Voluntary Co-Payment and Cost Sharing Schedules

Issue Date: December 2, 2008
Effective 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 - $26,91350%$35,145 - $36,33350%
$26,914 - $28,93155%$36,334 - $38,35055%
$28,932 - $30,95160%$38,351 - $40,37260%
$30,952 - $32,96865%$40,373 - $42,38865%
$32,969 - $34,98670%$42,389 - $44,40670%
$34,987 - $37,00775%$44,407 - $46,42575%
$37,008 - $39,02280%$46,426 - $48,44480%
$39,023 - $41,04185%$48,445 - $50,46185%
$41,042 - $43,06290%$50,462 - $52,48190%
$43,063 - $45,07995%$52,482 - $54,50195%
$45,080 and over100%$54,502 and over100%