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COMMONWEALTH OF PENNSYLVANIA

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PA Bulletin, Doc. No. 21-679

NOTICES

DEPARTMENT OF
HUMAN SERVICES

Income Limits and Co-payments for the Subsidized Child Care Program

[51 Pa.B. 2451]
[Saturday, May 1, 2021]

 This notice increases the income limits codified at 55 Pa. Code Chapter 3041, Appendix B (relating to co-payment chart family co-payment scale (based on the 2021 Federal Poverty Income Guidelines)) under 55 Pa. Code § 3041.107(b) (relating to availability and use of the Federal Poverty Income Guidelines). This increase is effective May 3, 2021.

 Section 3041.107(b) of 55 Pa. Code requires the Department of Human Services to update the co-payment schedule in 55 Pa. Code Chapter 3041, Appendix B to reflect changes in the Federal Poverty Income Guidelines (FPIG). Effective May 3, 2021, the income guidelines for the subsidized child care program are being raised due to increases in the FPIG. Under section 408.3 of the Human Services Code (62 P.S. § 408.3), the co-payment schedule is adjusted to reflect the increases. Chapter 3041, Appendix B of 55 Pa. Code also establishes the family co-payment levels according to the family's computed annual income and lists the weekly family co-payment based on the annual family income.

MEG SNEAD, 
Acting Secretary

Fiscal Note: 14-NOT-1434. No fiscal impact; (8) recommends adoption.


CO-PAYMENT CHART
FAMILY CO-PAYMENT SCALE EFFECTIVE MAY 3, 2021
(BASED ON THE 2021 FEDERAL POVERTY INCOME GUIDELINES)

Weekly  Family Size: 1  Weekly  Family Size: 2  Weekly  Family Size: 3
Co-pay
Annual Income
Co-pay
Annual Income
Co-pay
Annual Income
$5 Less than: $6,054 $5 Less than: $6,141 $5 Less than: $7,741
$6 $6,054.01 $6,810 $6 $6,141.01 $7,164 $7 $7,741.01 $9,031
$7 $6,810.01 $7,567 $7 $7,164.01 $8,187 $9 $9,031.01 $10,321
$8 $7,567.01 $8,324 $8 $8,187.01 $9,211 $10 $10,321.01 $11,611
$10 $8,324.01 $9,080 $10 $9,211.01 $10,234 $12 $11,611.01 $12,902
$11 $9,080.01 $9,837 $11 $10,234.01 $11,258 $14 $12,902.01 $14,192
$12 $9,837.01 $10,594 $13 $11,258.01 $12,281 $16 $14,192.01 $15,482
$14 $10,594.01 $11,351 $15 $12,281.01 $13,305 $19 $15,482.01$16,772
$16 $11,351.01 $12,107 $17 $13,305.01 $14,328 $21 $16,772.01 $18,062
$17 $12,107.01 $12,864 $19 $14,328.01 $15,351 $24 $18,062.01 $19,352
$19 $12,864.01 $13,621 $21 $15,351.01 $16,375 $27 $19,352.01 $20,642
$21 $13,621.01 $14,377 $23 $16,375.01 $17,398 $29 $20,642.01 $21,933
$22 $14,377.01 $15,134 $26 $17,398.01 $18,422 $32 $21,933.01 $23,223
$24 $15,134.01 $15,891 $28 $18,422.01 $19,445 $35 $23,223.01 $24,513
$25 $15,891.01 $16,647 $30 $19,445.01 $20,469 $38 $24,513.01 $25,803
$27 $16,647.01 $17,404 $32 $20,469.01 $21,492 $40 $25,803.01 $27,093
