Patient Share of Cost Table [33 Pa.B. 4754] The Patient Share of Cost Table is revised each year based on the release of HHS Federal poverty guidelines by the United States Department of Health and Human Services. These figures were published 68 FR 6456--6458.
Bureau of Family Health Division of Program Support and Coordination Patient Share of Cost (PSC) Table Effective April 1, 2003 PSC
$0
$0
$50
$250
$400
$550
$700
$850
$1,000
$1,150
% of
Poverty
0 to
100%
>100 to
185%
>185 to
225%
>225 to
250%
>250 to
275%
>275 to
300%
>300 to
325%
>325 to
350%
>350 to
375%
>375 to
400%
Size of Family Unit Income Ranges
Use these columns only for clients who were in DSHCP programs prior to January 1, 1997, and have continuous participation without a lapse in eligibility. 1 0 8,981 16,614 20,206 22,451 24,696 26,941 29,186 31,431 33,676 8,980 16,613 20,205 22,450 24,695 26,940 29,185 31,430 33,675 35,920 2 0 12,121 22,423 27,271 30,301 33,331 36,361 39,391 42,421 45,451 12,120 22,422 27,270 30,300 33,330 36,360 39,390 42,420 45,450 48,480 3 0 15,261 28,232 34,336 38,151 41,966 45,781 49,596 53,411 57,226 15,260 28,231 34,335 38,150 41,965 45,780 49,595 53,410 57,225 61,040 4 0 18,401 34,041 41,401 46,001 50,601 55,201 59,801 64,401 69,001 18,400 34,040 41,400 46,000 50,600 55,200 59,800 64,400 69,000 73,600 5 0 21,541 39,850 48,466 53,851 59,236 64,621 70,006 75,391 80,776 21,540 39,849 48,465 53,850 59,235 64,620 70,005 75,390 80,775 86,160 6 0 24,681 45,659 55,531 61,701 67,871 74,041 80,211 86,381 92,551 24,680 45,658 55,530 61,700 67,870 74,040 80,210 86,380 92,550 98,720 7 0 27,821 51,468 62,596 69,551 76,506 83,461 90,416 97,371 104,326 27,820 51,467 62,595 69,550 76,505 83,460 90,415 97,370 104,325 111,280 8 0 30,961 57,277 69,661 77,401 85,141 92,881 100,621 108,361 116,101 30,960 57,276 69,660 77,400 85,140 92,880 100,620 108,360 116,100 123,840 9 0 34,101 63,086 76,726 85,251 93,776 102,301 110,826 119,351 127,876 34,100 63,085 76,725 85,250 93,775 102,300 110,825 119,350 127,875 136,400 10 0 37,241 68,895 83,791 93,101 102,411 111,721 121,031 130,341 139,651 37,240 68,894 83,790 93,100 102,410 111,720 121,030 130,340 139,650 148,960 11 0 40,381 74,704 90,856 100,951 111,046 121,141 131,236 141,331 151,426 40,380 74,703 90,855 100,950 111,045 121,140 131,235 141,330 151,425 161,520 12 0 43,521 80,513 97,921 108,801 119,681 130,561 141,441 152,321 163,201 43,520 80,512 97,920 108,800 119,680 130,560 141,440 152,320 163,200 174,080 13 0 46,661 86,322 104,986 116,651 128,316 139,981 151,646 163,311 174,976 46,660 86,321 104,985 116,650 128,315 139,980 151,645 163,310 174,975 186,640 14 0 49,801 92,131 112,051 124,501 136,951 149,401 161,851 174,301 186,751 49,800 92,130 112,050 124,500 136,950 149,400 161,850 174,300 186,750 199,200 15 0 52,941 97,940 119,116 132,351 145,586 158,821 172,056 185,291 198,526 52,940 97,939 119,115 132,350 145,585 158,820 172,055 185,290 198,525 211,760 16 0 56,081 103,749 126,181 140,201 154,221 168,241 182,261 196,281 210,301 56,080 103,748 126,180 140,200 154,220 168,240 182,260 196,280 210,300 224,320 17 0 59,221 109,558 133,246 148,051 162,856 177,661 192,466 207,271 222,076 59,220 109,557 133,245 148,050 162,855 177,660 192,465 207,270 222,075 236,880 18 0 62,361 115,367 140,311 155,901 171,491 187,081 202,671 218,261 233,851 62,360 115,366 140,310 155,900 171,490 187,080 202,670 218,260 233,850 249,440 19 0 65,501 121,176 147,376 163,751 180,126 196,501 212,876 229,251 245,626 65,500 121,175 147,375 163,750 180,125 196,500 212,875 229,250 245,625 262,000 20 0 68,641 126,985 154,441 171,601 188,761 205,921 223,081 240,241 257,401 68,640 126,984 154,440 171,600 188,760 205,920 223,080 240,240 257,400 274,560 CALVIN B. JOHNSON, M.D., M.P.H.,
Secretary[Pa.B. Doc. No. 03-1857. Filed for public inspection September 19, 2003, 9:00 a.m.]
