MAGI Appendix A – DSS Manuals

MAGI income max with 5% -CHIP 75, UWHS, MPW POV, MHK, & AEG- FPL included and CHIP premium amounts 7/1/2022-4/30/2023
# of Persons		1	2	3	4	5	6	7	8	9	10	11
^#300% of Poverty	SMHB & CHIP 75	3455	4654	5854	7054	8253	9453	10653	11852	13052	14252	15451
	Premium	117	159	200	241	283	324	366	407	449	490	532
225% of Poverty	CHIP 74	2549	3434	4319	5204	6089	6974	7859	8744	9629	10514	11399
	Premium	48	65	82	99	115	132	150	167	184	200	217
^#201% of Poverty	UWHS	2333	3144	3954	4764	5575	6385	7195	8005	8816	9626	10436
^#196% of Poverty	MPW & MHK under 1	2277	3067	3858	4649	5439	6230	7020	7811	8602	9392	10183
185% of Poverty	CHIP 73	2096	2823	3551	4279	5006	5734	6462	7189	7917	8645	9372
	Premium	15	20	25	30	35	40	46	51	56	61	66
153%* of Poverty	CHIP 4M	1733	2335	2936	3538	4140	4742	5344	5945	6547	7149	7751
150% of Poverty	CHIP 71 & 72	1699	2289	2879	3469	4059	4649	5239	5829	6419	7009	7599
^#148% of Poverty	MHK	1733	2335	2937	3539	4140	4742	5344	5946	6548	7149	7751
141% of Poverty	MPW HIF	1597	2152	2707	3261	3816	4370	4925	5480	6034	6589	7143
^#133% of Poverty	AEG	1563	2106	2649	3192	3735	4277	4820	5363	5906	6449	6991
110%* of Poverty		1246	1678	2111	2544	2976	3409	3842	4274	4707	5140	5572
MHF/MPW MHF		141	241	301	353	400	445	490	532	574	616	658
100% of Poverty	(without 5%)	1133	1526	1920	2313	2706	3100	3493	3886	4280	4673	5066
*Income Ranges for CHIP 4M-Ages 1 through 5=148%-153% and ages 6 through 18=110%-153%; #=5% disregard applied at this level.
# of Persons		12	13	14	15	16	17	18	19	20	21	22
^#300% of Poverty	SMHB & CHIP 75	16651	17851	19050	20250	21450	22649	23849	25049	26248	27448	28648
	Premium	573	614	656	697	739	780	822	863	904	946	987
225% of Poverty	CHIP 74	12284	13169	14054	14939	15824	16709	17594	18479	19364	20249	21134
	Premium	234	251	269	285	302	319	336	352	370	387	404
^#201% of Poverty	UWHS	11246	12057	12867	13677	14487	15298	16108	16918	17729	18529	19349
^#196% of Poverty	MPW & MHK under 1	10523	11283	12044	12804	13565	14325	15086	15846	16606	17367	18127
185% of Poverty	CHIP 73	10100	10828	11555	12283	13011	13738	14466	15194	15921	16649	17377
	Premium	71	76	82	87	92	97	102	107	113	118	123
153%* of Poverty	CHIP 4M	8353	5954	9556	10158	10760	11362	11963	12565	13167	13769	14371
150% of Poverty	CHIP 71 & 72	8189	8779	9369	9959	10549	11139	11729	12319	12909	13499	14089
^#148% of Poverty	MHK	8353	8955	9557	10158	10760	11362	11964	12566	13167	13769	14371
141% of Poverty	MPW HIF	7698	8253	8807	9362	9916	10471	11026	11580	12135	12689	13244
^#133% of Poverty	AEG	7534	8077	8620	9163	9705	10248	10791	11334	11877	12419	12962
110%* of Poverty		6005	6438	6870	7303	7736	8168	8601	9034	9466	9899	10332
MHF/MPW MHF		700	742	784	826	868	910	952	994	1036	1078	1120
100% of Poverty	(without 5%)	5460	5853	6246	6640	7033	7426	7820	8213	8606	9000	9393
*Income Ranges for CHIP 4M-Ages 1 through 5=148%-153% and ages 6 through 18=110%-153%; #=5% disregard applied at this level.
Revised 07/2022

MAGI income max with 5% -CHIP 75, UWHS, MPW POV, MHK, & AEG- FPL included and CHIP premium amounts 4/1/2022 through 6/30/2022
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3455	4654	5854	7054	8253	9453	10653	11852	13052	14252	15451
	Premium	117	159	200	241	283	324	366	407	449	490	532
225% of Poverty	CHIP 74	2549	3434	4319	5204	6089	6974	7859	8744	9629	10514	11399
	Premium	48	65	82	99	115	132	150	167	184	200	217
201% of Poverty	UWHS	2333	3144	3954	4764	5575	6385	7195	8005	8816	9626	10436
196% of Poverty	MPW &	2277	3067	3858	4649	5439	6230	7020	7811	8602	9392	10183
	MHK under 1
185% of Poverty	CHIP 73	2096	2823	3551	4279	5006	5734	6462	7189	7917	8645	9372
	Premium	15	20	25	30	35	40	46	51	56	61	66
150% of Poverty	CHIP 71 & 72	1699	2289	2879	3469	4059	4649	5239	5829	6419	7009	7599
148% of Poverty	MHK	1733	2335	2937	3539	4140	4742	5344	5946	6548	7149	7751
141% of Poverty	MPW HIF	1597	2152	2707	3261	3816	4370	4925	5480	6034	6589	7143
133% of Poverty	AEG	1563	2106	2649	3192	3735	4277	4820	5363	5906	6449	6991
MHF/MPW MHF		141	241	301	353	400	445	490	532	574	616	658
100% of Poverty	(without 5%)	1133	1526	1920	2313	2706	3100	3493	3886	4280	4673	5066
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	16651	17851	19050	20250	21450	22649	23849	25049	26248	27448	28648
	Premium	573	614	656	697	739	780	822	863	904	946	987
225% of Poverty	CHIP 74	12284	13169	14054	14939	15824	16709	17594	18479	19364	20249	21134
	Premium	234	251	269	285	302	319	336	352	370	387	404
201% of Poverty	UWHS	11246	12057	12867	13677	14487	15298	16108	16918	17729	18529	19349
196% of Poverty	MPW & MHK under 1
	MPW & MHK under 1	10523	11283	12044	12804	13565	14325	15086	15846	16606	17367	18127
185% of Poverty	CHIP 73	10100	10828	11555	12283	13011	13738	14466	15194	15921	16649	17377
	Premium	71	76	82	87	92	97	102	107	113	118	123
150% of Poverty	CHIP 71 & 72	8189	8779	9369	9959	10549	11139	11729	12319	12909	13499	14089
148% of Poverty	MHK	8353	8955	9557	10158	10760	11362	11964	12566	13167	13769	14371
141% of Poverty	MPW HIF	7698	8253	8807	9362	9916	10471	11026	11580	12135	12689	13244
133% of Poverty	AEG	7534	8077	8620	9163	9705	10248	10791	11334	11877	12419	12962
MHF/MPW MHF		700	742	784	826	868	910	952	994	1036	1078	1120
100% of Poverty	(without 5%)	5460	5853	6246	6640	7033	7426	7820	8213	8606	9000	9393
Revised 04/2022

