[53 Pa.B. 7827]
[Saturday, December 16, 2023]

[Continued from previous Web Page]

APPENDIX A

Income to be Included, Deducted and Excluded in Determining Gross Monthly Income

PART I. Income inclusions.

 Income from the following sources is included when determining total gross monthly income:

 A. Money, wages or salary earned by a parent or caretaker before deductions for taxes, Social Security, savings bonds, pensions, union dues, health insurance and similar purposes, for work performed as an employee. This includes commissions, tips, piece-rate payments and cash bonuses. Income earned by an unemancipated minor is not included.

 B. Armed forces pay, which includes base pay plus cash, but does not include housing subsistence, allowances or the value of rent-free quarters.

 C. Voluntary and court-ordered support received for any person in the family.

 D. Net income from nonresident and real property, defined as gross receipts minus the expenses for continuing the income, such as depreciation charges, business taxes (not personal income taxes), interest on mortgages, repairs and similar expenses.

 E. Social Security benefits, Supplemental Security Income, survivors' benefits and permanent disability insurance payments made by the Social Security Administration before deductions of health insurance premiums.

 F. Railroad retirement, disability or survivors' benefit payments made by the United States Government under the Railroad Retirement Act of 1974 (45 U.S.C. §§ 231—231v) before deductions of health insurance premiums.

 G. State blind pension payments made by the Department.

 H. Public assistance benefits or retirement benefits.

 I. Private pensions and annuities, including retirement benefits paid to a retired person or their survivors by a former employer or a union, either directly or through an insurance company.

 J. Government employee pensions paid by Federal, State, county or other governmental agencies to former employees, including members of the armed forces, or their survivors.

 K. Unemployment compensation received from government unemployment insurance agencies or private companies during periods of unemployment and strike benefits received from union funds.

 L. Workers' compensation received from private or public insurance companies.

 M. Veterans' payments, defined as money paid periodically by the Veterans Administration to disabled members of the armed forces or to the survivors or dependents of deceased or disabled veterans, subsistence allowances paid to the survivors of deceased veterans and subsistence allowances paid to veterans for education and on-the-job training, as well as so-called ''refunds'' paid to ex-service persons as GI insurance premiums. For a disabled veteran in the Vocational Rehabilitation Program, the subsistence allowance and the veteran's disability allowance are counted as income.

 N. Capital gains, profit from S-corporations and dividends, including dividends from stocks, bonds, mutual funds or from membership in an association.

 O. Interest on savings and bonds.

 P. Income from estates and trust funds.

 Q. Net income from royalties.

 R. Lump sum cash of more than $100; inheritances, life insurance benefits; personal injury and other damage awards and settlements; retroactive benefits such as retirement, survivor's or disability insurance and delayed unemployment: divorce settlements; gifts; or workers' compensation.

 S. Lump-sum cash lottery winnings or cash prizes of more than $100.

 T. Profit from self-employment, calculated as total gross receipts minus costs of doing business. The costs of doing business shall only include the following:

 (1) Costs of maintaining a place of business, such as rent, utilities, insurance on the business and its property, and property taxes. If a business is operated in a home, the costs of maintaining a place of business are only those costs identified for the part of the home used exclusively for the business.

 (2) Interest on the purchase of income-producing equipment and property.

 (3) Employee labor costs, such as wage, salaries, taxes, benefits, unemployment compensation or workers' compensation.

 (4) Cost of goods sold, supplies and materials.

 (5) Advertising costs.

 (6) Accounting and legal fees.

 (7) Transportation costs necessary to produce income.

 U. Net income from room rent or room and board, calculated as follows: Gross income received minus $10 per month for each room rented. Divide the remainder by 2. That number is the income inclusion.

Conversion Table

 Convert weekly, biweekly, semimonthly and other pay periods to gross monthly amounts using the following conversion table:

Frequency of income	Conversion method
Daily	Multiply the daily income by the number of workdays in a week, then multiply by 4.3.
Weekly	Multiply by 4.3.
Biweekly (every 2 weeks)	Divide by 2, then multiply by 4.3.
Semimonthly (twice per month)	Multiply by 2 for monthly gross income.
Monthly	Use the figure given.
Quarterly	Divide by 3.
Annually	Divide by 12.
Lump sum income	Divide by 12.

PART II. Income deductions.

 The following are deducted when determining adjusted monthly income:

 A. Voluntary or court-ordered support paid by the parent or caretaker or a family member to a present or former spouse not residing in the same household.

 B. Voluntary or court-ordered child support paid by the parent or caretaker or family member to a person not residing in the same household.

 C. A medical expense not reimbursed through medical insurance that exceeds 10% of the family gross monthly income. The medical expense must have been incurred within the 90-day period prior to the date the parent or caretaker notifies the eligibility agency of that expense and there must be an expectation that the expense will continue to be incurred for the 6 months following the outset of the expense. Medical expenses are based on the monthly expenses or monthly payment plan, or both. Medical expenses include bills for doctors, hospital costs, dental services, health care premiums, institutional care, medications, prosthetic devices, durable medical equipment or mental health services.

