Payment Information
Voluntary Co-Payment and Cost Sharing Schedules
Issue Date: December 2, 2008Effective Date: January 1, 2009
Voluntary Co-Payment
| Family Size | Annual Gross Income | Voluntary Co-payment |
|---|---|---|
| 1 | $10,093 or less | $9/month |
| 2 | $14,645 or less | $17/month |
Cost Sharing for Home Care
| One Person Annual Gross Income | Monthly Co-payment | Two Person Family Annual Gross Income | Monthly Co-payment |
|---|---|---|---|
| $10,924 - $13,325 | $9 | $14,646 - $18,366 | $17 |
| $13,326 - $15,723 | $12 | $18,367 - $22,074 | $21 |
| $15,724 - $17,366 | $25 | $22,075 - $23,943 | $48 |
| $17,367 - $18,608 | $36 | $23,944 - $25,806 | $72 |
| $18,609 - $19,848 | $45 | $25,807 - $27,675 | $85 |
| $19,849 - $21,087 | $63 | $27,676 - $29,543 | $101 |
| $21,088 - $22,329 | $83 | $29,544 - $31,406 | $110 |
| $22,330 - $23,567 | $115 | $31,407 - $33,274 | $128 |
| $23,568 - $24,837 | $130 | $33,275 - $35,144 | $140 |
Cost Sharing for Respite Care
| One Person Annual Gross Income | Monthly Co-payment | Two Person Family Annual Gross Income | Monthly Co-payment |
|---|---|---|---|
| $24,838 - $26,913 | 50% | $35,145 - $36,333 | 50% |
| $26,914 - $28,931 | 55% | $36,334 - $38,350 | 55% |
| $28,932 - $30,951 | 60% | $38,351 - $40,372 | 60% |
| $30,952 - $32,968 | 65% | $40,373 - $42,388 | 65% |
| $32,969 - $34,986 | 70% | $42,389 - $44,406 | 70% |
| $34,987 - $37,007 | 75% | $44,407 - $46,425 | 75% |
| $37,008 - $39,022 | 80% | $46,426 - $48,444 | 80% |
| $39,023 - $41,041 | 85% | $48,445 - $50,461 | 85% |
| $41,042 - $43,062 | 90% | $50,462 - $52,481 | 90% |
| $43,063 - $45,079 | 95% | $52,482 - $54,501 | 95% |
| $45,080 and over | 100% | $54,502 and over | 100% |