Table 1: Family Co-Pay Fees Family of 2 Family of 3 Family of 4 Family of 5 Family of 6 Family of 7 Family of 8 Family of 9 Family of 10 From To 0 999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1,000 1,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2,000 2,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3,000 3,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4,000 4,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5,000 5,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6,000 6,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7,000 7,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8,000 8,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9,000 9,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10,000 10,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11,000 11,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12,000 12,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13,000 13,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14,000 14,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15,000 15,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16,000 16,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17,000 17,999 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18,000 18,999 $87.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19,000 19,999 $91.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20,000 20,999 $96.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21,000 21,999 $119.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22,000 22,999 $124.58 $95.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23,000 23,999 $129.99 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24,000 24,999 $135.41 $104.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25,000 25,999 $140.83 $108.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26,000 26,999 $146.24 $135.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27,000 27,999 $151.66 $140.00 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28,000 28,999 $157.08 $145.00 $108.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29,000 29,999 $162.49 $150.00 $112.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30,000 30,999 $167.91 $155.00 $116.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31,000 31,999 $173.33 $160.00 $146.66 $106.66 $0.00 $0.00 $0.00 $0.00 $0.00 32,000 32,999 $178.74 $165.00 $151.25 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 33,000 33,999 $184.16 $170.00 $155.83 $113.33 $0.00 $0.00 $0.00 $0.00 $0.00 34,000 34,999 $189.58 $175.00 $160.41 $116.66 $0.00 $0.00 $0.00 $0.00 $0.00 35,000 35,999 $194.99 $180.00 $165.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 36,000 36,999 $200.41 $185.00 $169.58 $154.16 $107.91 $0.00 $0.00 $0.00 $0.00 37,000 37,999 $205.83 $190.00 $174.16 $158.33 $110.83 $0.00 $0.00 $0.00 $0.00 38,000 38,999 $211.24 $195.00 $178.75 $162.50 $113.75 $0.00 $0.00 $0.00 $0.00 39,000 39,999 $200.00 $183.33 $166.66 $116.66 $0.00 $0.00 $0.00 $0.00 40,000 40,999 $205.00 $187.91 $170.83 $119.58 $0.00 $0.00 $0.00 $0.00 41,000 41,999 $210.00 $192.50 $175.00 $157.50 $122.50 $0.00 $0.00 $0.00 42,000 42,999 $215.00 $197.08 $179.16 $161.25 $161.25 $0.00 $0.00 $0.00 43,000 43,999 $220.00 $201.66 $183.33 $165.00 $165.00 $0.00 $0.00 $0.00 44,000 44,999 $225.00 $206.25 $187.50 $168.75 $168.75 $0.00 $0.00 $0.00 45,000 45,999 $230.00 $210.83 $191.66 $172.50 $172.50 $172.50 $0.00 $0.00 46,000 46,999 $235.00 $215.41 $195.83 $176.25 $176.25 $176.25 $0.00 $0.00 47,000 47,999 $240.00 $220.00 $200.00 $180.00 $180.00 $180.00 $0.00 $0.00 48,000 48,999 $245.00 $224.58 $204.16 $183.75 $183.75 $183.75 $0.00 $0.00 49,000 49,999 $229.16 $208.33 $187.50 $187.50 $187.50 $0.00 $0.00 50,000 50,999 $233.75 $212.50 $191.25 $191.25 $191.25 $191.25 $0.00 51,000 51,999 $238.33 $216.66 $195.00 $195.00 $195.00 $195.00 $0.00 52,000 52,999 $242.91 $220.83 $198.75 $198.75 $198.75 $198.75 $0.00 53,000 53,999 $247.50 $225.00 $202.50 $202.50 $202.50 $202.50 $0.00 54,000 54,999 $252.08 $229.16 $206.25 $206.25 $206.25 $206.25 $206.25 55,000 55,999 $256.66 $233.33 $210.00 $210.00 $210.00 $210.00 $210.00 56,000 56,999 $261.25 $237.50 $213.75 $213.75 $213.75 $213.75 $213.75 57,000 57,999 $241.66 $217.50 $217.50 $217.50 $217.50 $217.50 58,000 58,999 $245.83 $221.25 $221.25 $221.25 $221.25 $221.25 59,000 59,999 $250.00 $225.00 $225.00 $225.00 $225.00 $225.00 60,000 60,999 $254.16 $228.75 $228.75 $228.75 $228.75 $228.75 61,000 61,999 $258.33 $232.50 $232.50 $232.50 $232.50 $232.50 62,000 62,999 $262.50 $236.25 $236.25 $236.25 $236.25 $236.25 63,000 63,999 $266.66 $240.00 $240.00 $240.00 $240.00 $240.00 64,000 64,999 $270.83 $243.75 $243.75 $243.75 $243.75 $243.75 65,000 65,999 $275.00 $247.50 $247.50 $247.50 $247.50 $247.50 66,000 66,999 $251.25 $251.25 $251.25 $251.25 $251.25 67,000 67,999 $255.00 $255.00 $255.00 $255.00 $255.00 68,000 68,999 $258.75 $258.75 $258.75 $258.75 $258.75 69,000 69,999 $262.50 $262.50 $262.50 $262.50 $262.50 70,000 70,999 $266.25 $266.25 $266.25 $266.25 $266.25 71,000 71,999 $270.00 $270.00 $270.00 $270.00 $270.00 72,000 72,999 $273.75 $273.75 $273.75 $273.75 $273.75 73,000 73,999 $277.50 $277.50 $277.50 $277.50 $277.50 74,000 74,999 $281.25 $281.25 $281.25 $281.25 $281.25 75,000 75,999 $285.00 $285.00 $285.00 $285.00 76,000 76,999 $288.75 $288.75 $288.75 $288.75 77,000 77,999 $292.50 $292.50 $292.50 78,000 78,999 $296.25 $296.25 $296.25 79,000 79,999 $300.00 $300.00 80,000 80,999 $303.75 81,000 81,999 $307.50 Table 2: Family Co-Pay Rates Family of 2 Family of 3 Family of 4 Family of 5 Family of 6 or More Up to 50% SMI 5.50% 5% 4.50% 4% 3.50% 50% SMI -- 85% 6.50% 6% 5.50% 5% 4.50% Table 3: Income Eligibility Limits Low High 2-person families $45,313 $38,516 $38,000 $38,999 $22,657 $17,420 $6,504 3-person families $55,975 $47,579 $48,000 $48,999 $27,988 $21,960 $8,160 4-person families $66,637 $56,641 $56,000 $56,999 $33,319 $26,500 $9,828 5-person families $77,299 $65,704 $65,000 $65,999 $38,649 $31,040 $11,496 Annual Gross Family Income Range 2021 Federal Poverty Line 50% SMI Family Size State Median Income (SMI) Maximum Income Limit for Eligibility (85% of SMI) 50% of SMI KEY 2021 Federal Poverty Line TANF Maximum Income Limit (Annualized) 2018 TANF Eligibility 85% SMI Income range

6-person families $87,961 $74,767 $74,000 $74,999 $43,980 $35,580 $13,164 7-person families $89,960 $76,466 $76,000 $76,999 $44,980 $40,120 $14,820 8-person families $91,959 $78,165 $78,000 $78,999 $45,980 $44,660 $16,488 9-person families $93,958 $79,864 $79,000 $79,999 $46,979 $49,200 $18,156 10-person families $95,957 $81,564 $81,000 $81,999 $47,979 $53,740 $19,824 Effective 11/01/2021 Sources: 2014-2018 American Community Survey 5 Year Estimates; Low Income Home Energy Assistance Program (LIHEAP) State Median Income by Household Size for FFY 2021 (https://www.acf.hhs.gov/sites/default/files/documents/ocs/comm_liheap_im2002smiattachment_fy2021.pdf, 45 CFR 96.85); 2021 Federal Poverty Guidelines (https://aspe.hhs.gov/2021-poverty-guidelines#threshholds); TANF Income Guidelines (http://www.mdhs.ms.gov/economic-assistance/tanf/)