Rate Per Individual X Number of Individuals = Total Weekly Premium Rate per individual is calculated based on your family’s size and yearly income. The number of individuals will exclude any family members exempt from premiums.* \$[XX] X [XX] = \$[XX]

#### Rate Per Individual

The rate per individual is calculated based on your family’s size and yearly income.

 If your family size (including individuals exempt from premiums) is: And your yearly family income (before taxes) is: FPIG 133% 150% 200% 250% 400% 1 \$11,490 \$15,282 \$15,283- \$17,235 \$17,236 - \$22,980 \$22,981 - \$28,725 \$28,726 - \$45,960 2 \$15,510 \$20,628 \$20,629 - \$23,265 \$23,266 - \$31,020 \$31,021 - \$38,775 \$38,776 - \$62,040 3 \$19,530 \$25,975 \$25,976 - \$29,295 \$29,296 - \$39,060 \$39,061 - \$48,825 \$48,826 - \$78,120 4 \$23,550 \$31,322 \$31,323 - \$35,325 \$35,326 - \$47,100 \$47,101 - \$58,875 \$58,876 - \$94,200 5 \$27,570 \$36,668 \$36,669 - \$41,355 \$41,356 - \$55,140 \$55,141 - \$68,925 \$68,926 - \$110,280 6 \$31,590 \$42,015 \$42,016 - \$47,385 \$47,386 - \$63,180 \$63,181 - \$78,975 \$78,976 - \$126,360 7 \$35,610 \$47,361 \$47,362 - \$53,415 \$53,416 - \$71,220 \$71,221 - \$89,025 \$89,026 - \$142,440 8 \$39,630 \$52,708 \$52,709 - \$59,445 \$59,446 - \$79,260 \$79,261 - \$99,075 \$99,076 - \$158,520 Then your Plan Type is: Plan Type 1 Plan Type 11a Plan Type 11b Plan Type 111a Plan Type 111b And your weekly premium per individual is: \$0.00 \$0.00 \$9.00 \$18.00 \$27.00

If your household includes someone who is pregnant, under age 19, or disabled, you and/or your household members may be eligible for more benefits at lower cost through MassHealth. For more information, see www.mass.gov/masshealth or call 1-800-841-2900.

If your yearly family income has changed since you first applied for MSP and you believe you are eligible for a lower rate per individual, you may request an income recalculation.

#### Number of Individuals

The number of individuals will exclude any family members exempt from premiums.  Children 19 and under, disabled individuals and pregnant women are exempt from premiums.

MSP requires written documentation to verify disability or pregnancy status.

• To verify disability status, please provide a copy of the determination issued by the Social Security Administration or the Massachusetts Rehabilitation Commission, or a letter from your doctor on letterhead.