Aid Code Master Chart November 17, 2016

Transcription

1 Short-Doyle Medi-Cal (SDMC) Aid Code Master Chart vember 17, 2016 PURPOSE: The followg chart organizes Medi-Cal aid codes to six groups based on the percent of federal fancial participation (FFP) that will be paid for Medi-Cal Eligibles with that group, provided FFP is available: Refugee (100% FFP) Managed Risk Medical Insurance Board (MRMIB) at Title XXI 65% Aid codes (Regular FFP) at Title XIX 50% Title XXI of the Social Security Act (Enhanced FFP) at 65% Breast and Cervical Cancer Treatment Program (BCCTP) Aid Codes (Enhanced FFP) at 65% Mixed Fundg based on diagnostic and/or procedure codes. Emergency (Regular FFP) at Title XIX 50%, and/or Pregnancy (Enhanced FFP) at Title XXI 65% NEW UPDATES: Please note that EPSDT services do not apply to the SB 75 population; however, EPSDT services may apply to other populations outside of SB 75 that will be reimbursed with federal funds. Per Welfare and Institutions (W&I) Code, Section for the Medi-Cal program, pursuant to Senate Bill (SB) 75 (Chapter 18, Statutes of 2015) provides that dividuals under age 19, who do not have satisfactory immigration status or are unable to verify satisfactory

2 immigration status or citizenship, are eligible for the full scope of Medi-Cal benefits. Effective date is May 1, 2016 at 100% State General Funds (SGF). Listed below are the aid codes: G5, G7, J1, J2, J7, M3, M5, M7, M9, P5, P7, P9, 2H, 23, 24, 27, 3N, 34, 37, 39, 44, 47, 54, 59, 6H, 63, 64, 67, 7A, 7J, 72, 82, 83, T1, T2, T3, T4, T5, 7X, 8P, and 8R. Pursuant to section 1905(y) of the Act, the Patient Protection and Affordable Care Act (ACA) of 2010, provides for the enhancement the Federal Medical Assistance Percentage for MCHIP. As a result, the followg aid codes have been identified for the FMAP crease of 23% to total 88% for MCHIP for Title 21. The crease is effective from October 1, 2015 to September 30, 2019 E6, E7, H0, H1, H2, H3, H4, H5, H6, H9, M5, M6, T0, T1, T2, T3, T4, T5, T6, T7, T8, T9, 5C, 5D, 7X, 8X, 8N, 8P, 8R, and 8T. Per Information tice , reimbursement of federal fancial participation (FFP) is available for either; 1) acute psychiatric patient hospital services, or 2) psychiatric hospital professional services provided a Fee-For-Service Medi-Cal hospital for Medi-Cal eligible county mates who have been transferred off the grounds of a county correctional facility. The effective date is January 1, Listed below are the county mate aid codes: F3, G3, F4, and G4. Pursuant to section of the Welfare and Institutions Code, the followg Relative Caregiver Fundg Option Program (ARC Program) aid codes will be used to transition current foster care CalWORKs enrollees and foster care CalWORKs eligible enrollees to five separate Medi-Cal aid codes effective January 1, 2015: 2P, 2R, 2S, 2T and 2U. Page 2 of 66 Rev. 11/14/17

3 Table of Contents Refugee Aid Codes (100% FFP through-refugee Resettlement Program)...5 Senate Bill 75 Aid Codes...7 Title XIX 50% Regular FFP Title XIX 100% FFP Title XIX 65% Enhanced FFP -Breast and Cervical Cancer Treatment Program State Children's Health Insurance Program Healthy Families Program (HFP) Medicaid Children s Health Insurance Program (MCHIP) Title XIX Emergency & Title XXI Pregnancy Unallowable Federal Fancial Participation (FFP) Reimbursement APPENDIX Page 3 of 66 Rev. 11/14/17

4 Refugee Aid Codes (100% FFP through- Refugee Resettlement Program) Page 4 of 66 Rev. 11/14/17

5 Refugee Aid Codes (100% FFP through-refugee Resettlement Program) These aid codes are funded by the Refugee Resettlement Program (not Title XIX or XXI) Code 0A Benefit s SOC Y/N Effective Dates EPSDT N/A Program/Description MHS MEG DMC SD/MC Refugee Cash Assistance (FFP). Includes unaccompanied children. Covers all eligible refugees durg their first eight months the United States. Unaccompanied children are not subject to the eighth-month limitation provision. This population is the same as aid code 01, except that they are exempt from grant reductions on behalf of the Assistance Payments Demonstration Project/California Work Pays Demonstration Project. Refugee Cash Assistance (FFP). Includes unaccompanied children. Covers all eligible refugees durg their first eight months the United States. Unaccompanied children are not subject to the eighth-month limitation provision. Refugee Medical Assistance/Entrant Medical Assistance (FFP). Covers refugees and entrants who need Medi-Cal and who do not qualify for or want cash assistance. Entrant Cash Assistance (ECA) (FFP). Provides ECA benefits to Cuban/Haitian entrants, cludg unaccompanied children who are eligible, durg their first eight months the United States. (For entrants, the month begs with their date of parole.) Unaccompanied children are not subject to the eighth-month limitation provision. N/A N/A N/A Page 5 of 66 Rev. 11/17/16