$29 $17,404.01 $18,161 $34 $21,492.01 $22,515 $43 $27,093.01 $28,383
$30 $18,161.01 $18,918 $36 $22,515.01 $23,539 $46 $28,383.01 $29,673
$32 $18,918.01 $19,674 $39 $23,539.01 $24,562 $49 $29,673.01 $30,964
$34 $19,674.01 $20,431 $41 $24,562.01 $25,586 $52 $30,964.01 $32,254
$36 $20,431.01 $21,188 $43 $25,586.01 $26,609 $55 $32,254.01 $33,544
$37 $21,188.01 $21,944 $46 $26,609.01 $27,632 $58 $33,544.01 $34,834
$39 $21,944.01 $22,701 $48 $27,632.01 $28,656 $61 $34,834.01 $36,124
$41 $22,701.01 $23,458 $51 $28,656.01 $29,679 $64 $36,124.01 $37,414
$43 $23,458.01 $24,214 $53 $29,679.01 $30,703 $67 $37,414.01 $38,705
$45 $24,214.01 $24,971 $56 $30,703.01 $31,726 $71 $38,705.01 $39,995
$47 $24,971.01 $25,728 $59 $31,726.01 $32,750 $74 $39,995.01 $41,285
$50 $25,728.01 $26,485 $61 $32,750.01 $33,773 $77 $41,285.01 $42,575
$52 $26,485.01 $27,241 $64 $33,773.01 $34,796 $81 $42,575.01 $43,865
$54 $27,241.01 $27,998 $67 $34,796.01 $35,820 $85 $43,865.01 $45,155
$56 $27,998.01 $28,755 $70 $35,820.01 $36,843 $88 $45,155.01 $46,445
$58 $28,755.01 $29,511 $73 $36,843.01 $37,867 $92 $46,445.01 $47,736
$61 $29,511.01 $30,268 $76 $37,867.01 $38,890 $96 $47,736.01 $49,026
200% FPIG $25,760 $79 $38,890.01 $39,914 $100 $49,026.01 $50,316
$82 $39,914.01 $40,937 $104 $50,316.01 $51,606
200% FPIG $34,840 200% FPIG $43,920
Weekly  Family Size: 4  Weekly  Family Size: 5  Weekly  Family Size: 6
Co-pay
Annual Income
Co-pay
Annual Income
Co-pay
Annual Income
$5 Less than: $7,784 $5 Less than: $7,294 $5 Less than: $8,361
$7 $7,784.01 $9,341 $6 $7,294.01 $9,118 $7 $8,361.01 $10,452
$8 $9,341.01 $10,898 $8 $9,118.01 $10,942 $9 $10,452.01 $12,542
$10 $10,898.01 $12,455 $10 $10,942.01 $12,765 $11 $12,542.01 $14,632
$12 $12,455.01 $14,012 $12 $12,765.01 $14,589 $14 $14,632.01 $16,723
$15 $14,012.01 $15,569 $15 $14,589.01 $16,412 $17 $16,723.01 $18,813
$17 $15,569.01 $17,126 $17 $16,412.01 $18,236 $20 $18,813.01 $20,903
$20 $17,126.01 $18,683 $20 $18,236.01 $20,060 $23 $20,903.01 $22,994
$23 $18,683.01 $20,239 $23 $20,060.01 $21,883 $27 $22,994.01 $25,084
$26 $20,239.01 $21,796 $27 $21,883.01 $23,707 $30 $25,084.01 $27,174
$29 $21,796.01 $23,353 $30 $23,707.01 $25,530 $34 $27,174.01 $29,265
$32 $23,353.01 $24,910 $34 $25,530.01 $27,354 $39 $29,265.01 $31,355
$36 $24,910.01 $26,467 $38 $27,354.01 $29,178 $43 $31,355.01 $33,445
$39 $26,467.01 $28,024 $42 $29,178.01 $31,001 $48 $33,445.01 $35,536
$42 $28,024.01 $29,581 $46 $31,001.01 $32,825 $53 $35,536.01 $37,626
$45 $29,581.01 $31,138 $49 $32,825.01 $34,648 $57 $37,626.01 $39,716
$49 $31,138.01 $32,694 $53 $34,648.01 $36,472 $61 $39,716.01 $41,807
$52 $32,694.01 $34,251 $57 $36,472.01 $38,296 $65 $41,807.01 $43,897
