01	$60,701
$84	$51,855.01	$54,212	$87	$55,099.01	$57,723	$96	$60,701.01	$63,591
$89	$54,212.01	$56,569	$93	$57,723.01	$60,347	$103	$63,591.01	$66,482
$94	$56,569.01	$58,926	$99	$60,347.01	$62,971	$109	$66,482.01	$69,372
$100	$58,926.01	$61,283	$105	$62,971.01	$65,594	$115	$69,372.01	$72,263
$105	$61,283.01	$63,640	$111	$65,594.01	$68,218	$122	$72,263.01	$75,153
$111	$63,640.01	$65,997	$117	$68,218.01	$70,842	$129	$75,153.01	$78,044
$117	$65,997.01	$68,354	$123	$70,842.01	$73,466	$136	$78,044.01	$80,934
$123	$68,354.01	$70,712	$130	$73,466.01	$76,089	$143	$80,934.01	$83,825
$129	$70,712.01	$73,069	$137	$76,089.01	$78,713	$151	$83,825.01	$86,715
$135	$73,069.01	$75,426	$143	$78,713.01	$81,337	$158	$86,715.01	$89,606
$141	$75,426.01	$77,783	$150	$81,337.01	$83,961	$166	$89,606.01	$92,496
$148	$77,783.01	$80,140	$157	$83,961.01	$86,585	$173	$92,496.01	$95,387
$154	$80,140.01	$82,497	$165	$86,585.01	$89,208	$181	$95,387.01	$98,277
$161	$82,497.01	$84,854	$172	$89,208.01	$91,832	$189	$98,277.01	$101,168
$168	$84,854.01	$87,211	$179	$91,832.01	$94,456	$198	$101,168.01	$104,058
$175	$87,211.01	$89,568	$187	$94,456.01	$97,080	$206	$104,058.01	$106,949
$182	$89,568.01	$91,925	$195	$97,080.01	$99,703	$214	$106,949.01	$109,839
$189	$91,925.01	$94,282	$203	$99,703.01	$102,327	$223	$109,839.01	$112,730
	200% FPIG	$80,240	$211	$102,327.01	$104,951	$232	$112,730.01	$115,620
				200% FPIG	$89,320		200% FPIG	$98,400

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	Less than:	$9,472	$5	Less than:	$10,272	$5	Less than:	$11,072
$7	$9,472.01	$12,629	$8	$10,272.01	$13,696	$8	$11,072.01	$14,763
$10	$12,629.01	$15,786	$11	$13,696.01	$17,120	$12	$14,763.01	$18,453
$13	$15,786.01	$18,943	$14	$17,120.01	$20,544	$16	$18,453.01	$22,144
$17	$18,943.01	$22,101	$18	$20,544.01	$23,968	$20	$22,144.01	$25,835
$21	$22,101.01	$25,258	$23	$23,968.01	$27,392	$25	$25,835.01	$29,525
$25	$25,258.01	$28,415	$27	$27,392.01	$30,816	$30	$29,525.01	$33,216
$30	$28,415.01	$31,572	$33	$30,816.01	$34,240	$35	$33,216.01	$36,907
$35	$31,572.01	$34,729	$38	$34,240.01	$37,663	$41	$36,907.01	$40,597
$40	$34,729.01	$37,887	$44	$37,663.01	$41,087	$47	$40,597.01	$44,288
$46	$37,887.01	$41,044	$50	$41,087.01	$44,511	$54	$44,288.01	$47,979
$52	$41,044.01	$44,201	$56	$44,511.01	$47,935	$61	$47,979.01	$51,669
$58	$44,201.01	$47,358	$63	$47,935.01	$51,359	$68	$51,669.01	$55,360
$65	$47,358.01	$50,516	$71	$51,359.01	$54,783	$76	$55,360.01	$59,051
$72	$50,516.01	$53,673	$78	$54,783.01	$58,207	$84	$59,051.01	$62,741
$79	$53,673.01	$56,830	$86	$58,207.01	$61,631	$93	$62,741.01	$66,432
$86	$56,830.01	$59,987	$93	$61,631.01	$65,055	$100	$66,432.01	$70,123