6 Senate Bill 75 Aid Codes Page 6 of 66 Rev. 11/17/16

7 SB 75 Aid Codes Eligible for 100% SGF Effective May 1, 2016 Effective Dates EPSDT Other 5/1/16 Code Benefits SOC Program/Description MHS MEG DMC SB75 SD/MC G5 G7 Title XIX, Medi-Cal no SOC for county juvenile mates. Medi-Cal benefits limited to covered patient hospital or patient mental health services only, for juvenile mates county correctional facilities who receive those services off the grounds of the correctional facility Title XIX, Medi-Cal SOC for county juvenile mates. Medi-Cal benefits limited to covered patient hospital or patient mental health services only, for juvenile mates county correctional facilities who receive those services off the grounds of the correctional facility. Other 5/1/16 J1 Title XIX, Medi-Cal no share-of-cost (SOC) for Compassionately released/medical Probation County Inmates. Individuals who are Medi-Cal eligible aid code J1 will be entitled to all Medi-Cal covered services because they are not considered to be carcerated. The county is responsible for the non-federal share. Other 5/1/16 Page 7 of 66 Rev. 11/17/16

8 SB 75 Aid Codes Eligible for 100% SGF Effective May 1, 2016 Effective Dates EPSDT Other 5/1/16 Code Benefits SOC Program/Description MHS MEG DMC SB75 SD/MC J2 J7 M3 M5 M7 M9 Title XIX, Medi-Cal SOC for Compassionately released/medical Probation County Inmates. Individuals who are Medi-Cal eligible aid code J2 will be entitled to all Medi-Cal covered services because they are not considered to be carcerated. The county is responsible for the nonfederal share. Title XIX, Medi-Cal no SOC/SOC for disabled Compassionately released/medical Probation County Inmates who reside LTC facilities. Individuals who are Medi-Cal eligible aid code J7 will be entitled to all Medi-Cal covered LTC services because they are not considered to be carcerated. The county is responsible for the non-federal share. Parent/Caretaker Relative at 0% through 109% FPL: Citizen/Lawfully present. Expansion Child from 6 to 19 Yrs 108% through 133% FPL: Citizen/Lawfully present. Pregnant Women 0% through 138% FPL: Citizen/Lawfully present. Pregnant Women 138% - 213% FPL: Citizen/Lawfully present. Other 5/1/16 Other 5/1/16 MCHIP 5/1/16 Other 5/1/16 Other 1/1/14 Page 8 of 66 Rev. 11/17/16

9 SB 75 Aid Codes Eligible for 100% SGF Effective May 1, 2016 Effective Dates EPSDT Other 5/1/16 Code Benefits SOC Program/Description MHS MEG DMC SB75 SD/MC P5 P7 P9 2H 23 Children 6 to 19 years of age with 0 percent 133 percent Federal Poverty Level, Citizen/Lawfully present, full scope no cost Medi-Cal. Children 1 to 6 years of age with 0 percent 142 percent Federal Poverty Level, Citizen/Lawfully present, full scope, no cost Medi-Cal. Infant up to 1 year of age with 0 percent percent Federal Poverty Level, Citizen/Lawfully present, full scope, no cost Medi-Cal. Bld Federal Poverty Level covers bld dividuals the FPL for the Bld Program. Y/N Aid to the Bld LTC Status (FFP). Covers persons who meet the federal criteria for bldness, are medically needy, and are LTC status. Other 5/1/16 Other 5/1/16 Disabled 5/1/16 Other 5/1/16 24 For DMC only: Restricted to Narcotic Treatment Program Individual/Group Counselg and NTP dosg. Aid to the Bld Medically Needy (FFP). Covers persons who meet the federal criteria for bldness who do not wish or are not eligible for a cash grant, but are eligible for Medi-Cal only. Other 5/1/16 Page 9 of 66 Rev. 11/17/16

10 SB 75 Aid Codes Eligible for 100% SGF Effective May 1, 2016 Effective Dates EPSDT Other 5/1/16 Code Benefits SOC Program/Description MHS MEG DMC SB75 SD/MC 27 Aid to the Bld Medically Needy, SOC (FFP). Covers persons who meet the federal criteria for bldness who do not wish or are not eligible for a cash grant, but are eligible for Medi- Cal only. SOC is required of the beneficiaries. 3N Aid to Families with Dependent Other 5/1/16 Children (AFDC) 1931(b) n- CalWORKs 34 AFDC-MN (FFP). Covers families with deprivation of parental care or support who do not wish or are not eligible for a cash grant but are eligible for Medi-Cal only. Other 5/1/ AFDC-MN (FFP). Covers families with deprivation of parental care or support who do not wish or are not eligible for a cash grant, but are eligible for Medi-Cal only. SOC required of the beneficiaries. Initial Transitional Medi-Cal (TMC) (6 months). Provides six months of coverage for those discontued from CalWORKs or the Section 1931(b) program due to creased earngs or creased hours of employment. Other 5/1/16 Other 5/1/16 Page 10 of 66 Rev. 11/17/16