MAGI income max with 5% -CHIP 75, UWHS, MPW POV, MHK, & AEG- FPL included and CHIP premium amounts 7/1/2021 through 3/31/2022
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3274	4428	5582	6736	7890	9044	10198	11352	12505	13659	14813
	Premium	117	159	200	241	283	324	366	407	449	490	532
225% of Poverty	CHIP 74	2415	3267	4118	4969	5820	6672	7523	8374	9225	10077	10928
	Premium	48	65	82	99	115	132	150	167	184	200	217
201% of Poverty	UWHS	2212	2991	3770	4550	5329	6108	6888	7667	8446	9226	10005
196% of Poverty	MPW &	2158	2918	3679	4439	5200	5960	6721	7481	8241	9002	9762
	MHK under 1
185% of Poverty	CHIP 73	1986	2686	3386	4086	4786	5486	6186	6886	7585	8285	8985
	Premium	15	20	25	30	35	40	46	51	56	61	66
150% of Poverty	CHIP 71 & 72	1610	2178	2745	3313	3880	4448	5015	5583	6150	6718	7285
148% of Poverty	MHK	1643	2222	2800	3379	3958	4537	5116	5695	6273	6852	7431
141% of Poverty	MPW HIF	1514	2047	2581	3114	3648	4181	4715	5248	5781	6315	6848
133% of Poverty	AEG	1482	2004	2526	3048	3570	4092	4614	5136	5658	6181	6703
MHF/MPW MHF		141	241	301	353	400	445	490	532	574	616	658
100% of Poverty	(without 5%)	1074	1452	1830	2209	2587	2965	3344	3722	4100	4479	4857
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15967	17121	18275	19429	20583	21737	22891	24045	25199	26352	27506
	Premium	573	614	656	697	739	780	822	863	904	946	987
225% of Poverty	CHIP 74	11779	12630	13482	14333	15184	16035	16887	17738	18589	19440	20292
	Premium	234	251	269	285	302	319	336	352	370	387	404
201% of Poverty	UWHS	10785	11564	12343	13123	13902	14681	15461	16240	17020	17799	18578
196% of Poverty	MPW & MHK under 1
	MPW & MHK under 1	10523	11283	12044	12804	13565	14325	15086	15846	16606	17367	18127
185% of Poverty	CHIP 73	9685	10385	11085	11785	12485	13185	13885	14585	15285	15984	16684
	Premium	71	76	82	87	92	97	102	107	113	118	123
150% of Poverty	CHIP 71 & 72	7853	8420	8988	9555	10123	10690	11258	11825	12393	12960	13528
148% of Poverty	MHK	8010	8589	9168	9747	10325	10904	11483	12062	12641	13220	13799
141% of Poverty	MPW HIF	7382	7915	8449	8982	9516	10049	10583	11116	11649	12183	12716
133% of Poverty	AEG	7225	7747	8269	8791	9313	9835	10357	10879	11402	11924	12446
MHF/MPW MHF		700	742	784	826	868	910	952	994	1036	1078	1120
100% of Poverty	(without 5%)	5235	5614	5992	6370	6749	7127	7505	7884	8262	8640	9019
Revised 09/2021

MAGI income max with 5% -CHIP 75, UWHS, MPW POV, MHK, & MHF Adult- FPL included and CHIP premium amounts 7/1/2021 through 3/31/2022
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3274	4428	5582	6736	7890	9044	10198	11352	12505	13659	14813
	Premium	117	159	200	241	283	324	366	407	449	490	532
225% of Poverty	CHIP 74	2415	3267	4118	4969	5820	6672	7523	8374	9225	10077	10928
	Premium	48	65	82	99	115	132	150	167	184	200	217
201% of Poverty	UWHS	2212	2991	3770	4550	5329	6108	6888	7667	8446	9226	10005
196% of Poverty	MPW &	2158	2918	3679	4439	5200	5960	6721	7481	8241	9002	9762
	MHK under 1
185% of Poverty	CHIP 73	1986	2686	3386	4086	4786	5486	6186	6886	7585	8285	8985
	Premium	15	20	25	30	35	40	46	51	56	61	66
150% of Poverty	CHIP 71 & 72	1610	2178	2745	3313	3880	4448	5015	5583	6150	6718	7285
148% of Poverty	MHK	1643	2222	2800	3379	3958	4537	5116	5695	6273	6852	7431
141% of Poverty	MPW HIF	1514	2047	2581	3114	3648	4181	4715	5248	5781	6315	6848
MHF Adult		195	314	393	464	530	594	658	719	779	840	901
MHF Child/MPW MHF		141	241	301	353	400	445	490	532	574	616	658
100% of Poverty	(without 5%)	1074	1452	1830	2209	2587	2965	3344	3722	4100	4479	4857
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15967	17121	18275	19429	20583	21737	22891	24045	25199	26352	27506
	Premium	573	614	656	697	739	780	822	863	904	946	987
225% of Poverty	CHIP 74	11779	12630	13482	14333	15184	16035	16887	17738	18589	19440	20292
	Premium	234	251	269	285	302	319	336	352	370	387	404
201% of Poverty	UWHS	10785	11564	12343	13123	13902	14681	15461	16240	17020	17799	18578
196% of Poverty	MPW & MHK under 1
	MPW & MHK under 1	10523	11283	12044	12804	13565	14325	15086	15846	16606	17367	18127
185% of Poverty	CHIP 73	9685	10385	11085	11785	12485	13185	13885	14585	15285	15984	16684
	Premium	71	76	82	87	92	97	102	107	113	118	123
150% of Poverty	CHIP 71 & 72	7853	8420	8988	9555	10123	10690	11258	11825	12393	12960	13528
148% of Poverty	MHK	8010	8589	9168	9747	10325	10904	11483	12062	12641	13220	13799
141% of Poverty	MPW HIF	7382	7915	8449	8982	9516	10049	10583	11116	11649	12183	12716
MHF Adult		962	1023	1084	1145	1206	1267	1328	1389	1450	1510	1571
MHF Child/MPW MHF		700	742	784	826	868	910	952	994	1036	1078	1120
100% of Poverty	(without 5%)	5235	5614	5992	6370	6749	7127	7505	7884	8262	8640	9019
Revised 07/2021

