Free Declaration - District Court of Arizona - Arizona

Case 2:03-cv-02506-EHC

Document 138-5

Filed 03/10/2008

Page 1 of 2

Income Limits for AHCCCS Eligibility ­ April 1, 2008
Monthly Income Limit
Coverage for: Household Size % FPL 100% 1 2 3 4 5 6 7 8 9

All Arizona Residents Most Programs*

$867

$1,167

$1,467

$1,767

$2,067

$2,367

$2,667

$2,967

$3,267

Higher Limits with Full Coverage S.O.B.R.A. S.O.B.R.A. S.O.B.R.A. Pregnant Women 150% Children Under 1 year 140% Children Under 1 - 5 years 133%
$1,214 $1,153 $1,734 $1,750 $1,634 $1,552 $2,334 $2,200 $2,054 $1,951 $2,934 $3,534 $4,134 $4,734 $5,334 $5,934 $6,534 $2,650 $3,100 $3,550 $4,000 $4,450 $4,900

Children Ages 0-18 KidsCare (Premium) 200% Parents Living with their Eligible Children Ages 0-18 HIFA Parents (Premium) 200% Working People Age 16-64 with Disabilities Freedom to Work 250%

$1,734

$2,334

$2,934

$3,534

$4,134

$4,734

$5,334

$5,934

$6,534

$2,167

Special Limits that Permit Deduction of Recent Allowable Medical Expenses M.E.D. Program All Arizona Residents 40%
$347 $467 $587 $707 $827 $947 $1,067 $1,187 $1,307

Help with Medicare Premiums Medicare Beneficiaries Medicare Cost Sharing SLMB 120% Medicare Beneficiaries Medicare Cost Sharing QI 135%
$1,040 $1,170 $1,400 $1,575

Nursing Home Care and Equivalent Home and Community Services Arizona Long Term Care System 300% of the Federal Benefit Rate (FBR)
· · · · ·

$1,911

The Medicare Cost Sharing Programs income limits are for a single person (household size 1) or a married couple (household size 2). These programs provide an income deduction for dependent children. For S.O.B.R.A., adult's income is redistributed among the adult and his or her spouse and children. S.O.B.R.A. programs do not count siblings when determining children's eligibility or children's when determining the parents' eligibility. Therefore a S.O.B.R.A. child's household never has more than three members. For S.O.B.R.A. pregnant women, each expected baby is added to the household size. Freedom to Work counts only the applicant's earned income. The M.E.D. program reviews three months of income at the monthly amount above. Members are responsible to pay medical expenses deducted to become eligible KidsCare and HIFA Parents always* require payment of a monthly premium and Freedom to Work sometimes requires payment of a monthly premium.
*KidsCare and HIFA Parent premiums are not required for Native Americans

"Most programs" Include S.O.B.R.A. Children age 6 and over, SSI-MAO, AHCCCS for Families and Children, AHCCCS Care and Qualified Medicare Beneficiary (QMB). All programs allow certain deductions and/or disregards. These vary by program. All programs also have other requirements that vary by program. All programs require United States Citizenship or Eligible Immigrant status and a Social Security Number to be eligible for full coverage. Emergency coverage may be available to immigrants who do not meet the requirements. Family members who do not want AHCCCS Health Insurance are not required to provide information about citizenship, immigration status or Social Security Number. Income limits are subject to change
April 1, 2008

Case 2:03-cv-02506-EHC

Document 138-5

Filed 03/10/2008

Page 2 of 2