$55 $34,251.01 $35,808 $61 $38,296.01 $40,119 $70 $43,897.01 $45,987
$59 $35,808.01 $37,365 $65 $40,119.01 $41,943 $74 $45,987.01 $48,077
$62 $37,365.01 $38,922 $69 $41,943.01 $43,766 $79 $48,077.01 $50,168
$66 $38,922.01 $40,479 $73 $43,766.01 $45,590 $83 $50,168.01 $52,258
$69 $40,479.01 $42,036 $77 $45,590.01 $47,414 $88 $52,258.01 $54,348
$73 $42,036.01 $43,593 $81 $47,414.01 $49,237 $93 $54,348.01 $56,439
$77 $43,593.01 $45,149 $86 $49,237.01 $51,061 $98 $56,439.01 $58,529
$81 $45,149.01 $46,706 $90 $51,061.01 $52,884 $104 $58,529.01 $60,619
$85 $46,706.01 $48,263 $95 $52,884.01 $54,708 $109 $60,619.01 $62,710
$89 $48,263.01 $49,820 $100 $54,708.01 $56,532 $114 $62,710.01 $64,800
$93 $49,820.01 $51,377 $104 $56,532.01 $58,355 $120 $64,800.01 $66,890
$98 $51,377.01 $52,934 $109 $58,355.01 $60,179 $125 $66,890.01 $68,981
$102 $52,934.01 $54,491 $114 $60,179.01 $62,002 $131 $68,981.01 $71,071
$106 $54,491.01 $56,048 $119 $62,002.01 $63,826 $137 $71,071.01 $73,161
$111 $56,048.01 $57,604 $125 $63,826.01 $65,650 $143 $73,161.01 $75,252
$116 $57,604.01 $59,161 $130 $65,650.01 $67,473 $149 $75,252.01 $77,342
$120 $59,161.01 $60,718 $135 $67,473.01 $69,297 $155 $77,342.01 $79,432
$125 $60,718.01 $62,275 $141 $69,297.01 $71,120 $161 $79,432.01 $81,523
200% FPIG $53,000 $146 $71,120.01 $72,944 $168 $81,523.01 $83,613
200% FPIG $62,080 200% FPIG $71,160
Weekly  Family Size: 7  Weekly  Family Size: 8  Weekly  Family Size: 9
Co-pay
Annual Income
Co-pay
Annual Income
Co-pay
Annual Income
$5 Less than: $9,428 $5 Less than: $7,871 $5 Less than: $8,672
$7 $9,428.01 $11,785 $6 $7,871.01 $10,495 $6 $8,672.01 $11,562
$10 $11,785.01 $14,142 $8 $10,495.01 $13,119 $9 $11,562.01 $14,453
$13 $14,142.01 $16,499 $11 $13,119.01 $15,743 $12 $14,453.01 $17,343
$16 $16,499.01 $18,856 $14 $15,743.01 $18,366 $16 $17,343.01 $20,234
$19 $18,856.01 $21,213 $17 $18,366.01 $20,990 $19 $20,234.01 $23,124
$22 $21,213.01 $23,571 $21 $20,990.01 $23,614 $23 $23,124.01 $26,015
$26 $23,571.01 $25,928 $25 $23,614.01 $26,238 $27 $26,015.01 $28,905
$30 $25,928.01 $28,285 $29 $26,238.01 $28,862 $32 $28,905.01 $31,796
$34 $28,285.01 $30,642 $34 $28,862.01 $31,485 $37 $31,796.01 $34,686
$39 $30,642.01 $32,999 $38 $31,485.01 $34,109 $42 $34,686.01 $37,577
$44 $32,999.01 $35,356 $43 $34,109.01 $36,733 $48 $37,577.01 $40,467
$49 $35,356.01 $37,713 $49 $36,733.01 $39,357 $53 $40,467.01 $43,358
$54 $37,713.01 $40,070 $54 $39,357.01 $41,980 $60 $43,358.01 $46,248
$59 $40,070.01 $42,427 $60 $41,980.01 $44,604 $66 $46,248.01 $49,139
$64 $42,427.01 $44,784 $66 $44,604.01 $47,228 $73 $49,139.01 $52,029
$69 $44,784.01 $47,141 $71 $47,228.01 $49,852 $78 $52,029.01 $54,920
$74 $47,141.01 $49,498 $76 $49,852.01 $52,476 $84 $54,920.01 $57,810
