Voluntary Co-Payment and Cost Sharing Schedules

Issue Date: March 1, 2016
Effective Date: March 1, 2016

Voluntary Co-Payment

Family SizeAnnual Gross IncomeVoluntary Monthly Co-payment
1$11,881 or less$10/month
2$16,021 or less$18/month

Cost Sharing for Home Care

One Person
Annual Gross Income
Monthly
Co-payment
Two Person Family
Annual Gross Income
Monthly
Co-payment
$11,882 - $14,493$10$16,022 - $19,974$18
$14,494 - $17,100$13$19,975 - $24,008$23
$17,101 - $18,887$27$24,009 - $26,040$52
$18,888 - $20,238$39$26,041 - $28,066$78
$20,239 - $21,588$49$28,067 - $30,098$92
$21,589 - $22,933$69$30,099 - $32,131$110
$22,934 - $24,285$90$32,132 - $34,157$120
$24,286 - $25,630$125$34,158 - $36,189$139
$25,631 - $27,013$141$36,190 - $38,222$152

Cost Sharing for Respite Care

One Person
Annual Gross Income
Monthly
Co-payment
Two Person Family
Annual Gross Income
Monthly
Co-payment
$27,014 - $29,27050%$38,223 - $39,51650%
$29,271 - $31,46655%$39,517 - $41,70955%
$31,467 - $33,66260%$41,710 - $43,90860%
$33,663 - $35,85665%$43,909 - $46,10265%
$35,857 - $38,05070%$46,103 - $48,29670%
$38,051 - $40,24975%$48,297 - $50,49275%
$40,250 - $42,44080%$50,493 - $52,68880%
$42,441 - $44,63685%$52,689 - $54,88285%
$44,637 - $46,83490%$54,883 - $57,07790%
$46,835 - $49,02895%$57,078 - $59,27595%
$49,029 and over100%$59,276 and over100%