 D. The stepparent deduction as shown in Appendix C (relating to stepparent deduction chart).

PART III. Income exclusions.

 Income from the following sources is excluded in determining gross monthly income:

 A. Employment earnings of an individual who is an unemancipated minor.

 B. Tax refunds, including earned income tax credits.

 C. Withdrawals of bank, credit union or brokerage deposits.

 D. Money borrowed.

 E. Nonrecurring money in amounts under $100 per person per year, given as a gift, from any source.

 F. The value of benefits under the Food Stamp Act of 1977 (7 U.S.C. §§ 2011—2036d).

 G. The value of foods donated from the United States Department of Agriculture.

 H. The value of supplemental foods assistance under the Child Nutrition Act of 1966 (42 U.S.C. §§ 1771—1793) and the special food service programs for children under that act.

 I. Loans and grants, such as scholarships, obtained and used for conditions that preclude their use for living costs.

 J. A grant or loan to an undergraduate student for educational purposes, made or insured under any program administered under the Higher Education Act of 1965 (20 U.S.C. §§ 1001—1161aa-1).

 K. A payment received under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 U.S.C. §§ 4601—4655).

 L. A home produce used for household consumption.

 M. A payment made on behalf of an individual for household expenses, such as rent, food and utilities.

 N. Payments to Volunteers in Service to America under the Domestic Volunteer Service Act of 1973 (42 U.S.C. §§ 4950—5085), which include AmeriCorps income.

 O. Earnings received by any youth under the Workforce Investment Act of 1998, as amended (Pub.L. No. 105-220) or the Youth Build Program (Pub.L. No. 113-128) (29 U.S.C. § 3226).

 P. Foster care payments by a foster care placement agency, including payments to permanent legal custodians.

 Q. Stipends derived from the Foster Grandparent Program under section 211 of the Domestic Violence Service Act of 1973 (42 U.S.C. § 5011).

 R. Low Income Home Energy Assistance Program (LIHEAP) benefits and cash in-kind energy assistance provided by private agencies and utility companies.

 S. Adoption assistance payments by a county children and youth agency.

 T. Income received from Federal student aid or participation in a Federal work-study program.

 U. Payments made by the Veterans Administration to children of Vietnam veterans under The Benefits for Children of Vietnam Veterans Act (38 U.S.C. §§ 1802—1838).

APPENDIX B

Copayment Chart

Family Copayment Scale Effective January 17, 2022

(Based on the 2022 Federal Poverty Income Guidelines)

Weekly Co-pay	Family Size: 1 Annual Income		Weekly Co-pay	Family Size: 2 Annual Income		Weekly Co-pay	Family Size: 3 Annual Income
$5	Less than:	$7,567	$5	Less than:	$8,187	$5	Less than:	$7,741
$6	$7,567.01	$8,324	$6	$8,187.41	$9,211	$6	$7,741.01	$9,031
$7	$8,323.71	$9,080	$7	$9,210.84	$10,234	$7	$9,031.01	$10,321
$8	$9,080.41	$9,837	$8	$10,234.26	$11,258	$8	$10,321.01	$11,611
$9	$9,837.11	$10,594	$9	$11,257.69	$12,281	$9	$11,611.01	$12,902
$9	$10,593.81	$11,351	$10	$12,281.11	$13,305	$10	$12,902.01	$14,192
$10	$11,350.51	$12,107	$12	$13,304.54	$14,328	$12	$14,192.01	$15,482
$11	$12,107.21	$12,864	$13	$14,327.96	$15,351	$13	$15,482.01	$16,772
$12	$12,863.91	$13,621	$14	$15,351.39	$16,375	$15	$16,772.01	$18,062
$13	$13,620.61	$14,377	$15	$16,374.81	$17,398	$16	$18,062.01	$19,352
$14	$14,377.31	$15,134	$17	$17,398.24	$18,422	$18	$19,352.01	$20,642
$15	$15,134.01	$15,891	$18	$18,421.66	$19,445	$19	$20,642.01	$21,933
$16	$15,890.71	$16,647	$19	$19,445.09	$20,469	$21	$21,933.01	$23,223
$17	$16,647.41	$17,404	$21	$20,468.51	$21,492	$23	$23,223.01	$24,513
$19	$17,404.11	$18,161	$22	$21,491.94	$22,515	$24	$24,513.01	$25,803
$20	$18,160.81	$18,918	$24	$22,515.36	$23,539	$26	$25,803.01	$27,093
$21	$18,917.51	$19,674	$25	$23,538.79	$24,562	$28	$27,093.01	$28,383
$22	$19,674.21	$20,431	$27	$24,562.21	$25,586	$30	$28,383.01	$29,673
$23	$20,430.91	$21,188	$28	$25,585.64	$26,609	$32	$29,673.01	$30,964
$24	$21,187.61	$21,944	$30	$26,609.06	$27,632	$34	$30,964.01	$32,254
$26	$21,944.31	$22,701	$31	$27,632.49	$28,656	$36	$32,254.01	$33,544
$27	$22,701.01	$23,458	$33	$28,655.91	$29,679	$38	$33,544.01	$34,834
$28	$23,457.71	$24,214	$35	$29,679.34	$30,703	$40	$34,834.01	$36,124
$30	$24,214.41	$24,971	$36	$30,702.76	$31,726	$42	$36,124.01	$37,414
$31	$24,971.11	$25,728	$38	$31,726.19	$32,750	$44	$37,414.01	$38,705
$32	$25,727.81	$26,485	$40	$32,749.61	$33,773	$46	$38,705.01	$39,995
$34	$26,484.51	$27,241	$42	$33,773.04	$34,796	$48	$39,995.01	$41,285
$35	$27,241.21	$27,998	$44	$34,796.46	$35,820	$51	$41,285.01	$42,575
$37	$27,997.91	$28,755	$46	$35,819.89	$36,843	$53	$42,575.01	$43,865
$38	$28,754.61	$29,511	$48	$36,843.31	$37,867	$55	$43,865.01	$45,155
$40	$29,511.31	$30,268	$50	$37,866.74	$38,890	$58	$45,155.01	$46,445
	200% FPIG	$25,760	$52	$38,890.16	$39,914	$60	$46,445.01	$47,736
			$54	$39,913.59	$40,937	$63	$47,736.01	$49,026
				200% FPIG	$34,840	$65	$49,026.01	$50,316
						$68	$50,316.01	$51,606
							200% FPIG	$43,920

