Page 2

HCA 19-0096 (01/26) SSI/CNIL Standards Program Single Eligible Eligible Couple CNIL Income $994 $1,491 FBR (SSI Standard) $994 $1,491 1/2 FBR $497 N/A Shared Living FBR $663 $994 SSI Resources $2,000 $3,000 Non-Blind Substantial Gainful Activity (SGA) $1,690 $1,690 Blind Substantial Gainful Activity (SGA) $2,830 $2,830 Medicare Standards Program Cost Part A Premium: 40+ work quarters Free Part A Less then 40 but greater then 29 work quarters $311 Less then 30 work quarters $565 Part A Deductible: Inpatient Hospital = $1,736 per benefit period Part A coinsurance for Inpatient hospital $434 per day for 61st - 90th day; $868 per day for over 90 days Part A coinsurance for NF $217 per day for 21st - 100th day Part B Premium $203 Part B Deductible $283 Singles Low Income Subsidy (LIS) Resources $16,590 Couples Low Income Subsidy (LIS) Resources $33,100 Medicare Savings Program (Includes $20 disregard, except in 11+) Alternate financial eligibility standards 4/1/2025 Program Single Person 2-person Household 3-person Household 4-person Household 5-person Household 6-person Household 7-person Household 8-person Household 9-person Household 10-person Household 11-person+ Household QMB Income 110% FPL (S03) $1,454 $1,959 $2,463 $2,967 $3,472 $3,976 $4,479 $4,984 $5,488 $5,992 $504 SLMB Income 120% FPL (S05) $1,585 $2,136 $2,685 $3,235 $3,786 $4,335 $4,885 $5,436 $5,985 $6,535 $550 QI-1 Income 138% FPL (S06) $1,820 $2,453 $3,085 $3,717 $4,350 $4,982 $5,615 $6,248 $6,880 $7,512 $632 QDWI 200% FPL (S04) $2,628 $3,546 $4,462 $5,378 $6,296 $7,212 $8,128 $9,046 $9,962 $10,878 $916