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Income Cost Chart

How to use this chart:

Step 1: Locate the number of people in your household.
Step 2: Find the box that matches your household's annual gross income and the age of your children.
Step 3: Check the cost chart to see your appropriate, average monthly cost per child and the co-payments per child, per visit.

(Example: A four-person household with an annual income of $69,840 will have an average, monthly premium of $77 per child, plus any co-pays for services.)  Download PDF version of chart.

Income*


​Household
Size 

Free
Low Cost
​Full Cost
​ages 1-5
ages 6-18
ages 0-1​ages 1-18
ages 0-18
ages 0-18
​  ​ages 0-18
​1
$19,060-$25,252
$16,147-$25,252
​$26,101-$31,807
$25,252-$31,807
​$31,807-$34,964
​$34,364-38,120
​$38,120-No Limit
​2
​$25,843-$34,237
$21,892-$34,237
$35,389-$43,126
​$34,237-$43,126
​$43,126-$47,405
$47,405-$51,685
$51,685-No Limit
3
$32,625-$43,223
$27,638-$43,223
$44,677-$54,444
$43,223-$54,444
$54,444-$59,847
$59,847-$65,250
$65,250-No Limit
​4
​$39,407-$52,208
​$33,383-$52,208
​$53,965-$65,762
​$52,208-$65,762
​$65,762-$72,288
​$72,288-$78,814
​$78,814-No Limit
​5
$46,190-$61,194
$39,129-$61,194
$63,253-$77,081
$61,194-$77,081
$77,081-$84,730
$84,730-$92,379
$92,379-No Limit
​6
​$52,972-$70,180
​$44,875-$70,180
​$72,541-$88,399
​$70,180-$88,399
​$88,399-$97,172
​$97,172-$105,944
​$105,944-No Limit
​7
$59,755-$79,165
$50,620-$79,165
$81,829-$99,718
$79,165-$99,718
$99,718-$109,613
$109,613-$119,509
$119,509-No Limit
​8
​$66,537-$88,151
​$56,366-$88,151
​$91,117-$111,036
​$88,151-$111,036
​$111,036-$122,055
​$122,055-$133,074
​$133,074-No Limit
​9
$73,319-$97,136
$62,111-$97,136
$100,405-$122,354
$97,136-$122,354
$122,354-$134,496
$134,496-$146,638
$146,638-No Limit
​10
​$80,102-$106,122
​$67,857-$106,122
​$109,693-$133,673
​$106,122-$133,673
​$133,673-$146,938
​$146,938-$160,203
​$160,203-No Limit


Cost


​Free
Low cost
​ ​ 
​Full cost
​ages 1-5
ages 6-18
ages 0-1​
ages 1-18
ages 0-18
ages 0-18
ages 0-18
average monthly premium per child
​$0
​$0
​$55
​$55
​$77
$88
$258
​  co-payments  
  (per child, per visit)​ ​ ​ ​
doctor visit​$0
​$0
$5
​$5
​$5
$5
​$15
brand-name prescription
​$0
​$0
$9
$9
$9
$9​$18
generic prescription
​$0
​$0
$6
$6
$6
$6
​$10
specialist visit
​$0
​$0
$10
$10
$10
$10
$25
emergency room visit**
​$0
​$0
$25
$25
$25
$25
$50
*If your income is below any amount listed, your family could be eligible for Medical Assistance

**Emergency room visit co-pay applies if the child is not admitted for a hospital stay.


Questions? Call 1-800-986-KIDS (5437).
Chart updated January 24, 2018.