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Appendix A-20-2 Revise Date: 10/2019

From $ Up To $ # Months Counted for Medicaid 770,000 779,999 71 780,000 789,999 72 790,000 799,999 73 800,000 809,999 74 810,000 819,999 75 820,000 829,999 76 830,000 839,999 77 840,000 849,999 78 850,000 859,999 79 860,000 869,999 80 870,000 879,999 81 880,000 889,999 82 890,000 899,999 83 900,000 909,999 84 910,000 919,999 85 920,000 929,999 86 930,000 939,999 87 940,000 949,999 88 950,000 959,999 89 960,000 969,999 90 970,000 979,999 91 980,000 989,999 92 990,000 999,999 93 1,000,000 1,009,999 94 1,010,000 1,019,999 95 1,020,000 1,029,999 96 1,030,000 1,039,999 97 From $ Up To $ # Months Counted for Medicaid 1,040,000 1,049,999 98 1,050,000 1,059,999 99 1,060,000 1,069,999 100 1,070,000 1,079,999 101 1,080,000 1,089,999 102 1,090,000 1,099,999 103 1,100,000 1,109,999 104 1,110,000 1,119,999 105 1,120,000 1,129,999 106 1,130,000 1,139,999 107 1,140,000 1,149,999 108 1,150,000 1,159,999 109 1,160,000 1,169,999 110 1,170,000 1,179,999 111 1,180,000 1,189,999 112 1,190,000 1,199,999 113 1,200,000 1,209,999 114 1,210,000 1,219,999 115 1,220,000 1,229,999 116 1,230,000 1,239,999 117 1,240,000 1,249,999 118 1,250,000 1,259,999 119 1,260,000 or higher 120