Obsolete 0311 - Table VII - Income Limits for Medical Assistance & Medicare Cost-Sharing Programs

Effective Date: March 1, 2009 - February 28, 2011

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HH SIZE	MEDICAID Gross Income Tests for LIFC No Spenddown Allowed	MEDICAID Medically Needy Child,Medically Need Family Medically Needy Pregnant Woman, RM BMS Level Net test LIFC Spenddown Allowed Except for LIFC	MEDICAID Child Age 6-18 AM, BM, DM CHIP PLAN A 100% OF POVERTY Spenddown Allowed for AM, BM, DM Only	MEDICAID Pregnant Woman, Child Age 0-5 133% OF POVERTY No Spenddown Allowed	MEDICAID TR, LIFC - 12 Month Disregard 185% OF POVERTY No Spenddown Allowed	CHIP PLAN B PCN, & UPP Adults 150% OF POVERTY No Spenddown Allowed	CHIP PLAN C UPP Kids 200% OF POVERTY No Spenddown Allowed	MEDICAID WORK INCENTIVE 250% OF POVERTY No Spenddown Allowed	MEDICARE COST- SHARING QMB 100% OF POVERTY No Spenddown Allowed	MEDICARE COST- SHARING SLMB 120% OF POVERTY No Spenddown Allowed	MEDICARE COST- SHARING QI-1 135% OF POVERTY No Spenddown Allowed
1	623	382	903	1201	1670	1354	1805	2257	903	1083	1219
2	866	468	1215	1615	2247	1822	2429	3036	1215	1457	1640
3	1079	583	1526	2030	2823	2289	3052	3815
4	1262	682	1838	2444	3400	2757	3675	4594
5	1437	777	2150	2859	3976	3224	4299	5373	PMV (Presumed Maximum Value): Single: $244.66 Couple: $357.00 NH Personal Needs Allowance: $45.00 Medicare Part B: $96.40 per month 1619B Income Limit: $2427/mo.
6	1584	857	2461	3273	4553	3692	4922	6153
7	1658	897	2773	3688	5130	4159	5545	6932
8	1735	938	3085	4102	5706	4627	6169	7711
9	1817	982	3396	4517	6283	5094	6792	8490
10	1893	1023	3708	4931	6859	5562	7415	9269
PCN Eligible Individuals with income below 50% of the FPL pay a $25 premium. Divide 100% of the FPL amount by 2 to find 50% of FPL, then round up. PCN Eligible Individuals receiving General Financial Assistance pay only a $15 premium. SOCIAL SECURITY/SUPPLEMENTAL SECURITY INCOME (SSI) Information Full SSI for Single living alone: $674.00 (No State Suppl) SSI for Single receiving In-Kind Support: $449.34 (+$3.13 State Suppl) Full SSI for Couple living alone: $1,011.00 (+$4.60 State Suppl) SSI for Couple receiving In-kind Support: $674.00 (+$9.73 State Suppl)