$92	$59,987.01	$63,145	$100	$65,055.01	$68,479	$108	$70,123.01	$73,814
$98	$63,145.01	$66,302	$107	$68,479.01	$71,903	$115	$73,814.01	$77,504
$105	$66,302.01	$69,459	$114	$71,903.01	$75,327	$123	$77,504.01	$81,195
$112	$69,459.01	$72,616	$121	$75,327.01	$78,751	$131	$81,195.01	$84,886
$119	$72,616.01	$75,773	$129	$78,751.01	$82,175	$139	$84,886.01	$88,576
$126	$75,773.01	$78,931	$137	$82,175.01	$85,599	$147	$88,576.01	$92,267
$133	$78,931.01	$82,088	$145	$85,599.01	$89,023	$156	$92,267.01	$95,958
$141	$82,088.01	$85,245	$153	$89,023.01	$92,447	$165	$95,958.01	$99,648
$149	$85,245.01	$88,402	$161	$92,447.01	$95,871	$174	$99,648.01	$103,339
$156	$88,402.01	$91,560	$170	$95,871.01	$99,295	$183	$103,339.01	$107,030
$164	$91,560.01	$94,717	$178	$99,295.01	$102,719	$192	$107,030.01	$110,720
$173	$94,717.01	$97,874	$187	$102,719.01	$106,142	$202	$110,720.01	$114,411
$181	$97,874.01	$101,031	$196	$106,142.01	$109,566	$211	$114,411.01	$118,102
$189	$101,031.01	$104,188	$205	$109,566.01	$112,990	$221	$118,102.01	$121,792
$198	$104,188.01	$107,346	$215	$112,990.01	$116,414	$231	$121,792.01	$125,483
$207	$107,346.01	$110,503	$224	$116,414.01	$119,838	$242	$125,483.01	$129,174
$216	$110,503.01	$113,660	$234	$119,838.01	$123,262	$252	$129,174.01	$132,864
$225	$113,660.01	$116,817	$244	$123,262.01	$126,686	$263	$132,864.01	$136,555
$234	$116,817.01	$119,975	$254	$126,686.01	$130,110	$274	$136,555.01	$140,246
$244	$119,975.01	$123,132	$264	$130,110.01	$133,534	$285	$140,246.01	$143,936
$253	$123,132.01	$126,289	$275	$133,534.01	$136,958	$296	$143,936.01	$147,627
	200% FPIG	$107,480		200% FPIG	$116,560		200% FPIG	$125,640

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	Less than:	$11,872	$5	Less than:	$8,448	$5	Less than:	$8,982
$9	$11,872.01	$15,830	$6	$8,448.01	$12,672	$6	$8,982.01	$13,473
$12	$15,830.01	$19,787	$9	$12,672.01	$16,897	$10	$13,473.01	$17,963
$17	$19,787.01	$23,744	$13	$16,897.01	$21,121	$14	$17,963.01	$22,454
$21	$23,744.01	$27,702	$18	$21,121.01	$25,345	$19	$22,454.01	$26,945
$26	$27,702.01	$31,659	$23	$25,345.01	$29,569	$24	$26,945.01	$31,436
$32	$31,659.01	$35,617	$28	$29,569.01	$33,793	$30	$31,436.01	$35,927
$38	$35,617.01	$39,574	$34	$33,793.01	$38,017	$36	$35,927.01	$40,418
$44	$39,574.01	$43,531	$40	$38,017.01	$42,241	$43	$40,418.01	$44,909
$51	$43,531.01	$47,489	$47	$42,241.01	$46,465	$50	$44,909.01	$49,399
$58	$47,489.01	$51,446	$54	$46,465.01	$50,690	$57	$49,399.01	$53,890
$65	$51,446.01	$55,404	$62	$50,690.01	$54,914	$65	$53,890.01	$58,381
$73	$55,404.01	$59,361	$70	$54,914.01	$59,138	$74	$58,381.01	$62,872
$82	$59,361.01	$63,318	$78	$59,138.01	$63,362	$83	$62,872.01	$67,363
$90	$63,318.01	$67,276	$87	$63,362.01	$67,586	$93	$67,363.01	$71,854
