DEPARTMENT OF PUBLIC WELFARE Income Limits and Co-payments for the Subsidized Child Care Program [42 Pa.B. 2853]
[Saturday, May 19, 2012]This notice increases the income limits codified in 55 Pa. Code Chapter 3041, Appendix B (relating to co-payment chart family co-payment scale effective May 7, 2012 (based on the 2012 Federal Poverty Income Guidelines) under 55 Pa. Code § 3041.107(b) (relating to availability and use of the Federal Poverty Income Guidelines). This increase became effective May 7, 2012.
Section 3041.107(b) of 55 Pa. Code requires the Department of Public Welfare to update the copayment schedule in 55 Pa. Code Chapter 3041, Appendix B to reflect changes in the Federal Poverty Income Guidelines (FPIG). Effective May 7, 2012, 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 copayment schedule is adjusted in incremental amounts to reflect the increases. Chapter 3041, Appendix B of 55 Pa. Code also establishes the family copayment levels according to the family's computed annual income and lists the weekly family copayment based on the annual family income.
GARY D. ALEXANDER,
SecretaryFiscal Note: 14-NOT-756. No fiscal impact; (8) recommends adoption.
CO-PAYMENT CHART
FAMILY CO-PAYMENT SCALE EFFECTIVE MAY 7, 2012
(BASED ON THE 2012 FEDERAL POVERTY INCOME GUIDELINES)Weekly Family Size: 1 Weekly Family Size: 2 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $9,170 $5.00 Less than: $8,660 $10.00 $9,170.01 $11,170 $10.00 $8,660.01 $13,000 $15.00 $11,170.01 $13,170 $15.00 $13,000.01 $13,130 $20.00 $13,170.01 $15,170 $20.00 $13,130.01 $15,130 $25.00 $15,170.01 $17,170 $24.00 $15,130.01 $17,130 $30.00 $17,170.01 $19,170 $28.00 $17,130.01 $19,130 $35.00 $19,170.01 $21,170 $32.00 $19,130.01 $21,130 $40.00 $21,170.01 $23,170 $36.00 $21,130.01 $23,130 $45.00 $23,170.01 $25,170 $41.00 $23,130.01 $25,130 $50.00 $25,170.01 $26,250 $46.00 $25,130.01 $27,130 $51.00 $27,130.01 $29,130 $57.00 $29,130.01 $31,130 $63.00 $31,130.01 $33,130 $69.00 $33,130.01 $35,130 $74.00 $35,130.01 $35,556 200% FPIG $22,340 200% FPIG $30,260 Weekly Family Size: 3 Weekly Family Size: 4 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $13,870 $10.00 $8,660.01 $14,730 $16.00 $13,870.01 $15,090 $17.00 $14,730.01 $17,050 $21.00 $15,090.01 $17,090 $23.00 $17,050.01 $19,050 $26.00 $17,090.01 $19,090 $27.00 $19,050.01 $21,050 $30.00 $19,090.01 $21,090 $32.00 $21,050.01 $23,050 $34.00 $21,090.01 $23,090 $36.00 $23,050.01 $25,050 $38.00 $23,090.01 $25,090 $40.00 $25,050.01 $27,050 $42.00 $25,090.01 $27,090 $44.00 $27,050.01 $29,050 $47.00 $27,090.01 $29,090 $48.00 $29,050.01 $31,050 $52.00 $29,090.01 $31,090 $52.00 $31,050.01 $33,050 $57.00 $31,090.01 $33,090 $57.00 $33,050.01 $35,050 $62.00 $33,090.01 $35,090 $62.00 $35,050.01 $37,050 $67.00 $35,090.01 $37,090 $67.00 $37,050.01 $39,050 $73.00 $37,090.01 $39,090 $72.00 $39,050.01 $41,050 $79.00 $39,090.01 $41,090 $77.00 $41,050.01 $43,050 $85.00 $41,090.01 $43,090 $82.00 $43,050.01 $45,050 $90.00 $43,090.01 $44,862 $87.00 $45,050.01 $47,050 $93.00 $47,050.01 $49,050 $99.00 $49,050.01 $51,050 $105.00 $51,050.01 $53,050 $111.00 $53,050.01 $54,168 200% FPIG $38,180 200% FPIG $46,100 Weekly Family Size: 5 Weekly Family Size: 6 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $15,600 $10.00 $8,660.01 $16,470 $18.00 $15,600.01 $19,010 $19.00 $16,470.01 $20,970 $25.00 $19,010.01 $21,010 $27.00 $20,970.01 $22,970 $29.00 $21,010.01 $23,010 $31.00 $22,970.01 $24,970 $33.00 $23,010.01 $25,010 $35.00 $24,970.01 $26,970 $38.00 $25,010.01 $27,010 $39.00 $26,970.01 $28,970 $42.00 $27,010.01 $29,010 $44.00 $28,970.01 $30,970 $46.00 $29,010.01 $31,010 $48.00 $30,970.01 $32,970 $50.00 $31,010.01 $33,010 $52.00 $32,970.01 $34,970 $54.00 $33,010.01 $35,010 $56.00 $34,970.01 $36,970 $58.00 $35,010.01 $37,010 $60.00 $36,970.01 $38,970 $62.00 $37,010.01 $39,010 $64.00 $38,970.01 $40,970 $67.00 $39,010.01 $41,010 $68.00 $40,970.01 $42,970 $72.00 $41,010.01 $43,010 $73.00 $42,970.01 $44,970 $77.00 $43,010.01 $45,010 $78.00 $44,970.01 $46,970 $82.00 $45,010.01 $47,010 $83.00 $46,970.01 $48,970 $87.00 $47,010.01 $49,010 $88.00 $48,970.01 $50,970 $92.00 $49,010.01 $51,010 $93.00 $50,970.01 $52,970 $97.00 $51,010.01 $53,010 $98.00 $52,970.01 $54,970 $103.00 $53,010.01 $55,010 $103.00 $54,970.01 $56,970 $109.00 $55,010.01 $57,010 $108.00 $56,970.01 $58,970 $115.00 $57,010.01 $59,010 $113.00 $58,970.01 $60,970 $121.00 $59,010.01 $61,010 $119.00 $60,970.01 $62,970 $127.00 $61,010.01 $63,010 $125.00 $62,970.01 $64,970 $132.00 $63,010.01 $63,474 $131.00 $64,970.01 $66,970 $137.00 $66,970.01 $68,970 $143.00 $68,970.01 $70,970 $149.00 $70,970.01 $72,780 200% FPIG $54,020 200% FPIG $61,940 Weekly Family Size: 7 Weekly Family Size: 8 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $17,330 $10.00 $8,660.01 $18,200 $20.00 $17,330.01 $22,930 $21.00 $18,200.01 $24,890 $29.00 $22,930.01 $24,930 $31.00 $24,890.01 $26,890 $33.00 $24,930.01 $26,930 $35.00 $26,890.01 $28,890 $37.00 $26,930.01 $28,930 $39.00 $28,890.01 $30,890 $41.00 $28,930.01 $30,930 $43.00 $30,890.01 $32,890 $45.00 $30,930.01 $32,930 $47.00 $32,890.01 $34,890 $50.00 $32,930.01 $34,930 $51.00 $34,890.01 $36,890 $54.00 $34,930.01 $36,930 $56.00 $36,890.01 $38,890 $58.00 $36,930.01 $38,930 $60.00 $38,890.01 $40,890 $62.00 $38,930.01 $40,930 $64.00 $40,890.01 $42,890 $66.00 $40,930.01 $42,930 $68.00 $42,890.01 $44,890 $70.00 $42,930.01 $44,930 $72.00 $44,890.01 $46,890 $74.00 $44,930.01 $46,930 $76.00 $46,890.01 $48,890 $78.00 $46,930.01 $48,930 $80.00 $48,890.01 $50,890 $83.00 $48,930.01 $50,930 $84.00 $50,890.01 $52,890 $88.00 $50,930.01 $52,930 $88.00 $52,890.01 $54,890 $93.00 $52,930.01 $54,930 $93.00 $54,890.01 $56,890 $98.00 $54,930.01 $56,930 $98.00 $56,890.01 $58,890 $103.00 $56,930.01 $58,930 $103.00 $58,890.01 $60,890 $108.00 $58,930.01 $60,930 $108.00 $60,890.01 $62,890 $113.00 $60,930.01 $62,930 $113.00 $62,890.01 $64,890 $118.00 $62,930.01 $64,930 $118.00 $64,890.01 $66,890 $123.00 $64,930.01 $66,930 $123.00 $66,890.01 $68,890 $128.00 $66,930.01 $68,930 $128.00 $68,890.01 $70,890 $134.00 $68,930.01 $70,930 $133.00 $70,890.01 $72,890 $140.00 $70,930.01 $72,930 $138.00 $72,890.01 $74,890 $146.00 $72,930.01 $74,930 $143.00 $74,890.01 $76,890 $152.00 $74,930.01 $76,930 $149.00 $76,890.01 $78,890 $158.00 $76,930.01 $78,930 $155.00 $78,890.01 $80,890 $164.00 $78,930.01 $80,930 $161.00 $80,890.01 $82,890 $170.00 $80,930.01 $82,086 $167.00 $82,890.01 $84,890 $173.00 $84,890.01 $86,890 $179.00 $86,890.01 $88,890 $185.00 $88,890.01 $90,890 $191.00 $90,890.01 $91,392 200% FPIG $69,860 200% FPIG $77,780 Weekly Family Size: 9 Weekly Family Size: 10 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $19,070 $10.00 $8,660.01 $19,930 $22.00 $19,070.01 $26,850 $23.00 $19,930.01 $28,810 $33.00 $26,850.01 $28,850 $35.00 $28,810.01 $30,810 $37.00 $28,850.01 $30,850 $39.00 $30,810.01 $32,810 $41.00 $30,850.01 $32,850 $43.00 $32,810.01 $34,810 $45.00 $32,850.01 $34,850 $47.00 $34,810.01 $36,810 $49.00 $34,850.01 $36,850 $51.00 $36,810.01 $38,810 $53.00 $36,850.01 $38,850 $55.00 $38,810.01 $40,810 $57.00 $38,850.01 $40,850 $59.00 $40,810.01 $42,810 $62.00 $40,850.01 $42,850 $63.00 $42,810.01 $44,810 $66.00 $42,850.01 $44,850 $68.00 $44,810.01 $46,810 $70.00 $44,850.01 $46,850 $72.00 $46,810.01 $48,810 $74.00 $46,850.01 $48,850 $76.00 $48,810.01 $50,810 $78.00 $48,850.01 $50,850 $80.00 $50,810.01 $52,810 $82.00 $50,850.01 $52,850 $84.00 $52,810.01 $54,810 $86.00 $52,850.01 $54,850 $88.00 $54,810.01 $56,810 $90.00 $54,850.01 $56,850 $92.00 $56,810.01 $58,810 $94.00 $56,850.01 $58,850 $96.00 $58,810.01 $60,810 $99.00 $58,850.01 $60,850 $100.00 $60,810.01 $62,810 $104.00 $60,850.01 $62,850 $104.00 $62,810.01 $64,810 $109.00 $62,850.01 $64,850 $109.00 $64,810.01 $66,810 $114.00 $64,850.01 $66,850 $114.00 $66,810.01 $68,810 $119.00 $66,850.01 $68,850 $119.00 $68,810.01 $70,810 $124.00 $68,850.01 $70,850 $124.00 $70,810.01 $72,810 $129.00 $70,850.01 $72,850 $129.00 $72,810.01 $74,810 $134.00 $72,850.01 $74,850 $134.00 $74,810.01 $76,810 $139.00 $74,850.01 $76,850 $139.00 $76,810.01 $78,810 $144.00 $76,850.01 $78,850 $144.00 $78,810.01 $80,810 $149.00 $78,850.01 $80,850 $149.00 $80,810.01 $82,810 $154.00 $80,850.01 $82,850 $154.00 $82,810.01 $84,810 $160.00 $82,850.01 $84,850 $159.00 $84,810.01 $86,810 $166.00 $84,850.01 $86,850 $164.00 $86,810.01 $88,810 $172.00 $86,850.01 $88,850 $169.00 $88,810.01 $90,810 $178.00 $88,850.01 $90,850 $174.00 $90,810.01 $92,810 $184.00 $90,850.01 $92,850 $180.00 $92,810.01 $94,810 $190.00 $92,850.01 $94,850 $186.00 $94,810.01 $96,810 $196.00 $94,850.01 $96,850 $192.00 $96,810.01 $98,810 $202.00 $96,850.01 $98,850 $198.00 $98,810.01 $100,810 $207.00 $98,850.01 $100,698 $204.00 $100,810.01 $102,810 $210.00 $102,810.01 $104,810 $216.00 $104,810.01 $106,810 $222.00 $106,810.01 $108,810 $228.00 $108,810.01 $110,004 200% FPIG $85,700 200% FPIG $93,620 Weekly Family Size: 11 Weekly Family Size: 12 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $20,800 $10.00 $8,660.01 $21,670 $24.00 $20,800.01 $30,770 $25.00 $21,670.01 $32,730 $37.00 $30,770.01 $32,770 $40.00 $32,730.01 $34,730 $41.00 $32,770.01 $34,770 $43.00 $34,730.01 $36,730 $45.00 $34,770.01 $36,770 $47.00 $36,730.01 $38,730 $49.00 $36,770.01 $38,770 $51.00 $38,730.01 $40,730 $53.00 $38,770.01 $40,770 $55.00 $40,730.01 $42,730 $57.00 $40,770.01 $42,770 $59.00 $42,730.01 $44,730 $61.00 $42,770.01 $44,770 $63.00 $44,730.01 $46,730 $65.00 $44,770.01 $46,770 $67.00 $46,730.01 $48,730 $69.00 $46,770.01 $48,770 $71.00 $48,730.01 $50,730 $74.00 $48,770.01 $50,770 $75.00 $50,730.01 $52,730 $78.00 $50,770.01 $52,770 $80.00 $52,730.01 $54,730 $82.00 $52,770.01 $54,770 $84.00 $54,730.01 $56,730 $86.00 $54,770.01 $56,770 $88.00 $56,730.01 $58,730 $90.00 $56,770.01 $58,770 $92.00 $58,730.01 $60,730 $94.00 $58,770.01 $60,770 $96.00 $60,730.01 $62,730 $98.00 $60,770.01 $62,770 $100.00 $62,730.01 $64,730 $102.00 $62,770.01 $64,770 $104.00 $64,730.01 $66,730 $106.00 $64,770.01 $66,770 $108.00 $66,730.01 $68,730 $110.00 $66,770.01 $68,770 $112.00 $68,730.01 $70,730 $114.00 $68,770.01 $70,770 $116.00 $70,730.01 $72,730 $119.00 $70,770.01 $72,770 $120.00 $72,730.01 $74,730 $124.00 $72,770.01 $74,770 $125.00 $74,730.01 $76,730 $129.00 $74,770.01 $76,770 $130.00 $76,730.01 $78,730 $134.00 $76,770.01 $78,770 $135.00 $78,730.01 $80,730 $139.00 $78,770.01 $80,770 $140.00 $80,730.01 $82,730 $144.00 $80,770.01 $82,770 $145.00 $82,730.01 $84,730 $149.00 $82,770.01 $84,770 $150.00 $84,730.01 $86,730 $154.00 $84,770.01 $86,770 $155.00 $86,730.01 $88,730 $159.00 $86,770.01 $88,770 $160.00 $88,730.01 $90,730 $164.00 $88,770.01 $90,770 $165.00 $90,730.01 $92,730 $169.00 $90,770.01 $92,770 $170.00 $92,730.01 $94,730 $174.00 $92,770.01 $94,770 $175.00 $94,730.01 $96,730 $179.00 $94,770.01 $96,770 $180.00 $96,730.01 $98,730 $184.00 $96,770.01 $98,770 $185.00 $98,730.01 $100,730 $189.00 $98,770.01 $100,770 $190.00 $100,730.01 $102,730 $195.00 $100,770.01 $102,770 $195.00 $102,730.01 $104,730 $201.00 $102,770.01 $104,770 $200.00 $104,730.01 $106,730 $207.00 $104,770.01 $106,770 $206.00 $106,730.01 $108,730 $213.00 $106,770.01 $108,770 $212.00 $108,730.01 $110,730 $219.00 $108,770.01 $110,770 $218.00 $110,730.01 $112,730 $225.00 $110,770.01 $112,770 $224.00 $112,730.01 $114,730 $231.00 $112,770.01 $114,770 $230.00 $114,730.01 $116,730 $237.00 $114,770.01 $116,770 $236.00 $116,730.01 $118,730 $243.00 $116,770.01 $118,770 $242.00 $118,730.01 $120,730 $249.00 $118,770.01 $119,310 $248.00 $120,730.01 $122,730 $254.00 $122,730.01 $124,730 $260.00 $124,730.01 $126,730 $266.00 $126,730.01 $128,616 200% FPIG $101,540 200% FPIG $109,460 Weekly Family Size: 13 Weekly Family Size: 14 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $22,530 $10.00 $8,660.01 $23,400 $26.00 $22,530.01 $34,690 $27.00 $23,400.01 $36,650 $42.00 $34,690.01 $36,690 $44.00 $36,650.01 $38,650 $45.00 $36,690.01 $38,690 $47.00 $38,650.01 $40,650 $49.00 $38,690.01 $40,690 $51.00 $40,650.01 $42,650 $53.00 $40,690.01 $42,690 $55.00 $42,650.01 $44,650 $57.00 $42,690.01 $44,690 $59.00 $44,650.01 $46,650 $61.00 $44,690.01 $46,690 $63.00 $46,650.01 $48,650 $65.00 $46,690.01 $48,690 $67.00 $48,650.01 $50,650 $69.00 $48,690.01 $50,690 $71.00 $50,650.01 $52,650 $73.00 $50,690.01 $52,690 $75.00 $52,650.01 $54,650 $77.00 $52,690.01 $54,690 $79.00 $54,650.01 $56,650 $81.00 $54,690.01 $56,690 $83.00 $56,650.01 $58,650 $86.00 $56,690.01 $58,690 $87.00 $58,650.01 $60,650 $90.00 $58,690.01 $60,690 $92.00 $60,650.01 $62,650 $94.00 $60,690.01 $62,690 $96.00 $62,650.01 $64,650 $98.00 $62,690.01 $64,690 $100.00 $64,650.01 $66,650 $102.00 $64,690.01 $66,690 $104.00 $66,650.01 $68,650 $106.00 $66,690.01 $68,690 $108.00 $68,650.01 $70,650 $110.00 $68,690.01 $70,690 $112.00 $70,650.01 $72,650 $114.00 $70,690.01 $72,690 $116.00 $72,650.01 $74,650 $118.00 $72,690.01 $74,690 $120.00 $74,650.01 $76,650 $122.00 $74,690.01 $76,690 $124.00 $76,650.01 $78,650 $126.00 $76,690.01 $78,690 $128.00 $78,650.01 $80,650 $130.00 $78,690.01 $80,690 $132.00 $80,650.01 $82,650 $135.00 $80,690.01 $82,690 $136.00 $82,650.01 $84,650 $140.00 $82,690.01 $84,690 $140.00 $84,650.01 $86,650 $145.00 $84,690.01 $86,690 $145.00 $86,650.01 $88,650 $150.00 $86,690.01 $88,690 $150.00 $88,650.01 $90,650 $155.00 $88,690.01 $90,690 $155.00 $90,650.01 $92,650 $160.00 $90,690.01 $92,690 $160.00 $92,650.01 $94,650 $165.00 $92,690.01 $94,690 $165.00 $94,650.01 $96,650 $170.00 $94,690.01 $96,690 $170.00 $96,650.01 $98,650 $175.00 $96,690.01 $98,690 $175.00 $98,650.01 $100,650 $180.00 $98,690.01 $100,690 $180.00 $100,650.01 $102,650 $185.00 $100,690.01 $102,690 $185.00 $102,650.01 $104,650 $190.00 $102,690.01 $104,690 $190.00 $104,650.01 $106,650 $195.00 $104,690.01 $106,690 $195.00 $106,650.01 $108,650 $200.00 $106,690.01 $108,690 $200.00 $108,650.01 $110,650 $205.00 $108,690.01 $110,690 $205.00 $110,650.01 $112,650 $210.00 $110,690.01 $112,690 $210.00 $112,650.01 $114,650 $215.00 $112,690.01 $114,690 $215.00 $114,650.01 $116,650 $221.00 $114,690.01 $116,690 $220.00 $116,650.01 $118,650 $227.00 $116,690.01 $118,690 $225.00 $118,650.01 $120,650 $233.00 $118,690.01 $120,690 $230.00 $120,650.01 $122,650 $239.00 $120,690.01 $122,690 $236.00 $122,650.01 $124,650 $245.00 $122,690.01 $124,690 $242.00 $124,650.01 $126,650 $251.00 $124,690.01 $126,690 $248.00 $126,650.01 $128,650 $257.00 $126,690.01 $128,690 $254.00 $128,650.01 $130,650 $263.00 $128,690.01 $130,690 $260.00 $130,650.01 $132,650 $269.00 $130,690.01 $132,690 $266.00 $132,650.01 $134,650 $275.00 $132,690.01 $134,690 $272.00 $134,650.01 $136,650 $281.00 $134,690.01 $136,690 $278.00 $136,650.01 $138,650 $287.00 $136,690.01 $137,922 $284.00 $138,650.01 $140,650 $290.00 $140,650.01 $142,650 $296.00 $142,650.01 $144,650 $302.00 $144,650.01 $146,650 $307.00 $146,650.01 $147,228 200% FPIG $117,380 200% FPIG $125,300 Weekly Family Size: 15 Weekly Family Size: 16 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $25,130 $10.00 $8,660.01 $26,870 $29.00 $25,130.01 $38,610 $31.00 $26,870.01 $42,570 $47.00 $38,610.01 $40,610 $51.00 $42,570.01 $44,570 $50.00 $40,610.01 $42,610 $54.00 $44,570.01 $46,570 $53.00 $42,610.01 $44,610 $58.00 $46,570.01 $48,570 $57.00 $44,610.01 $46,610 $62.00 $48,570.01 $50,570 $61.00 $46,610.01 $48,610 $66.00 $50,570.01 $52,570 $65.00 $48,610.01 $50,610 $70.00 $52,570.01 $54,570 $69.00 $50,610.01 $52,610 $74.00 $54,570.01 $56,570 $73.00 $52,610.01 $54,610 $78.00 $56,570.01 $58,570 $77.00 $54,610.01 $56,610 $82.00 $58,570.01 $60,570 $81.00 $56,610.01 $58,610 $86.00 $60,570.01 $62,570 $85.00 $58,610.01 $60,610 $90.00 $62,570.01 $64,570 $89.00 $60,610.01 $62,610 $94.00 $64,570.01 $66,570 $93.00 $62,610.01 $64,610 $99.00 $66,570.01 $68,570 $98.00 $64,610.01 $66,610 $104.00 $68,570.01 $70,570 $102.00 $66,610.01 $68,610 $108.00 $70,570.01 $72,570 $106.00 $68,610.01 $70,610 $112.00 $72,570.01 $74,570 $110.00 $70,610.01 $72,610 $116.00 $74,570.01 $76,570 $114.00 $72,610.01 $74,610 $120.00 $76,570.01 $78,570 $118.00 $74,610.01 $76,610 $124.00 $78,570.01 $80,570 $122.00 $76,610.01 $78,610 $128.00 $80,570.01 $82,570 $126.00 $78,610.01 $80,610 $132.00 $82,570.01 $84,570 $130.00 $80,610.01 $82,610 $136.00 $84,570.01 $86,570 $134.00 $82,610.01 $84,610 $140.00 $86,570.01 $88,570 $138.00 $84,610.01 $86,610 $144.00 $88,570.01 $90,570 $142.00 $86,610.01 $88,610 $148.00 $90,570.01 $92,570 $146.00 $88,610.01 $90,610 $152.00 $92,570.01 $94,570 $150.00 $90,610.01 $92,610 $156.00 $94,570.01 $96,570 $155.00 $92,610.01 $94,610 $160.00 $96,570.01 $98,570 $160.00 $94,610.01 $96,610 $165.00 $98,570.01 $100,570 $165.00 $96,610.01 $98,610 $170.00 $100,570.01 $102,570 $170.00 $98,610.01 $100,610 $175.00 $102,570.01 $104,570 $175.00 $100,610.01 $102,610 $180.00 $104,570.01 $106,570 $180.00 $102,610.01 $104,610 $185.00 $106,570.01 $108,570 $185.00 $104,610.01 $106,610 $190.00 $108,570.01 $110,570 $190.00 $106,610.01 $108,610 $195.00 $110,570.01 $112,570 $195.00 $108,610.01 $110,610 $200.00 $112,570.01 $114,570 $200.00 $110,610.01 $112,610 $205.00 $114,570.01 $116,570 $205.00 $112,610.01 $114,610 $210.00 $116,570.01 $118,570 $210.00 $114,610.01 $116,610 $215.00 $118,570.01 $120,570 $215.00 $116,610.01 $118,610 $220.00 $120,570.01 $122,570 $220.00 $118,610.01 $120,610 $225.00 $122,570.01 $124,570 $225.00 $120,610.01 $122,610 $230.00 $124,570.01 $126,570 $230.00 $122,610.01 $124,610 $235.00 $126,570.01 $128,570 $235.00 $124,610.01 $126,610 $240.00 $128,570.01 $130,570 $240.00 $126,610.01 $128,610 $245.00 $130,570.01 $132,570 $245.00 $128,610.01 $130,610 $250.00 $132,570.01 $134,570 $251.00 $130,610.01 $132,610 $255.00 $134,570.01 $136,570 $257.00 $132,610.01 $134,610 $260.00 $136,570.01 $138,570 $263.00 $134,610.01 $136,610 $266.00 $138,570.01 $140,570 $269.00 $136,610.01 $138,610 $272.00 $140,570.01 $142,570 $275.00 $138,610.01 $140,610 $278.00 $142,570.01 $144,570 $281.00 $140,610.01 $142,610 $284.00 $144,570.01 $146,570 $287.00 $142,610.01 $144,610 $290.00 $146,570.01 $148,570 $293.00 $144,610.01 $146,610 $296.00 $148,570.01 $150,570 $299.00 $146,610.01 $148,610 $302.00 $150,570.01 $152,570 $305.00 $148,610.01 $150,610 $308.00 $152,570.01 $154,570 $311.00 $150,610.01 $152,610 $314.00 $154,570.01 $156,570 $317.00 $152,610.01 $154,610 $320.00 $156,570.01 $158,570 $324.00 $154,610.01 $156,534 $326.00 $158,570.01 $160,570 $332.00 $160,570.01 $162,570 $338.00 $162,570.01 $164,570 $345.00 $164,570.01 $165,840 200% FPIG $133,220 