Weekly Co-pay	Family Size: 4 Annual Income		Weekly Co-pay	Family Size: 5 Annual Income		Weekly Co-pay	Family Size: 6 Annual Income
$5	Less than:	$9,341	$5	Less than:	$9,118	$5	Less than:	$8,361
$7	$9,341.01	$10,898	$6	$9,118.01	$10,942	$6	$8,361.01	$10,452
$8	$10,898.01	$12,455	$8	$10,942.01	$12,765	$7	$10,452.01	$12,542
$9	$12,455.01	$14,012	$9	$12,765.01	$14,589	$9	$12,542.01	$14,632
$11	$14,012.01	$15,569	$11	$14,589.01	$16,412	$11	$14,632.01	$16,723
$13	$15,569.01	$17,126	$13	$16,412.01	$18,236	$13	$16,723.01	$18,813
$14	$17,126.01	$18,683	$15	$18,236.01	$20,060	$15	$18,813.01	$20,903
$16	$18,683.01	$20,239	$17	$20,060.01	$21,883	$17	$20,903.01	$22,994
$18	$20,239.01	$21,796	$19	$21,883.01	$23,707	$19	$22,994.01	$25,084
$19	$21,796.01	$23,353	$21	$23,707.01	$25,530	$21	$25,084.01	$27,174
$21	$23,353.01	$24,910	$23	$25,530.01	$27,354	$24	$27,174.01	$29,265
$23	$24,910.01	$26,467	$25	$27,354.01	$29,178	$26	$29,265.01	$31,355
$25	$26,467.01	$28,024	$27	$29,178.01	$31,001	$29	$31,355.01	$33,445
$27	$28,024.01	$29,581	$30	$31,001.01	$32,825	$31	$33,445.01	$35,536
$29	$29,581.01	$31,138	$32	$32,825.01	$34,648	$34	$35,536.01	$37,626
$32	$31,138.01	$32,694	$35	$34,648.01	$36,472	$37	$37,626.01	$39,716
$34	$32,694.01	$34,251	$37	$36,472.01	$38,296	$40	$39,716.01	$41,807
$36	$34,251.01	$35,808	$40	$38,296.01	$40,119	$42	$41,807.01	$43,897
$38	$35,808.01	$37,365	$42	$40,119.01	$41,943	$45	$43,897.01	$45,987
$41	$37,365.01	$38,922	$45	$41,943.01	$43,766	$48	$45,987.01	$48,077
$43	$38,922.01	$40,479	$47	$43,766.01	$45,590	$51	$48,077.01	$50,168
$45	$40,479.01	$42,036	$50	$45,590.01	$47,414	$54	$50,168.01	$52,258
$48	$42,036.01	$43,593	$53	$47,414.01	$49,237	$58	$52,258.01	$54,348
$50	$43,593.01	$45,149	$56	$49,237.01	$51,061	$61	$54,348.01	$56,439
$53	$45,149.01	$46,706	$59	$51,061.01	$52,884	$64	$56,439.01	$58,529
$56	$46,706.01	$48,263	$62	$52,884.01	$54,708	$68	$58,529.01	$60,619
$58	$48,263.01	$49,820	$65	$54,708.01	$56,532	$71	$60,619.01	$62,710
$61	$49,820.01	$51,377	$68	$56,532.01	$58,355	$75	$62,710.01	$64,800
$64	$51,377.01	$52,934	$71	$58,355.01	$60,179	$78	$64,800.01	$66,890
$67	$52,934.01	$54,491	$75	$60,179.01	$62,002	$82	$66,890.01	$68,981
$70	$54,491.01	$56,048	$78	$62,002.01	$63,826	$86	$68,981.01	$71,071
$73	$56,048.01	$57,604	$81	$63,826.01	$65,650	$89	$71,071.01	$73,161
$76	$57,604.01	$59,161	$85	$65,650.01	$67,473	$93	$73,161.01	$75,252
$79	$59,161.01	$60,718	$88	$67,473.01	$69,297	$97	$75,252.01	$77,342
$82	$60,718.01	$62,275	$92	$69,297.01	$71,120	$101	$77,342.01	$79,432
	200% FPIG	$53,000	$96	$71,120.01	$72,944	$106	$79,432.01	$81,523
				200% FPIG	$62,080	$110	$81,523.01	$83,613
							200% FPIG	$71,160