$78 $49,498.01 $51,855 $82 $52,476.01 $55,099 $90 $57,810.01 $60,701
$84 $51,855.01 $54,212 $87 $55,099.01 $57,723 $96 $60,701.01 $63,591
$89 $54,212.01 $56,569 $93 $57,723.01 $60,347 $103 $63,591.01 $66,482
$94 $56,569.01 $58,926 $99 $60,347.01 $62,971 $109 $66,482.01 $69,372
$100 $58,926.01 $61,283 $105 $62,971.01 $65,594 $115 $69,372.01 $72,263
$105 $61,283.01 $63,640 $111 $65,594.01 $68,218 $122 $72,263.01 $75,153
$111 $63,640.01 $65,997 $117 $68,218.01 $70,842 $129 $75,153.01 $78,044
$117 $65,997.01 $68,354 $123 $70,842.01 $73,466 $136 $78,044.01 $80,934
$123 $68,354.01 $70,712 $130 $73,466.01 $76,089 $143 $80,934.01 $83,825
$129 $70,712.01 $73,069 $137 $76,089.01 $78,713 $151 $83,825.01 $86,715
$135 $73,069.01 $75,426 $143 $78,713.01 $81,337 $158 $86,715.01 $89,606
$141 $75,426.01 $77,783 $150 $81,337.01 $83,961 $166 $89,606.01 $92,496
$148 $77,783.01 $80,140 $157 $83,961.01 $86,585 $173 $92,496.01 $95,387
$154 $80,140.01 $82,497 $165 $86,585.01 $89,208 $181 $95,387.01 $98,277
$161 $82,497.01 $84,854 $172 $89,208.01 $91,832 $189 $98,277.01 $101,168
$168 $84,854.01 $87,211 $179 $91,832.01 $94,456 $198 $101,168.01 $104,058
$175 $87,211.01 $89,568 $187 $94,456.01 $97,080 $206 $104,058.01 $106,949
$182 $89,568.01 $91,925 $195 $97,080.01 $99,703 $214 $106,949.01 $109,839
$189 $91,925.01 $94,282 $203 $99,703.01 $102,327 $223 $109,839.01 $112,730
200% FPIG $80,240 $211 $102,327.01 $104,951 $232 $112,730.01 $115,620
200% FPIG $89,320 200% FPIG $98,400
Weekly  Family Size: 10  Weekly  Family Size: 11  Weekly  Family Size: 12
Co-pay
Annual Income
Co-pay
Annual Income
Co-pay
Annual Income
$5 Less than: $9,472 $5 Less than: $10,272 $5 Less than: $11,072
$7 $9,472.01 $12,629 $8 $10,272.01 $13,696 $8 $11,072.01 $14,763
$10 $12,629.01 $15,786 $11 $13,696.01 $17,120 $12 $14,763.01 $18,453
$13 $15,786.01 $18,943 $14 $17,120.01 $20,544 $16 $18,453.01 $22,144
$17 $18,943.01 $22,101 $18 $20,544.01 $23,968 $20 $22,144.01 $25,835
$21 $22,101.01 $25,258 $23 $23,968.01 $27,392 $25 $25,835.01 $29,525
$25 $25,258.01 $28,415 $27 $27,392.01 $30,816 $30 $29,525.01 $33,216
$30 $28,415.01 $31,572 $33 $30,816.01 $34,240 $35 $33,216.01 $36,907
$35 $31,572.01 $34,729 $38 $34,240.01 $37,663 $41 $36,907.01 $40,597
$40 $34,729.01 $37,887 $44 $37,663.01 $41,087 $47 $40,597.01 $44,288
$46 $37,887.01 $41,044 $50 $41,087.01 $44,511 $54 $44,288.01 $47,979
$52 $41,044.01 $44,201 $56 $44,511.01 $47,935 $61 $47,979.01 $51,669
$58 $44,201.01 $47,358 $63 $47,935.01 $51,359 $68 $51,669.01 $55,360
$65 $47,358.01 $50,516 $71 $51,359.01 $54,783 $76 $55,360.01 $59,051
$72 $50,516.01 $53,673 $78 $54,783.01 $58,207 $84 $59,051.01 $62,741
$79 $53,673.01 $56,830 $86 $58,207.01 $61,631 $93 $62,741.01 $66,432
$86 $56,830.01 $59,987 $93 $61,631.01 $65,055 $100 $66,432.01 $70,123