MAGI income max with 5% -CHIP 75, UWHS, MPW POV, MHK, & MHF Adult- FPL included and CHIP premium amounts 4/01/2021 through 06/30/2021
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3274	4428	5582	6736	7890	9044	10198	11352	12505	13659	14813
	Premium	117	159	200	241	283	324	366	407	449	490	532
225% of Poverty	CHIP 74	2415	3267	4118	4969	5820	6672	7523	8374	9225	10077	10928
	Premium	48	65	82	99	115	132	150	167	184	200	217
201% of Poverty	UWHS	2212	2991	3770	4550	5329	6108	6888	7667	8446	9226	10005
196% of Poverty	MPW &	2158	2918	3679	4439	5200	5960	6721	7481	8241	9002	9762
	MHK under 1
185% of Poverty	CHIP 73	1986	2686	3386	4086	4786	5486	6186	6886	7585	8285	8985
	Premium	15	20	25	30	35	40	46	51	56	61	66
150% of Poverty	CHIP 71 & 72	1610	2178	2745	3313	3880	4448	5015	5583	6150	6718	7285
148% of Poverty	MHK	1643	2222	2800	3379	3958	4537	5116	5695	6273	6852	7431
141% of Poverty	MPW HIF	1514	2047	2581	3114	3648	4181	4715	5248	5781	6315	6848
MHF Adult		195	314	393	464	530	594	658	719	779	840	901
MHF Child/MPW MHF		141	241	301	353	400	445	490	532	574	616	658
100% of Poverty	(without 5%)	1074	1452	1830	2209	2587	2965	3344	3722	4100	4479	4857
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15967	17121	18275	19429	20583	21737	22891	24045	25199	26352	27506
	Premium	573	614	656	697	739	780	822	863	904	946	987
225% of Poverty	CHIP 74	11779	12630	13482	14333	15184	16035	16887	17738	18589	19440	20292
	Premium	234	251	269	285	302	319	336	352	370	387	404
201% of Poverty	UWHS	10785	11564	12343	13123	13902	14681	15461	16240	17020	17799	18578
196% of Poverty	MPW & MHK under 1
	MPW & MHK under 1	10523	11283	12044	12804	13565	14325	15086	15846	16606	17367	18127
185% of Poverty	CHIP 73	9685	10385	11085	11785	12485	13185	13885	14585	15285	15984	16684
	Premium	71	76	82	87	92	97	102	107	113	118	123
150% of Poverty	CHIP 71 & 72	7853	8420	8988	9555	10123	10690	11258	11825	12393	12960	13528
148% of Poverty	MHK	8010	8589	9168	9747	10325	10904	11483	12062	12641	13220	13799
141% of Poverty	MPW HIF	7382	7915	8449	8982	9516	10049	10583	11116	11649	12183	12716
MHF Adult		962	1023	1084	1145	1206	1267	1328	1389	1450	1510	1571
MHF Child/MPW MHF		700	742	784	826	868	910	952	994	1036	1078	1120
100% of Poverty	(without 5%)	5235	5614	5992	6370	6749	7127	7505	7884	8262	8640	9019
Revised 04/2021

MAGI income max with 5% -CHIP 75, UWHS, MPW, MHK, & MHF Adult- FPL included and CHIP premium amounts 11/22/2020 through 3/31/2021
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3244	4382	5521	6660	7798	8937	10076	11214	12353	13492	14630
	Premium	117	159	200	241	283	324	366	407	449	490	532
225% of Poverty	CHIP 74	2393	3233	4073	4913	5753	6593	7433	8273	9113	9953	10793
	Premium	48	65	82	99	115	132	150	167	184	200	217
201% of Poverty	UWHS	2191	2960	3729	4498	5267	6036	6805	7574	8343	9113	9882
196% of Poverty	MPW &	2138	2888	3639	4389	5139	5890	6640	7391	8141	8891	9642
	MHK under 1
185% of Poverty	CHIP 73	1968	2658	3349	4040	4730	5421	6112	6802	7493	8184	8874
	Premium	15	20	25	30	35	40	46	51	56	61	66
150% of Poverty	CHIP 71 & 72	1595	2155	2715	3275	3835	4395	4955	5515	6075	6635	7195
148% of Poverty	MHK	1627	2199	2770	3341	3912	4483	5055	5626	6197	6768	7339
141% of Poverty	MPW HIF	1500	2026	2553	3079	3605	4132	4658	5185	5711	6237	6764
MHF Adult		195	313	392	463	528	592	656	716	777	838	898
MHF Child		141	241	301	353	400	445	490	532	574	616	658
100% of Poverty	(without 5%)	1064	1437	1810	2184	2557	2930	3304	3677	4050	4424	4797
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15769	16908	18046	19185	20324	21462	22601	23740	24878	26017	27156
	Premium	573	614	656	697	739	780	822	863	904	946	987
225% of Poverty	CHIP 74	11633	12473	13313	14153	14993	15833	16673	17513	18353	19193	20033
	Premium	234	251	269	285	302	319	336	352	370	387	404
201% of Poverty	UWHS	10651	11420	12189	12958	13727	14496	15265	16034	16803	17572	18341
196% of Poverty	MPW & MHK under 1
	MPW & MHK under 1	10392	11143	11893	12643	13394	14144	14895	15645	16395	17146	17896
185% of Poverty	CHIP 73	9565	10256	10946	11637	12328	13018	13709	14400	15090	15781	16472
	Premium	71	76	82	87	92	97	102	107	113	118	123
150% of Poverty	CHIP 71 & 72	7755	8315	8875	9435	9995	10555	11115	11675	12235	12795	13355
148% of Poverty	MHK	7911	8482	9053	9624	10195	10767	11338	11909	12480	13051	13623
141% of Poverty	MPW HIF	7290	7817	8343	8869	9396	9922	10449	10975	11501	12028	12554
MHF Adult		959	1020	1080	1141	1202	1262	1323	1384	1444	1505	1566
MHF Child		700	742	784	826	868	910	952	994	1036	1078	1120
100% of Poverty	(without 5%)	5170	5544	5917	6290	6664	7037	7410	7784	8157	8530	8904
Revised 11/2020

