Income Levels 510-03-85-40

(Revised 6/1/2015 ML #3441)

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IM 5292

IM 5292 Attachment

IM 5272

Amended IM 5272

IM 5272 Attachment

Amended IM 5272 Attachment

(N.D.A.C. Sections 75-02-02.1-40, 75-02-02.1-22(7), 75-02-02.1-24.2(8), and 75-02-02.1-24(5))

Following are the Income Levels for the various categories under ACA Medicaid Categorically Needy:

Parents and Caretakers of Deprived Children and their Spouses who are NOT eligible for Medicare, SSI or over age 65 – (ACA Equivalent to 1931 Levels).

The family size is increased for each unborn when determining the appropriate family size.

Number of Persons Monthly Income Level Yearly Income Level

1

$517

$6,204

2 694 8,328

3 871 10,452

4 1048 12,576

5 1226 14,712

6 1403 16,836

7 1580 18,960

8 1757 21,084

9 1934 23,208

10 2111 25,332

Plus - 1 178 2,136

Effective January 1, 2014

Parents and Caretaker Relatives who ARE Medicare beneficiaries, SSI recipients or over age 65. (Parent and Caretaker Relative fixed dollar level listed in #1 above PLUS the 5% Federal Poverty Level disregard.)

The family size is increased for each unborn when determining the appropriate family size.

Household Size Monthly Income Annual Income

1 $566 $6,792

2 760 9,120

3 955 11,460

4 1,149 13,788

5 1,344 16,128

6 1,539 18,468

7 1,733 20,796

8 1,927 23,124

9 2,122 25,464

10 2,316 27,792

Plus - 1 195 2,339

Effective April 1, 2015

Children ages 6 through 18 and Individuals eligible for the Adult Expansion Group - 133% + the 5% disregard or 138%.

The family size is increased for each unborn when determining the appropriate family size.

Household Size Monthly Income Level Annual Income Level

1 $1,353 $16,243

2 1,831 21,983

3 2,310 27,724

4 2,788 33,465

5 3,267 39,206

6 3,745 44,947

7 4,223 50,687

8 4,702 56,428

9 5,180 62,169

10 5,659 67,910

Plus - 1 478 5,741

Effective April 1, 2015

Children ages 0 through 5 and Pregnant Women - 147% + the 5% disregard or 152%.

The family size is increased for each unborn when determining the appropriate family size.

Household Size Monthly Income Level Annual Income Level

1 $1,490 $17,890

2 2,017 24,214

3 2,544 30,537

4 3,071 36,860

5 3,598 43,183

6 4,125 49,506

7 4,652 55,830

8 5,179 62,153

9 5,706 68,476

10 6,233 74,799

+1 526 6,323

Effective April 1, 2015

ACA Medically Needy (Pregnant Women) – 90% of Poverty Level.

The family size is increased for each unborn when determining the appropriate family size.

Household Size Monthly Income Level Yearly Income Level

1 $882 $10,593

2 1,194 14,337

3
1,506
18,081

4 1,818 21,825

5 2,130 25,569

6 2,442 29,313

7 2,754 33,057

8 3,066 36,801

9 3,378 40,545

10 3,690 44,289

+1 312 3,744

Effective April 1, 2015

ACA Medically Needy (Child 0 to 21) - 92% of Poverty Level.

The family size is increased for each unborn when determining the appropriate family size.

Household

Size

Monthly Income Level

Yearly Income

Level

1
$902
$10,828

2 $1,221 $14,656

3 $1,540 $18,483

4 $1,859 $22,310

5 $2,178 $26,137

6 $2,497 $29,964

7 $2,815 $33,792

8 $3,134 $37,619

9 $3,453 $41,446

10 $3,772 $45,273

+1 $318 $3,827

Effective April 1, 2015

ACA Medically Needy (Parents/Caretaker relative and their spouses) - 93% of Poverty Level.

The family size is increased for each unborn when determining the appropriate family size.

