us-oh/guidance/dcy/procedure-letter-21-2025-08-29/page-3

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us-oh/guidance/dcy/procedure-letter-21-2025-08-29/page-3 — Page 3 · Axiom

Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End 1 $0.00 $131.00 $0.00 $132.00 $196.00 $0.00 $197.00 $261.00 $0.00 $262.00 $327.00 $0.00 $328.00 $392.00 $0.00 $393.00 $457.00 $0.00 2 $0.00 $177.00 $0.00 $178.00 $265.00 $0.00 $266.00 $353.00 $0.00 $354.00 $441.00 $0.00 $442.00 $529.00 $0.00 $530.00 $617.00 $0.00 3 $0.00 $223.00 $0.00 $224.00 $334.00 $0.00 $335.00 $445.00 $0.00 $446.00 $556.00 $0.00 $557.00 $667.00 $0.00 $668.00 $778.00 $0.00 4 $0.00 $268.00 $0.00 $269.00 $402.00 $0.00 $403.00 $536.00 $0.00 $537.00 $670.00 $0.00 $671.00 $804.00 $0.00 $805.00 $938.00 $0.00 5 $0.00 $314.00 $0.00 $315.00 $471.00 $0.00 $472.00 $628.00 $0.00 $629.00 $785.00 $0.00 $786.00 $942.00 $0.00 $943.00 $1,099.00 $0.00 6 $0.00 $360.00 $0.00 $361.00 $540.00 $0.00 $541.00 $720.00 $0.00 $721.00 $899.00 $0.00 $900.00 $1,079.00 $0.00 $1,080.00 $1,259.00 $0.00 7 $0.00 $406.00 $0.00 $407.00 $609.00 $0.00 $610.00 $811.00 $0.00 $812.00 $1,014.00 $0.00 $1,015.00 $1,217.00 $0.00 $1,218.00 $1,419.00 $0.00 8 $0.00 $452.00 $0.00 $453.00 $677.00 $0.00 $678.00 $903.00 $0.00 $904.00 $1,129.00 $0.00 $1,130.00 $1,354.00 $0.00 $1,355.00 $1,580.00 $0.00 9 $0.00 $498.00 $0.00 $499.00 $746.00 $0.00 $747.00 $995.00 $0.00 $996.00 $1,243.00 $0.00 $1,244.00 $1,492.00 $0.00 $1,493.00 $1,740.00 $0.00 10 $0.00 $543.00 $0.00 $544.00 $815.00 $0.00 $816.00 $1,086.00 $0.00 $1,087.00 $1,358.00 $0.00 $1,359.00 $1,629.00 $0.00 $1,630.00 $1,901.00 $0.00 11 $0.00 $589.00 $0.00 $590.00 $884.00 $0.00 $885.00 $1,178.00 $0.00 $1,179.00 $1,472.00 $0.00 $1,473.00 $1,767.00 $0.00 $1,768.00 $2,061.00 $0.00 12 $0.00 $635.00 $0.00 $636.00 $952.00 $0.00 $953.00 $1,270.00 $0.00 $1,271.00 $1,587.00 $0.00 $1,588.00 $1,904.00 $0.00 $1,905.00 $2,222.00 $0.00 13 $0.00 $681.00 $0.00 $682.00 $1,021.00 $0.00 $1,022.00 $1,361.00 $0.00 $1,362.00 $1,702.00 $0.00 $1,703.00 $2,042.00 $0.00 $2,043.00 $2,382.00 $0.00 14 $0.00 $727.00 $0.00 $728.00 $1,090.00 $0.00 $1,091.00 $1,453.00 $0.00 $1,454.00 $1,816.00 $0.00 $1,817.00 $2,179.00 $0.00 $2,180.00 $2,542.00 $0.00 15 $0.00 $773.00 $0.00 $774.00 $1,159.00 $0.00 $1,160.00 $1,545.00 $0.00 $1,546.00 $1,931.00 $0.00 $1,932.00 $2,317.00 $0.00 $2,318.00 $2,703.00 $0.00 Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End 1 $458.00 $522.00 $0.00 $523.00 $587.00 $0.00 $588.00 $653.00 $0.00 $654.00 $718.00 $0.00 $719.00 $783.00 $0.00 $784.00 $848.00 $0.00 2 $618.00 $705.00 $0.00 $706.00 $794.00 $0.00 $795.00 $882.00 $0.00 $883.00 $970.00 $0.00 $971.00 $1,058.00 $0.00 $1,059.00 $1,146.00 $0.00 3 $779.00 $889.00 $0.00 $890.00 $1,000.00 $0.00 $1,001.00 $1,111.00 $0.00 $1,112.00 $1,222.00 $0.00 $1,223.00 $1,333.00 $0.00 $1,334.00 $1,444.00 $0.00 4 $939.00 $1,072.00 $0.00 $1,073.00 $1,206.00 $0.00 $1,207.00 $1,340.00 $0.00 $1,341.00 $1,474.00 $0.00 $1,475.00 $1,608.00 $0.00 $1,609.00 $1,742.00 $0.00 5 $1,100.00 $1,255.00 $0.00 $1,256.00 $1,412.00 $0.00 $1,413.00 $1,569.00 $0.00 $1,570.00 $1,726.00 $0.00 $1,727.00 $1,883.00 $0.00 $1,884.00 $2,040.00 $0.00 6 $1,260.00 $1,439.00 $0.00 $1,440.00 $1,619.00 $0.00 $1,620.00 $1,798.00 $0.00 $1,799.00 $1,978.00 $0.00 $1,979.00 $2,158.00 $0.00 $2,159.00 $2,338.00 $0.00 7 $1,420.00 $1,622.00 $0.00 $1,623.00 $1,825.00 $0.00 $1,826.00 $2,028.00 $0.00 $2,029.00 $2,230.00 $0.00 $2,231.00 $2,433.00 $0.00 $2,434.00 $2,636.00 $0.00 8 $1,581.00 $1,805.00 $0.00 $1,806.00 $2,031.00 $0.00 $2,032.00 $2,257.00 $0.00 $2,258.00 $2,482.00 $0.00 $2,483.00 $2,708.00 $0.00 $2,709.00 $2,934.00 $0.00 9 $1,741.00 $1,989.00 $0.00 $1,990.00 $2,237.00 $0.00 $2,238.00 $2,486.00 $0.00 $2,487.00 $2,734.00 $0.00 $2,735.00 $2,983.00 $0.00 $2,984.00 $3,232.00 $0.00 10 $1,902.00 $2,172.00 $0.00 $2,173.00 $2,444.00 $0.00 $2,445.00 $2,715.00 $0.00 $2,716.00 $2,987.00 $0.00 $2,988.00 $3,258.00 $0.00 $3,259.00 $3,529.00 $0.00 11 $2,062.00 $2,355.00 $0.00 $2,356.00 $2,650.00 $0.00 $2,651.00 $2,944.00 $0.00 $2,945.00 $3,239.00 $0.00 $3,240.00 $3,533.00 $0.00 $3,534.00 $3,827.00 $0.00 12 $2,223.00 $2,539.00 $0.00 $2,540.00 $2,856.00 $0.00 $2,857.00 $3,173.00 $0.00 $3,174.00 $3,491.00 $0.00 $3,492.00 $3,808.00 $0.00 $3,809.00 $4,125.00 $0.00 13 $2,383.00 $2,722.00 $0.00 $2,723.00 $3,062.00 $0.00 $3,063.00 $3,403.00 $0.00 $3,404.00 $3,743.00 $0.00 $3,744.00 $4,083.00 $0.00 $4,084.00 $4,423.00 $0.00 14 $2,543.00 $2,905.00 $0.00 $2,906.00 $3,269.00 $0.00 $3,270.00 $3,632.00 $0.00 $3,633.00 $3,995.00 $0.00 $3,996.00 $4,358.00 $0.00 $4,359.00 $4,721.00 $0.00 15 $2,704.00 $3,089.00 $0.00 $3,090.00 $3,475.00 $0.00 $3,476.00 $3,861.00 $0.00 $3,862.00 $4,247.00 $0.00 $4,248.00 $4,633.00 $0.00 $4,634.00 $5,019.00 $0.00 Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End Lower End Higher End 1 $849.00 $913.00 $0.00 $914.00 $979.00 $0.00 $980.00 $1,044.00 $0.00 $1,045.00 $1,109.00 $0.00 $1,110.00 $1,174.00 $0.00 $1,175.00 $1,239.00 $0.00 2 $1,147.00 $1,234.00 $0.00 $1,235.00 $1,322.00 $0.00 $1,323.00 $1,410.00 $0.00 $1,411.00 $1,499.00 $0.00 $1,500.00 $1,587.00 $0.00 $1,588.00 $1,675.00 $0.00 3 $1,445.00 $1,555.00 $0.00 $1,556.00 $1,666.00 $0.00 $1,667.00 $1,777.00 $0.00 $1,778.00 $1,888.00 $0.00 $1,889.00 $1,999.00 $0.00 $2,000.00 $2,110.00 $0.00 