11 SB 75 Aid Codes Eligible for 100% SGF Effective May 1, 2016 Effective Dates EPSDT Code Benefits SOC Program/Description MHS MEG DMC SB75 SD/MC 44 Income Disregard Program. Pregnant Other 5/1/16 (FFP) United States Citizen/Permanent Resident Alien/PRUCOL Alien. Provides family planng, pregnancy-related and postpartum services for any age female if family come is at or below 200 percent of the federal poverty level Income Disregard Program (FFP). Infant United States Citizen, Permanent Resident Alien/PRUCOL Alien. Provides full Medi-Cal benefits to fants up to one-year-old and contues beyond one year when patient status, which began before first birthday, contues and family come is at or below 200 percent of the federal poverty level. Four-Month Contug Eligibility (FFP). Covers persons discontued from AFDC due to the creased collection of child/spousal support payments but eligible for Medi-Cal only. Other 5/1/16 Other 5/1/16 59 Contug TMC (6 months). Provides an additional six months of TMC for beneficiaries who had six months of itial TMC coverage under aid code 39 Other 5/1/16 Page 11 of 66 Rev. 11/17/16

12 SB 75 Aid Codes Eligible for 100% SGF Effective May 1, 2016 Effective Dates EPSDT Disabled 5/1/16 Code Benefits SOC Program/Description MHS MEG DMC SB75 SD/MC 6H Y/N Federal Poverty Level Disabled (FPL Disabled). Provides full-scope Medi-Cal ( share of cost) to qualified disabled dividuals/couples Aid to the Disabled LTC Status (FFP). Covers persons who meet the federal defition of disability who are medically needy and LTC status. For DMC only: Restricted to Narcotic Treatment Program Individual/Group Counselg and NTP dosg. Aid to the Disabled Medically Needy (FFP). Covers persons who meet the federal defition of disability and do not wish or are not eligible for cash grant, but are eligible for Medi-Cal only. Aid to the Disabled Medically Needy, SOC (FFP). (See aid code 64 for defition of Disabled MN.) SOC is required of the beneficiaries. Disabled 5/1/16 Disabled 5/1/16 Disabled 5/1/16 Page 12 of 66 Rev. 11/17/16

13 SB 75 Aid Codes Eligible for 100% SGF Effective May 1, 2016 Effective Dates EPSDT Other 5/1/16 Code Benefits SOC Program/Description MHS MEG DMC SB75 SD/MC 7A 7J 72 Child (FFP) United States Citizen, Lawful Permanent Resident/PRUCOL/ (IRCA Amnesty Alien [ABD or Under 18]). Provides full benefits to otherwise eligible children, ages 6 to 19 and beyond 19 when patient status began before the 19th birthday and family come is at or below 100 percent of the federal poverty level. Contuous Eligibility for Children (CEC) program. Provides full-scope benefits to children up to the 19 years of age who would otherwise lose their share of cost 133 Percent Program. Child-United States Citizen, Permanent Resident Alien/PRUCOL Alien (FFP). Provides full Medi-Cal benefits to children ages 1 up to 6 and beyond 6 years when patient status, which began before 6th birthday, contues, and family come is at or below 133 percent of the federal poverty level. Other 5/1/16 Other 5/1/16 Page 13 of 66 Rev. 11/17/16

14 SB 75 Aid Codes Eligible for 100% SGF Effective May 1, 2016 Effective Dates EPSDT MCHIP 5/1/16 Code Benefits SOC Program/Description MHS MEG DMC SB75 SD/MC 7X One-Month Healthy Families (HF) Bridge (FFP). Provides one additional calendar month of health care benefits with no Share of Cost, through the same health care delivery system, to Medi-Cal-eligible children meetg the criteria of the HF Bridgg Program. 8P 133 Percent Program. Child United States Citizen (with excess property), Permanent Resident Alien/PRUCOL Alien (FFP). Provides full-scope Medi- Cal benefits to children ages 1 up to 6 and beyond 6 years when patient status, which began before 6th birthday, contues, and family come is at or below 133 percent of the federal poverty level. MCHIP 5/1/16 8R 100 Percent Program. Child (FFP) United States Citizen (with excess property), Lawful Permanent Resident / PRUCOL / (IRCA Amnesty Alien [ABD or Under 18]). Provides full scope benefits to otherwise eligible children, ages 6 to 19 and beyond 19 when patient status begs before the 19 th birthday and family come is at or below 100 percent of the federal poverty level. MCHIP 5/1/16 Page 14 of 66 Rev. 11/17/16