$92 $59,987.01 $63,145 $100 $65,055.01 $68,479 $108 $70,123.01 $73,814
$98 $63,145.01 $66,302 $107 $68,479.01 $71,903 $115 $73,814.01 $77,504
$105 $66,302.01 $69,459 $114 $71,903.01 $75,327 $123 $77,504.01 $81,195
$112 $69,459.01 $72,616 $121 $75,327.01 $78,751 $131 $81,195.01 $84,886
$119 $72,616.01 $75,773 $129 $78,751.01 $82,175 $139 $84,886.01 $88,576
$126 $75,773.01 $78,931 $137 $82,175.01 $85,599 $147 $88,576.01 $92,267
$133 $78,931.01 $82,088 $145 $85,599.01 $89,023 $156 $92,267.01 $95,958
$141 $82,088.01 $85,245 $153 $89,023.01 $92,447 $165 $95,958.01 $99,648
$149 $85,245.01 $88,402 $161 $92,447.01 $95,871 $174 $99,648.01 $103,339
$156 $88,402.01 $91,560 $170 $95,871.01 $99,295 $183 $103,339.01 $107,030
$164 $91,560.01 $94,717 $178 $99,295.01 $102,719 $192 $107,030.01 $110,720
$173 $94,717.01 $97,874 $187 $102,719.01 $106,142 $202 $110,720.01 $114,411
$181 $97,874.01 $101,031 $196 $106,142.01 $109,566 $211 $114,411.01 $118,102
$189 $101,031.01 $104,188 $205 $109,566.01 $112,990 $221 $118,102.01 $121,792
$198 $104,188.01 $107,346 $215 $112,990.01 $116,414 $231 $121,792.01 $125,483
$207 $107,346.01 $110,503 $224 $116,414.01 $119,838 $242 $125,483.01 $129,174
$216 $110,503.01 $113,660 $234 $119,838.01 $123,262 $252 $129,174.01 $132,864
$225 $113,660.01 $116,817 $244 $123,262.01 $126,686 $263 $132,864.01 $136,555
$234 $116,817.01 $119,975 $254 $126,686.01 $130,110 $274 $136,555.01 $140,246
$244 $119,975.01 $123,132 $264 $130,110.01 $133,534 $285 $140,246.01 $143,936
$253 $123,132.01 $126,289 $275 $133,534.01 $136,958 $296 $143,936.01 $147,627
200% FPIG $107,480 200% FPIG $116,560 200% FPIG $125,640
Weekly  Family Size: 13  Weekly  Family Size: 14  Weekly  Family Size: 15
Co-pay
Annual Income
Co-pay
Annual Income
Co-pay
Annual Income
$5 Less than: $11,872 $5 Less than: $8,448 $5 Less than: $8,982
$9 $11,872.01 $15,830 $6 $8,448.01 $12,672 $6 $8,982.01 $13,473
$12 $15,830.01 $19,787 $9 $12,672.01 $16,897 $10 $13,473.01 $17,963
$17 $19,787.01 $23,744 $13 $16,897.01 $21,121 $14 $17,963.01 $22,454
$21 $23,744.01 $27,702 $18 $21,121.01 $25,345 $19 $22,454.01 $26,945
$26 $27,702.01 $31,659 $23 $25,345.01 $29,569 $24 $26,945.01 $31,436
$32 $31,659.01 $35,617 $28 $29,569.01 $33,793 $30 $31,436.01 $35,927
$38 $35,617.01 $39,574 $34 $33,793.01 $38,017 $36 $35,927.01 $40,418
$44 $39,574.01 $43,531 $40 $38,017.01 $42,241 $43 $40,418.01 $44,909
$51 $43,531.01 $47,489 $47 $42,241.01 $46,465 $50 $44,909.01 $49,399
$58 $47,489.01 $51,446 $54 $46,465.01 $50,690 $57 $49,399.01 $53,890
$65 $51,446.01 $55,404 $62 $50,690.01 $54,914 $65 $53,890.01 $58,381
$73 $55,404.01 $59,361 $70 $54,914.01 $59,138 $74 $58,381.01 $62,872
$82 $59,361.01 $63,318 $78 $59,138.01 $63,362 $83 $62,872.01 $67,363
