Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 4 - HEAD INJURY PROGRAM › Appendix A - BUREAU OF FAMILY HEALTHDIVISION CHILD AND ADULT HEALTH SERVICES

Current through Register Vol. 54, No. 28, July 13, 2024
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).