15 Title XIX 50% Regular FFP Page 15 of 66 Rev. 11/17/16

16 Title XIX 50% Regular FFP Effective Dates EPSDT Other 1/1/14 Code Benefits SOC Program/Description MHS MEG DMC SD/MC F3 Restricted Medi-Cal eligible, Inmates from County correctional facilities. Title XIX, restricted to Medi-Cal covered hospital patient services only for mates county correctional facilities who receive those services off the grounds of the correctional facility. Eligibility will be determed by County staff. G3 Restricted Medi-Cal share-of-cost eligible, Inmates from County correctional facilities. Title XIX, restricted to Medi-Cal covered hospital patient services only for mates county correctional facilities who receive those services off the grounds of the correctional facility. Eligibility will be determed by County staff H7 Hospital Presumptive Eligibility for Children age 1-6 (FPL at or below 142 percent FPL) H8 Hospital Presumptive Eligibility for Children age 6-19 (FPL at or below 108 percent FPL) J5 K1 Title XIX, Medi-Cal no SOC/SOC for aged (>65 years old) Compassionately released/medical Probation County Inmates who reside long-term care (LTC) facilities. Individuals who are Medi-Cal eligible aid code J5 will be entitled to all Medi-Cal covered LTC services because they are not considered to be carcerated. The county is responsible for the non-federal share. Two Parent Safety Net & Drug/Fleeg Felon Family Other 1/1/14 Other 1/1/14 Other 1/1/14 Other 1/1/14 Other 4/1/13 Page 16 of 66 Rev. 11/17/16

17 Title XIX 50% Regular FFP Effective Dates EPSDT Code Benefits SOC Program/Description MHS MEG DMC SD/MC P1 Hospital PE Children 0-1 (at or below 208 Other 1/1/14 percent FPL) P2 Hospital PE Parent/Caretaker Relative (at Other 1/1/14 or below 125 percent FPL) P3 Hospital PE Adults (19-64) Other 1/1/14 (at or below 138 percent FPL) P4 Limited Hospital PE Pregnant Women (at or below 213 percent FPL). Limited to Ambulatory prenatal services. Other 1/1/ Adoption Assistance Program (AAP) (FFP). A cash grant program to facilitate the adoption of hard-to-place children who would require permanent foster care placement without such assistance. Other Adoption Assistance Program/Aid for Other Adoption of Children (AAP/AAC). Covers cash grant children receivg Medi-Cal by virtue of eligibility to AAP/AAC benefits. Adoption Assistance Program (AAP) Child. Other Covers children receivg federal AAP cash subsidies from out of state. Provides eligibility for Contued Eligibility for Children (CEC) if for some reason the child is no longer eligible under AAP prior to his/her 18th birthday. AAP Title IV-E Federal Cash and Medi-Cal. Other 1/1/12 Page 17 of 66 Rev. 11/17/16

18 Title XIX 50% Regular FFP Effective Dates EPSDT Code Benefits SOC Program/Description MHS MEG DMC SD/MC 0W BCCTP transitional Medi-Cal coverage: Other Provides transitional no cost-full scope Medi- Cal coverage while county makes determation of eligibility under any other Medi-Cal program to beneficiaries formerly aid code OP who no longer meet federal BCCTP requirements due to turng 65, obtag creditable health surance or who no longer need treatment for breast and/or cervical cancer. 1E Contued eligibility for the Aged (FFP), Other Covers former SSI beneficiaries who are Aged (with exception of persons who are deceased or carcerated a correctional facility) until the county predetermes their eligibility. 1H Federal poverty level Aged (FPL-Aged) Other Provides full scope (no share of cost) Medi- Cal to qualified aged dividuals/couples. 1X Multipurpose Senior Services Program Medi-Cal Qualified, Eligible due to application of spousal impoverishment rules. Covers persons 65 years and older who meet the Medi-Cal criteria for patient care a nursg facility. Other Page 18 of 66 Rev. 11/17/16

19 Title XIX 50% Regular FFP Effective Dates EPSDT Other Code Benefits SOC Program/Description MHS MEG DMC SD/MC 1Y Y/N Multipurpose Senior Services Program Medi-Cal Qualified, Eligible due to application of spousal impoverishment rules. Covers persons 65 yrs. and older who meet the Medi-Cal criteria for patient care a nursg facility. SSI/SSP Aid to the Aged (FFP). A cash assistance program admistered by the SSA which pays a cash grant to needy persons 65 years of age or older. Aid to the Aged LTC (FFP) Covers persons 65 years of age or older who are medically needy and LTC status for DMC only: Restricted to Narcotic Treatment Program Individual/Group Counselg and NTP dosg. Other Other 14 Aid to the Aged Medically Needy (FFP). Covers persons 65 years of age or older who do not wish or are not eligible for a cash grant, but are eligible for Medi-Cal only. Other 16 Aid to the Aged Pickle Eligible (FFP). Covers persons 65 years of age or older who were eligible for and receivg SSI/SSP and Title II benefits concurrently any month sce April 1977 and were subsequently discontued from SSI/SSP but would be eligible to receive SSI/SSP if their Title II cost-of-livg creases were disregarded. These persons are eligible for Medi-Cal benefits as public assistance recipients accordance with the provisions the Lynch V. Rank lawsuit. Other Page 19 of 66 Rev. 11/17/16

