Ariz. Admin. Code § tit. 6, ch. 6, art. 12, app A

Current through Register Vol. 30, No. 45, November 8, 2024

Appendix A - Cost of Care Portion Table

DEPARTMENT OF ECONOMIC SECURITY DIVISION OF DEVELOPMENTAL DISABILITIES COST OF CARE PORTION TABLE

Income based on 200% of federal poverty guidelines issued January 23, 2009

PERCENT TO PAY OF SERVICES RECEIVED		FAMILY SIZE
			1		2		3		4		5		6		7		8		9		10
		M O N T H L Y F A M I L Y I N C O M E
0.0%			$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00
		to	$1,805	to	$2,428	to	$3,052	to	$3,675	to	$4,298	to	$4,922	to	$5,545	to	$6,168	to	$6,792	to	$7,415
15.0%			$1,806		$2,429		$3,053		$3,676		$4,299		$4,923		$5,546		$6,169		$6,793		$7,416
		to	$2,058	to	$2,768	to	$3,479	to	$4,190	to	$4,900	to	$5,611	to	$6,321	to	$7,032	to	$7,743	to	$8,453
20.0%			$2,059		$2,769		$3,480		$4,191		$4,901		$5,612		$6,322		$7,033		$7,744		$8,454
		to	$2,310	to	$3,108	to	$3,906	to	$4,704	to	$5,502	to	$6,300	to	$7,098	to	$7,895	to	$8,693	to	$9,491
25.0%			$2,311		$3,109		$3,907		$4,705		$5,503		$6,301		$7,099		$7,896		$8,694		$9,492
		to	$2,563	to	$3,448	to	$4,333	to	$5,219	to	$6,104	to	$6,989	to	$7,874	to	$8,759	to	$9,644	to	$10,529
30.0%			$2,564		$3,449		$4,334		$5,220		$6,105		$6,990		$7,875		$8,760		$9,645		$10,530
		to	$2,816	to	$3,788	to	$4,761	to	$5,733	to	$6,705	to	$7,678	to	$8,650	to	$9,623	to	$10,595	to	$11,567
35.0%			$2,817		$3,789		$4,762		$5,734		$6,706		$7,679		$8,651		$9,624		$10,596		$11,568
		to	$3,069	to	$4,128	to	$5,188	to	$6,248	to	$7,307	to	$8,367	to	$9,427	to	$10,486	to	$11,546	to	$12,606
40.0%			$3,070		$4,129		$5,189		$6,249		$7,308		$8,368		$9,428		$10,487		$11,547		$12,607
		to	$3,321	to	$4,468	to	$5,615	to	$6,762	to	$7,909	to	$9,056	to	$10,203	to	$11,350	to	$12,497	to	$13,644
45.0%			$3,322		$4,469		$5,616		$6,763		$7,910		$9,057		$10,204		$11,351		$12,498		$13,645
		to	$3,574	to	$4,808	to	$6,042	to	$7,277	to	$8,511	to	$9,745	to	$10,979	to	$12,213	to	$13,448	to	$14,682
50.0%			$3,575		$4,809		$6,043		$7,278		$8,512		$9,746		$10,980		$12,214		$13,449		$14,683
		to	$3,827	to	$5,148	to	$6,470	to	$7,791	to	$9,112	to	$10,434	to	$11,755	to	$13,077	to	$14,398	to	$15,720
55.0%			$3,828		$5,149		$6,471		$7,792		$9,113		$10,435		$11,756		$13,078		$14,399		$15,721
		to	$4,079	to	$5,488	to	$6,897	to	$8,306	to	$9,714	to	$11,123	to	$12,532	to	$13,940	to	$15,349	to	$16,758
60.0%			$4,080		$5,489		$6,898		$8,307		$9,715		$11,124		$12,533		$13,941		$15,350		$16,759
		to	$4,332	to	$5,828	to	$7,324	to	$8,820	to	$10,316	to	$11,812	to	$13,308	to	$14,804	to	$16,300	to	$17,796
65.0%			$4,333		$5,829		$7,325		$8,821		$10,317		$11,813		$13,309		$14,805		$16,301		$17,797
		to	$4,585	to	$6,168	to	$7,751	to	$9,335	to	$10,918	to	$12,501	to	$14,084	to	$15,668	to	$17,251	to	$18,834
70.0%			$4,586		$6,169		$7,752		$9,336		$10,919		$12,502		$14,085		$15,669		$17,252		$18,835
		to	$4,837	to	$6,508	to	$8,178	to	$9,849	to	$11,520	to	$13,190	to	$14,861	to	$16,531	to	$18,202	to	$19,872
75.0%			$4,838		$6,509		$8,179		$9,850		$11,521		$13,191		$14,862		$16,532		$18,203		$19,873
		to	$5,090	to	$6,848	to	$8,606	to	$10,364	to	$12,121	to	$13,879	to	$15,637	to	$17,395	to	$19,153	to	$20,910
80.0%			$5,091		$6,849		$8,607		$10,365		$12,122		$13,880		$15,638		$17,396		$19,154		$20,911
		to	$5,343	to	$7,188	to	$9,033	to	$10,878	to	$12,723	to	$14,568	to	$16,413	to	$18,258	to	$20,103	to	$21,948
85.0%			$5,344		$7,189		$9,034		$10,879		$12,724		$14,569		$16,414		$18,259		$20,104		$21,949
		to	$5,596	to	$7,528	to	$9,460	to	$11,393	to	$13,325	to	$15,257	to	$17,190	to	$19,122	to	$21,054	to	$22,987
90.0%			$5,597		$7,529		$9,461		$11,394		$13,326		$15,258		$17,191		$19,123		$21,055		$22,988
		to	$5,848	to	$7,868	to	$9,887	to	$11,907	to	$13,927	to	$15,946	to	$17,966	to	$19,985	to	$22,005	to	$24,025
95.0%			$5,849		$7,869		$9,888		$11,908		$13,928		$15,947		$17,967		$19,986		$22,006		$24,026
		to	$6,101	to	$8,208	to	$10,315	to	$12,422	to	$14,528	to	$16,635	to	$18,742	to	$20,849	to	$22,956	to	$25,063
100.0%			$6,102		$8,209		$10,316		$12,423		$14,529		$16,636		$18,743		$20,850		$22,957		$25,064
			Or greater		Or greater		Or greater		Or greater		Or greater		Or greater		Or greater		Or greater		Or greater		Or greater

