Voluntary Co-Payment and Cost Sharing Schedules

Issue Date: February 17, 2017
Effective Date: March 1, 2017

Voluntary Co-Payment

Family SizeAnnual Gross IncomeVoluntary Monthly Co-payment
1$12,061 or less$10.00
2$16,241 or less$18.00

Cost Sharing for Home Care

One Person
Annual Gross Income
Monthly
Co-payment
Two Person Family
Annual Gross Income
Monthly
Co-payment
$12,062 - $14,536$10.00$16,242 - $20,034$18.00
$14,537 - $17,151$13.00$20,035 - $24,080$23.00
$17,152 - $18,944$27.00$24,081 - $26,118$52.00
$18,945 - $20,299$39.00$26,119 - $28,150$78.00
$20,300 - $21,653$49.00$28,151 - $30,188$92.00
$21,654 - $23,002$69.00$30,189 - $32,227$110.00
$23,003 - $24,358$90.00$32,228 - $34,259$120.00
$24,359 - $25,707$125.00$34,260 - $36,298$139.00
$25,708 - $27,094$141.00$36,299 - $38,337$152.00

Cost Sharing for Over Income

One Person
Annual Gross Income
Monthly
Co-payment
Two Person Family
Annual Gross Income
Monthly
Co-payment
$27,095 - $29,35850%$38,338 - $39,63550%
$29,359 - $31,56055%$39,636 - $41,83455%
$31,561 - $33,76360%$41,835 - $44,04060%
$33,764 - $35,96465%$44,041 - $46,24065%
$35,965 - $38,16470%$46,241 - $48,44170%
$38,165 - $40,37075%$48,442 - $50,64375%
$40,371 - $42,56780%$50,644 - $52,84680%
$42,568 - $44,77085%$52,847 - $55,04785%
$44,771 - $46,97590%$55,048 - $57,24890%
$46,976 - $49,17595%$57,249 - $59,45395%
$49,176 and over100%$59,454 and over100%