$100	$67,276.01	$71,233	$96	$67,586.01	$71,810	$103	$71,854.01	$76,344
$107	$71,233.01	$75,191	$106	$71,810.01	$76,034	$113	$76,344.01	$80,835
$115	$75,191.01	$79,148	$115	$76,034.01	$80,258	$122	$80,835.01	$85,326
$123	$79,148.01	$83,105	$123	$80,258.01	$84,483	$131	$85,326.01	$89,817
$132	$83,105.01	$87,063	$132	$84,483.01	$88,707	$140	$89,817.01	$94,308
$140	$87,063.01	$91,020	$141	$88,707.01	$92,931	$150	$94,308.01	$98,799
$149	$91,020.01	$94,978	$150	$92,931.01	$97,155	$159	$98,799.01	$103,290
$158	$94,978.01	$98,935	$159	$97,155.01	$101,379	$169	$103,290.01	$107,780
$167	$98,935.01	$102,892	$169	$101,379.01	$105,603	$179	$107,780.01	$112,271
$177	$102,892.01	$106,850	$179	$105,603.01	$109,827	$190	$112,271.01	$116,762
$186	$106,850.01	$110,807	$189	$109,827.01	$114,051	$200	$116,762.01	$121,253
$196	$110,807.01	$114,765	$199	$114,051.01	$118,276	$211	$121,253.01	$125,744
$206	$114,765.01	$118,722	$209	$118,276.01	$122,500	$222	$125,744.01	$130,235
$216	$118,722.01	$122,679	$220	$122,500.01	$126,724	$234	$130,235.01	$134,726
$227	$122,679.01	$126,637	$231	$126,724.01	$130,948	$245	$134,726.01	$139,216
$237	$126,637.01	$130,594	$242	$130,948.01	$135,172	$257	$139,216.01	$143,707
$248	$130,594.01	$134,552	$253	$135,172.01	$139,396	$269	$143,707.01	$148,198
$259	$134,552.01	$138,509	$265	$139,396.01	$143,620	$282	$148,198.01	$152,689
$270	$138,509.01	$142,466	$277	$143,620.01	$147,844	$294	$152,689.01	$157,180
$282	$142,466.01	$146,424	$289	$147,844.01	$152,069	$307	$157,180.01	$161,671
$294	$146,424.01	$150,381	$301	$152,069.01	$156,293	$320	$161,671.01	$166,161
$305	$150,381.01	$154,339	$313	$156,293.01	$160,517	$333	$166,161.01	$170,652
$318	$154,339.01	$158,296	$326	$160,517.01	$164,741	$347	$170,652.01	$175,143
	200% FPIG	$134,720	$339	$164,741.01	$168,965	$360	$175,143.01	$179,634
				200% FPIG	$143,800		200% FPIG	$152,880

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	Less than:	$9,515	$5	Less than:	$10,049	$5	Less than:	$10,582
$7	$9,515.01	$14,273	$7	$10,049.01	$15,073	$7	$10,582.01	$15,873
$11	$14,273.01	$19,030	$11	$15,073.01	$20,097	$12	$15,873.01	$21,164
$15	$19,030.01	$23,788	$16	$20,097.01	$25,122	$17	$21,164.01	$26,455
$20	$23,788.01	$28,545	$21	$25,122.01	$30,146	$22	$26,455.01	$31,746
$26	$28,545.01	$33,303	$27	$30,146.01	$35,170	$28	$31,746.01	$37,037
$32	$33,303.01	$38,061	$33	$35,170.01	$40,194	$35	$37,037.01	$42,328
$38	$38,061.01	$42,818	$40	$40,194.01	$45,219	$42	$42,328.01	$47,619
$45	$42,818.01	$47,576	$48	$45,219.01	$50,243	$50	$47,619.01	$52,910
$53	$47,576.01	$52,333	$56	$50,243.01	$55,267	$59	$52,910.01	$58,201
$61	$52,333.01	$57,091	$64	$55,267.01	$60,292	$68	$58,201.01	$63,492
