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APPENDIX A-5 Revised 03-01-2026 MONTHLY COUNTABLE PREMIUM MONTHLY COUNTABLE PREMIUM EARNINGS - INDIVIDUAL PER MONTH EARNINGS - COUPLE PER MONTH Below $1995 $0 Below $2705 $0 $1995-$1999.99 $99 $2705-$2719.99 $135 $2000-$2019.99 $100 $2720-$2739.99 $136 $2020-$2039.99 $101 $2740-$2759.99 $137 $2040-$2059.99 $102 $2760-$2779.99 $138 $2060-$2079.99 $103 $2780-$2799.99 $139 $2080-$2099.99 $104 $2800-$2819.99 $140 $2100-$2119.99 $105 $2820-$2839.99 $141 $2120-$2139.99 $106 $2840-$2859.99 $142 $2140-$2159.99 $107 $2860-$2879.99 $143 $2160-$2179.99 $108 $2880-$2899.99 $144 $2180-$2199.99 $109 $2900-$2919.99 $145 $2200-$2219.99 $110 $2920-$2939.99 $146 $2220-$2239.99 $111 $2940-$2959.99 $147 $2240-$2259.99 $112 $2960-$2979.99 $148 $2260-$2279.99 $113 $2980-$2999.99 $149 $2280-$2299.99 $114 $3000-$3019.99 $150 $2300-$2319.99 $115 $3020-$3039.99 $151 $2320-$2339.99 $116 $3040-$3059.99 $152 $2340-$2359.99 $117 $3060-$3079.99 $153 $2360-$2379.99 $118 $3080-$3099.99 $154 $2380-$2399.99 $119 $3100-$3119.99 $155 $2400-$2419.99 $120 $3120-$3139.99 $156 $2420-$2439.99 $121 $3140-$3159.99 $157 $2440-$2459.99 $122 $3160-$3179.99 $158 $2460-$2479.99 $123 $3180-$3199.99 $159 $2480-$2499.99 $124 $3200-$3219.99 $160 $2500-$2519.99 $125 $3220-$3239.99 $161 $2520-$2539.99 $126 $3240-$3259.99 $162 $2540-$2559.99 $127 $3260-$3279.99 $163 $2560-$2579.99 $128 $3280-$3299.99 $164 $2580-$2599.99 $129 $3300-$3319.99 $165 $2600-$2619.99 $130 $3320-$3339.99 $166 $2620-$2639.99 $131 $3340-$3359.99 $167 $2640-$2659.99 $132 $3360-$3379.99 $168 $2660-$2679.99 $133 $3380-$3399.99 $169 SLIDING SCALE FOR WORKING DISABLED PREMIUMS* ELIGIBILITY POLICY AND PROCEDURES MANUAL