MAGI income maximums with 5% of FPL included and CHIP premium amounts 04/01/2020 through 11/21/2020
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3244	4382	5521	6660	7798	8937	10076	11214	12353	13492	14630
	Premium	117	159	200	241	283	324	366	407	449	490	532
225% of Poverty	CHIP 74	2446	3305	4163	5022	5881	6739	7598	8457	9315	10174	11033
	Premium	48	65	82	99	115	132	150	167	184	200	217
201% of Poverty	UWHS	2191	2960	3729	4498	5267	6036	6805	7574	8343	9113	9882
196% of Poverty	MPW &	2138	2888	3639	4389	5139	5890	6640	7391	8141	8891	9642
	MHK under 1
185% of Poverty	CHIP 73	2021	2730	3439	4149	4858	5567	6277	6986	7695	8405	9114
	Premium	15	20	25	30	35	40	46	51	56	61	66
150% of Poverty	CHIP 71 & 72	1649	2227	2806	3385	3963	4542	5121	5699	6278	6857	7435
148% of Poverty	MHK	1627	2199	2770	3341	3912	4483	5055	5626	6197	6768	7339
141% of Poverty	MPW HIF	1554	2099	2643	3189	3734	4278	4824	5369	5913	6460	7004
MHF		195	313	392	463	528	592	656	716	777	838	898
100% of Poverty	(without 5%)	1064	1437	1810	2184	2557	2930	3304	3677	4050	4424	4797
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15769	16908	18046	19185	20324	21462	22601	23740	24878	26017	27156
	Premium	573	614	656	697	739	780	822	863	904	946	987
225% of Poverty	CHIP 74	11891	12750	13609	14467	15326	16185	17043	17902	18761	19619	20478
	Premium	234	251	269	285	302	319	336	352	370	387	404
201% of Poverty	UWHS	10651	11420	12189	12958	13727	14496	15265	16034	16803	17572	18341
196% of Poverty	MPW & MHK under 1
	MPW & MHK under 1	10392	11143	11893	12643	13394	14144	14895	15645	16395	17146	17896
185% of Poverty	CHIP 73	9823	10533	11242	11951	12661	13370	14079	14789	15498	16207	16917
	Premium	71	76	82	87	92	97	102	107	113	118	123
150% of Poverty	CHIP 71 & 72	8014	8593	9171	9750	10329	10907	11486	12065	12643	13222	13801
148% of Poverty	MHK	7911	8482	9053	9624	10195	10767	11338	11909	12480	13051	13623
141% of Poverty	MPW HIF	7549	8095	8639	9184	9730	10317	10819	11365	11910	12454	13000
MHF		959	1020	1080	1141	1202	1262	1323	1384	1444	1505	1566
100% of Poverty	(without 5%)	5170	5544	5917	6290	6664	7037	7410	7784	8157	8530	8904
Revised 04/2020
MAGI income maximums with 5% of FPL included and CHIP premium amounts 07/01/2019 through 03/31/2020
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &

	CHIP 75	3175	4298	5422	6545	7669	8792	9916	11039	12162	13286	14409
	Premium	117	159	200	241	283	324	366	407	449	490	532
225% of Poverty	CHIP 74	2394	3242	4089	4936	5783	6630	7477	8325	9172	10019	10866
	Premium	48	65	82	99	115	132	150	167	184	200	217
201% of Poverty	UWHS	2145	2903	3662	4421	5180	5938	6697	7456	8215	8974	9732
196% of Poverty	MPW &	2093	2833	3573	4314	5054	5794	6535	7275	8015	8756	9496
	MHK under 1
185% of Poverty	CHIP 73	1978	2678	3378	4078	4777	5477	6177	6877	7577	8277	8976
	Premium	15	20	25	30	35	40	46	51	56	61	66
150% of Poverty	CHIP 71 & 72	1614	2185	2756	3327	3897	4468	5039	5610	6181	6752	7323
148% of Poverty	MHK	1593	2157	2720	3284	3847	4411	4974	5538	6101	6665	7228
141% of Poverty	MPW HIF	1520	2058	2596	3133	3671	4209	4747	5284	5822	6360	6898
MHF		194	312	390	461	526	590	653	713	774	834	895
100% of Poverty	(without 5%)	1041	1410	1778	2146	2515	2883	3251	3620	3988	4356	4725
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15533	16656	17779	18903	20026	21150	22273	23397	24520	25643	26767
	Premium	573	614	656	697	739	780	822	863	904	946	987
225% of Poverty	CHIP 74	11713	12560	13408	14255	15102	15949	16796	17643	18491	19338	20185
	Premium	234	251	269	285	302	319	336	352	370	387	404
201% of Poverty	UWHS	10491	11250	12009	12767	13526	14285	15044	15802	16561	17320	18079
196% of Poverty	MPW & MHK under 1	10236	10977	11717	12457	13198	13938	14679	15419	16159	16900	17640
185% of Poverty	CHIP 73	9676	10376	11076	11776	12476	13175	13875	14575	15275	15975	16675
	Premium	71	76	82	87	92	97	102	107	113	118	123
150% of Poverty	CHIP 71 & 72	7894	8465	9036	9607	10178	10748	11319	11890	12461	13032	13603
148% of Poverty	MHK	7792	8356	8919	9483	10046	10610	11173	11737	12300	12864	13428
141% of Poverty	MPW HIF	7436	7973	8511	9049	9587	10124	10622	11200	11738	12275	12813
MHF		955	1016	1076	1136	1197	1257	1318	1378	1438	1499	1559
100% of Poverty	(without 5%)	5093	5461	5830	6198	6566	6935	7303	7671	8040	8408	8776
Revised 07/2019