$90 $63,318.01 $67,276 $87 $63,362.01 $67,586 $93 $67,363.01 $71,854
$100 $67,276.01 $71,233 $96 $67,586.01 $71,810 $103 $71,854.01 $76,344
$107 $71,233.01 $75,191 $106 $71,810.01 $76,034 $113 $76,344.01 $80,835
$115 $75,191.01 $79,148 $115 $76,034.01 $80,258 $122 $80,835.01 $85,326
$123 $79,148.01 $83,105 $123 $80,258.01 $84,483 $131 $85,326.01 $89,817
$132 $83,105.01 $87,063 $132 $84,483.01 $88,707 $140 $89,817.01 $94,308
$140 $87,063.01 $91,020 $141 $88,707.01 $92,931 $150 $94,308.01 $98,799
$149 $91,020.01 $94,978 $150 $92,931.01 $97,155 $159 $98,799.01 $103,290
$158 $94,978.01 $98,935 $159 $97,155.01 $101,379 $169 $103,290.01 $107,780
$167 $98,935.01 $102,892 $169 $101,379.01 $105,603 $179 $107,780.01 $112,271
$177 $102,892.01 $106,850 $179 $105,603.01 $109,827 $190 $112,271.01 $116,762
$186 $106,850.01 $110,807 $189 $109,827.01 $114,051 $200 $116,762.01 $121,253
$196 $110,807.01 $114,765 $199 $114,051.01 $118,276 $211 $121,253.01 $125,744
$206 $114,765.01 $118,722 $209 $118,276.01 $122,500 $222 $125,744.01 $130,235
$216 $118,722.01 $122,679 $220 $122,500.01 $126,724 $234 $130,235.01 $134,726
$227 $122,679.01 $126,637 $231 $126,724.01 $130,948 $245 $134,726.01 $139,216
$237 $126,637.01 $130,594 $242 $130,948.01 $135,172 $257 $139,216.01 $143,707
$248 $130,594.01 $134,552 $253 $135,172.01 $139,396 $269 $143,707.01 $148,198
$259 $134,552.01 $138,509 $265 $139,396.01 $143,620 $282 $148,198.01 $152,689
$270 $138,509.01 $142,466 $277 $143,620.01 $147,844 $294 $152,689.01 $157,180
$282 $142,466.01 $146,424 $289 $147,844.01 $152,069 $307 $157,180.01 $161,671
$294 $146,424.01 $150,381 $301 $152,069.01 $156,293 $320 $161,671.01 $166,161
$305 $150,381.01 $154,339 $313 $156,293.01 $160,517 $333 $166,161.01 $170,652
$318 $154,339.01 $158,296 $326 $160,517.01 $164,741 $347 $170,652.01 $175,143
200% FPIG $134,720 $339 $164,741.01 $168,965 $360 $175,143.01 $179,634
200% FPIG $143,800 200% FPIG $152,880
Weekly  Family Size: 16  Weekly  Family Size: 17  Weekly  Family Size: 18
Co-pay
Annual Income
Co-pay
Annual Income
Co-pay
Annual Income
$5 Less than: $9,515 $5 Less than: $10,049 $5 Less than: $10,582
$7 $9,515.01 $14,273 $7 $10,049.01 $15,073 $7 $10,582.01 $15,873
$11 $14,273.01 $19,030 $11 $15,073.01 $20,097 $12 $15,873.01 $21,164
$15 $19,030.01 $23,788 $16 $20,097.01 $25,122 $17 $21,164.01 $26,455
$20 $23,788.01 $28,545 $21 $25,122.01 $30,146 $22 $26,455.01 $31,746
$26 $28,545.01 $33,303 $27 $30,146.01 $35,170 $28 $31,746.01 $37,037
$32 $33,303.01 $38,061 $33 $35,170.01 $40,194 $35 $37,037.01 $42,328
$38 $38,061.01 $42,818 $40 $40,194.01 $45,219 $42 $42,328.01 $47,619
$45 $42,818.01 $47,576 $48 $45,219.01 $50,243 $50 $47,619.01 $52,910
$53 $47,576.01 $52,333 $56 $50,243.01 $55,267 $59 $52,910.01 $58,201