Weekly Co-pay	Family Size: 7 Annual Income		Weekly Co-pay	Family Size: 8 Annual Income		Weekly Co-pay	Family Size: 9 Annual Income
$5	Less than:	$9,428	$5	Less than:	$10,495	$5	Less than:	$8,672
$6	$9,428.01	$11,785	$7	$10,495.01	$13,119	$6	$8,672.01	$11,562
$8	$11,785.01	$14,142	$9	$13,119.01	$15,743	$8	$11,562.01	$14,453
$10	$14,142.01	$16,499	$11	$15,743.01	$18,366	$10	$14,453.01	$17,343
$12	$16,499.01	$18,856	$14	$18,366.01	$20,990	$12	$17,343.01	$20,234
$14	$18,856.01	$21,213	$16	$20,990.01	$23,614	$15	$20,234.01	$23,124
$17	$21,213.01	$23,571	$18	$23,614.01	$26,238	$18	$23,124.01	$26,015
$19	$23,571.01	$25,928	$21	$26,238.01	$28,862	$20	$26,015.01	$28,905
$21	$25,928.01	$28,285	$24	$28,862.01	$31,485	$23	$28,905.01	$31,796
$24	$28,285.01	$30,642	$27	$31,485.01	$34,109	$26	$31,796.01	$34,686
$27	$30,642.01	$32,999	$30	$34,109.01	$36,733	$29	$34,686.01	$37,577
$29	$32,999.01	$35,356	$33	$36,733.01	$39,357	$33	$37,577.01	$40,467
$32	$35,356.01	$37,713	$36	$39,357.01	$41,980	$36	$40,467.01	$43,358
$35	$37,713.01	$40,070	$39	$41,980.01	$44,604	$40	$43,358.01	$46,248
$39	$40,070.01	$42,427	$43	$44,604.01	$47,228	$43	$46,248.01	$49,139
$42	$42,427.01	$44,784	$46	$47,228.01	$49,852	$47	$49,139.01	$52,029
$45	$44,784.01	$47,141	$50	$49,852.01	$52,476	$51	$52,029.01	$54,920
$48	$47,141.01	$49,498	$53	$52,476.01	$55,099	$55	$54,920.01	$57,810
$51	$49,498.01	$51,855	$57	$55,099.01	$57,723	$59	$57,810.01	$60,701
$54	$51,855.01	$54,212	$61	$57,723.01	$60,347	$63	$60,701.01	$63,591
$58	$54,212.01	$56,569	$64	$60,347.01	$62,971	$67	$63,591.01	$66,482
$61	$56,569.01	$58,926	$68	$62,971.01	$65,594	$71	$66,482.01	$69,372
$65	$58,926.01	$61,283	$72	$65,594.01	$68,218	$75	$69,372.01	$72,263
$69	$61,283.01	$63,640	$76	$68,218.01	$70,842	$80	$72,263.01	$75,153
$72	$63,640.01	$65,997	$81	$70,842.01	$73,466	$84	$75,153.01	$78,044
$76	$65,997.01	$68,354	$85	$73,466.01	$76,089	$89	$78,044.01	$80,934
$80	$68,354.01	$70,712	$89	$76,089.01	$78,713	$93	$80,934.01	$83,825
$84	$70,712.01	$73,069	$94	$78,713.01	$81,337	$98	$83,825.01	$86,715
$88	$73,069.01	$75,426	$98	$81,337.01	$83,961	$103	$86,715.01	$89,606
$92	$75,426.01	$77,783	$103	$83,961.01	$86,585	$108	$89,606.01	$92,496
$97	$77,783.01	$80,140	$107	$86,585.01	$89,208	$113	$92,496.01	$95,387
$101	$80,140.01	$82,497	$112	$89,208.01	$91,832	$118	$95,387.01	$98,277
$105	$82,497.01	$84,854	$117	$91,832.01	$94,456	$124	$98,277.01	$101,168
$110	$84,854.01	$87,211	$122	$94,456.01	$97,080	$129	$101,168.01	$104,058
$114	$87,211.01	$89,568	$127	$97,080.01	$99,703	$135	$104,058.01	$106,949
$119	$89,568.01	$91,925	$132	$99,703.01	$102,327	$140	$106,949.01	$109,839
$124	$91,925.01	$94,282	$138	$102,327.01	$104,951	$146	$109,839.01	$112,730
	200% FPIG	$80,240		200% FPIG	$89,320	$152	$112,730.01	$115,620
							200% FPIG	$98,400

