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  Home >> Eligiblity Policy and Oversight >> Download Applications

 Application Download Page
 Checklist for Required Documentation
 Income Limits for the Specific Program


The information below is based on the selected need for coverage made on a previous page.

This page will provide you with:

  • An Application
  • A Checklist Of Required Documentation
  • Income Limits
For the Medicaid program or other coverage programs managed by DHHS.

Note: Coverage is provided under many categories with different income limits. More than one income table may be presented . Not all programs providing coverage are Medicaid programs.

Income Limits

Healthy Connections Plans for Children Under Age 19
COVERAGE FOR CHILDREN AGE 1 TO 19
March 1, 2009
100%, 133%, 150%, 185%, and 200% of the Federal Poverty Level
Family Size 100% FPL 133% FPL 150% FPL 185% FPL 200% FPL
1 $903 $1,201 $1,354 $1,670 $1,805
2 $1,215 $1,615 $1,822 $2,247 $2,429
3 $1,526 $2,030 $2,289 $2,823 $3,052
4 $1,838 $2,444 $2,757 $3,400 $3,675
5 $2,150 $2,859 $3,224 $3,976 $4,299
6 $2,461 $3,273 $3,692 $4,553 $4,992
7 $2,773 $3,688 $4,159 $5,130 $5,545
8 $3,085 $4,102 $4,627 $5,706 $6,169
Each additional person $312 $415 $468 $577 $624

For each additional family member add the amount shown to the monthly income.

Printable Applications
Applications in Adobe PDF Format Form Link Description
FM 505 «SC Healthy Connections Plans for Children Under Age 19.

What else you will need.
Check List for FM 505
Then Mail Applications to: ¬
(FM 505) Mail to County Office



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