Pa. Code tit. 28, pt. I, ch. 4, app A

Current through Register Vol. 54, No. 45, November 9, 2024

Appendix A - BUREAU OF FAMILY HEALTHDIVISION CHILD AND ADULT HEALTH SERVICES

PATIENT SHARE of COST (PSC) TABLE

PSC	$0	$0	$50	$250	$400	$550	$700	$850	$1000	$1150
% of Poverty	0 to 100%	[GREATER THAN]100 to 185%	[GREATER THAN] 185 to 225%	[GREATER THAN] 225 to 250%	[GREATER THAN] 250 to 275%	[GREATER THAN] 275 to 300%	[GREATER THAN]300 to 325%	[GREATER THAN] 325 to 350%	[GREATER THAN] 350 to 375%	[GREATER THAN] 375 to 400%
Size of Family Unit	Income Ranges						Use these columns only for clients who were in DCAHS programs prior to 1/1/97 and have continuous participation without a lapse in eligibility.
1	0	8,591	15,893	19,329	21,476	23,624	25,771	27,919	30,066	32,214
8,590	15,892	19,328	21,475	23,623	25,770	27,918	30,065	32,213	34,360
2	0	11,611	21,480	26,124	29,026	31,929	34,831	37,734	40,636	43,539
11,610	21,479	26,123	29,025	31,928	34,830	37,733	40,635	43,538	46,440
3	0	14,631	27,067	32,919	36,576	40,234	43,891	47,549	51,206	54,864
14,630	27,066	32,918	36,575	40,233	43,890	47,548	51,205	54,863	58,520
4	0	17,651	32,654	39,714	44,126	48,539	52,951	57,364	61,776	66,189
17,650	32,653	39,713	44,125	48,538	52,950	57,363	61,775	66,188	70,600
5	0	20,671	38,241	46,509	51,676	56,844	62,011	67,179	72,346	77,514
20,670	38,240	46,508	51,675	56,843	62,010	67,178	72,345	77,513	82,680
6	0	23,691	43,828	53,304	59,226	65,149	71,071	76,994	82,916	88,839
23,690	43,827	53,303	59,225	65,148	71,070	76,993	82,915	88,838	94,760
7	0	26,711	49,415	60,099	66,776	73,454	80,131	86,809	93,486	100,164
26,710	49,414	60,098	66,775	73,453	80,130	86,808	93,485	100,163	106,840
8	0	29,731	55,002	66,894	74,326	81,759	89,191	96,624	104,056	111,489
29,730	55,001	66,893	74,325	81,758	89,190	96,623	104,055	111,488	118,920
9	0	32,751	60,589	73,689	81,876	90,064	98,251	106,439	114,626	122,814
32,750	60,588	73,688	81,875	90,063	98,250	106,438	114,625	122,813	131,000
10	0	35,771	66,176	80,484	89,426	98,369	107,311	116,254	125,196	134,139
35,770	66,175	80,483	89,425	98,368	107,310	116,253	125,195	134,138	143,080
11	0	38,791	71,763	87,279	96,976	106,674	116,371	126,069	135,766	145,464
38,790	71,762	87,278	96,975	106,673	116,370	126,068	135,765	145,463	155,160
12	0	41,811	77,350	94,074	104,526	114,979	125,431	135,884	146,336	156,789
41,810	77,349	94,073	104,525	114,978	125,430	135,883	146,335	156,788	167,240
13	0	44,831	82,937	100,869	112,076	123,284	134,491	145,699	156,906	168,114
44,830	82,936	100,868	112,075	123,283	134,490	145,698	156,905	168,113	179,320
14	0	47,851	88,524	107,664	119,626	131,589	143,551	155,514	167,476	179,439
47,850	88,523	107,663	119,625	131,588	143,550	155,513	167,475	179,438	191,400
15	0	50,871	94,111	114,459	127,176	139,894	152,611	165,329	178,046	190,764
50,870	94,110	114,458	127,175	139,893	152,610	165,328	178,045	190,763	203,480
16	0	53,891	99,698	121,254	134,726	148,199	161,671	175,144	188,616	202,089
53,890	99,697	121,253	134,725	148,198	161,670	175,143	188,615	202,088	215,560

This table is revised each year based on the release of HHS Federal Poverty Income Guidelines by the United States Department of Health and Human Services. The figures above were published in the Federal Register: February 16, 2001 (Volume 66, Number 33) Notices: (pages 10695-10697).