$69	$57,091.01	$61,848	$73	$60,292.01	$65,316	$77	$63,492.01	$68,783
$78	$61,848.01	$66,606	$83	$65,316.01	$70,340	$87	$68,783.01	$74,074
$88	$66,606.01	$71,364	$93	$70,340.01	$75,365	$98	$74,074.01	$79,365
$98	$71,364.01	$76,121	$104	$75,365.01	$80,389	$109	$79,365.01	$84,656
$109	$76,121.01	$80,879	$115	$80,389.01	$85,413	$121	$84,656.01	$89,947
$120	$80,879.01	$85,636	$126	$85,413.01	$90,437	$133	$89,947.01	$95,238
$129	$85,636.01	$90,394	$136	$90,437.01	$95,462	$144	$95,238.01	$100,529
$139	$90,394.01	$95,152	$146	$95,462.01	$100,486	$154	$100,529.01	$105,821
$148	$95,152.01	$99,909	$157	$100,486.01	$105,510	$165	$105,821.01	$111,112
$158	$99,909.01	$104,667	$167	$105,510.01	$110,535	$176	$111,112.01	$116,403
$169	$104,667.01	$109,424	$178	$110,535.01	$115,559	$188	$116,403.01	$121,694
$179	$109,424.01	$114,182	$189	$115,559.01	$120,583	$199	$121,694.01	$126,985
$190	$114,182.01	$118,939	$201	$120,583.01	$125,608	$211	$126,985.01	$132,276
$201	$118,939.01	$123,697	$212	$125,608.01	$130,632	$224	$132,276.01	$137,567
$212	$123,697.01	$128,455	$224	$130,632.01	$135,656	$236	$137,567.01	$142,858
$224	$128,455.01	$133,212	$236	$135,656.01	$140,680	$249	$142,858.01	$148,149
$236	$133,212.01	$137,970	$249	$140,680.01	$145,705	$262	$148,149.01	$153,440
$248	$137,970.01	$142,727	$262	$145,705.01	$150,729	$275	$153,440.01	$158,731
$260	$142,727.01	$147,485	$275	$150,729.01	$155,753	$289	$158,731.01	$164,022
$273	$147,485.01	$152,242	$288	$155,753.01	$160,778	$303	$164,022.01	$169,313
$285	$152,242.01	$157,000	$301	$160,778.01	$165,802	$317	$169,313.01	$174,604
$298	$157,000.01	$161,758	$315	$165,802.01	$170,826	$332	$174,604.01	$179,895
$312	$161,758.01	$166,515	$329	$170,826.01	$175,851	$347	$179,895.01	$185,186
$325	$166,515.01	$171,273	$343	$175,851.01	$180,875	$362	$185,186.01	$190,477
$339	$171,273.01	$176,030	$358	$180,875.01	$185,899	$377	$190,477.01	$195,768
$353	$176,030.01	$180,788	$373	$185,899.01	$190,923	$393	$195,768.01	$201,059
$367	$180,788.01	$185,545	$388	$190,923.01	$195,948	$408	$201,059.01	$206,350
$382	$185,545.01	$190,303	$403	$195,948.01	$200,972	$425	$206,350.01	$211,641
	200% FPIG	$161,960		200% FPIG	$171,040		200% FPIG	$180,120

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	Less than:	$11,116	$5	Less than:	$11,649	$5	Less than:	$12,182
$8	$11,116.01	$16,673	$8	$11,649.01	$17,473	$8	$12,182.01	$18,274
$12	$16,673.01	$22,231	$13	$17,473.01	$23,298	$13	$18,274.01	$24,365
$18	$22,231.01	$27,789	$18	$23,298.01	$29,122	$19	$24,365.01	$30,456
$23	$27,789.01	$33,347	$25	$29,122.01	$34,947	$26	$30,456.01	$36,547
$30	$33,347.01	$38,904	$31	$34,947.01	$40,771	$33	$36,547.01	$42,638
