Obsolete 0116 - Table VII Income Limits for Medical Assistance and Medicare Cost-Sharing

Effective Date: March 1, 2015 - December 31, 2015

HH Size	Parent or Caretaker Relative	PREGNANT WOMAN CHILD 0-5	CHILD 6-18	Medically Needy Family- related REFUGEE BMS Level	PCR - 12 Month TRANSITIONAL	CHIP PLAN B	CHIP PLAN C UPP	PCN 95% FPL	Aged & Disabled		MEDICARE COST-SHARING
	Parent or Caretaker Relative	PREGNANT WOMAN CHILD 0-5	CHILD 6-18		PCR - 12 Month TRANSITIONAL	CHIP PLAN B	CHIP PLAN C UPP		Poverty and Med Needy ABD	Medicaid Work Incentive 250% FPL	QMB	SLMB 120% FPL	QI-1
		139% FPL	133% FPL		185% FPL	150% FPL	200% FPL		100% FPL	Medicaid Work Incentive 250% FPL	100% FPL	SLMB 120% FPL	135% FPL
1	438	1364	1305	382	1815	1472	1962	932	981	2453	981	1177	1325
2	544	1846	1766	468	2456	1992	2655	1262	1328	3319	1328	1593	1793
3	678	2328	2227	583	3098	2512	3349	1591	1675	4186
4	797	2809	2688	682	3739	3032	4042	1920	2021	5053
5	912	3291	3149	777	4380	3552	4735	2250	2368	5919	PMV (Presumed Maximum Value): Single: $264.33 Couple: $386.66 NH Personal Needs Allowance: $45.00 Medicare Part B: $104.90 per month 1619B Income Limit: $2872.00/mo.
6	1012	3773	3610	857	5022	4072	5429	2579	2715	6786
7	1072	4255	4071	897	5663	4592	6122	2908	3061	7653
8	1132	4737	4532	938	6304	5112	6815	3238	3408	8519
9	1196	5219	4994	982	6946	5632	7509	3567	3755	9386
10	1257	5701	5455	1023	7587	6152	8202	3896	4101	10,253
SOCIAL SECURITY/SUPPLEMENTAL SECURITY INCOME (SSI) Information Full SSI for Single living alone: $733.00 (No State Supplement) SSI for Single receiving In-Kind Support: $488.67 (+$3.13 State Supplement) Full SSI for Couple living alone: $1,100.00 (+$4.60 State Supplement) SSI for Couple receiving In-kind Support: $733.34 (+$9.73 State Supplement)