MAGI income maximums with 5% of FPL included and CHIP premium amounts 04/01/2019 through 06/30/2019
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3175	4298	5422	6545	7669	8792	9916	11039	12162	13286	14409
	Premium	114	154	195	235	276	316	357	397	438	478	519
225% of Poverty	CHIP 74	2394	3242	4089	4936	5783	6630	7477	8325	9172	10019	10866
	Premium	46	63	79	96	112	129	146	162	179	196	213
201% of Poverty	UWHS	2145	2903	3662	4421	5180	5938	6697	7456	8215	8974	9732
196% of Poverty	MPW &	2093	2833	3573	4314	5054	5794	6535	7275	8015	8756	9496
	MHK under 1
185% of Poverty	CHIP 73	1978	2678	3378	4078	4777	5477	6177	6877	7577	8277	8976
	Premium	14	19	24	29	34	39	44	49	54	60	65
150% of Poverty	CHIP 71 & 72	1614	2185	2756	3327	3897	4468	5039	5610	6181	6752	7323
148% of Poverty	MHK	1593	2157	2720	3284	3847	4411	4974	5538	6101	6665	7228
141% of Poverty	MPW HIF	1520	2058	2596	3133	3671	4209	4747	5284	5822	6360	6898
MHF		194	312	390	461	526	590	653	713	774	834	895
100% of Poverty	(without 5%)	1041	1410	1778	2146	2515	2883	3251	3620	3988	4356	4725
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15533	16656	17779	18903	20026	21150	22273	23397	24520	25643	26767
	Premium	559	600	640	681	721	762	802	843	883	924	964
225% of Poverty	CHIP 74	11713	12560	13408	14255	15102	15949	16796	17643	18491	19338	20185
	Premium	229	246	262	279	295	312	328	345	361	378	394
201% of Poverty	UWHS	10491	11250	12009	12767	13526	14285	15044	15802	16561	17320	18079
196% of Poverty	MPW & MHK under 1	10236	10977	11717	12457	13198	13938	14679	15419	16159	16900	17640
185% of Poverty	CHIP 73	9676	10376	11076	11776	12476	13175	13875	14575	15275	15975	16675
	Premium	70	75	80	85	90	95	100	105	110	115	120
150% of Poverty	CHIP 71 & 72	7894	8465	9036	9607	10178	10748	11319	11890	12461	13032	13603
148% of Poverty	MHK	7792	8356	8919	9483	10046	10610	11173	11737	12300	12864	13428
141% of Poverty	MPW HIF	7436	7973	8511	9049	9587	10124	10622	11200	11738	12275	12813
MHF		955	1016	1076	1136	1197	1257	1318	1378	1438	1499	1559
100% of Poverty	(without 5%)	5093	5461	5830	6198	6566	6935	7303	7671	8040	8408	8776
Revised 04/2019

MAGI income maximums with 5% of FPL included and CHIP premium amounts 07/01/2018 through 03/31/2019
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3086	4184	5282	6380	7478	8576	9674	10772	11870	12968	14066
	Premium	114	154	195	235	276	316	357	397	438	478	519
225% of Poverty	CHIP 74	2327	3155	3983	4811	5639	6467	7295	8123	8951	9779	10607
	Premium	46	63	79	96	112	129	146	162	179	196	213
201% of Poverty	UWHS	2085	2826	3568	4309	5051	5793	6534	7276	8017	8759	9501
196% of Poverty	MPW &	2034	2758	3481	4205	4928	5652	6376	7099	7823	8546	9270
	MHK under 1
185% of Poverty	CHIP 73	1923	2607	3291	3975	4659	5343	6027	6711	7395	8079	8763
	Premium	14	19	24	29	34	39	44	49	54	60	65
150% of Poverty	CHIP 71 & 72	1569	2127	2685	3243	3801	4359	4917	5475	6033	6591	7149
148% of Poverty	MHK	1548	2099	2650	3201	3752	4302	4853	5404	5955	6506	7056
141% of Poverty	MPW HIF	1478	2004	2529	3055	3580	4106	4632	5157	5683	6208	6734
MHF		192	310	388	458	523	586	649	709	769	829	889
100% of Poverty	(without 5%)	1012	1372	1732	2092	2452	2812	3172	3532	3892	4252	4612
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15164	16262	17360	18458	19556	20654	21752	22850	23948	25046	26144
	Premium	559	600	640	681	721	762	802	843	883	924	964
225% of Poverty	CHIP 74	11435	12263	13091	13919	14747	15575	16403	17231	18059	18887	19715
	Premium	229	246	262	279	295	312	328	345	361	378	394
201% of Poverty	UWHS	10242	10984	11725	12467	13209	13950	14692	15433	16175	16917	17658
196% of Poverty	MPW & MHK under 1	9994	10717	11441	12164	12888	13612	14335	15059	15782	16506	17230
185% of Poverty	CHIP 73	9447	10131	10815	11499	12183	12867	13551	14235	14919	15603	16287
	Premium	70	75	80	85	90	95	100	105	110	115	120
150% of Poverty	CHIP 71 & 72	7707	8265	8823	9381	9939	10497	11055	11613	12171	12729	13287
148% of Poverty	MHK	7607	8158	8709	9260	9810	10361	10912	11463	12014	12564	13115
141% of Poverty	MPW HIF	7260	7785	8311	8836	9362	9888	10413	10939	11464	11990	12516
MHF		949	1009	1069	1129	1189	1249	1309	1369	1429	1489	1549
100% of Poverty	(without 5%)	4972	5332	5692	6052	6412	6772	7132	7492	7852	8212	8572
Revised 07/2018

