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TABLE 1:
Family Size |
0 thru 135% FPL Full Subsidy |
136 thru 140% FPL 75% Subsidy |
141 thru 145% FPL 50% Subsidy |
146 thru 149% FPL 25% Subsidy |
1 |
0 - 1257 |
1257.01- 1304 |
1304.01 - 1350 |
1350.01 - 1396.99 |
2 |
0 - 1703 |
1703.01 - 1766 |
1766.01- 1829 |
1829.01 - 1891.99 |
3 |
0 - 2148 |
2148.01- 2228 |
2228.01 - 2307 |
2307.01 - 2386.99 |
4 |
0 - 2594 |
2594.01 - 2690 |
2690.01- 2786 |
2786.01 - 2881.99 |
5 |
0 - 3039 |
3039.01 - 3152 |
3152.01 - 3264 |
3264.01 - 3376.99 |
6 |
0 - 3485 |
3485.01 - 3614 |
3614.01 - 3743 |
3743.01 - 3871.99 |
7 |
0 - 3930 |
3930.01 - 4076 |
4076.01 - 4221 |
4221.01 - 4366.99 |
8 |
0 - 4376 |
4376.01 – 4538 |
4538.01 - 4700 |
4700.01 - 4862.99 |
TABLE 2: LIS Eligibility
Calculation Subsidy Calculation for One Person
Countable Resources in $ |
≤135%FPL |
136% thru 140% FPL |
141% thru 145% FPL |
146% thru 149% FPL |
≥150% |
< $6,940 |
A |
C |
D |
E |
F |
> $6,940 to ≤11,570 |
B |
C |
D |
E |
F |
> $11,570 |
F |
F |
F |
F |
F |
Subsidy Calculation for a Couple
Countable Resources |
< 135% FPL |
136% thru 140% FPL |
141% thru 145% FPL |
146% thru 149% |
> 150% |
< $10,410 |
A |
C |
D |
E |
F |
>$10,410 to < 23,120 |
B |
C |
D |
E |
F |
> $23,120 |
F |
F |
F |
F |
F |
*These resource limits do not include $1,500 per person burial expense.
TABLE 3: LIS Benefit Determination
Subsidy |
Subsidized Monthly Premium |
Yearly Deductible |
Pre- Catastrophic Co-pay per Prescription |
Coverage Gap? Y/N |
Catastrophic Co-pay per Prescription |
A |
100% |
$0 |
$2.40/$6.00 |
N |
$0 |
B |
100% |
$60 |
15% |
N |
$2.40/$6.00 |
C |
75% |
$60 |
15% |
N |
$2.40/$6.00 |
D |
50% |
$60 |
15% |
N |
$2.40/$6.00 |
E |
25% |
$60 |
15% |
N |
$2.40/$6.00 |
F (No subsidy) |
0% |
$295 |
25% |
Y |
@5% |
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For questions or clarification on any of the policy contained in these manuals, please contact your local county office. |
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