Obsolete 0717 - Table VII - Income Limits for Medical Assistance & Medicare Cost-Sharing Programs

Effective Date: March 1, 2017 - June 30, 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	1397	1337	382	1860	1508	2010	955	1005	2513	1005	1206	1357
2	544	1882	1800	468	2504	2030	2707	1286	1354	3384	1354	1624	1827
3	678	2366	2264	583	3149	2553	3404	1617	1702	4255
4	797	2850	2727	682	3793	3075	4100	1948	2050	5125
5	912	3334	3190	777	4437	3598	4797	2279	2399	5996	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	3818	3654	857	5082	4120	5494	2610	2747	6867
7	1072	4303	4117	897	5726	4643	6190	2941	3095	7738
8	1132	4787	4580	938	6371	5165	6887	3272	3444	8609
9	1196	5271	5043	982	7015	5688	7584	3603	3792	9480
10	1257	5755	5507	1023	7659	6210	8280	3933	4140	10,350
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)