MAGI income maximums with 5% of FPL included and CHIP premium amounts 04/01/2018 through 06/30/2018
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3086	4184	5282	6380	7478	8576	9674	10772	11870	12968	14066
	Premium	113	152	191	231	270	309	348	387	427	466	505
225% of Poverty	CHIP 74	2327	3155	3983	4811	5639	6467	7295	8123	8951	9779	10607
	Premium	46	62	78	95	111	126	142	158	174	190	207
201% of Poverty	UWHS	2085	2826	3568	4309	5051	5793	6534	7276	8017	8759	9501
196% of Poverty	MPW &	2034	2758	3481	4205	4928	5652	6376	7099	7823	8546	9270
	MHK under 1
185% of Poverty	CHIP 73	1923	2607	3291	3975	4659	5343	6027	6711	7395	8079	8763
	Premium	14	19	24	29	34	38	43	48	53	58	63
150% of Poverty	CHIP 71 & 72	1569	2127	2685	3243	3801	4359	4917	5475	6033	6591	7149
148% of Poverty	MHK	1548	2099	2650	3201	3752	4302	4853	5404	5955	6506	7056
141% of Poverty	MPW HIF	1478	2004	2529	3055	3580	4106	4632	5157	5683	6208	6734
MHF		192	310	388	458	523	586	649	709	769	829	889
100% of Poverty	(without 5%)	1012	1372	1732	2092	2452	2812	3172	3532	3892	4252	4612
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15164	16262	17360	18458	19556	20654	21752	22850	23948	25046	26144
	Premium	544	583	623	662	701	740	779	818	858	897	936
225% of Poverty	CHIP 74	11435	12263	13091	13919	14747	15575	16403	17231	18059	18887	19715
	Premium	223	239	254	270	286	303	319	335	351	367	382
201% of Poverty	UWHS	10242	10984	11725	12467	13209	13950	14692	15433	16175	16917	17658
196% of Poverty	MPW & MHK under 1	9994	10717	11441	12164	12888	13612	14335	15059	15782	16506	17230
185% of Poverty	CHIP 73	9447	10131	10815	11499	12183	12867	13551	14235	14919	15603	16287
	Premium	68	73	77	82	87	92	97	102	107	112	116
150% of Poverty	CHIP 71 & 72	7707	8265	8823	9381	9939	10497	11055	11613	12171	12729	13287
148% of Poverty	MHK	7607	8158	8709	9260	9810	10361	10912	11463	12014	12564	13115
141% of Poverty	MPW HIF	7260	7785	8311	8836	9362	9888	10413	10939	11464	11990	12516
MHF		949	1009	1069	1129	1189	1249	1309	1369	1429	1489	1549
100% of Poverty	(without 5%)	4972	5332	5692	6052	6412	6772	7132	7492	7852	8212	8572
Revised 04/2018

MAGI income maximums with 5% of FPL included and CHIP premium amounts 07/01/2017 through 03/31/2018
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3066	4128	5191	6253	7315	8378	9440	10503	11565	12627	13690
	Premium	113	152	191	231	270	309	348	387	427	466	505
225% of Poverty	CHIP 74	2312	3113	3914	4715	5517	6318	7119	7920	8721	9522	10324
	Premium	46	62	78	95	111	126	142	158	174	190	207
201% of Poverty	UWHS	2071	2788	3506	4223	4941	5659	6376	7094	7811	8529	9246
196% of Poverty	MPW &	2021	2721	3421	4121	4821	5521	6221	6922	7622	8322	9022
	MHK under 1
185% of Poverty	CHIP 73	1910	2572	3234	3895	4557	5219	5881	6543	7205	7866	8528
	Premium	14	19	24	29	34	38	43	48	53	58	63
150% of Poverty	CHIP 71 & 72	1558	2098	2638	3178	3718	4258	4798	5338	5878	6417	6957
148% of Poverty	MHK	1538	2071	2604	3137	3670	4203	4736	5269	5802	6335	6868
141% of Poverty	MPW HIF	1468	1977	2485	2993	3503	4011	4519	5029	5537	6045	6554
100% of Poverty		1005	1354	1702	2050	2399	2747	3095	3444	3792	4140	4489
MHF		192	308	386	456	520	582	645	704	764	823	882
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	14752	15815	16877	17940	19002	20064	21127	22189	23252	24314	25376
	Premium	544	583	623	662	701	740	779	818	858	897	936
225% of Poverty	CHIP 74	11125	11667	12727	13528	14329	15131	15932	16733	17534	18335	19136
	Premium	223	239	254	270	286	303	319	335	351	367	382
201% of Poverty	UWHS	9964	10682	11399	12117	12834	13552	14269	14987	15705	16422	17140
196% of Poverty	MPW & MHK under 1	9722	10422	11122	11823	12523	13223	13923	14623	15323	16024	16724
185% of Poverty	CHIP 73	9190	9852	10514	11176	11837	12499	13161	13823	14485	15147	15808
	Premium	68	73	77	82	87	92	97	102	107	112	116
150% of Poverty	CHIP 71 & 72	7497	8037	8577	9117	9657	10197	10737	11277	11817	12357	12896
148% of Poverty	MHK	7401	7934	8466	8999	9532	10065	10598	11131	11664	12197	12730
141% of Poverty	MPW HIF	7063	7571	8080	8588	9096	9606	10114	10622	11132	11640	12148
100% of Poverty		4837	5185	5534	5882	6230	6579	6927	7275	7624	7972	8320
MHF		942	1002	1060	1120	1180	1239	1298	1358	1417	1477	1536

Revised 06/2017

MAGI income maximums with 5% of FPL included and CHIP premium amounts 04/01/2017 through 06/30/2017
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3066	4128	5191	6253	7315	8378	9440	10503	11565	12627	13690
	Premium	111	150	189	228	267	305	344	383	422	461	500
225% of Poverty	CHIP 74	2312	3113	3914	4715	5517	6318	7119	7920	8721	9522	10324
	Premium	46	62	78	93	109	125	141	157	173	188	204
201% of Poverty	UWHS	2071	2788	3506	4223	4941	5659	6376	7094	7811	8529	9246
196% of Poverty	MPW &	2021	2721	3421	4121	4821	5521	6221	6922	7622	8322	9022
	MHK under 1
185% of Poverty	CHIP 73	1910	2572	3234	3895	4557	5219	5881	6543	7205	7866	8528
	Premium	14	19	24	28	33	38	43	48	53	57	62
150% of Poverty	CHIP 71 & 72	1558	2098	2638	3178	3718	4258	4798	5338	5878	6417	6957
148% of Poverty	MHK	1538	2071	2604	3137	3670	4203	4736	5269	5802	6335	6868
141% of Poverty	MPW HIF	1468	1977	2485	2993	3503	4011	4519	5029	5537	6045	6554
100% of Poverty		1005	1354	1702	2050	2399	2747	3095	3444	3792	4140	4489
MHF		192	309	386	456	520	582	645	704	764	823	882
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	14752	15815	16877	17940	19002	20064	21127	22189	23252	24314	25376
	Premium	539	578	617	656	695	734	773	812	851	890	929
225% of Poverty	CHIP 74	11125	11667	12727	13528	14329	15131	15932	16733	17534	18335	19136
	Premium	220	236	253	269	285	300	316	332	348	364	380
201% of Poverty	UWHS	9964	10682	11399	12117	12834	13552	14269	14987	15705	16422	17140
196% of Poverty	MPW & MHK under 1	9722	10422	11122	11823	12523	13223	13923	14623	15323	16024	16724
185% of Poverty	CHIP 73	9190	9852	10514	11176	11837	12499	13161	13823	14485	15147	15808
	Premium	67	72	77	82	87	91	96	101	106	111	116
150% of Poverty	CHIP 71 & 72	7497	8037	8577	9117	9657	10197	10737	11277	11817	12357	12896
148% of Poverty	MHK	7401	7934	8466	8999	9532	10065	10598	11131	11664	12197	12730
141% of Poverty	MPW HIF	7063	7571	8080	8588	9096	9606	10114	10622	11132	11640	12148
100% of Poverty		4837	5185	5534	5882	6230	6579	6927	7275	7624	7972	8320
MHF		942	1002	1060	1120	1180	1239	1298	1358	1417	1477	1536