$37	$38,904.01	$44,462	$39	$40,771.01	$46,596	$40	$42,638.01	$48,730
$45	$44,462.01	$50,020	$47	$46,596.01	$52,420	$49	$48,730.01	$54,821
$53	$50,020.01	$55,578	$55	$52,420.01	$58,245	$58	$54,821.01	$60,912
$62	$55,578.01	$61,135	$65	$58,245.01	$64,069	$68	$60,912.01	$67,003
$71	$61,135.01	$66,693	$74	$64,069.01	$69,894	$78	$67,003.01	$73,094
$81	$66,693.01	$72,251	$85	$69,894.01	$75,718	$89	$73,094.01	$79,186
$92	$72,251.01	$77,809	$96	$75,718.01	$81,543	$100	$79,186.01	$85,277
$103	$77,809.01	$83,366	$108	$81,543.01	$87,367	$113	$85,277.01	$91,368
$115	$83,366.01	$88,924	$120	$87,367.01	$93,192	$126	$91,368.01	$97,459
$127	$88,924.01	$94,482	$133	$93,192.01	$99,016	$139	$97,459.01	$103,550
$140	$94,482.01	$100,040	$147	$99,016.01	$104,841	$153	$103,550.01	$109,642
$151	$100,040.01	$105,597	$158	$104,841.01	$110,665	$165	$109,642.01	$115,733
$162	$105,597.01	$111,155	$170	$110,665.01	$116,490	$177	$115,733.01	$121,824
$173	$111,155.01	$116,713	$182	$116,490.01	$122,314	$190	$121,824.01	$127,915
$185	$116,713.01	$122,271	$194	$122,314.01	$128,138	$203	$127,915.01	$134,006
$197	$122,271.01	$127,828	$207	$128,138.01	$133,963	$216	$134,006.01	$140,098
$209	$127,828.01	$133,386	$219	$133,963.01	$139,787	$229	$140,098.01	$146,189
$222	$133,386.01	$138,944	$233	$139,787.01	$145,612	$243	$146,189.01	$152,280
$235	$138,944.01	$144,502	$246	$145,612.01	$151,436	$257	$152,280.01	$158,371
$248	$144,502.01	$150,059	$260	$151,436.01	$157,261	$272	$158,371.01	$164,462
$262	$150,059.01	$155,617	$274	$157,261.01	$163,085	$287	$164,462.01	$170,554
$275	$155,617.01	$161,175	$289	$163,085.01	$168,910	$302	$170,554.01	$176,645
$289	$161,175.01	$166,733	$303	$168,910.01	$174,734	$317	$176,645.01	$182,736
$304	$166,733.01	$172,290	$318	$174,734.01	$180,559	$333	$182,736.01	$188,827
$318	$172,290.01	$177,848	$334	$180,559.01	$186,383	$349	$188,827.01	$194,918
$333	$177,848.01	$183,406	$349	$186,383.01	$192,208	$365	$194,918.01	$201,010
$349	$183,406.01	$188,964	$365	$192,208.01	$198,032	$382	$201,010.01	$207,101
$364	$188,964.01	$194,521	$382	$198,032.01	$203,857	$399	$207,101.01	$213,192
$380	$194,521.01	$200,079	$398	$203,857.01	$209,681	$416	$213,192.01	$219,283
$396	$200,079.01	$205,637	$415	$209,681.01	$215,506	$434	$219,283.01	$225,374
$412	$205,637.01	$211,195	$432	$215,506.01	$221,330	$452	$225,374.01	$231,466
$429	$211,195.01	$216,752	$450	$221,330.01	$227,155	$470	$231,466.01	$237,557
$446	$216,752.01	$222,310	$467	$227,155.01	$232,979	$489	$237,557.01	$243,648
	200% FPIG	$189,200		200% FPIG	$198,280		200% FPIG	$207,360

[Pa.B. Doc. No. 21-679. Filed for public inspection April 30, 2021, 9:00 a.m.]

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