How to Apply for Services

Household
Size

Gross Monthly Income
for Elderly/Disabled
Households

Gross Monthly Income
for All Other
Households

Maximum
Monthly
Allotment

1

1404

1107

162

2

1883

1484

298

3

2361

1861

426

4

2840

2238

542

5

3318

2615

643

6

3797

2992

772

7

4275

3369

853

8

4758

3746

975

For each additional member add: 

479

377

122

Household Size

Gross Income 

Maximum Cash
Assistance Amount

1

608

274

2

843

380

3

1050

474

4

1230

555

5

1400

632

6

1542

696

7

1615

728

8

1690

763

Household
Size

Gross Income
 

Maximum Cash
Assistance Amount

1

608

261

2

843

362

Household Size

Gross Monthly
Income

2

$2007.00

3

$2479.00

4

$2951.00

5

$3423.00

6

$3895.00

7

$3984.00

8

$4072.00

9

$4161.00

10

$4249.00

Household
Size

GrossIncome
Limit for:

 Family
Medicaid

(FM-O)

Income Limit for:

Medically Needy
Child (CM) 

Regular Family
Medicaid (FM)

 Pregnant Women (PG)

Refugees (RM)

Net Income Limit
for Family Medicaid

(FM-O)

Income Limit for:

Newborn Plus
(NB+)

Childrens Health
Insurance Program

(CHIP PLAN A)

Technology
Dependent Children

100% of Poverty

Income Limitfor:

PreNatal (PN)

Newborn (NB)

Baby Your Baby

133% of Poverty

Income Limit for:

Transitional
benefits for
Family Medicaid

(FM-O)

185% of Poverty

Income Limit for:

Childrens Health
Insurance Program

(CHIP PLAN B)

Utah’s Premium
Partnership for
Health Insurance

(UPP Adults)

150% of Poverty

Income Limit for:

Childrens Health
Insurance Program

(CHIP PLAN C)

Utah’s Premium
Partnership for
Health Insurance

(UPP Children)

200% of Poverty

Household
Size

Income Limit
for:

Refugees (RM)

Income Limit
for:

Aged, Blind, or Disabled
(AM, BM, DM)

Brain Injury Mental
Retardation and
Related Concerns

(DDMR)

Aging Home and
Community Based
Program (AW)

100% of Poverty

Income Limit
for:

Primary Care
Network (PCN)

150% of Poverty

Income Limit
for:

MEDICAID WORK

INCENTIVE

(MWI)

250% of Poverty

Income Limit
for:

MEDICARE
COST-SHARING

QMB

100% of Poverty

Income Limit
for:

MEDICARE
COST- SHARING

SLMB

120% of Poverty

Income Limit
for:

MEDICARE
COST-SHARING
QI-1

135% of Poverty

1

382

867

1277

2167

867

1040

1170

2

468

1167

1750

2917

1167

1400

1575