Revised 04/01/2017

MAGI income maximums with 5% of FPL included and CHIP premium amounts 07/01/2016 through 03/31/2017
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3020	4072	5124	6177	7229	8281	9336	10393	11451	12508	13565
	Premium	111	150	189	228	267	305	344	383	422	461	500
225% of Poverty	CHIP 74	2277	3071	3864	4658	5451	6245	7040	7838	8635	9432	10230
	Premium	46	62	78	93	109	125	141	157	173	188	204
201% of Poverty	UWHS	2040	2751	3461	4172	4883	5458	6306	7020	7734	8448	9162
196% of Poverty	MPW &	1990	2684	3377	4071	4764	5458	6153	6850	7546	8243	8940
	MHK under 1
185% of Poverty	CHIP 73	1881	2537	3192	3848	4503	5159	5816	6475	7133	7792	8451
	Premium	14	19	24	28	33	38	43	48	53	57	62
150% of Poverty	CHIP 71 & 72	1535	2070	2604	3139	3674	4209	4745	5282	5819	6357	6894
148% of Poverty	MHK	1515	2043	2571	3099	3627	4154	4684	5214	5744	6275	6805
141% of Poverty	MPW HIF	1446	1950	2453	2957	3461	3964	4469	4975	5482	5988	6494
100% of Poverty		990	1335	1680	2025	2370	2715	3061	3408	3755	4101	4448
MHF		191	308	385	455	519	581	644	703	762	822	881
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	14623	15680	16737	17795	18852	19909	20967	22024	23081	24139	21596
	Premium	539	578	617	656	695	734	773	812	851	890	929
225% of Poverty	CHIP 74	11027	11824	12622	13419	14216	15014	15811	16608	17406	18203	19000
	Premium	220	236	253	269	285	300	316	332	348	364	380
201% of Poverty	UWHS	9876	10591	11305	12019	12733	13447	14161	14875	15590	16304	17018
196% of Poverty	MPW & MHK under 1	9637	10334	11030	11727	12424	13121	13818	14514	15211	15908	16605
185% of Poverty	CHIP 73	9109	9768	10427	11085	11744	12403	13061	13720	14379	15037	15696
	Premium	67	72	77	82	87	91	96	101	106	111	116
150% of Poverty	CHIP 71 & 72	7431	7969	8506	9043	9581	10118	10655	11193	11730	12267	12805
148% of Poverty	MHK	7336	7866	8396	8927	9457	9988	10518	11048	11579	12109	12640
141% of Poverty	MPW HIF	7000	7506	8012	8518	9025	9531	10037	10543	11049	11555	12061
100% of Poverty		4795	5141	5488	5835	6181	6528	6875	7221	7568	7915	8261
MHF		940	1000	1059	1118	1178	1237	1296	1356	1415	1474	1534
Revised 06/01/2016

MAGI income with 5% of FPL included and CHIP premium amounts 04/01/2016 through 06/30/2016
# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	SMHB &
	CHIP 75	3086	4184	5282	6380	7478	8576	9674	10772	11870	12968	14066
	Premium	113	152	191	231	270	309	348	387	427	466	505
225% of Poverty	CHIP 74	2327	3155	3983	4811	5639	6467	7295	8123	8951	9779	10607
	Premium	46	62	78	95	111	126	142	158	174	190	207
201% of Poverty	UWHS	2085	2826	3568	4309	5051	5793	6534	7276	8017	8759	9501
196% of Poverty	MPW &	2034	2758	3481	4205	4928	5652	6376	7099	7823	8546	9270
	MHK under 1
185% of Poverty	CHIP 73	1923	2607	3291	3975	4659	5343	6027	6711	7395	8079	8763
	Premium	14	19	24	29	34	38	43	48	53	58	63
150% of Poverty	CHIP 71 & 72	1569	2127	2685	3243	3801	4359	4917	5475	6033	6591	7149
148% of Poverty	MHK	1548	2099	2650	3201	3752	4302	4853	5404	5955	6506	7056
141% of Poverty	MPW HIF	1478	2004	2529	3055	3580	4106	4632	5157	5683	6208	6734
MHF		192	310	388	458	523	586	649	709	769	829	889
100% of Poverty	(without 5%)	1012	1372	1732	2092	2452	2812	3172	3532	3892	4252	4612
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	SMHB &
	CHIP 75	15164	16262	17360	18458	19556	20654	21752	22850	23948	25046	26144
	Premium	544	583	623	662	701	740	779	818	858	897	936
225% of Poverty	CHIP 74	11435	12263	13091	13919	14747	15575	16403	17231	18059	18887	19715
	Premium	223	239	254	270	286	303	319	335	351	367	382
201% of Poverty	UWHS	10242	10984	11725	12467	13209	13950	14692	15433	16175	16917	17658
196% of Poverty	MPW & MHK under 1	9994	10717	11441	12164	12888	13612	14335	15059	15782	16506	17230
185% of Poverty	CHIP 73	9447	10131	10815	11499	12183	12867	13551	14235	14919	15603	16287
	Premium	68	73	77	82	87	92	97	102	107	112	116
150% of Poverty	CHIP 71 & 72	7707	8265	8823	9381	9939	10497	11055	11613	12171	12729	13287
148% of Poverty	MHK	7607	8158	8709	9260	9810	10361	10912	11463	12014	12564	13115
141% of Poverty	MPW HIF	7260	7785	8311	8836	9362	9888	10413	10939	11464	11990	12516
MHF		949	1009	1069	1129	1189	1249	1309	1369	1429	1489	1549
100% of Poverty	(without 5%)	4972	5332	5692	6052	6412	6772	7132	7492	7852	8212	8572
Revised 03/03/2016

