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Page | 5 MAGI INCOME CHARTS NOTE: The income charts in this section are associated with Chapter M04 – Modified Adjusted Gross Income (MAGI) of the Medical Assistance Eligibility Manual.

Income Chart Name: 5% Federal Poverty Level (FPL) Income Disregard Amounts - All Localities Effective Date: January 13, 2026 Household Size Monthly Amount 1 $67 2 $91 3 $114 4 $138 5 $162 6 $185 7 $209 8 $233 Each additional, add $24

Income Chart Name: Gap-Filling Rule Evaluation 100% Federal Poverty Level (FPL) Income Limits Effective Date: January 13, 2026 Household size Annual (Use for Gap-Filling Evaluation) Monthly 1 $15,960 $1,330 2 $21,640 $1,804 3 $27,320 $2,277 4 $33,000 $2,750 5 $38,680 $3,224 6 $44,360 $3,697 7 $50,040 $4,170 8 $55,720 $4,644 Each additional, add $5,680 $474