Weekly Co-pay	Family Size: 10 Annual Income		Weekly Co-pay	Family Size: 11 Annual Income		Weekly Co-pay	Family Size: 12 Annual Income
$5	Less than:	$9,472	$5	Less than:	$10,272	$5	Less than:	$11,072
$6	$9,472.01	$12,629	$7	$10,272.01	$13,696	$7	$11,072.01	$14,763
$8	$12,629.01	$15,786	$9	$13,696.01	$17,120	$10	$14,763.01	$18,453
$11	$15,786.01	$18,943	$12	$17,120.01	$20,544	$13	$18,453.01	$22,144
$14	$18,943.01	$22,101	$15	$20,544.01	$23,968	$16	$22,144.01	$25,835
$16	$22,101.01	$25,258	$18	$23,968.01	$27,392	$19	$25,835.01	$29,525
$19	$25,258.01	$28,415	$21	$27,392.01	$30,816	$22	$29,525.01	$33,216
$22	$28,415.01	$31,572	$24	$30,816.01	$34,240	$26	$33,216.01	$36,907
$25	$31,572.01	$34,729	$28	$34,240.01	$37,663	$30	$36,907.01	$40,597
$29	$34,729.01	$37,887	$31	$37,663.01	$41,087	$34	$40,597.01	$44,288
$32	$37,887.01	$41,044	$35	$41,087.01	$44,511	$38	$44,288.01	$47,979
$36	$41,044.01	$44,201	$39	$44,511.01	$47,935	$42	$47,979.01	$51,669
$40	$44,201.01	$47,358	$43	$47,935.01	$51,359	$46	$51,669.01	$55,360
$43	$47,358.01	$50,516	$47	$51,359.01	$54,783	$51	$55,360.01	$59,051
$47	$50,516.01	$53,673	$51	$54,783.01	$58,207	$55	$59,051.01	$62,741
$52	$53,673.01	$56,830	$56	$58,207.01	$61,631	$60	$62,741.01	$66,432
$56	$56,830.01	$59,987	$60	$61,631.01	$65,055	$65	$66,432.01	$70,123
$60	$59,987.01	$63,145	$65	$65,055.01	$68,479	$70	$70,123.01	$73,814
$64	$63,145.01	$66,302	$69	$68,479.01	$71,903	$75	$73,814.01	$77,504
$68	$66,302.01	$69,459	$74	$71,903.01	$75,327	$80	$77,504.01	$81,195
$73	$69,459.01	$72,616	$79	$75,327.01	$78,751	$85	$81,195.01	$84,886
$77	$72,616.01	$75,773	$84	$78,751.01	$82,175	$91	$84,886.01	$88,576
$82	$75,773.01	$78,931	$89	$82,175.01	$85,599	$96	$88,576.01	$92,267
$87	$78,931.01	$82,088	$94	$85,599.01	$89,023	$102	$92,267.01	$95,958
$92	$82,088.01	$85,245	$100	$89,023.01	$92,447	$107	$95,958.01	$99,648
$97	$85,245.01	$88,402	$105	$92,447.01	$95,871	$113	$99,648.01	$103,339
$102	$88,402.01	$91,560	$111	$95,871.01	$99,295	$119	$103,339.01	$107,030
$107	$91,560.01	$94,717	$116	$99,295.01	$102,719	$125	$107,030.01	$110,720
$113	$94,717.01	$97,874	$122	$102,719.01	$106,142	$132	$110,720.01	$114,411
$118	$97,874.01	$101,031	$128	$106,142.01	$109,566	$138	$114,411.01	$118,102
$124	$101,031.01	$104,188	$134	$109,566.01	$112,990	$145	$118,102.01	$121,792
$129	$104,188.01	$107,346	$140	$112,990.01	$116,414	$151	$121,792.01	$125,483
$135	$107,346.01	$110,503	$147	$116,414.01	$119,838	$158	$125,483.01	$129,174
$141	$110,503.01	$113,660	$153	$119,838.01	$123,262	$165	$129,174.01	$132,864
$147	$113,660.01	$116,817	$159	$123,262.01	$126,686	$172	$132,864.01	$136,555
$153	$116,817.01	$119,975	$166	$126,686.01	$130,110	$179	$136,555.01	$140,246
$159	$119,975.01	$123,132	$173	$130,110.01	$133,534	$186	$140,246.01	$143,936
$166	$123,132.01	$126,289	$180	$133,534.01	$136,958	$194	$143,936.01	$147,627
	200% FPIG	$107,480		200% FPIG	$116,560		200% FPIG	$125,640

