Obsolete 0317 - Table VII Income Limits for Medical Assistance & Medicare Cost-Sharing Programs

Effective Date: January 1, 2017 - February 28, 2017

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	1377	1317	382	1832	1485	1980	941	990	2475	990	1188	1337
2	544	1856	1776	468	2470	2003	2670	1269	1335	3338	1335	1602	1803
3	678	2336	2235	583	3108	2520	3360	1596	1680	4200
4	797	2815	2694	682	3747	3038	4050	1924	2025	5063
5	912	3295	3153	777	4385	3555	4740	2252	2370	5925	PMV (Presumed Maximum Value): Single: $265.00 Couple: $387.66 NH Personal Needs Allowance: $45.00 Medicare Part B: $109.00/$134.00 per month 1619B Income Limit: $2872.00/mo.
6	1012	3774	3611	857	5023	4073	5430	2580	2715	6788
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: $490.00 (+$3.13 State Supplement) Full SSI for Couple living alone: $1,100.00 (+$4.60 State Supplement) SSI for Couple receiving In-kind Support: $735.34 (+$9.73 State Supplement)