Family Size 2 School-Age Co-payment
| Monthly Income |
Monthly Co-Pay |
| $0-542 |
$1.00 |
| 543-677 |
1.50 |
| 678-812 |
5.50 |
| 813-948 |
9.00 |
| 949-1083 |
14.00 |
| 1084-1218 |
20.00 |
| 1219-1354 |
27.00 |
| 1355-1489 |
35.00 |
| 1490-1624 |
44.00 |
| 1625-1760 |
53.50 |
| 1761-1895 |
64.50 |
| 1896-2030 |
76.50 |
| 2031-2166 |
89.00 |
| 2167-2193 |
103.00 |
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 redetermination will be income eligible if they fall within the levels below.
| Monthly Income |
Monthly Co-Pay |
| $2194-2301 |
$103.00 |
| 2302-2436 |
117.50 |
| 2437-2504 |
127.00 |
Family Size 3 School-Age Co-Payment
| Monthly Income |
Monthly Co-Pay |
| $0-681 |
$1.00 |
| 682-851 |
1.50 |
| 852-1021 |
7.00 |
| 1022-1192 |
11.00 |
| 1193-1362 |
17.50 |
| 1363-1532 |
25.00 |
| 1533-1702 |
34.00 |
| 1703-1872 |
44.00 |
| 1873-2042 |
55.00 |
| 2043-2213 |
67.50 |
| 2214-2383 |
81.00 |
| 2384-2553 |
96.00 |
| 2554-2723 |
112.00 |
| 2724-2757 |
129.50 |
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 redetermination will be income eligible if they fall within the levels below.
| Monthly Income |
Monthly Co-Pay |
| $2758-2893 |
129.50 |
| 2894-3063 |
148.00 |
| 3064-3149 |
160.00 |
Family Size 4 School-Age Co-Payment
| Monthly Income |
Monthly Co-Pay |
| $0-820 |
$1.00 |
| 821-1025 |
1.50 |
| 1026-1230 |
8.50 |
| 1231-1435 |
13.50 |
| 1436-1640 |
21.00 |
| 1641-1845 |
30.00 |
| 1846-2050 |
40.50 |
| 2051-2265 |
52.50 |
| 2256-2460 |
66.50 |
| 2461-2665 |
81.00 |
| 2666-2870 |
97.50 |
| 2871-3075 |
115.50 |
| 3076-3280 |
135.00 |
| 3281-3321 |
156.00 |
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 redetermination will be income eligible if they fall within the levels below.
| Monthly Income |
Monthly Co-Pay |
| $3322-3485 |
156.00 |
| 3486-3690 |
178.50 |
| 3691-3793 |
192.50 |
Family Size 5 School-Age Co-Payment
| Monthly Income |
Monthly Co-Pay |
| $0-960 |
$1.00 |
| 961-1200 |
1.50 |
| 1201-1439 |
10.00 |
| 1440-1679 |
16.00 |
| 1680-1919 |
24.50 |
| 1920-2159 |
35.50 |
| 2160-2399 |
47.50 |
| 2400-2639 |
61.50 |
| 2640-2878 |
77.50 |
| 2879-3118 |
95.00 |
| 3119-3358 |
114.50 |
| 3359-3598 |
135.50 |
| 3599-3838 |
158.00 |
| 3839-3886 |
182.50 |
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 redetermination will be income eligible if they fall within the levels below.
| Monthly Income |
Monthly Co-Pay |
| $3887-4078 |
$182.50 |
| 4079-4317 |
208.50 |
| 4318-4437 |
225.50 |
Family Size 6 School-Age Co-Payment
| Monthly Income |
Monthly Co-Pay |
| $0-1099 |
$1.00 |
| 1100-1374 |
1.50 |
| 1375-1648 |
11.50 |
| 1649-1923 |
18.00 |
| 1924-2198 |
28.00 |
| 2199-2472 |
40.50 |
| 2473-2747 |
54.50 |
| 2748-3022 |
70.50 |
| 3023-3296 |
89.00 |
| 3297-3571 |
109.00 |
| 3572-3846 |
131.00 |
| 3847-4120 |
155.00 |
| 4121-4395 |
181.0 |
| 4396-4450 |
209.00 |
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 redetermination will be income eligible if they fall within the levels below.