Weekly Co-pay	Family Size: 13 Annual Income		Weekly Co-pay	Family Size: 14 Annual Income		Weekly Co-pay	Family Size: 15 Annual Income
$5	Less than:	$11,872	$5	Less than:	$12,672	$5	Less than:	$8,982
$8	$11,872.01	$15,830	$8	$12,672.01	$16,897	$6	$8,982.01	$13,473
$11	$15,830.01	$19,787	$11	$16,897.01	$21,121	$9	$13,473.01	$17,963
$14	$19,787.01	$23,744	$15	$21,121.01	$25,345	$12	$17,963.01	$22,454
$17	$23,744.01	$27,702	$18	$25,345.01	$29,569	$15	$22,454.01	$26,945
$20	$27,702.01	$31,659	$22	$29,569.01	$33,793	$19	$26,945.01	$31,436
$24	$31,659.01	$35,617	$26	$33,793.01	$38,017	$23	$31,436.01	$35,927
$28	$35,617.01	$39,574	$30	$38,017.01	$42,241	$27	$35,927.01	$40,418
$32	$39,574.01	$43,531	$34	$42,241.01	$46,465	$32	$40,418.01	$44,909
$36	$43,531.01	$47,489	$38	$46,465.01	$50,690	$36	$44,909.01	$49,399
$40	$47,489.01	$51,446	$43	$50,690.01	$54,914	$41	$49,399.01	$53,890
$45	$51,446.01	$55,404	$48	$54,914.01	$59,138	$46	$53,890.01	$58,381
$50	$55,404.01	$59,361	$53	$59,138.01	$63,362	$51	$58,381.01	$62,872
$54	$59,361.01	$63,318	$58	$63,362.01	$67,586	$56	$62,872.01	$67,363
$59	$63,318.01	$67,276	$63	$67,586.01	$71,810	$62	$67,363.01	$71,854
$65	$67,276.01	$71,233	$69	$71,810.01	$76,034	$67	$71,854.01	$76,344
$70	$71,233.01	$75,191	$74	$76,034.01	$80,258	$73	$76,344.01	$80,835
$75	$75,191.01	$79,148	$80	$80,258.01	$84,483	$79	$80,835.01	$85,326
$80	$79,148.01	$83,105	$86	$84,483.01	$88,707	$85	$85,326.01	$89,817
$86	$83,105.01	$87,063	$91	$88,707.01	$92,931	$91	$89,817.01	$94,308
$91	$87,063.01	$91,020	$97	$92,931.01	$97,155	$97	$94,308.01	$98,799
$97	$91,020.01	$94,978	$104	$97,155.01	$101,379	$104	$98,799.01	$103,290
$103	$94,978.01	$98,935	$110	$101,379.01	$105,603	$110	$103,290.01	$107,780
$109	$98,935.01	$102,892	$116	$105,603.01	$109,827	$117	$107,780.01	$112,271
$115	$102,892.01	$106,850	$123	$109,827.01	$114,051	$124	$112,271.01	$116,762
$121	$106,850.01	$110,807	$130	$114,051.01	$118,276	$131	$116,762.01	$121,253
$128	$110,807.01	$114,765	$136	$118,276.01	$122,500	$138	$121,253.01	$125,744
$134	$114,765.01	$118,722	$143	$122,500.01	$126,724	$145	$125,744.01	$130,235
$141	$118,722.01	$122,679	$151	$126,724.01	$130,948	$153	$130,235.01	$134,726
$148	$122,679.01	$126,637	$158	$130,948.01	$135,172	$160	$134,726.01	$139,216
$155	$126,637.01	$130,594	$165	$135,172.01	$139,396	$168	$139,216.01	$143,707
$162	$130,594.01	$134,552	$173	$139,396.01	$143,620	$176	$143,707.01	$148,198
$169	$134,552.01	$138,509	$181	$143,620.01	$147,844	$184	$148,198.01	$152,689
$177	$138,509.01	$142,466	$189	$147,844.01	$152,069	$192	$152,689.01	$157,180
$184	$142,466.01	$146,424	$197	$152,069.01	$156,293	$201	$157,180.01	$161,671
$192	$146,424.01	$150,381	$205	$156,293.01	$160,517	$209	$161,671.01	$166,161
$200	$150,381.01	$154,339	$213	$160,517.01	$164,741	$218	$166,161.01	$170,652
$208	$154,339.01	$158,296	$222	$164,741.01	$168,965	$227	$170,652.01	$175,143
	200% FPIG	$134,720		200% FPIG	$143,800	$236	$175,143.01	$179,634
							200% FPIG	$152,880

