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Note: Effective 1/1/23, Former foster care children enrolled in Medicaid (any state) on their 18th birthday will transition to MA 15 (Refer to 1620.74.00 and 2035.30.25).

3010.30.40 CERTAIN CHILDREN / PREMIUMS, AND (MED 3)

This chart lists the income standards for children from birth through 18 years of age (MA 10), which is Package C, Children's Health Plan. The standard is based on 250% of the Federal Poverty Level (FPL) and effective March 1, 2026 For children with income above 158% FPL standard and below the 250% FPL standard, there are tiers to determine the premium amount, which will also consider the number of children covered.

AG SIZE MONTHLY LIMIT TIER 1 (175% FPL) MONTHLY LIMIT TIER 2 (200% FPL) 1 $2328.00 $2660.00 2 $3156.00 $3607.00 3 $3985.00 $4554.00 4 $4813.00 $5500.00 5 $5641.00 $6447.00 6 $6470.00 $7394.00

NUMBER OF CHILDREN MONTHLY PREMIUMS TIER 1 TIER 2 1 $22.00 $33.00 2 or more $33.00 $50.00

AG SIZE MONTHLY LIMIT TIER 3 (225% FPL) MONTHLY LIMIT TIER 4 (250% FPL) 1 $2993.00 $3325.00 2 $4058.00 $4509.00 3 $5123.00 $5692.00 4 $6188.00 $6875.00 5 $7253.00 $8059.00 6 $8318.00 $9242.00

NUMBER OF CHILDREN MONTHLY PREMIUMS TIER 3 TIER 4 1 $42.00 $53.00 2 or more $53.00 $70.00

3010.35.00 INCOME STANDARDS (MED 4)