$61 $52,333.01 $57,091 $64 $55,267.01 $60,292 $68 $58,201.01 $63,492
$69 $57,091.01 $61,848 $73 $60,292.01 $65,316 $77 $63,492.01 $68,783
$78 $61,848.01 $66,606 $83 $65,316.01 $70,340 $87 $68,783.01 $74,074
$88 $66,606.01 $71,364 $93 $70,340.01 $75,365 $98 $74,074.01 $79,365
$98 $71,364.01 $76,121 $104 $75,365.01 $80,389 $109 $79,365.01 $84,656
$109 $76,121.01 $80,879 $115 $80,389.01 $85,413 $121 $84,656.01 $89,947
$120 $80,879.01 $85,636 $126 $85,413.01 $90,437 $133 $89,947.01 $95,238
$129 $85,636.01 $90,394 $136 $90,437.01 $95,462 $144 $95,238.01 $100,529
$139 $90,394.01 $95,152 $146 $95,462.01 $100,486 $154 $100,529.01 $105,821
$148 $95,152.01 $99,909 $157 $100,486.01 $105,510 $165 $105,821.01 $111,112
$158 $99,909.01 $104,667 $167 $105,510.01 $110,535 $176 $111,112.01 $116,403
$169 $104,667.01 $109,424 $178 $110,535.01 $115,559 $188 $116,403.01 $121,694
$179 $109,424.01 $114,182 $189 $115,559.01 $120,583 $199 $121,694.01 $126,985
$190 $114,182.01 $118,939 $201 $120,583.01 $125,608 $211 $126,985.01 $132,276
$201 $118,939.01 $123,697 $212 $125,608.01 $130,632 $224 $132,276.01 $137,567
$212 $123,697.01 $128,455 $224 $130,632.01 $135,656 $236 $137,567.01 $142,858
$224 $128,455.01 $133,212 $236 $135,656.01 $140,680 $249 $142,858.01 $148,149
$236 $133,212.01 $137,970 $249 $140,680.01 $145,705 $262 $148,149.01 $153,440
$248 $137,970.01 $142,727 $262 $145,705.01 $150,729 $275 $153,440.01 $158,731
$260 $142,727.01 $147,485 $275 $150,729.01 $155,753 $289 $158,731.01 $164,022
$273 $147,485.01 $152,242 $288 $155,753.01 $160,778 $303 $164,022.01 $169,313
$285 $152,242.01 $157,000 $301 $160,778.01 $165,802 $317 $169,313.01 $174,604
$298 $157,000.01 $161,758 $315 $165,802.01 $170,826 $332 $174,604.01 $179,895
$312 $161,758.01 $166,515 $329 $170,826.01 $175,851 $347 $179,895.01 $185,186
$325 $166,515.01 $171,273 $343 $175,851.01 $180,875 $362 $185,186.01 $190,477
$339 $171,273.01 $176,030 $358 $180,875.01 $185,899 $377 $190,477.01 $195,768
$353 $176,030.01 $180,788 $373 $185,899.01 $190,923 $393 $195,768.01 $201,059
$367 $180,788.01 $185,545 $388 $190,923.01 $195,948 $408 $201,059.01 $206,350
$382 $185,545.01 $190,303 $403 $195,948.01 $200,972 $425 $206,350.01 $211,641
200% FPIG $161,960 200% FPIG $171,040 200% FPIG $180,120
Weekly  Family Size: 19  Weekly  Family Size: 20  Weekly  Family Size: 21
Co-pay
Annual Income
Co-pay
Annual Income
Co-pay
Annual Income
$5 Less than: $11,116 $5 Less than: $11,649 $5 Less than: $12,182
$8 $11,116.01 $16,673 $8 $11,649.01 $17,473 $8 $12,182.01 $18,274
$12 $16,673.01 $22,231 $13 $17,473.01 $23,298 $13 $18,274.01 $24,365
$18 $22,231.01 $27,789 $18 $23,298.01 $29,122 $19 $24,365.01 $30,456
$23 $27,789.01 $33,347 $25 $29,122.01 $34,947 $26 $30,456.01 $36,547
