Obsolete 0215 - Table VII Income Limits for Medical Assistance and Medicare Cost Sharing Programs

Effective Date: January 1, 2015 - January 31, 2015

HH Size	Parent or Caretaker Relative	PREGNANT WOMAN CHILD 0-5	CHILD 6-18	Medically Needy Family- related REFUGEE	PCR - 12 Month TRANSI-TIONAL	CHIP PLAN B	CHIP PLAN C UPP	Poverty Aged & Disabled Med Needy ABD PCN	Medicaid Work Incentive	MEDICARE COST-SHARING
	Parent or Caretaker Relative	PREGNANT WOMAN CHILD 0-5	CHILD 6-18	Medically Needy Family- related REFUGEE	PCR - 12 Month TRANSI-TIONAL	CHIP PLAN B	CHIP PLAN C UPP	Poverty Aged & Disabled Med Needy ABD PCN	Medicaid Work Incentive	QMB	SLMB	QI-1
		139% FPL	133% FPL	BMS Level	185% FPL	150% FPL	200% FPL	100% FPL	250% FPL	100% FPL	120% FPL	135% FPL
1	438	1352	1294	382	1800	1459	1945	973	2432	973	1167	1313
2	544	1823	1744	468	2426	1967	2622	1311	3278	1311	1573	1770
3	678	2293	2194	583	3051	2474	3299	1650	4123
4	797	2763	2644	682	3677	2982	3975	1988	4969
5	912	3233	3094	777	4303	3489	4652	2326	5815	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: $2794.00/mo.
6	1012	3704	3544	857	4929	3997	5329	2665	6661
7	1072	4174	3994	897	5555	4504	6005	3003	7507
8	1132	4644	4444	938	6181	5012	6682	3341	8353
9	1196	5115	4894	982	6807	5519	7359	3680	9198
10	1257	5585	5344	1023	7433	6027	8035	4018	10044
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)