200% FPIG $141,140 Weekly Family Size: 17 Weekly Family Size: 18 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $27,730 $10.00 $8,660.01 $28,600 $32.00 $27,730.01 $44,530 $33.00 $28,600.01 $46,490 $53.00 $44,530.01 $46,530 $56.00 $46,490.01 $48,490 $56.00 $46,530.01 $48,530 $59.00 $48,490.01 $50,490 $60.00 $48,530.01 $50,530 $62.00 $50,490.01 $52,490 $64.00 $50,530.01 $52,530 $66.00 $52,490.01 $54,490 $68.00 $52,530.01 $54,530 $70.00 $54,490.01 $56,490 $72.00 $54,530.01 $56,530 $74.00 $56,490.01 $58,490 $76.00 $56,530.01 $58,530 $78.00 $58,490.01 $60,490 $80.00 $58,530.01 $60,530 $82.00 $60,490.01 $62,490 $84.00 $60,530.01 $62,530 $86.00 $62,490.01 $64,490 $88.00 $62,530.01 $64,530 $90.00 $64,490.01 $66,490 $92.00 $64,530.01 $66,530 $94.00 $66,490.01 $68,490 $96.00 $66,530.01 $68,530 $98.00 $68,490.01 $70,490 $100.00 $68,530.01 $70,530 $102.00 $70,490.01 $72,490 $105.00 $70,530.01 $72,530 $106.00 $72,490.01 $74,490 $110.00 $72,530.01 $74,530 $111.00 $74,490.01 $76,490 $114.00 $74,530.01 $76,530 $116.00 $76,490.01 $78,490 $118.00 $76,530.01 $78,530 $120.00 $78,490.01 $80,490 $122.00 $78,530.01 $80,530 $124.00 $80,490.01 $82,490 $126.00 $80,530.01 $82,530 $128.00 $82,490.01 $84,490 $130.00 $82,530.01 $84,530 $132.00 $84,490.01 $86,490 $134.00 $84,530.01 $86,530 $136.00 $86,490.01 $88,490 $138.00 $86,530.01 $88,530 $140.00 $88,490.01 $90,490 $142.00 $88,530.01 $90,530 $144.00 $90,490.01 $92,490 $146.00 $90,530.01 $92,530 $148.00 $92,490.01 $94,490 $150.00 $92,530.01 $94,530 $152.00 $94,490.01 $96,490 $154.00 $94,530.01 $96,530 $156.00 $96,490.01 $98,490 $158.00 $96,530.01 $98,530 $160.00 $98,490.01 $100,490 $162.00 $98,530.01 $100,530 $164.00 $100,490.01 $102,490 $166.00 $100,530.01 $102,530 $168.00 $102,490.01 $104,490 $171.00 $102,530.01 $104,530 $172.00 $104,490.01 $106,490 $176.00 $104,530.01 $106,530 $176.00 $106,490.01 $108,490 $181.00 $106,530.01 $108,530 $181.00 $108,490.01 $110,490 $186.00 $108,530.01 $110,530 $186.00 $110,490.01 $112,490 $191.00 $110,530.01 $112,530 $191.00 $112,490.01 $114,490 $196.00 $112,530.01 $114,530 $196.00 $114,490.01 $116,490 $201.00 $114,530.01 $116,530 $201.00 $116,490.01 $118,490 $206.00 $116,530.01 $118,530 $206.00 $118,490.01 $120,490 $211.00 $118,530.01 $120,530 $211.00 $120,490.01 $122,490 $216.00 $120,530.01 $122,530 $216.00 $122,490.01 $124,490 $221.00 $122,530.01 $124,530 $221.00 $124,490.01 $126,490 $226.00 $124,530.01 $126,530 $226.00 $126,490.01 $128,490 $231.00 $126,530.01 $128,530 $231.00 $128,490.01 $130,490 $236.00 $128,530.01 $130,530 $236.00 $130,490.01 $132,490 $241.00 $130,530.01 $132,530 $241.00 $132,490.01 $134,490 $246.00 $132,530.01 $134,530 $246.00 $134,490.01 $136,490 $251.00 $134,530.01 $136,530 $251.00 $136,490.01 $138,490 $256.00 $136,530.01 $138,530 $256.00 $138,490.01 $140,490 $261.00 $138,530.01 $140,530 $261.00 $140,490.01 $142,490 $266.00 $140,530.01 $142,530 $266.00 $142,490.01 $144,490 $271.00 $142,530.01 $144,530 $271.00 $144,490.01 $146,490 $276.00 $144,530.01 $146,530 $276.00 $146,490.01 $148,490 $282.00 $146,530.01 $148,530 $281.00 $148,490.01 $150,490 $288.00 $148,530.01 $150,530 $286.00 $150,490.01 $152,490 $294.00 $150,530.01 $152,530 $292.00 $152,490.01 $154,490 $300.00 $152,530.01 $154,530 $298.00 $154,490.01 $156,490 $306.00 $154,530.01 $156,530 $304.00 $156,490.01 $158,490 $312.00 $156,530.01 $158,530 $310.00 $158,490.01 $160,490 $318.00 $158,530.01 $160,530 $316.00 $160,490.01 $162,490 $324.00 $160,530.01 $162,530 $322.00 $162,490.01 $164,490 $330.00 $162,530.01 $164,530 $328.00 $164,490.01 $166,490 $336.00 $164,530.01 $166,530 $334.00 $166,490.01 $168,490 $342.00 $166,530.01 $168,530 $340.00 $168,490.01 $170,490 $348.00 $168,530.01 $170,530 $346.00 $170,490.01 $172,490 $354.00 $170,530.01 $172,530 $352.00 $172,490.01 $174,490 $360.00 $172,530.01 $174,530 $358.00 $174,490.01 $176,490 $366.00 $174,530.01 $175,146 $364.00 $176,490.01 $178,490 $370.00 $178,490.01 $180,490 $376.00 $180,490.01 $182,490 $383.00 $182,490.01 $184,452 200% FPIG $149,060 200% FPIG $156,980 Weekly Family Size: 19 Weekly Family Size: 20 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $5.00 Less than: $8,660 $10.00 $8,660.01 $29,470 $10.00 $8,660.01 $30,330 $34.00 $29,470.01 $48,450 $35.00 $30,330.01 $50,410 $58.00 $48,450.01 $50,450 $60.00 $50,410.01 $52,410 $61.00 $50,450.01 $52,450 $63.00 $52,410.01 $54,410 $64.00 $52,450.01 $54,450 $66.00 $54,410.01 $56,410 $68.00 $54,450.01 $56,450 $70.00 $56,410.01 $58,410 $72.00 $56,450.01 $58,450 $74.00 $58,410.01 $60,410 $76.00 $58,450.01 $60,450 $78.00 $60,410.01 $62,410 $80.00 $60,450.01 $62,450 $82.00 $62,410.01 $64,410 $84.00 $62,450.01 $64,450 $86.00 $64,410.01 $66,410 $88.00 $64,450.01 $66,450 $90.00 $66,410.01 $68,410 $92.00 $66,450.01 $68,450 $94.00 $68,410.01 $70,410 $96.00 $68,450.01 $70,450 $98.00 $70,410.01 $72,410 $100.00 $70,450.01 $72,450 $102.00 $72,410.01 $74,410 $104.00 $72,450.01 $74,450 $106.00 $74,410.01 $76,410 $108.00 $74,450.01 $76,450 $110.00 $76,410.01 $78,410 $112.00 $76,450.01 $78,450 $114.00 $78,410.01 $80,410 $117.00 $78,450.01 $80,450 $118.00 $80,410.01 $82,410 $122.00 $80,450.01 $82,450 $123.00 $82,410.01 $84,410 $126.00 $82,450.01 $84,450 $128.00 $84,410.01 $86,410 $130.00 $84,450.01 $86,450 $132.00 $86,410.01 $88,410 $134.00 $86,450.01 $88,450 $136.00 $88,410.01 $90,410 $138.00 $88,450.01 $90,450 $140.00 $90,410.01 $92,410 $142.00 $90,450.01 $92,450 $144.00 $92,410.01 $94,410 $146.00 $92,450.01 $94,450 $148.00 $94,410.01 $96,410 $150.00 $94,450.01 $96,450 $152.00 $96,410.01 $98,410 $154.00 $96,450.01 $98,450 $156.00 $98,410.01 $100,410 $158.00 $98,450.01 $100,450 $160.00 $100,410.01 $102,410 $162.00 $100,450.01 $102,450 $164.00 $102,410.01 $104,410 $166.00 $102,450.01 $104,450 $168.00 $104,410.01 $106,410 $170.00 $104,450.01 $106,450 $172.00 $106,410.01 $108,410 $174.00 $106,450.01 $108,450 $176.00 $108,410.01 $110,410 $178.00 $108,450.01 $110,450 $180.00 $110,410.01 $112,410 $182.00 $110,450.01 $112,450 $184.00 $112,410.01 $114,410 $186.00 $112,450.01 $114,450 $188.00 $114,410.01 $116,410 $191.00 $114,450.01 $116,450 $192.00 $116,410.01 $118,410 $196.00 $116,450.01 $118,450 $196.00 $118,410.01 $120,410 $201.00 $118,450.01 $120,450 $201.00 $120,410.01 $122,410 $206.00 $120,450.01 $122,450 $206.00 $122,410.01 $124,410 $211.00 $122,450.01 $124,450 $211.00 $124,410.01 $126,410 $216.00 $124,450.01 $126,450 $216.00 $126,410.01 $128,410 $221.00 $126,450.01 $128,450 $221.00 $128,410.01 $130,410 $226.00 $128,450.01 $130,450 $226.00 $130,410.01 $132,410 $231.00 $130,450.01 $132,450 $231.00 $132,410.01 $134,410 $236.00 $132,450.01 $134,450 $236.00 $134,410.01 $136,410 $241.00 $134,450.01 $136,450 $241.00 $136,410.01 $138,410 $246.00 $136,450.01 $138,450 $246.00 $138,410.01 $140,410 $251.00 $138,450.01 $140,450 $251.00 $140,410.01 $142,410 $256.00 $140,450.01 $142,450 $256.00 $142,410.01 $144,410 $261.00 $142,450.01 $144,450 $261.00 $144,410.01 $146,410 $266.00 $144,450.01 $146,450 $266.00 $146,410.01 $148,410 $271.00 $146,450.01 $148,450 $271.00 $148,410.01 $150,410 $276.00 $148,450.01 $150,450 $276.00 $150,410.01 $152,410 $281.00 $150,450.01 $152,450 $281.00 $152,410.01 $154,410 $286.00 $152,450.01 $154,450 $286.00 $154,410.01 $156,410 $291.00 $154,450.01 $156,450 $291.00 $156,410.01 $158,410 $296.00 $156,450.01 $158,450 $296.00 $158,410.01 $160,410 $301.00 $158,450.01 $160,450 $301.00 $160,410.01 $162,410 $307.00 $160,450.01 $162,450 $306.00 $162,410.01 $164,410 $313.00 $162,450.01 $164,450 $311.00 $164,410.01 $166,410 $319.00 $164,450.01 $166,450 $316.00 $166,410.01 $168,410 $325.00 $166,450.01 $168,450 $321.00 $168,410.01 $170,410 $331.00 $168,450.01 $170,450 $327.00 $170,410.01 $172,410 $337.00 $170,450.01 $172,450 $333.00 $172,410.01 $174,410 $343.00 $172,450.01 $174,450 $339.00 $174,410.01 $176,410 $349.00 $174,450.01 $176,450 $345.00 $176,410.01 $178,410 $355.00 $176,450.01 $178,450 $351.00 $178,410.01 $180,410 $361.00 $178,450.01 $180,450 $357.00 $180,410.01 $182,410 $367.00 $180,450.01 $182,450 $363.00 $182,410.01 $184,410 $373.00 $182,450.01 $184,450 $369.00 $184,410.01 $186,410 $379.00 $184,450.01 $186,450 $375.00 $186,410.01 $188,410 $385.00 $186,450.01 $188,450 $381.00 $188,410.01 $190,410 $391.00 $188,450.01 $190,450 $387.00 $190,410.01 $192,410 $397.00 $190,450.01 $192,450 $393.00 $192,410.01 $194,410 $403.00 $192,450.01 $193,758 $399.00 $194,410.01 $196,410 $405.00 $196,410.01 $198,410 $411.00 $198,410.01 $200,410 $417.00 $200,410.01 $202,410 $424.00 $202,410.01 $203,064 200% FPIG $164,900 200% FPIG $172,820 Weekly Family Size: 21 Weekly Family Size: 21 Co-pay Annual Income Co-pay Annual Income $5.00 Less than: $8,660 $222.00 $130,370.01 $132,370 $10.00 $8,660.01 $32,070 $227.00 $132,370.01 $134,370 $37.00 $32,070.01 $52,370 $232.00 $134,370.01 $136,370 $63.00 $52,370.01 $54,370 $237.00 $136,370.01 $138,370 $66.00 $54,370.01 $56,370 $242.00 $138,370.01 $140,370 $69.00 $56,370.01 $58,370 $247.00 $140,370.01 $142,370 $72.00 $58,370.01 $60,370 $252.00 $142,370.01 $144,370 $76.00 $60,370.01 $62,370 $257.00 $144,370.01 $146,370 $80.00 $62,370.01 $64,370 $262.00 $146,370.01 $148,370 $84.00 $64,370.01 $66,370 $267.00 $148,370.01 $150,370 $88.00 $66,370.01 $68,370 $272.00 $150,370.01 $152,370 $92.00 $68,370.01 $70,370 $277.00 $152,370.01 $154,370 $96.00 $70,370.01 $72,370 $282.00 $154,370.01 $156,370 $100.00 $72,370.01 $74,370 $287.00 $156,370.01 $158,370 $104.00 $74,370.01 $76,370 $292.00 $158,370.01 $160,370 $108.00 $76,370.01 $78,370 $297.00 $160,370.01 $162,370 $112.00 $78,370.01 $80,370 $302.00 $162,370.01 $164,370 $116.00 $80,370.01 $82,370 $307.00 $164,370.01 $166,370 $120.00 $82,370.01 $84,370 $312.00 $166,370.01 $168,370 $124.00 $84,370.01 $86,370 $317.00 $168,370.01 $170,370 $129.00 $86,370.01 $88,370 $322.00 $170,370.01 $172,370 $134.00 $88,370.01 $90,370 $327.00 $172,370.01 $174,370 $138.00 $90,370.01 $92,370 $332.00 $174,370.01 $176,370 $142.00 $92,370.01 $94,370 $338.00 $176,370.01 $178,370 $146.00 $94,370.01 $96,370 $344.00 $178,370.01 $180,370 $150.00 $96,370.01 $98,370 $350.00 $180,370.01 $182,370 $154.00 $98,370.01 $100,370 $356.00 $182,370.01 $184,370 $158.00 $100,370.01 $102,370 $362.00 $184,370.01 $186,370 $162.00 $102,370.01 $104,370 $368.00 $186,370.01 $188,370 $166.00 $104,370.01 $106,370 $374.00 $188,370.01 $190,370 $170.00 $106,370.01 $108,370 $380.00 $190,370.01 $192,370 $174.00 $108,370.01 $110,370 $386.00 $192,370.01 $194,370 $178.00 $110,370.01 $112,370 $392.00 $194,370.01 $196,370 $182.00 $112,370.01 $114,370 $398.00 $196,370.01 $198,370 $186.00 $114,370.01 $116,370 $404.00 $198,370.01 $200,370 $190.00 $116,370.01 $118,370 $410.00 $200,370.01 $202,370 $194.00 $118,370.01 $120,370 $416.00 $202,370.01 $204,370 $198.00 $120,370.01 $122,370 $422.00 $204,370.01 $206,370 $202.00 $122,370.01 $124,370 $428.00 $206,370.01 $208,370 $207.00 $124,370.01 $126,370 $434.00 $208,370.01 $210,370 $212.00 $126,370.01 $128,370 $441.00 $210,370.01 $212,370 $217.00 $128,370.01 $130,370 200% FPIG $180,740 [Pa.B. Doc. No. 12-946. Filed for public inspection May 18, 2012, 9:00 a.m.]
