Family Size 2

Monthly Income Monthly Co-pay
$0-$531 $2
$532-$664 $3

Approval of new applications is closed for all income levels listed below, effective July 1, 2015, unless a family receives TANF, has a Special Needs child or is a Teen Parent in high school or GED full time. Families that submit a change of information or a redetermination will be income eligible if they fall within the levels below.

Monthly Income Monthly Co-pay
$665-$797 $11
$798-$930 $17
$931-$1062 $27
$1063-$1195 $39
$1196-$1328 $53
$1329-$1461 $68
$1462-$1593 $86
$1594-$1726 $105
$1727-$1859 $127
$1860-$1992 $150
$1993-$2124 $175
$2125-$2257 $202
$2258-$2390 $231
$2391-$2456 $250

Family Size 3

Monthly Income Monthly Co-pay
$000-$670 $2
$671-$838 $3

Approval of new applications is closed for all income levels listed below, effective July 1, 2015, unless a family receives TANF, has a Special Needs child or is a Teen Parent in high school or GED full time. Families that submit a change of information or a redetermination will be income eligible if they fall within the levels below.

Monthly Income Monthly Co-pay
$839-$1005 $14
$1006-$1172 $22
$1173-$1340 $34
$1341-$1507 $49
$1508-$1675 $67
$1676-$1842 $86
$1843-$2009 $108
$2010-$2177 $133
$2178-$2344 $160
$2345-$2512 $189
$2513-$2679 $221
$2680-$2847 $255
$2848-$3014 $291
$3015-$3098 $315

Family Size 4

Monthly Income Monthly Co-pay
$000-$809 $2
$810-$1011 $3

Approval of new applications is closed for all income levels listed below, effective July 1, 2015, unless a family receives TANF, has a Special Needs child or is a Teen Parent in high school or GED full time. Families that submit a change of information or a redetermination will be income eligible if they fall within the levels below.

Monthly Income Monthly Co-pay
$1012-$1213 $17
$1214-$1415 $27
$1416-$1617 $42
$1618-$1819 $59
$1820-$2021 $80
$2022-$2223 $104
$2224-$2425 $131
$2426-$2628 $160
$2629-$2830 $193
$2831-$3032 $228
$3033-$3234 $266
$3235-$3436 $308
$3437-$3638 $352
$3639 - $3739 $380

Family Size 5

Monthly Income Monthly Co-pay
$000-$947 $2
$948-$1184 $3

Approval of new applications is closed for all income levels listed below, effective July 1, 2015, unless a family receives TANF, has a Special Needs child or is a Teen Parent in high school or GED full time. Families that submit a change of information or a redetermination will be income eligible if they fall within the levels below.

Monthly Income Monthly Co-pay
$1185-$1421 $20
$1422-$1658 $31
$1659-$1894 $49
$1895-$2131 $70
$2132-$2368 $94
$2369-$2605 $122
$2606-$2841 $153
$2842-$3078 $188
$3079-$3315 $226
$3316-$3552 $267
$3553-$3788 $312
$3789-$4025 $360
$4026-$4262 $412
$4263-$4380 $445

Family size 6

Monthly Income Monthly Co-pay
$0-$1086 $2
$1087-$1358 $3

Approval of new applications is closed for all income levels listed below, effective July 1, 2015, unless a family receives TANF, has a Special Needs child or is a Teen Parent in high school or GED full time. Families that submit a change of information or a redetermination will be income eligible if they fall within the levels below.

Monthly Income Monthly Co-pay
$1359-$1629 $22
$1630-$1900 $36
$1901-$2172 $56
$2173-$2443 $80
$2444-$2715 $108
$2716-$2986 $140
$2987-$3257 $175
$3258-$3529 $215
$3530-$3800 $259
$3801-$4072 $306
$4073-$4343 $358
$4344-$4615 $413
$4616-$4886 $472
$4887-$5022 $510

Family Size 7

Monthly Income Monthly Co-pay
$0-$1225 $2
$1226-$1531 $3

Approval of new applications is closed for all income levels listed below, effective July 1, 2015, unless a family receives TANF, has a Special Needs child or is a Teen Parent in high school or GED full time. Families that submit a change of information or a redetermination will be income eligible if they fall within the levels below.

Monthly Income Monthly Co-pay
$1532-$1837 $25
$1838-$2143 $40
$2144-$2449 $63
$2450-$2755 $90
$2756-$3061 $122
$3062-$3367 $158
$3368-$3673 $198
$3674-$3980 $243
$3981-$4286 $292
$4287-$4592 $345
$4593-$4898 $403
$4899-$5204 $466
$5205-$5510 $533
$5511-$5663 $575

Family Size 8

Monthly Income Monthly Co-pay
$0-$1363 $2
$1364-$1704 $3

Approval of new applications is closed for all income levels listed below, effective July 1, 2015, unless a family receives TANF, has a Special Needs child or is a Teen Parent in high school or GED full time. Families that submit a change of information or a redetermination will be income eligible if they fall within the levels below.

Monthly Income Monthly Co-pay
$1705-$2045 $28
$2046-$2386 $45
$2387-$2726 $70
$2727-$3067 $100
$3068-$3408 $135
$3409-$3749 $175
$3750-$4089 $220
$4090-$4430 $270
$4431-$4771 $325
$4772-$5112 $384
$5113-$5452 $449
$5453-$5793 $518
$5794-$6134 $593
$6135-$6304 $641

Family Size 9

Monthly Income Monthly Co-pay
$0-$1502 $2
$1503-$1878 $3

Approval of new applications is closed for all income levels listed below, effective July 1, 2015, unless a family receives TANF, has a Special Needs child or is a Teen Parent in high school or GED full time. Families that submit a change of information or a redetermination will be income eligible if they fall within the levels below.

Monthly Income Monthly Co-pay
$1879-$2253 $31
$2254-$2628 $49
$2629-$3004 $77
$3005-$3379 $110
$3380-$3755 $149
$3756-$4130 $193
$4131-$4505 $243
$4506-$4881 $298
$4882-$5256 $358
$5257-$5632 $424
$5633-$6007 $495
$6008-$6383 $571
$6384-$6758 $653
$6759-$6946 $706

Family Size 10

Monthly Income Monthly Co-pay
$0-$1641 $2
$1642-$2051 $3

Approval of new applications is closed for all income levels listed below, effective July 1, 2015, unless a family receives TANF, has a Special Needs child or is a Teen Parent in high school or GED full time. Families that submit a change of information or a redetermination will be income eligible if they fall within the levels below.

Monthly Income Monthly Co-pay
$2052-$2461 $34
$2462-$2871 $54
$2872-$3281 $84
$3282-$3691 $121
$3692-$4101 $163
$4102-$4511 $211
$4512-$4921 $265
$4922-$5332 $325
$5333-$5742 $391
$5743-$6152 $463
$6153-$6562 $540
$6563-$6972 $624
$6973-$7382 $713
$7383-$7587 $771