Medicaid Coverage Groups Chart. Institutional and Non institutional programs.
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Medicaid Coverage Groups Chart. Institutional and Non institutional programs.

Revised April 25, 2013

Purpose: This chart is used as a cheat sheet for medical coverage groups used in the ACES system.

NOTE:

Scope Terms:

CN-Categorically Needy

MN-Medically Needy

MSP-Medicare Savings Program

AEM-Alien Emergent Medical

MCS-Medical Care Services-STATE FUNDED, non federally matched.

SSI and SSI related. Aged/Blind/Disabled (ABD) Category

Category ACES Description  Scope
Aged/Blind/Disabled (ABD)
(ABD) SSI & State Supplement  S01  SSI recipients and 1619B eligibles  CN
(ABD) SSI related-CN  S02  ABD Categorically Needy  CN
(ABD) Medicare Programs  S03  QMB  Medicare Savings Program (MSP)  Medicare premium and medicare co payments  MSP
(ABD) Medicare Programs  S04  QDWI Medicare Savings Program   MSP
(ABD) Medicare Programs  S05  SLMB Medicare Savings Program. Medicare Premium only  MSP
(ABD) Medicare Programs  S06  QI-1 (ESLMB) Medicare Savings Program  MSP
(ABD) AEM-Emergency Medical  S07  Undocumented Alien, Emergency related services only  AEM
(ABD) SSI related MN  S95  Medically Needy no Spenddown  MN
(ABD) SSI related MN Spenddown  S99  Medically Needy with Spenddown  MN
ABD-Living in an alternate living facility (ALF) 388-513-1305  G03  Non institutional in an ALF CN-P income under the SIL  and under state rate x 31 days + $38.84  CN
ABD-Living in an alternate living facility (ALF) 388-513-1305  G95  Medically needy non institutional in ALF-no spenddown  MN
ABD-Living in an alternate living facility (ALF) 388-513-1305  G99  Medically needy non institutional in ALF-with spenddown  MN
ABD Healthcare for Workers with Disabilities (HWD )  S08  CN-P premium based program.  Substantial Gainful Activity (SGA ) not a factor in disability determination  CN
 ABD-Institutional & Waivers  ACES  SSI related Institutional Programs  
ABD-HCBS Waivers (HCS and DDD) and Hospice SSI recipient. New medical coverage group effective 2/1/2011  L21  Categorically Needy DDD/HCS Waivers or Hospice.  SSI recipient CN
ABD-HCBS Waivers (HCS and DDD) and Hospice. 

L22

  Categorically Needy DDD/HCS Waivers or Hospice.  Income under the SIL  CN
ABD-Non Citizen Hospice 

L04

  Must be pre-approved by HRSA medical consultant. Emergency related services hospitalization only  AEM
ABD-Residing in a medical institution 30 days or more  L01  SSI recipient.  Categorically Needy  CN
ABD-Residing in a medical institution 30 days or more  L02  SSI related. Categorically Needy.  Income at or below the SIL  CN
ABD-Residing in a medical institution 30 days or more -  L04 Undocumented alien/non citizen LTC must be pre-approved by ADSA headquarters for state-funded nursing facility coverage.  Emergency related services in Hospital must be pre-approved by HRSA medical consultant.   AEM
 ABD-Residing in a medical institution 30 days or more-MN  L95  Medically Needy-No Spenddown.  Income over the SIL, Income under the state rate  MN
 ABD-Residing in a medical institution 30 days or more-MN  spenddown  L99  Medically Needy-With Spenddown. Income over the SIL.  Income over the state rate but under the private rate.  Locks into state NF rate  MN

NOTE:

ABD-Institutional is also called the "300% Group".  The difference between CN and MN is the Medicaid Special Income Level (SIL) which is 300% of the federal benefit rate (FBR ).  The FBR is also known as the SSI standard. 

Institutional programs are unique in that there is initial eligibility and post eligibility.  Post eligibility is the calculation that determines what the client must pay toward their cost of care.  This is also called participation.

Institutional programs are used for those residing or projected to reside in a medical institution 30 days or more and for Home & Community Based Waiver programs authorized by DDD and HCS.

Institutional medical programs are under the L, and K track.  L track programs are ABD related and K track is institutional children and families based on TANF related income and resource eligibility.

For more information on institutional medical programs see Overview of LTC.

Long Term Care table of contents.

State funded Aged, Blind, Disabled (ABD) cash and State Funded Medical Care Services (MCS)

 Category  ACES  Description  Scope
 Aged, Blind, Disabled cash with state medical care services (MCS) or MCS only for individuals not eligible for ABD cash.     G01  ABD state cash with state funded medical or MCS only.   MCS
Aged, Blind, Disabled (DL-X, DL-D, DL-A)  state cash with federally matched CN-P Medicaid.  Effective 11/1/2011 this program will be called the Aged/Blind/Disabled Cash Program.   G02  ABD cash with federally matched medical  CN
 ADATSA State Program Drug & Alcohol TX program-State Funded  W01    MCS
 ADATSA Medical Care-State Funded  W02    MCS
 ADATSA DETOX Medical-State Funded  W03    MCS

Family/Children Related Institutional

 Category  ACES  Description  Scope
 TANF related income/resource rules  KO1  CN Family/child in medical institution  CN
   K03 Undocumented alien family in medical institution. Emergency related services only.   AEM
   K95  Family LTC MN no spenddown in medical institution  MN
   K99  Family LTC MN with spenddown in medical institution  MN

Family/Children Related non institutional

 Category  ACES  Description  Scope
 Family and children related Medical programs F01  TANF cash and Medical  CN
  F02  Transitional Medical  CN
  F03  Post TANF Child/Spousal Support  CN
  F04  TANF related  CN
  F05  Newborn  CN
  F06  Categorically Needy Medical Children-Apple Kids  CN
  F07  Children's Health Insurance Program (CHIP).  Note this is not Medicaid funded.   CN
  F09  Undocumented alien-Emergency related Service Only  AEM
  F10  Interim Categorically Needy  CN
  F95  Medically Needy no spenddown  MN
  F99  Medically Needy with spenddown  MN

DCFS/JRA Medical-Foster Care

 Category  ACES  Description  Scope
 Foster Care  D01  SSI recipient FC/AS/JRA  CN
 Foster Care  D02  FC/AS/JRA  CN
Foster Care Medical is handled by a special unit at HRSA/Childrens Medical CSO 076

Refugee

 Category  ACES  Description  Scope
 Refugee cash and medical  R01  Cash & Medical  CN
 Transitional 4 month extension  R02  4 month Medical extension  CN
 Refugee Medical only  R03  Medical only  CN

Mental Health-Institutional, Breast & Cervical Cancer Program, Take Charge, Psychiatric inpatient

 Category  ACES  Description  Scope
 Mental Health Institutional  I01  Inpatient Psychiatric (Mental Health)  CN
 Breast & Cervical Cancer Program  S30  Breast & Cervical Cancer-Health Department approval.  CN
 Take Charge  P06  Family Planning  Family Planning Only
 Psychiatric Inpatient-State Funded  M99  Psychiatric Indigent Inpatient spenddown Mental Health Approval only  MCS
Modification Date: April 25, 2013