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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 SLIDING SCALE FOR WORKING DISABLED PREMIUMS* ELIGIBILITY POLICY AND PROCEDURES MANUAL $4160-$4179.99 $208 $4180-$4199.99 $209 $4200-$4219.99 $210 $4220-$4239.99 $211 $4240-$4259.99 $212 $4260-$4279.99 $213 $4280-$4299.99 $214 $4300-$4319.99 $215 $4320-$4339.99 $216 $4340-$4359.99 $217 $4360-$4379.99 $218 $4380-$4399.99 $219 $4400-$4419.99 $220 $4420-$4439.99 $221 $4440-$4459.99 $222 $4460-$4479.99 $223 $4480-$4499.99 $224 $4500-$4509 $225 Premiums are payable for individuals/couples with countable earned income between 150% - 250% of the poverty level for an individual or couple. The premium is 5% of countable earnings.