4 $1,743.00 $1,876.00 $0.00 $1,877.00 $2,010.00 $0.00 $2,011.00 $2,144.00 $0.00 $2,145.00 $2,278.00 $0.00 $2,279.00 $2,412.00 $0.00 $2,413.00 $2,546.00 $0.00 5 $2,041.00 $2,197.00 $0.00 $2,198.00 $2,354.00 $0.00 $2,355.00 $2,510.00 $0.00 $2,511.00 $2,667.00 $0.00 $2,668.00 $2,824.00 $0.00 $2,825.00 $2,981.00 $0.00 6 $2,339.00 $2,518.00 $0.00 $2,519.00 $2,697.00 $0.00 $2,698.00 $2,877.00 $0.00 $2,878.00 $3,057.00 $0.00 $3,058.00 $3,237.00 $0.00 $3,238.00 $3,417.00 $0.00 7 $2,637.00 $2,838.00 $0.00 $2,839.00 $3,041.00 $0.00 $3,042.00 $3,244.00 $0.00 $3,245.00 $3,447.00 $0.00 $3,448.00 $3,649.00 $0.00 $3,650.00 $3,852.00 $0.00 8 $2,935.00 $3,159.00 $0.00 $3,160.00 $3,385.00 $0.00 $3,386.00 $3,610.00 $0.00 $3,611.00 $3,836.00 $0.00 $3,837.00 $4,062.00 $0.00 $4,063.00 $4,287.00 $0.00 9 $3,233.00 $3,480.00 $0.00 $3,481.00 $3,729.00 $0.00 $3,730.00 $3,977.00 $0.00 $3,978.00 $4,226.00 $0.00 $4,227.00 $4,474.00 $0.00 $4,475.00 $4,723.00 $0.00 10 $3,530.00 $3,801.00 $0.00 $3,802.00 $4,072.00 $0.00 $4,073.00 $4,344.00 $0.00 $4,345.00 $4,615.00 $0.00 $4,616.00 $4,887.00 $0.00 $4,888.00 $5,158.00 $0.00 11 $3,828.00 $4,122.00 $0.00 $4,123.00 $4,416.00 $0.00 $4,417.00 $4,710.00 $0.00 $4,711.00 $5,005.00 $0.00 $5,006.00 $5,299.00 $0.00 $5,300.00 $5,594.00 $0.00 12 $4,126.00 $4,443.00 $0.00 $4,444.00 $4,760.00 $0.00 $4,761.00 $5,077.00 $0.00 $5,078.00 $5,394.00 $0.00 $5,395.00 $5,712.00 $0.00 $5,713.00 $6,029.00 $0.00 13 $4,424.00 $4,763.00 $0.00 $4,764.00 $5,104.00 $0.00 $5,105.00 $5,444.00 $0.00 $5,445.00 $5,784.00 $0.00 $5,785.00 $6,124.00 $0.00 $6,125.00 $6,464.00 $0.00 14 $4,722.00 $5,084.00 $0.00 $5,085.00 $5,447.00 $0.00 $5,448.00 $5,810.00 $0.00 $5,811.00 $6,174.00 $0.00 $6,175.00 $6,537.00 $0.00 $6,538.00 $6,900.00 $0.00 15 $5,020.00 $5,405.00 $0.00 $5,406.00 $5,791.00 $0.00 $5,792.00 $6,177.00 $0.00 $6,178.00 $6,563.00 $0.00 $6,564.00 $6,949.00 $0.00 $6,950.00 $7,335.00 $0.00 Weekly Copayment 95% Monthly FPL Weekly Copayment 90% Monthly FPL Weekly Copayment 10% Monthly FPL Weekly Copayment 85% Monthly FPL Weekly Copayment 15% Monthly FPL Weekly Copayment 70% Monthly FPL 30% Monthly FPL 50% Monthly FPL Weekly Copayment Weekly Copayment 20% Monthly FPL 40% Monthly FPL 60% Monthly FPL 45% Monthly FPL Weekly Copayment Weekly Copayment Weekly Copayment 55% Monthly FPL Family Size 80% Monthly FPL Family Size Weekly Copayment 35% Monthly FPL Weekly Copayment Weekly Copayment Family Size Weekly Copayment 65% Monthly FPL Publicly Funded Child Care Family Weekly Copayment Desk Aid Using Family's Monthly Income Effective 10/01/2025 Weekly Copayment Weekly Copayment Weekly Copayment 25% Monthly FPL 75% Monthly FPL