20 Title XIX 50% Regular FFP Effective Dates EPSDT Other Code Benefits SOC Program/Description MHS MEG DMC SD/MC 17 2A 2E Aid to the Aged Medically Needy, SOC (FFP). Covers persons 65 years of age or older who do not wish or are not eligible for a cash grant, but are eligible for Medi-Cal only. SOC required. Abandoned baby program. Provides full scope benefits to children up to 3 months of age who were voluntarily surrendered with 72 hours of birth pursuant to the Safe Arms for Newborns Act Contued eligibility for the Bld (FFP), Covers former SSI beneficiaries who are Bld (with exception of persons who are deceased or carcerated a correctional facility) until the county determes their eligibility. 2P Foster children and youth up to age 18 years old participatg the ARC Program and who do not qualify for CalWORKs. Other Other Foster Care 1/1/15 Page 20 of 66 Rev. 11/17/16

21 Title XIX 50% Regular FFP Effective Dates EPSDT Code Benefits SOC Program/Description MHS MEG DMC SD/MC 2R Foster children and youth age 18 but under 21 years old participatg the ARC Program as a non-mor dependent and who do not qualify for CalWORKs. Foster Care 1/1/15 2S Foster children and youth up to age 18 years old participatg the ARC Program and who qualify for federal CalWORKs. Foster Care 1/1/15 2T Foster children and youth up to age 18 years old participatg the ARC Program and who qualify for CalWORKs. Foster Care 1/1/15 2U Foster children and youth age 18 but under 21 years old participatg the ARC Program as a non-mor dependent and who qualify for CalWORKs. Foster Care 1/1/ SSI/SSP Aid to the Bld (FFP). A cash assistance program admistered by the SSA, which pays a cash grant to needy bld persons of any age. Aid to the Bld Pickle Eligible (FFP). Covers persons who meet the federal criteria for bldness and are covered by the provisions of the Lynch vs. Rank lawsuit. (See aid code 16 for defition of Pickle Eligible.) Other Other Page 21 of 66 Rev. 11/17/16

22 Title XIX 50% Regular FFP Effective Dates EPSDT Other Code Benefits SOC Program/Description MHS MEG DMC SD/MC 3A 3C 3D 3E 3F 3G 3H Safety Net All other Families, CalWORKs Timed-Out, Child-Only Case. (FFP) Provides for contued cash and Medi-Cal coverage of children whose parents have been discontued from cash aid and removed from assistance unit (AU) due to reachg the CalWORKs 60-month time limit without meetg a time extender exception. Safety Net Two Parent, CalWORKs Timed-Out, Child-Only Case. (FFP) Provides for contued cash and Medi-Cal coverage of children whose parents have been discontued from cash aid and removed from AU due to reachg the CalWORKs 60 month time limit without meetg a time extender exception. t on cash aid, but cash-lked Medi-Cal eligible because the dividual has been determed to be eligible for CalWORKs. CalWORKs Legal Immigrant- Family Group (FFP). Provides aid to families which a child is deprived because of the absence, capacity or death of either parent. Two Parent Safety Net & Drug/Fleeg Felon Family Other Other Other Other 4/1/13 CalWORKs Zero Parent Exempt. Other CalWORKs Zero Parent Mixed. Other Page 22 of 66 Rev. 11/17/16

23 Title XIX 50% Regular FFP Effective Dates EPSDT Other Code Benefits SOC Program/Description MHS MEG DMC SD/MC 3L 3M 3P 3R 3U 3W CalWORKs Legal Immigrant- Family Group FAMILY GROUP (FFP). Provides aid to families which a child is deprived because of the absence, capacity or death of either parent. CalWORKs Legal Immigrant- Family Group Unemployed (FFP). Provides aid to families which a child is deprived because of the unemployment of a parent livg the home. Other CalWORKs All Families Exempt. Other CalWORKs Zero Parent Exempt. Other CalWORKs Legal Immigrant- Family Group Unemployed (FFP). Provides aid to families which a child is deprived because of the unemployment of a parent livg the home. Other Temporary Assistance to needy Families Other (TANF) Timed-Out Mixed Case CalWORKs All Families Other TANF Timed out. Other CalWORKs Zero Parent Other CalWORKs Two Parent Other Page 23 of 66 Rev. 11/17/16

24 Title XIX 50% Regular FFP Effective Dates EPSDT Disabled Code Benefits SOC Program/Description MHS MEG DMC SD/MC A Aid to Disabled Widow/ers (FFP). Covers persons who began receivg Title II SSA before age 60 who were eligible for and receivg SSI/SSP and Title II benefits concurrently and were subsequently discontued from SSI/SSP but would be eligible to receive SSI/SSP if their Title II disabled widow/ers reduction factor and subsequent COLAs were disregarded. Contug Medi-Cal Eligibility (FFP). Edwards v. Kizer court order provides for unterrupted, no SOC Medi-Cal benefits for families discontued from AFDC until the family s eligibility or eligibility for Medi-Cal only has been determed and an appropriate tice of Action sent. Adoption Assistance Program (AAP). Program for AAP children for whom there is a state-only AAP agreement between any state other than California and adoptive parent(s). Other Other 4E Hospital Presumptive Eligibility for Former Other 1/1/14 Foster Care Children up to age 26 come screeng. 4F Kship Guardianship Assistance Payment (K-GAP). Federal program for children relative placement receivg cash assistance. Foster Care Page 24 of 66 Rev. 11/17/16

