Mr. Smith lives alone and applies for the subsidy. He receives $1,072 per month in
Social Security benefits before the Medicare Part B premium deduction and a private
pension of $500 per month before taxes. Assume that his countable resources are below
the limit. His countable income is:
Income Type

Income Calculation

Social Security

$12,864 (12 x $1072)

Private pension

+$5,400 (12 x $450)


$18264


 $240 (12 x the $20 general income exclusion)


Total Countable Unearned Income = $18,024

Assume that the applicable FPL for a oneperson family is $12,880. (We used the 2021
FPL rates for this example. For the current FPL rates, see HI 03001.020C.3.). We determine the subsidy income limits as follows:
$12,880 x 135% = $17,388.00
$12,880 x 140% = $18,032.00
$12,880 x 145% = $18,676.00
$12,880 x 150% = $19,320.00
Analysis: Mr. Smith’s countable income is greater than 135% of the poverty guideline, but it
is less than 140% of the poverty guideline. Therefore, Mr. Smith is eligible for a
75% premium subsidy. Assuming that Mr. Smith’s Part D premium is $35 per month, his
subsidy covers $26.25 (75%) of his monthly premium. He is required to pay $8.75 per
month for the 25% of the premium not covered by the subsidy, assuming there are no
late enrollment fees.