2021 MAGI INCOME STANDARDS (Effective : 03/01/2021)

1 2021 magi income standards ( effective : 03/01/2021). Parent/Caretaker Adult Child 6<19 Child 1<6 Child <1 Pregnant Woman S-CHIP Child <19. Coverage Relative 17-1718-11 17-1715-11 17-1715-11 17-1715-11 17-1716-11 17-1715-11. Group 17-1717-11. TMA . MIN MAX MIN MAX MIN MAX MIN MAX MIN MAX MIN MAX MIN. INCOME MAX magi . magi magi magi magi magi magi magi magi magi magi magi magi magi . STANDARDS STD . STD STD STD STD STD STD STD STD STD STD STD STD STD . FPL** 100% 105% 133% 138% 133% 138% 139% 144% 191% 196% 191% 196% 308% 313%. HH 1 $1,235 $1,297 $1,643 $1,705 $1,643 $1,705 $1,717 $1,779 $2,359 $2,421 $2,359 $2,421 $3,804 $3,866. 2 $1,670 $1,754 $2,222 $2,305 $2,222 $2,305 $2,322 $2,405 $3,190 $3,274 $3,190 $3,274 $5,144 $5,228. 3 $2,105 $2,211 $2,800 $2,905 $2,800 $2,905 $2,926 $3,032 $4,021 $4,126 $4,021 $4,126 $6,484 $6,589. 4 $2,540 $2,667 $3,379 $3,506 $3,379 $3,506 $3,531 $3,658 $4,852 $4,979 $4,852 $4,979 $7,824 $7,951. 5 $2,975 $3,124 $3,957 $4,106 $3,957 $4,106 $4,136 $4,284 $5,683 $5,831 $5,683 $5,831 $9,163 $9,312.

2 6 $3,410 $3,581 $4,536 $4,706 $4,536 $4,706 $4,740 $4,911 $6,514 $6,684 $6,514 $6,684 $10,503 $10,674. 7 $3,868 $4,062 $5,145 $5,338 $5,145 $5,338 $5,377 $5,570 $7,388 $7,582 $7,388 $7,582 $11,914 $12,107. 8 $4,280 $4,494 $5,693 $5,907 $5,693 $5,907 $5,950 $6,164 $8,175 $8,389 $8,175 $8,389 $13,183 $13,397. 9 $4,715 $4,951 $6,271 $6,507 $6,271 $6,507 $6,554 $6,790 $9,006 $9,242 $9,006 $9,242 $14,523 $14,758. 10 $5,150 $5,408 $6,850 $7,107 $6,850 $7,107 $7,159 $7,416 $9,837 $10,094 $9,837 $10,094 $15,862 $16,112. Add'l HH. Member $435 $457 $579 $601 $579 $601 $605 $627 $831 $853 $831 $853 $1,340 $1,362. **Federal Poverty Level MIN magi STANDARD: This is the minimum magi INCOME standard for the State of Hawaii used to determine eligibility for an individual applying for participation in this magi group. MAX magi STANDARD: This is the minimum magi INCOME standard plus the 5% disregard used to determine eligibility for an individual whose INCOME exceeds the minimum INCOME standard under this magi group.

3 The 5% INCOME disregard is ONLY added to the highest INCOME standard the individual qualifies for and ONLY if it will make them eligible. effective 10/1/16, The Centers for Medicare and Medicaid Services approved Hawaii's request to extend Transitional Medical Assistance (TMA) for twelve consecutive months due to earned INCOME -related reasons. NOTE: ASSETS ARE EXEMPT FOR INDIVIDUALS SUBJECT TO magi METHODOLOGY. 3/1/2021. 2021 magi -EXCEPTED INCOME STANDARDS ( effective : 03/01/2021). Optional Mandatory Categorically Medically Needy Categorically. Needy Needy(OCN). Medically Needy (MN) Spenddown Coverage (MCN) (Aged, Disabled) SLMB QI-1 QDWI. (Aged, Blind, Disabled) (Pregnant Women/. Group (Aged, Blind, QMB/BHH 17-1722-18 17-1722-70 17-1722-26. 17-1719-11 Children). Disabled) 17-1719-11. 17-1719-11 17-1722-10. SSI INCOME HH Size MNIL* 100%** 120%** 135%** 200%** 300%**. Standard*. 1 $469 $794 $1,235 $1,482 $1,668 $2,470 $3,705.

4 2 $632 $1,191 $1,670 $2,004 $2,255 $3,340 $5,010. 3 $795 $1,588 $2,105 $2,526 $2,842 $4,210 $6,315. 4 $958 $1,985 $2,540 $3,048 $3,429 $5,080 $7,620. 5 $1,121 $2,382 $2,975 $3,570 $4,017 $5,950 $8,925. 6 $1,284 $2,779 $3,410 $4,092 $4,604 $6,820 $10,230. 7 $1,447 $3,176 $3,868 $4,614 $5,191 $7,690 $11,535. 8 $1,610 $3,573 $4,280 $5,136 $5,778 $8,560 $12,840. 9 $1,773 $3,970 $4,715 $5,658 $6,366 $9,430 $14,145. 10 $1,936 $4,367 $5,150 $6,180 $6,953 $10,300 $15,450. Add'l Member $163 $397 $435 $522 $588 $870 $1,305. * MNIL, SSI: Applicable INCOME STANDARDS for these groups. ** FPL: Federal Poverty Level 2021 magi -EXCEPTED ASSET LIMITS. COVERAGE GROUP AGED, BLIND OR DISABLED, SPENDDOWN QDWI QMB, SLMB, QI-1. HH-1 $2,000 $4,000 $7,970. HH-2 $3,000 $6,000 $11,960. Add'l Individual $250 $500 $500. 3/1/2021.