WAG 25-03-02 (4)

Extended Medical Standards, Premiums and Co-pays

2021 Income Standards

Revised manual text

# In

Unit

Medical Extension

185% FPL

(No limit for first 6 months;

limit for Adults after first 6 months only)

  All Kids

  Share

157% FPL

   All Kids

Premium Level 1

  209% FPL

  All Kids

Premium Level 2

  318% FPL
1 $ 1,986 $1,579 - 1,685 $1,686 - 2,243 $2,244 - 3,413
2 2,686 2,135 - 2,279 2,280 - 3,034 3,035 - 4,616
3 3,386 2,691 - 2,873 2,874 - 3,825 3,826 - 5,819
4 4,085 3,247 - 3,467 3,468 - 4,615 4,616 - 7,023
5 4,785 3,803 - 4,061 4,062 - 5,406 5,407 - 8,226
6 5,485 4,360 - 4,655 4,656 - 6,197 6,198 - 9,429
7 6,185 4,916 - 5,249 5,250 - 6,988 6,989 - 10,632
8 6,885 5,472 - 5,843 5,844 - 7,778 7,779 - 11,835
9 7,585 6,028 - 6,437 6,438 - 8,569 8,570 - 13,038
10 8,285 6,584 - 7,031 7,032 - 9,360 9,361 - 14,241
Each add'l +699 $593 +790 +1,202

All Kids & FamilyCare Premiums and Physician Co-Pays

Assist

children & adults
Co-Pay for Physician Office Visit

$ 0 for children

$ 0 for Medicaid adults
Monthly Premium None
Max Monthly Premium N/A
Max Co-Payments per Year N/A