PERCENT TO PAY OF SERVICES RECEIVED		FAMILY SIZE
			11		12		13		14		15		16		17		18		19		20
		M O N T H L Y F A M I L Y I N C O M E
0.0%			$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00
		to	$8,038	to	$8,662	to	$9,285	to	$9,908	to	$10,532	to	$11,155	to	$11,778	to	$12,402	to	$13,025	to	$13,648
15.0%			$8,039		$8,663		$9,286		$9,909		$10,533		$11,156		$11,779		$12,403		$13,026		$13,649
		to	$9,164	to	$9,874	to	$10,585	to	$11,296	to	$12,006	to	$12,717	to	$13,427	to	$14,138	to	$14,849	to	$15,559
20.0%			$9,165		$9,875		$10,586		$11,297		$12,007		$12,718		$13,428		$14,139		$14,850		$15,560
		to	$10,289	to	$11,087	to	$11,885	to	$12,683	to	$13,481	to	$14,278	to	$15,076	to	$15,874	to	$16,672	to	$17,470
25.0%			$10,290		$11,088		$11,886		$12,684		$13,482		$14,279		$15,077		$15,875		$16,673		$17,471
		to	$11,414	to	$12,300	to	$13,185	to	$14,070	to	$14,955	to	$15,840	to	$16,725	to	$17,610	to	$18,496	to	$19,381
30.0%			$11,415		$12,301		$13,186		$14,071		$14,956		$15,841		$16,726		$17,611		$18,497		$19,382
		to	$12,540	to	$13,512	to	$14,485	to	$15,457	to	$16,429	to	$17,402	to	$18,374	to	$19,347	to	$20,319	to	$21,291
35.0%			$12,541		$13,513		$14,486		$15,458		$16,430		$17,403		$18,375		$19,348		$20,320		$21,292
		to	$13,665	to	$14,725	to	$15,785	to	$16,844	to	$17,904	to	$18,964	to	$20,023	to	$21,083	to	$22,143	to	$23,202
40.0%			$13,666		$14,726		$15,786		$16,845		$17,905		$18,965		$20,024		$21,084		$22,144		$23,203
		to	$14,791	to	$15,937	to	$17,084	to	$18,231	to	$19,378	to	$20,525	to	$21,672	to	$22,819	to	$23,966	to	$25,113
45.0%			$14,792		$15,938		$17,085		$18,232		$19,379		$20,526		$21,673		$22,820		$23,967		$25,114
		to	$15,916	to	$17,150	to	$18,384	to	$19,619	to	$20,853	to	$22,087	to	$23,321	to	$24,555	to	$25,790	to	$27,024
50.0%			$15,917		$17,151		$18,385		$19,620		$20,854		$22,088		$23,322		$24,556		$25,791		$27,025
		to	$17,041	to	$18,363	to	$19,684	to	$21,006	to	$22,327	to	$23,649	to	$24,970	to	$26,292	to	$27,613	to	$28,934
55.0%			$17,042		$18,364		$19,685		$21,007		$22,328		$23,650		$24,971		$26,293		$27,614		$28,935
		to	$18,167	to	$19,575	to	$20,984	to	$22,393	to	$23,802	to	$25,210	to	$26,619	to	$28,028	to	$29,437	to	$30,845
60.0%			$18,168		$19,576		$20,985		$22,394		$23,803		$25,211		$26,620		$28,029		$29,438		$30,846
		to	$19,292	to	$20,788	to	$22,284	to	$23,780	to	$25,276	to	$26,772	to	$28,268	to	$29,764	to	$31,260	to	$32,756
65.0%			$19,293		$20,789		$22,285		$23,781		$25,277		$26,773		$28,269		$29,765		$31,261		$32,757
		to	$20,417	to	$22,001	to	$23,584	to	$25,167	to	$26,750	to	$28,334	to	$29,917	to	$31,500	to	$33,084	to	$34,667
70.0%			$20,418		$22,002		$23,585		$25,168		$26,751		$28,335		$29,918		$31,501		$33,085		$34,668
