Family Size 2

revision to column amountsMonthly Income revision to column amountsMonthly Co-Pay
$0-534 $2.00
535-668 3.00
669-801 11.00
802-935 18.00
936-1068 27.00
1069-1202 39.00
1203-1335 53.00
1336-1469 69.00
1470-1602 86.00
1603-1736 106.00
1737-1869 127.00
1870-2003 151.00
2004-2136 176.00
2137-2163 203.00

Approval of new applications is closed for all income levels listed below, effective November 9, 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.

revision to column amountMonthly Income revision to column amountsMonthly Co-Pay
$2164-2270 $203.00
2271-2403 232.00
2404-2470 251.00

Family Size 3

revision to column amountsMonthly Income revision to column amountsMonthly Co-Pay
$0-672 $2.00
673-840 3.00
841-1008 14.00
1009-1176 22.00
1177-1344 35.00
1345-1512 49.00
1513-1680 67.00
1681-1848 86.00
1849-2016 109.00
2017-2184 133.00
2185-2352 160.00
2353-2520 190.00
2521-2688 221.00
2689-2722 256.00

Approval of new applications is closed for all income levels listed below, effective November 9, 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.

revision to column amountsMonthly Income revision to column amountsMonthly Co-Pay
$2723-2856 $256.00
2857-3024 292.00
3025-3108 316.00

Family Size 4

revision to column amountsMonthly Income revision to column amountsMonthly Co-Pay
$0-810 $2.00
811-1013 3.00
1014-1215 17.00
1216-1418 27.00
1419-1620 42.00
1621-1823 60.00
1824-2025 80.00
2026-2228 104.00
2229-2430 131.00
2431-2633 161.00
2634-2835 193.00
2836-3038 228.00
3039-3240 267.00
3241-3281 308.00

Approval of new applications is closed for all income levels listed below, effective November 9, 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.

revision to column amountsMonthly Income revision to column amountsMonthly Co-Pay
$3282-3443 $308.00
3444-3645 352.00
2646-3747 381.00

Family Size 5

revision to column amountsMonthly Income revision to column amountsMonthly Co-Pay
$0-948 $2.00
949-1185 3.00
1186-1422 20.00
1423-1659 31.00
1660-1896 49.00
1897-2133 70.00
2134-2370 94.00
2371-2607 122.00
2608-2844 153.00
2845-3081 188.00
3082-3318 226.00
3319-3555 267.00
3556-3792 312.00
3793-3840 361.00

Approval of new applications is closed for all income levels listed below, effective November 9, 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.

revision to column amountsMonthly Income revision to column amountsMonthly Co-Pay
$3841-4029 $361.00
4030-4266 412.00
4267-4385 446.00

Family Size 6

revisions to column amountsMonthly Income revisions to column amountsMonthly Co-Pay
$0-1086 $2.00
1087-1358 3.00
1359-1629 22.00
1630-1901 36.00
1902-2172 56.00
2173-2444 80.00
2445-2715 108.00
2716-2987 140.00
2988-3258 176.00
3259-3530 215.00
3531-3801 259.00
3802-4073 306.00
4074-4344 358.00
4345-4399 413.00

Approval of new applications is closed for all income levels listed below, effective November 9, 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.

revisions to column amountsMonthly Income revisions to column amountsMonthly Co-Pay
$4400-4616 $413.00
4617-4887 472.00
4888-5023 510.00

Family Size 7

Monthly Income Monthly Co-Pay
$0-1225 $2.00
1226-1531 3.00
1532-1837 25.00
1838-2143 40.00
2144-2449 63.00
2450-2755 90.00
2756-3061 122.00
3062-3367 158.00
3368-3673 198.00
3674-3980 243.00
3981-4286 292.00
4287-4592 345.00
4593-4898 403.00
4899-4959 466.00

Approval of new applications is closed for all income levels listed below, effective November 9, 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
$4960-5204 $466.00
5205-5510 533.00
5511-5663 575.00

Family Size 8

Monthly Income Monthly Co-Pay
$0-1363 $2.00
1364-1704 3.00
1705-2045 28.00
2046-2386 45.00
2387-2726 70.00
2727-3067 100.00
3068-3408 135.00
3409-3749 175.00
3750-4089 220.00
4090-4430 270.00
4431-4771 325.00
4772-5112 384.00
5113-5452 449.00
5453-5521 518.00

Approval of new applications is closed for all income levels listed below, effective November 9, 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
$5522-5793 $518.00
5794-6134 593.00
6135-6304 641.00

Family Size 9

Monthly Income Monthly Co-Pay
$0-1502 $2.00
1503-1878 3.00
1879-2253 31.00
2254-2628 49.00
2629-3004 77.00
3005-3379 110.00
3380-3755 149.00
3756-4130 193.00
4131-4505 243.00
4506-4881 298.00
4882-5256 358.00
5257-5632 424.00
5633-6007 495.00
6008-6082 571.00

Approval of new applications is closed for all income levels listed below, effective November 9, 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
$6083-6383 $571.00
6384-6758 653.00
6759-6946 706.00

Family Size 10

Monthly Income Monthly Co-Pay
$0-1641 $2.00
1642-2051 3.00
2052-2461 34.00
2462-2871 54.00
2872-3281 84.00
3282-3691 121.00
3692-4101 163.00
4102-4511 211.00
4512-4921 265.00
4922-5332 325.00
5333-5742 391.00
5743-6152 463.00
6153-6562 540.00
6563-6644 624.00

Approval of new applications is closed for all income levels listed below, effective November 9, 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
$6645-6972 $624.00
6973-7382 713.00
7383-7587 771.00