Household

Size

Monthly Income Level

Yearly Income

Level

1
$912
$10,946

2 $1,234 $14,815

3 $1,556 $18,684

4 $1,879 $22,553

5 $2,201 $26,421

6 $2,524 $30,290

7 $2,846 $34,159

8 $3,168 $38,028

9 $3,491 $41,897

10 $3,813 $45,765

+1 $322 $3,869

Effective April 1, 2015

ACA Maintenance of Effort – Medicaid – Children ages 6 through 18.

The family size is increased for each unborn when determining the appropriate family size.

Household

Size

111% FPL

Monthly

111% FPL

Annual

133% FPL

Monthly

133% FPL

Annual

1
$1,088
$13,065 $1,304 $15,654

2 $1,473 $17,682 $1,765 $21,187

3 $1,858 $22,300 $2,226 $26,720

4 $2,243 $26,918 $2,687 $32,253

5 $2,627 $31,535 $3,148 $37,785

6 $3,012 $36,153 $3,609 $43,318

7 $3,397 $40,770 $4,070 $48,851

8 $3,782 $45,388 $4,531 $54,384

9 $4,167 $50,006 $4,993 $59,917

10 $4,551 $54,623
$5,454
$65,449

+1 $384 $4,618 $461 $5,533

Effective April 1, 2015

Number of Persons	Monthly Income Level	Yearly Income Level
1	$517	$6,204
2	694	8,328
3	871	10,452
4	1048	12,576
5	1226	14,712
6	1403	16,836
7	1580	18,960
8	1757	21,084
9	1934	23,208
10	2111	25,332
Plus - 1	178	2,136
Effective January 1, 2014

Household Size	Monthly Income	Annual Income
1	$566	$6,792
2	760	9,120
3	955	11,460
4	1,149	13,788
5	1,344	16,128
6	1,539	18,468
7	1,733	20,796
8	1,927	23,124
9	2,122	25,464
10	2,316	27,792
Plus - 1	195	2,339
Effective April 1, 2015

Household Size	Monthly Income Level	Annual Income Level
1	$1,353	$16,243
2	1,831	21,983
3	2,310	27,724
4	2,788	33,465
5	3,267	39,206
6	3,745	44,947
7	4,223	50,687
8	4,702	56,428
9	5,180	62,169
10	5,659	67,910
Plus - 1	478	5,741
Effective April 1, 2015

Household Size	Monthly Income Level	Yearly Income Level
1	$882	$10,593
2	1,194	14,337
3	1,506	18,081
4	1,818	21,825
5	2,130	25,569
6	2,442	29,313
7	2,754	33,057
8	3,066	36,801
9	3,378	40,545
10	3,690	44,289
+1	312	3,744
Effective April 1, 2015

Household Size	Monthly Income Level	Yearly Income Level
1	$902	$10,828
2	$1,221	$14,656
3	$1,540	$18,483
4	$1,859	$22,310
5	$2,178	$26,137
6	$2,497	$29,964
7	$2,815	$33,792
8	$3,134	$37,619
9	$3,453	$41,446
10	$3,772	$45,273
+1	$318	$3,827
Effective April 1, 2015

Household Size	111% FPL Monthly	111% FPL Annual	133% FPL Monthly	133% FPL Annual
1	$1,088	$13,065	$1,304	$15,654
2	$1,473	$17,682	$1,765	$21,187
3	$1,858	$22,300	$2,226	$26,720
4	$2,243	$26,918	$2,687	$32,253
5	$2,627	$31,535	$3,148	$37,785
6	$3,012	$36,153	$3,609	$43,318
7	$3,397	$40,770	$4,070	$48,851
8	$3,782	$45,388	$4,531	$54,384
9	$4,167	$50,006	$4,993	$59,917
10	$4,551	$54,623	$5,454	$65,449
+1	$384	$4,618	$461	$5,533
Effective April 1, 2015