MAGI income with 5% of FPL included and CHIP premium amounts effective 07/01/2015 – 3/31/2016

300% of Poverty	CHIP 75	3020	4072	5124	6176	7229	8281	9336	10393	11451	12508	13343
	Premium	110	149	188	227	266	305	344	383	422	461	500
225% of Poverty	CHIP 74	2278	3071	3864	4658	5452	6245	7040	7837	8635	9432	10007
	Premium	45	61	77	93	109	125	141	157	173	188	204
201% of Poverty	UWHS	2040	2751	3461	4172	4883	5594	6306	7020	7734	8448	8940
196% of Poverty	MPW & MHK under 1	1991	2684	3377	4070	4765	5458	6153	6849	7547	8243	8718
185% of Poverty	CHIP 73	1882	2537	3192	3848	4504	5159	5816	6474	7134	7792	8228
	Premium	14	19	23	28	33	38	43	48	53	57	62
150% of Poverty	CHIP 71 & 72	1535	2070	2604	3139	3674	4209	4745	5282	5820	6357	6672
148% of Poverty	MHK	1516	2043	2571	3098	3627	4155	4684	5214	5745	6275	6583
141% of Poverty	MWP HIF	1446	1950	2453	2957	3461	3965	4469	4975	5482	5988	6271
100% of Poverty		990	1335	1680	2025	2370	2715	3061	3408	3755	4101	4448
MHF		191	308	385	455	519	581	644	703	762	822	881
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	CHIP 75	3149	4206	5263	6321	7378	8435	9493	10550	11607	12665	13722
	Premium	539	578	617	656	695	734	773	812	851	890	929
225% of Poverty	CHIP 74	2375	3172	3969	4767	5564	6361	7159	7956	8753	9551	10348
	Premium	220	236	253	269	285	300	316	332	348	364	380
201% of Poverty	UWHS	2127	2841	3555	4270	4984	5697	6412	7126	7840	8555	9268
196% of Poverty	MPW & MHK under 1	2076	2772	3469	4166	4863	5559	6257	6953	7650	8347	9044
185% of Poverty	CHIP 73	1962	2621	3279	3938	4597	5255	5914	6573	7231	7890	8549
	Premium	67	72	77	82	87	91	96	101	106	111	116
150% of Poverty	CHIP 71 & 72	1601	2138	2675	3213	3750	4287	4825	5362	5899	6437	6974
148% of Poverty	MHK	1580	2110	2640	3172	3702	4232	4763	5293	5823	6354	6884
141% of Poverty	MWP HIF	1508	2014	2520	3026	3532	4038	4545	5051	5556	6063	6569
100% of Poverty		1033	1379	1726	2073	2419	2766	3113	3459	3806	4153	4499
MHF		940	1000	1059	1118	1178	1237	1296	1356	1415	1474	1534

Revised 03/03/2016


# of Persons		1	2	3	4	5	6	7	8	9	10	11
300% of Poverty	CHIP 75	2992	4049	5107	6164	7221	8279	9336	10393	11451	12508	13565
	Premium	109	148	186	224	262	300	338	376	414	452	490
225% of Poverty	CHIP 74	2256	3054	3851	4648	5446	6243	7040	7838	8635	9432	10230
	Premium	45	60	76	92	107	122	138	154	170	185	200
201% of Poverty	UWHS	2021	2735	3449	4163	4878	5592	6306	7020	7734	8448	9162
196% of Poverty	MPW & MHK under 1	1972	2669	3366	4062	4759	5456	6153	6850	7546	8243	8940
185% of Poverty	CHIP 73	1864	2523	3181	3840	4499	5157	5816	6475	7133	7792	8451
	Premium	14	18	23	28	33	37	42	47	52	56	61
150% of Poverty	CHIP 71 & 72	1521	2058	2595	3133	3670	4207	4745	5282	5819	6357	6894
148% of Poverty	MHK	1501	2032	2562	3092	3623	4153	4684	5214	5744	6275	6805
141% of Poverty	MWP HIF	1433	1939	2445	2951	3457	3963	4469	4975	5482	5988	6494
100% of Poverty		981	1328	1675	2021	2368	2715	3061	3408	3755	4101	4448
MHF		191	308	385	455	519	581	644	703	762	822	881
# of Persons		12	13	14	15	16	17	18	19	20	21	22
300% of Poverty	CHIP 75	14623	15680	16737	17795	18852	19909	20967	22024	23081	24139	25196
	Premium	528	566	604	642	680	718	757	795	833	871	909
225% of Poverty	CHIP 74	11027	11824	12622	13419	14216	15014	15811	16608	17406	18203	19000
	Premium	216	231	247	263	279	293	309	325	341	356	371
201% of Poverty	UWHS	9876	10591	11305	12019	12733	13447	14161	14875	15590	16304	17018
196% of Poverty	MPW & MHK under 1	9637	10334	11030	11727	12424	13121	13818	14514	15211	15908	16605
185% of Poverty	CHIP 73	9109	9768	10427	11085	11744	12403	13061	13720	14379	15037	15696
	Premium	66	70	75	80	85	89	94	99	104	108	113
150% of Poverty	CHIP 71 & 72	7431	7969	8506	9043	9581	10118	10655	11193	11730	12267	12805
148% of Poverty	MHK	7336	7866	8396	8927	9457	9988	10518	11048	11579	12109	12640
141% of Poverty	MWP HIF	7000	7506	8012	8518	9025	9531	10037	10543	11049	11555	12061
100% of Poverty		4795	5141	5488	5835	6181	6528	6875	7221	7568	7915	8261
MHF		940	1000	1059	1118	1178	1237	1296	1356	1415	1474	1534

Revised 5/20/2015

Section 1800.000.00 Appendix A, Page 18