| Monthly Income |
Monthly Co-Pay |
| 4451-4670 |
209.00 |
| 4671-4944 |
239.00 |
| 4945-5082 |
258.00 |
Family Size 7 School-Age Co-Payment
| Monthly Income |
Monthly Co-Pay |
| $0-1238 |
$1.00 |
| 1239-1548 |
1.50 |
| 1549-1857 |
13.00 |
| 1858-2167 |
20.50 |
| 2168-2476 |
32.00 |
| 2477-2786 |
45.50 |
| 2787-3095 |
61.50 |
| 3096-3405 |
79.50 |
| 3406-3714 |
100.00 |
| 3715-4024 |
122.50 |
| 4025-4333 |
147.50 |
| 4334-4643 |
174.50 |
| 4644-4952 |
204.00 |
| 4953-5014 |
235.50 |
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 redetermination will be income eligible if they fall within the levels below.
| Monthly Income |
Monthly Co-Pay |
| $5015-5262 |
235.50 |
| 5263-5571 |
269.00 |
| 5572-5726 |
291.00 |
Family Size 8 School-Age Co-payment
| Monthly Income |
Monthly Co-Pay |
| $0-1378 |
$1.00 |
| 1379-1722 |
1.50 |
| 1723-2066 |
14.00 |
| 2067-2411 |
22.50 |
| 2412-2755 |
35.50 |
| 2756-3099 |
50.50 |
| 3100-3444 |
68.50 |
| 3445-3788 |
86.50 |
| 3789-4132 |
111.50 |
| 4133-4477 |
136.50 |
| 4478-4821 |
164.00 |
| 4822-5165 |
194.00 |
| 5166-5510 |
227.00 |
| 5511-5579 |
262.00 |
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 redetermination will be income eligible if they fall within the levels below.
| Monthly Income |
Monthly Co-Pay |
| $5580-5854 |
$262.00 |
| 5855-6198 |
299.50 |
| 6199-6371 |
323.50 |
Family Size 9 School-Age Co-payment
| Monthly Income |
Monthly Co-pay |
| $0-1517 |
$1.00 |
| 1518-1896 |
1.50 |
| 1897-2275 |
15.50 |
| 2276-2655 |
25.00 |
| 2656-3034 |
39.00 |
| 3035-3413 |
56.00 |
| 3414-3792 |
75.50 |
| 3793-4171 |
97.50 |
| 4172-4550 |
122.50 |
| 4551-4930 |
150.50 |
| 4931-5309 |
180.50 |
| 5310-5688 |
214.00 |
| 5689-6067 |
250.00 |
| 6068-6142 |
288.50 |
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 redetermination will be income eligible if they fall within the levels below.
| Monthly Income |
Monthly Co-Pay |
| $6144-6446 |
$288.50 |
| 6447-6825 |
330.00 |
| 6826-7015 |
356.50 |
Family Size 10 School-Age Co-Payment
| Monthly Income |
Monthly Co-Pay |
| $0-1656 |
$1.00 |
| 1657-2070 |
1.50 |
| 2071-2484 |
17.00 |
| 2485-2898 |
27.00 |
| 2899-3312 |
42.50 |
| 3313-3726 |
61.00 |
| 3727-4140 |
82.00 |
| 4141-4554 |
106.50 |
| 4555-4968 |
134.00 |
| 4969-5382 |
164.00 |
| 5383-5796 |
197.50 |
| 5797-6210 |
233.50 |
| 6211-6624 |
272.50 |
| 6625-6707 |
315.00 |
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 redetermination will be income eligible if they fall within the levels below.
| Monthly Income |
Monthly Co-Pay |
| $6708-7038 |
$315.00 |
| 7039-7452 |
360.00 |
| 7453-7659 |
389.00 |
