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Notice and Hearings Process policy for notices.

b. If no communication has been received from the fee collector on the first workday following the date on which the fee was due, contact the collection office/individual to verify payment status. If payment has not been made, document the contact and deny the application for non- payment of the fee. If it is a recertification, terminate after timely notice.

Note: If the recertification is late, provide coverage without enrollment fee payment until timely notice is effective.

5. Individuals Currently Receiving in Other Programs

Other than at application or recertification, an enrollment fee is not due.

B. Premiums

Applicants/beneficiaries with countable income above 200% of FPL must pay a monthly premium in addition to an enrollment fee of $50 per year. The premiums increase with income range until income exceeds 450% of FPL, at which point a 100% premium is due.

The 100% premium is based upon the average claims paid for an a/b receiving Medicaid and may change yearly.

Federal Poverty Level Income Range - HCWD Individual Monthly Premium Income Range - HCWD Couple Monthly Premium 0-150% $0 - 1,995 0 $0 – 2,705 0 151-200% $1,995.01 - 2,660 0 $2,705.01 - 3,607 0 201-250% $2,660.01 - 3,325 196 $3,607.01 - 4,509 265 251-300% $3,325.01 - 3,990 235 $4,509.01 – 5,410 318 301-350% $3,990.01 - 4,655 274 $5,410.01 – 6,311 370 351-400% $4,655.01 – 5,320 313 $6,311.01 – 7,213 423 401-450% $5,320.01 – 5,985 352 $7,213.01 – 8,115 476 451 and above $5,985.01 and up 875 $8,115.01 and up 875

Docusign Envelope ID: B8C63DC7-7367-4210-853E-B7B004802EE4