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 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 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 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 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 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 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