25 Title XIX 50% Regular FFP Effective Dates EPSDT Code Benefits SOC Program/Description MHS MEG DMC SD/MC 4G 4H 4L 4M 4N 4S 4T 4W K-GAP. State-only program for children relative placement receivg cash assistance. Foster Care Foster Care children CalWORKs Foster Care 12/13/10 Foster care children Social Security Act Foster 12/13/10 Title XIX, Section 1931 (b) program. Care This program covers former foster care Other youth who were foster care on their eighteenth birthday. Coverage extends until the 21st birthday and provides full-scope, nocost benefits. CalWORKs FC State Cash Aid/ FFP Medi- Foster 1/1/12 Cal. Care K-GAP Title IV-E Federal Cash and Medi- Foster 1/1/12 Cal. Care Children IV-E K-GAP Program. Foster 1/1/11 Care K-GAP State Cash Aid/FFP Medi-Cal after Foster 1/1/12 full Medi-Cal determation. Care AFDC-FC/n-Fed (State FC). Provides Foster fancial assistance for those children who Care are need of substitute parentg and who have been placed foster care. AFDC-FC/Fed (FFP). Provides fancial assistance for those children who are need of substitute parentg and who have been placed foster care. Foster Care Page 25 of 66 Rev. 11/17/16

26 Title XIX 50% Regular FFP Effective Dates EPSDT Code Benefits SOC Program/Description MHS MEG DMC SD/MC 43 AFDC-FC State Cash Aid/FFP Medi-Cal. Foster Care 1/1/12 45 Children Supported by Public Funds (FFP). Children whose needs are met whole or part by public funds other than AFDC-FC. Other 46 Out of State Interstate Compact Foster Care children from out of state placed CA Foster Care 49 AFDC-FC Title IV-E/Federal Cash and Medi- Cal Foster Care 1/1/12 5E 5K 6A Healthy Families to the Medi-Cal Presumptive Eligibility (PE) program. Provides immediate, temporary, fee-for service, full-scope Medi-Cal benefits to certa children under the age of 19. T21 effective through 3/31/09; T19 effective 4/1/09. Emergency Assistance (EA) Program (FFP). Covers child welfare cases placed EA foster care. Disabled Adult Children (DAC)/Bldness (FFP). Other 10/25/10 Foster Care Other Page 26 of 66 Rev. 11/17/16

27 Title XIX 50% Regular FFP Effective Dates EPSDT Code Benefits SOC Program/Description MHS MEG DMC SD/MC 6C Disabled Adult Children (DAC)/Disabled (FFP). Disabled 6E 6G 6J 6N 6P Contued eligibility for the Disabled (FFP), Covers former SSI beneficiaries who are Disabled (with exception of persons who are deceased or carcerated a correctional facility) until the county determes their eligibility. 250 Percent Program Workg Disabled. Provides full-scope Medi-Cal benefits to workg disabled recipients who meet the requirements of the 250 Percent Program. SB87 Pendg Disability Program. Provides full scope (no share of cost) benefits to recipients21 to 65 years of age, who have lost their non-disability lkage to Medi-Cal and are claimg disability. Medi-Cal coverage contues unterrupted durg the determation period. Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)/ Longer Disabled Recipients (FFP). Former SSI disabled recipients (adults and children not aid code 6P) who are appealg their cessation of SSI disability. PRWORA/ Longer Disabled Children (FFP). Covers children under age 18 who lost SSI cash benefits on or after July 1, 1997, due to PRWORA of 1996, which provides a stricter defition of disability for children. Disabled Disabled 3/16/09 Other Disabled Disabled Page 27 of 66 Rev. 11/17/16

28 Title XIX 50% Regular FFP Effective Dates EPSDT Disabled Code Benefits SOC Program/Description MHS MEG DMC SD/MC 6R 6V 6W 6X 6Y 60 SB87 Pendg Disability Program. Provides full scope (no share of cost) benefits to recipients 21 to 65 years of age, who have lost their non-disability lkage to Medi-Cal and are claimg disability. Medi-Cal coverage contues unterrupted durg the determation period. Aid to the Disabled DDS Waiver (FFP). Covers persons who qualify for the Department of Developmental Services (DDS) Regional Waiver. Aid to the Disabled DDS Waiver (FFP). Covers persons who qualify for the Department of Developmental Services (DDS) Regional Waiver. Aid to the Disabled Model Waiver (FFP). Covers persons who qualify for the Model Waiver. Aid to the Disabled Model Waiver (FFP). Covers persons who qualify for the Model Waiver. SSI/SSP Aid to the Disabled (FFP). A cash assistance program admistered by the SSA that pays a cash grant to needy persons who meet the federal defition of disability. Disabled Disabled Disabled Disabled Disabled Page 28 of 66 Rev. 11/17/16

