Obsolete 0313 Table VII - Income Limits for Medical Assistance and Medicare Cost-Sharing Programs

Effective Date: January 1, 2013 - February 28, 2013

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 150% OF POVERTY No Spenddown Allowed	CHIP PLAN C UPP 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	931	1239	1723	1397	1862	2328	931	1117	1257
2	866	468	1261	1677	2333	1892	2522	3153	1261	1513	1703
3	1079	583	1591	2116	2944	2387	3182	3978
4	1262	682	1921	2555	3554	2882	3842	4803
5	1437	777	2251	2994	4165	3377	4502	5628	PMV (Presumed Maximum Value): Single: $256.66 Couple: $375.33 NH Personal Needs Allowance: $45.00 Medicare Part B: $104.90 per month 1619B Income Limit: $2794.00/mo.
6	1584	857	2581	3433	4775	3872	5162	6453
7	1658	897	2911	3872	5386	4367	5822	7278
8	1735	938	3241	4311	5996	4862	6482	8103
9	1817	982	3571	4750	6607	5357	7142	8928
10	1893	1023	3900	5189	7217	5852	7802	9753
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: $710.00 (No State Suppl) SSI for Single receiving In-Kind Support: $473.34 (+$3.13 State Suppl) Full SSI for Couple living alone: $1,066.00 (+$4.60 State Suppl) SSI for Couple receiving In-kind Support: $710.67 (+$9.73 State Suppl)