$30 $33,347.01 $38,904 $31 $34,947.01 $40,771 $33 $36,547.01 $42,638
$37 $38,904.01 $44,462 $39 $40,771.01 $46,596 $40 $42,638.01 $48,730
$45 $44,462.01 $50,020 $47 $46,596.01 $52,420 $49 $48,730.01 $54,821
$53 $50,020.01 $55,578 $55 $52,420.01 $58,245 $58 $54,821.01 $60,912
$62 $55,578.01 $61,135 $65 $58,245.01 $64,069 $68 $60,912.01 $67,003
$71 $61,135.01 $66,693 $74 $64,069.01 $69,894 $78 $67,003.01 $73,094
$81 $66,693.01 $72,251 $85 $69,894.01 $75,718 $89 $73,094.01 $79,186
$92 $72,251.01 $77,809 $96 $75,718.01 $81,543 $100 $79,186.01 $85,277
$103 $77,809.01 $83,366 $108 $81,543.01 $87,367 $113 $85,277.01 $91,368
$115 $83,366.01 $88,924 $120 $87,367.01 $93,192 $126 $91,368.01 $97,459
$127 $88,924.01 $94,482 $133 $93,192.01 $99,016 $139 $97,459.01 $103,550
$140 $94,482.01 $100,040 $147 $99,016.01 $104,841 $153 $103,550.01 $109,642
$151 $100,040.01 $105,597 $158 $104,841.01 $110,665 $165 $109,642.01 $115,733
$162 $105,597.01 $111,155 $170 $110,665.01 $116,490 $177 $115,733.01 $121,824
$173 $111,155.01 $116,713 $182 $116,490.01 $122,314 $190 $121,824.01 $127,915
$185 $116,713.01 $122,271 $194 $122,314.01 $128,138 $203 $127,915.01 $134,006
$197 $122,271.01 $127,828 $207 $128,138.01 $133,963 $216 $134,006.01 $140,098
$209 $127,828.01 $133,386 $219 $133,963.01 $139,787 $229 $140,098.01 $146,189
$222 $133,386.01 $138,944 $233 $139,787.01 $145,612 $243 $146,189.01 $152,280
$235 $138,944.01 $144,502 $246 $145,612.01 $151,436 $257 $152,280.01 $158,371
$248 $144,502.01 $150,059 $260 $151,436.01 $157,261 $272 $158,371.01 $164,462
$262 $150,059.01 $155,617 $274 $157,261.01 $163,085 $287 $164,462.01 $170,554
$275 $155,617.01 $161,175 $289 $163,085.01 $168,910 $302 $170,554.01 $176,645
$289 $161,175.01 $166,733 $303 $168,910.01 $174,734 $317 $176,645.01 $182,736
$304 $166,733.01 $172,290 $318 $174,734.01 $180,559 $333 $182,736.01 $188,827
$318 $172,290.01 $177,848 $334 $180,559.01 $186,383 $349 $188,827.01 $194,918
$333 $177,848.01 $183,406 $349 $186,383.01 $192,208 $365 $194,918.01 $201,010
$349 $183,406.01 $188,964 $365 $192,208.01 $198,032 $382 $201,010.01 $207,101
$364 $188,964.01 $194,521 $382 $198,032.01 $203,857 $399 $207,101.01 $213,192
$380 $194,521.01 $200,079 $398 $203,857.01 $209,681 $416 $213,192.01 $219,283
$396 $200,079.01 $205,637 $415 $209,681.01 $215,506 $434 $219,283.01 $225,374
$412 $205,637.01 $211,195 $432 $215,506.01 $221,330 $452 $225,374.01 $231,466
$429 $211,195.01 $216,752 $450 $221,330.01 $227,155 $470 $231,466.01 $237,557
$446 $216,752.01 $222,310 $467 $227,155.01 $232,979 $489 $237,557.01 $243,648
200% FPIG $189,200 200% FPIG $198,280 200% FPIG $207,360
[Pa.B. Doc. No. 21-679. Filed for public inspection April 30, 2021, 9:00 a.m.]



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