29 Title XIX 50% Regular FFP Effective Dates EPSDT Disabled Code Benefits SOC Program/Description MHS MEG DMC SD/MC S 7W 76 Restricted to 60-day postpartum services 8E Aid to the Disabled Pickle Eligibles (FFP). Covers persons who meet the federal defition of disability and are covered by the provisions of the Lynch V. Rank lawsuit. age limit for this aid code. Aid to the Disabled IHSS (FFP). Covers persons who meet the federal defition of disability and are eligible for IHSS. (See aid codes 18 and 65 for defition of eligibility for IHSS). Express Lane Enrollment. CalFRESH parents from 19 through 64 years of age who are neither bld nor disabled. Disabled Phased out from 9/05 to 1/06 Other 4/1/14 Express Lane Enrollment for Children. Other 2/1/14 60-Day Postpartum Program (FFP). Provides Medi-Cal at no SOC to women who, while pregnant, were eligible for, applied for, and received Medi-Cal benefits. They may contue to be eligible for all postpartum services and family planng. This coverage begs on the last day of pregnancy and ends the last day of the month which the 60th day occurs. Accelerated Enrollment. Provides immediate, temporary, fee-for-service, full scope Medi-Cal benefits up to the age of 65. T21 effective through 3/31/09; T19 effective 4/1/09. Other Other Page 29 of 66 Rev. 11/17/16

30 Title XIX 50% Regular FFP Effective Dates EPSDT Other Code Benefits SOC Program/Description MHS MEG DMC SD/MC 8G Qualified Severely Impaired Workg Individual Program Aid Code. Allows recipients of the Qualified Severely Impaired Workg Individual Program to contue their Medi-Cal eligibility. 8U 8V CHDP Gateway Deemed Infant. Provides fullscope, no Share of Cost (SOC) Medi-Cal benefits for fants born to mothers who were enrolled Medi-Cal with no SOC the month of the fant s birth. CHDP Gateway Deemed Infant SOC. Provides full-scope Medi-Cal benefits with a Share of Cost (SOC) for fants born to mothers who were enrolled Medi-Cal with a SOC the month of the fant s birth and SOC was met. Other 10/11/10 Other 10/11/10 8W 80 Restricted to Medicare expenses Medically Indigent (MI)-Accelerated Enrollment (AE)- CHDP Gateway for Medi- Cal. Provides for the pre-enrollment of CHILDREN to the Medi-Cal program that are Screened as Cost Medi-Cal Eligible. Provides Temporary, full scope Medi-Cal benefits with no SOC. Please note: T21 through 3/31/09; however, T19 effective 4/1/09. Qualified Medicare Beneficiary (QMB). Provides payment of Medicare Part A premium and Part A and B cosurance and deductibles for eligible low come aged, bld, or disabled dividuals. Other Other Page 30 of 66 Rev. 11/17/16

31 Title XIX 50% Regular FFP Effective Dates EPSDT Other Code Benefits SOC Program/Description MHS MEG DMC SD/MC 86 MI-Confirmed Pregnancy (FFP). Covers persons aged 21 years or older, with confirmed pregnancy, who meets the eligibility requirements of medically digent. 87 MI-Confirmed Pregnancy (FFP). Covers person s aged 21 or older, with confirmed pregnancy, who meet the eligibility requirements of medically digent but are not eligible for 185 percent/200 percent or the MN programs. Other Page 31 of 66 Rev. 11/17/16

32 Title XIX 100% FFP Page 32 of 66 Rev. 11/17/16

33 Title XIX 100% FFP Please note: The FFP will be at 100% from 2014 through All of the dividuals these aid codes should be placed to the appropriate ACA aid code for ongog eligibility by March Effective Dates Code Benefits SOC Program / Description MHS MEG DMC SD/MC 7U L1 Express Lane Enrollment for adults. Medicaid Expansion Adults aged 19 through 64 years of age, enrolled LIHP MCE program on December 31, 2013 with 0 percent 138 percent Federal Poverty Level N0 Limited Adults aged 19 through 64 years of age, mates county jail enrolled LIHP MCE program on December 31, 2013, with 0 percent 138 percent Federal Poverty Level (FPL), limited to covered patient hospital services provided off the grounds of the correctional facility. Medicaid Expansion Medicaid Expansion EPSDT 2/1/14 1/1/14 1/1/14 Title XIX 100% FFP - Enhanced Title XIX federal fundg is available for those who are newly eligible the adults group. Please note the FFP category will decrease to the followg: 100 % for ; 95% for 2017; 94% for 2018; 93% 2019; 90% for 2020 and thereafter. Effective Dates EPSDT Code Benefits SOC Program / Description MHS MEG DMC SD/MC M1 Adult 19 to 65 Yrs. at or below 138% FPL: Citizen/Lawfully Present Medicaid Expansion 1/1/14 M2 Restricted Adult 19 to 65 Yrs. at or below 138% FPL: Undocumented-Restricted to emergency and pregnancy related services. Medicaid Expansion 1/1/14 Page 33 of 66 Rev. 11/17/16