Weekly Co-pay	Family Size: 16 Annual Income		Weekly Co-pay	Family Size: 17 Annual Income		Weekly Co-pay	Family Size: 18 Annual Income
$5	Less than:	$9,515	$5	Less than:	$10,049	$5	Less than:	$10,582
$6	$9,515.01	$14,273	$6	$10,049.01	$15,073	$7	$10,582.01	$15,873
$9	$14,273.01	$19,030	$10	$15,073.01	$20,097	$10	$15,873.01	$21,164
$13	$19,030.01	$23,788	$13	$20,097.01	$25,122	$14	$21,164.01	$26,455
$16	$23,788.01	$28,545	$17	$25,122.01	$30,146	$18	$26,455.01	$31,746
$20	$28,545.01	$33,303	$21	$30,146.01	$35,170	$23	$31,746.01	$37,037
$24	$33,303.01	$38,061	$26	$35,170.01	$40,194	$27	$37,037.01	$42,328
$29	$38,061.01	$42,818	$30	$40,194.01	$45,219	$32	$42,328.01	$47,619
$33	$42,818.01	$47,576	$35	$45,219.01	$50,243	$37	$47,619.01	$52,910
$38	$47,576.01	$52,333	$40	$50,243.01	$55,267	$42	$52,910.01	$58,201
$43	$52,333.01	$57,091	$46	$55,267.01	$60,292	$48	$58,201.01	$63,492
$48	$57,091.01	$61,848	$51	$60,292.01	$65,316	$54	$63,492.01	$68,783
$54	$61,848.01	$66,606	$57	$65,316.01	$70,340	$60	$68,783.01	$74,074
$60	$66,606.01	$71,364	$63	$70,340.01	$75,365	$66	$74,074.01	$79,365
$65	$71,364.01	$76,121	$69	$75,365.01	$80,389	$73	$79,365.01	$84,656
$71	$76,121.01	$80,879	$75	$80,389.01	$85,413	$79	$84,656.01	$89,947
$78	$80,879.01	$85,636	$82	$85,413.01	$90,437	$86	$89,947.01	$95,238
$84	$85,636.01	$90,394	$89	$90,437.01	$95,462	$93	$95,238.01	$100,529
$90	$90,394.01	$95,152	$95	$95,462.01	$100,486	$100	$100,529.01	$105,821
$96	$95,152.01	$99,909	$102	$100,486.01	$105,510	$107	$105,821.01	$111,112
$103	$99,909.01	$104,667	$109	$105,510.01	$110,535	$115	$111,112.01	$116,403
$110	$104,667.01	$109,424	$116	$110,535.01	$115,559	$122	$116,403.01	$121,694
$117	$109,424.01	$114,182	$123	$115,559.01	$120,583	$130	$121,694.01	$126,985
$124	$114,182.01	$118,939	$131	$120,583.01	$125,608	$138	$126,985.01	$132,276
$131	$118,939.01	$123,697	$138	$125,608.01	$130,632	$146	$132,276.01	$137,567
$138	$123,697.01	$128,455	$146	$130,632.01	$135,656	$154	$137,567.01	$142,858
$146	$128,455.01	$133,212	$154	$135,656.01	$140,680	$162	$142,858.01	$148,149
$154	$133,212.01	$137,970	$162	$140,680.01	$145,705	$171	$148,149.01	$153,440
$162	$137,970.01	$142,727	$171	$145,705.01	$150,729	$180	$153,440.01	$158,731
$170	$142,727.01	$147,485	$179	$150,729.01	$155,753	$189	$158,731.01	$164,022
$178	$147,485.01	$152,242	$188	$155,753.01	$160,778	$198	$164,022.01	$169,313
$186	$152,242.01	$157,000	$197	$160,778.01	$165,802	$207	$169,313.01	$174,604
$195	$157,000.01	$161,758	$206	$165,802.01	$170,826	$217	$174,604.01	$179,895
$204	$161,758.01	$166,515	$215	$170,826.01	$175,851	$226	$179,895.01	$185,186
$213	$166,515.01	$171,273	$224	$175,851.01	$180,875	$236	$185,186.01	$190,477
$222	$171,273.01	$176,030	$234	$180,875.01	$185,899	$246	$190,477.01	$195,768
$231	$176,030.01	$180,788	$244	$185,899.01	$190,923	$257	$195,768.01	$201,059
$240	$180,788.01	$185,545	$254	$190,923.01	$195,948	$267	$201,059.01	$206,350
$250	$185,545.01	$190,303	$264	$195,948.01	$200,972	$278	$206,350.01	$211,641
	200% FPIG	$161,960		200% FPIG	$171,040		200% FPIG	$180,120

