Obsolete 0312 - Table VII - Income Limits for Medical Assistance & Medicare Cost-Sharing Programs

Effective Date: March 1, 2011 - February 29, 2012

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	908	1207	1679	1362	1815	2269	908	1089	1226
2	866	468	1226	1631	2268	1839	2452	3065	1226	1471	1655
3	1079	583	1545	2054	2857	2317	3089	3861
4	1262	682	1863	2478	3446	2794	3725	4657
5	1437	777	2181	2901	4035	3272	4362	5453	PMV (Presumed Maximum Value): Single: $244.66 Couple: $357.00 NH Personal Needs Allowance: $45.00 Medicare Part B: $96.40 per month or $115.50 1619B Income Limit: $2431/mo.
6	1584	857	2500	3324	4624	3749	4999	6248
7	1658	897	2818	3748	5213	4227	5635	7044
8	1735	938	3136	4171	5802	4704	6272	7840
9	1817	982	3455	4595	6391	5182	6909	8636
10	1893	1023	3773	5018	6980	5659	7545	9432
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)