eLaws | eCases | State of Pennsylvania |
 Pennsylvania Code (Last Updated: April 5, 2016)
 Title 55. PUBLIC WELFARE
 PART II. Public Assistance Manual
 Subpart C. Eligibility Requirements
 Chapter 140. Special MA Eligibility Provisions
 SubChapter E. THE CATEGORICALLY NEEDY BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT PROGRAM FOR QUALIFIED WOMEN

  Appendix B.

Latest version.


  • MEDICAID FOR CHILDREN WITH SPECIAL NEEDS MONTHLY PREMIUM CHART



    Family Size

    Parents
    Annual Income

    At least—Less Than     		2 3 4 5 6 7 8 Each Additional member
    $0-$39,999.99 NO PREMIUM IF INCOME BELOW 200% FPIG
    $40-$49,999.99 $30 $29 $27 $26 $24 $0 $0 $0
    $50-$59,999.99 $40 $38 $36 $34 $33 $31 $0 $0
    $60-$69,999.99 $50 $48 $45 $43 $41 $39 $37 $0
    $70-$79,999.99 $60 $57 $54 $51 $49 $46 $43 $0
    $80-$89,999.99 $75 $71 $68 $64 $61 $58 $55 (-$3)
    $90-$99,999.99 $100 $95 $90 $86 $81 $77 $73 (-$4)
    $100-$109,999.99 $150 $143 $135 $129 $122 $116 $111 (-$5)
    $110-$119,999.99 $200 $190 $181 $171 $163 $155 $148 (-$7)
    $120-$129,999.99 $250 $238 $226 $214 $204 $193 $185 (-$8)
    $130-$139,999.99 $300 $285 $271 $257 $244 $232 $222 (-$10)
    $140-$149,999.99 $350 $333 $316 $300 $285 $271 $259 (-$12)
    $150-$159,999.99 $400 $380 $361 $343 $326 $310 $297 (-$13)
    $160-$169,999.99 $475 $451 $429 $407 $387 $368 $352 (-$16)
    $170-$179,999.99 $600 $570 $542 $514 $489 $464 $442 (-$22)
    $180-$189,999.99 $675 $641 $609 $579 $550 $522 $497 (-$25)
    $190-$199,999.99 $800 $760 $722 $686 $652 $619 $588 (-$31)
    $200-$249,999.99 $925 $879 $835 $793 $753 $716 $679 (-$37)
    $250-$299,999.99 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
    $300-$349,999.99 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
    $350-$399,999.99 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
    $400-$449.999.00 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
    $450-$499,999.99 $1,000 $950 $903 $857 $815 $774 $739 (-$35)
    $500,000 + $1,000 $950 $903 $857 $815 $774 $739 (-$35)



    Source

    The provisions of this Appendix B adopted December 30, 2005, effective upon receipt of written notification that the United States Department of Health and Human Services has granted the waiver requested by the Department under section 1115 of the Social Security Act, the Department will publish notice thereof in the Pennsylvania Bulletin. The regulations adopted by this order become effective 30 days after receipt of the Federal waiver, 35 Pa.B. 7013.

    Cross References

    This appendix is cited in 55 Pa. Code § 140.604 (relating to premiums).