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Revision 25-1; Effective May 7, 2025
Refer to the following copayment schedule to determine the person’s copayment percentage. The copayment schedule is based on paying a copayment when the income limit exceeds 300% of Supplemental Security Income.
Copayment Schedule
| Net Monthly Income From | Net Monthly Income To | Net Monthly Income Percentage |
|---|---|---|
| $0 | $2,901.00 | 0% |
| $2,901.01 | $3,263.63 | 3% |
| $3,263.64 | $3,384.50 | 5% |
| $3,384.51 | $3,868.00 | 7% |
| $3,868.01 | $4,351.50 | 9% |
| $4,351.51 | $4,835.00 | 12% |
| $4,835.01 | $5,318.49 | 15% |
| $5,318.50 | $5,801.99 | 20% |
| $5,802.00 | $6,285.49 | 30% |
| $6,285.50 | $6,768.99 | 40% |
| $6,769.00 | $7,252.49 | 50% |
| $7,252.50 | $7,977.74 | 60% |
| $7,977.75 | $8,702.99 | 70% |
| $8,703.00 | $9,669,98 | 80% |
| $9,669.99 | $10,636.98 | 90% |
| 10,636.99 | Higher | 100% |