Weekly Co-pay	Family Size: 19 Annual Income		Weekly Co-pay	Family Size: 20 Annual Income		Weekly Co-pay	Family Size: 21 Annual Income
$5	Less than:	$11,116	$5	Less than:	$11,649	$5	Less than:	$12,182
$7	$11,116.01	$16,673	$7	$11,649.01	$17,473	$8	$12,182.01	$18,274
$11	$16,673.01	$22,231	$11	$17,473.01	$23,298	$12	$18,274.01	$24,365
$15	$22,231.01	$27,789	$16	$23,298.01	$29,122	$16	$24,365.01	$30,456
$19	$27,789.01	$33,347	$20	$29,122.01	$34,947	$21	$30,456.01	$36,547
$24	$33,347.01	$38,904	$25	$34,947.01	$40,771	$26	$36,547.01	$42,638
$29	$38,904.01	$44,462	$30	$40,771.01	$46,596	$31	$42,638.01	$48,730
$34	$44,462.01	$50,020	$35	$46,596.01	$52,420	$37	$48,730.01	$54,821
$39	$50,020.01	$55,578	$41	$52,420.01	$58,245	$43	$54,821.01	$60,912
$45	$55,578.01	$61,135	$47	$58,245.01	$64,069	$49	$60,912.01	$67,003
$50	$61,135.01	$66,693	$53	$64,069.01	$69,894	$55	$67,003.01	$73,094
$57	$66,693.01	$72,251	$59	$69,894.01	$75,718	$62	$73,094.01	$79,186
$63	$72,251.01	$77,809	$66	$75,718.01	$81,543	$69	$79,186.01	$85,277
$70	$77,809.01	$83,366	$73	$81,543.01	$87,367	$76	$85,277.01	$91,368
$76	$83,366.01	$88,924	$80	$87,367.01	$93,192	$84	$91,368.01	$97,459
$83	$88,924.01	$94,482	$87	$93,192.01	$99,016	$92	$97,459.01	$103,550
$91	$94,482.01	$100,040	$95	$99,016.01	$104,841	$100	$103,550.01	$109,642
$98	$100,040.01	$105,597	$103	$104,841.01	$110,665	$107	$109,642.01	$115,733
$105	$105,597.01	$111,155	$110	$110,665.01	$116,490	$115	$115,733.01	$121,824
$113	$111,155.01	$116,713	$118	$116,490.01	$122,314	$124	$121,824.01	$127,915
$120	$116,713.01	$122,271	$126	$122,314.01	$128,138	$132	$127,915.01	$134,006
$128	$122,271.01	$127,828	$134	$128,138.01	$133,963	$141	$134,006.01	$140,098
$136	$127,828.01	$133,386	$143	$133,963.01	$139,787	$149	$140,098.01	$146,189
$145	$133,386.01	$138,944	$152	$139,787.01	$145,612	$158	$146,189.01	$152,280
$153	$138,944.01	$144,502	$160	$145,612.01	$151,436	$168	$152,280.01	$158,371
$162	$144,502.01	$150,059	$169	$151,436.01	$157,261	$177	$158,371.01	$164,462
$171	$150,059.01	$155,617	$179	$157,261.01	$163,085	$187	$164,462.01	$170,554
$180	$155,617.01	$161,175	$188	$163,085.01	$168,910	$197	$170,554.01	$176,645
$189	$161,175.01	$166,733	$198	$168,910.01	$174,734	$207	$176,645.01	$182,736
$198	$166,733.01	$172,290	$208	$174,734.01	$180,559	$217	$182,736.01	$188,827
$208	$172,290.01	$177,848	$218	$180,559.01	$186,383	$228	$188,827.01	$194,918
$218	$177,848.01	$183,406	$228	$186,383.01	$192,208	$239	$194,918.01	$201,010
$228	$183,406.01	$188,964	$239	$192,208.01	$198,032	$250	$201,010.01	$207,101
$238	$188,964.01	$194,521	$249	$198,032.01	$203,857	$261	$207,101.01	$213,192
$248	$194,521.01	$200,079	$260	$203,857.01	$209,681	$272	$213,192.01	$219,283
$259	$200,079.01	$205,637	$271	$209,681.01	$215,506	$284	$219,283.01	$225,374
$270	$205,637.01	$211,195	$283	$215,506.01	$221,330	$296	$225,374.01	$231,466
$281	$211,195.01	$216,752	$294	$221,330.01	$227,155	$308	$231,466.01	$237,557
$292	$216,752.01	$222,310	$306	$227,155.01	$232,979	$320	$237,557.01	$243,648
	200% FPIG	$189,200		200% FPIG	$198,280		200% FPIG	$207,360

APPENDIX C

Stepparent Deduction Chart

County of residence	Family composition/size
	2	3	4	5	6	Each additional person
Adams, Allegheny, Berks, Blair, Bradford, Butler, Centre, Columbia, Crawford, Cumberland, Dauphin, Delaware, Erie, Lackawanna, Lebanon, Lehigh, Luzerne, Lycoming, Monroe, Montour, Northampton, Philadelphia, Sullivan, Susquehanna, Union, Warren, Wayne, Westmoreland, Wyoming and York	$461	$587	$724	$859	$976	$121
Armstrong, Bedford, Cambria, Clarion, Clearfield, Fayette, Forest, Fulton, Greene, Huntingdon, Jefferson, Juniata, Northumberland, Schuylkill and Somerset	$406	$532	$662	$791	$894	$121
Beaver, Cameron, Carbon, Clinton, Elk, Franklin, Indiana, Lawrence, McKean, Mercer, Mifflin, Perry, Potter, Snyder, Tioga, Venango and Washington	$444	$573	$698	$829	$943	$121
Bucks, Chester, Lancaster, Montgomery and Pike	$481	$614	$749	$885	$1,001	$121

[Pa.B. Doc. No. 23-1752. Filed for public inspection December 15, 2023, 9:00 a.m.]

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