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

1430

1127

176

2

1925

1517

323

3

2420

1907

463

4

2915

2297

588

5

3410

2687

698

6

3905

3077

838

7

4400

3467

926

8

4859

3857

1058

For each additional member add: 

495

390

132

Household Size

Gross Income 

Maximum Cash
Assistance Amount

1

608

288

2

843

399

3

1050

498

4

1230

583

5

1400

663

6

1542

731

7

1615

765

8

1690

801

Household
Size

Gross Income
 

Maximum Cash
Assistance Amount

1

608

261

2

843

362

Household Size

Gross Monthly
Income at application

Gross Monthly Income
while receiving
Child Care Assistance*

2

$2018

$2522

3

$2493

$3116

4

$2967

$3709

5

$3442

$4303

6

$3917

$4896

7

$4006

$5007

8

$4095

$5119

9

$4184

$5230

10

$4273

$5341

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