		to	$21,543	to	$23,213	to	$24,884	to	$26,554	to	$28,225	to	$29,895	to	$31,566	to	$33,236	to	$34,907	to	$36,578
75.0%			$21,544		$23,214		$24,885		$26,555		$28,226		$29,896		$31,567		$33,237		$34,908		$36,579
		to	$22,668	to	$24,426	to	$26,184	to	$27,942	to	$29,699	to	$31,457	to	$33,215	to	$34,973	to	$36,731	to	$38,488
80.0%			$22,669		$24,427		$26,185		$27,943		$29,700		$31,458		$33,216		$34,974		$36,732		$38,489
		to	$23,793	to	$25,639	to	$27,484	to	$29,329	to	$31,174	to	$33,019	to	$34,864	to	$36,709	to	$38,554	to	$40,399
85.0%			$23,794		$25,640		$27,485		$29,330		$31,175		$33,020		$34,865		$36,710		$38,555		$40,400
		to	$24,919	to	$26,851	to	$28,784	to	$30,716	to	$32,648	to	$34,581	to	$36,513	to	$38,445	to	$40,378	to	$42,310
90.0%			$24,920		$26,852		$28,785		$30,717		$32,649		$34,582		$36,514		$38,446		$40,379		$42,311
		to	$26,044	to	$28,064	to	$30,083	to	$32,103	to	$34,123	to	$36,142	to	$38,162	to	$40,181	to	$42,201	to	$44,221
95.0%			$26,045		$28,065		$30,084		$32,104		$34,124		$36,143		$38,163		$40,182		$42,202		$44,222
		to	$27,170	to	$29,276	to	$31,383	to	$33,490	to	$35,597	to	$37,704	to	$39,811	to	$41,918	to	$44,025	to	$46,131
100.0%			$27,171		$29,277		$31,384		$33,491		$35,598		$37,705		$39,812		$41,919		$44,026		$46,132
			Or greater		Or greater		Or greater		Or greater		Or greater		Or greater		Or greater		Or greater		Or greater		Or greater

To determine amount to pay:

1. Find family size, include any children out of the home that are receiving Division services.

2. Find Monthly Family Income (round to the nearest whole dollar).

3. Move down the correct family size column to the cell that contains the range corresponding to the monthly family income.

4. From that cell move to the far left to the percent pay column.

5. The percent is the percent you are required to pay monthly for the services your family / child received.

6. The payment amount is not to exceed the cost of services provided.

Ariz. Admin. Code tit. 6, ch. 6, art. 12, app A

Adopted effective February 17, 1982 (Supp. 82-1). Former Appendix A repealed, new Appendix A adopted effective September 30, 1993, under an exemption from A.R.S. Title 41, Chapter 6 (Supp. 93-3). Former Appendix A repealed, new Appendix A adopted effective December 1, 1996, under an exemption from A.R.S. Title 41, Chapter 6; filed in the Office of the Secretary of State, November 22, 1996 (96-4). Amended by exempt rulemaking at 10 A.A.R. 205, effective January 1, 2004 (Supp. 03-4). Former Appendix A repealed; new Appendix A made by exempt rulemaking at 16 A.A.R. 314, effective January 25, 2010 (Supp. 10-1).