34 Title XIX 100% FFP - Enhanced Title XIX federal fundg is available for those who are newly Effective Dates eligible the adults group. Please note the FFP category will decrease to the followg: 100 % for ; 95% for 2017; 94% for 2018; 93% 2019; 90% for 2020 and thereafter. Code Benefits SOC Program / Description MHS MEG DMC SD/MC N7 Limited Medi-Cal no SOC for County Adult Inmates. Medi-Cal benefits limited to covered patient hospital services only, for adult mates aged 19 through 64 years of age county correctional facilities who receive those services off the grounds of the correctional facility. Medicaid Expansion EPSDT 1/1/14 N8 Restricted This Aid code will reflect the new ACA adult group aged Aid code provides restricted Medi-Cal benefits, without a share of cost, limited to patient hospital emergency related services only, who receive those services off the grounds of the correctional facility. Medicaid Expansion 1/1/14 Page 34 of 66 Rev. 11/17/16

35 Title XIX (Enhanced FFP 65%) Breast and Cervical Cancer Treatment Program Page 35 of 66 Rev. 11/17/16

36 Title XIX (Enhanced FFP 65%) Breast and Cervical Cancer Treatment Program (BCCTP) Aid Codes Effective Dates EPSDT Code Benefits SOC Program/Description MHS MEG DMC SD/MC 0M BCCTP-Accelerated Enrollment (AE). Provides AE for temporary full-scope, no SOC Medi-Cal for females under 65 years of age who are diagnosed with breast and/or cervical cancer. Eligibility limited to 2 months 0N BCCTP-AE, Provides AE for temporary full scope, no SOC Medi-Cal for females under 65 years of age who have diagnosed with breast and/or cervical cancer and are without creditable surance coverage. time limit 0P BCCTP-Federal, Provides full-scope, no SOC Medi-Cal for females under 65 years of age who have diagnosed with breast and/or cervical cancer and are without creditable surance coverage 0U Restricted to pregnancy and/or emergency services BCCTP Provides services for females with unsatisfactory immigration status, who are under 65 years of age, who have been diagnosed with breast and/or cervical cancer and are found need of treatment. They are eligible for Federal BCCTP for Emergency services for the duration of treatment. Does not cover dividuals with creditable health surance. State-only cancer treatment payments are 18 months (breast) and 24 months (cervical). Other Other Other Other Page 36 of 66 Rev. 11/17/16

37 Title XIX (Enhanced FFP 65%) Breast and Cervical Cancer Treatment Program (BCCTP) Aid Codes Code Benefits SOC Program/Description MHS MEG DMC SD/MC 0V Restricted to pregnancy and/or emergency services Post 0U eligibility for federal Medi-Cal Emergency services only and who contue to meet Federal BCCTP criteria. State-only pregnancy-related and LTC; for dividuals whose 0U eligibility has expired and who are determed to be still need of breast or cervical cancer treatment. Effective Dates EPSDT Other Page 37 of 66 Rev. 11/17/16

38 State Children's Health Insurance Program(SCHIP) & Healthy Family Program (HFP) Title XXI 65% FFP SCHIP The State Children's Health Insurance Program (SCHIP) was established by the federal government the late 1990 s to provide health surance to children families at or below 200 percent of the federal poverty level. SCHIP allowed states to create new programs to serve these children and families and/or expand their existg Medicaid programs. California elected to create the Healthy Families Program (HFP), servg children with family comes below 250% of the federal poverty level and expand Medi-Cal programs to serve lower come children that would not previously qualify for Medi-Cal. HFP The HFP was established to provide a basic health, vision, and dental benefit package (provided by HFP health plans) that cludes a mental health benefit for children assessed with serious emotional disturbances (SED). Mental health services for children meetg the SED criteria are provided by the county mental health departments. The enhanced Federal Medicaid Assistance Percentage (FMAP) of 65% under Title XXI is provided for HFP health and mental health service expenditures Page 38 of 66 Rev. 11/17/16

39 Effective Dates Title XXI (Enhanced FFP 65%) Healthy Families - MRMIB - SCHIP EPSDT Code Benefits SOC Program / Description MHS MEG DMC SD/MC 9H HF services only (no The Healthy Families (HF) Program provides a comprehensive health surance plan for unsured children from 1 to 19 years of age N/A 1/1/14 9R Medi- Cal) CCS Services only (no Medi- Cal) whose family s come is at or below 200 percent of the federal poverty level. HF covers medical, dental and vision services to enrolled children. CCS-eligible Healthy Families Child. A child this program is enrolled a Healthy Families plan and is eligible for all CCS benefits (i.e., diagnosis, treatment, therapy and case management) N/A 1/1/14 Page 39 of 66 Rev. 11/17/16

40 Title XXI FMAP crease of 23% to total 88% for Medicaid Children s Health Insurance Program (MCHIP) Page 40 of 66 Rev. 11/17/16

41 MCHIP Pursuant to section 1905(y) of the Patient Protection and Affordable Care Act of 2010, the enhancement the Federal Medical Assistance Percentage for MCHIP resulted an crease of 23% to total 88% for MCHIP under Title XXI. The crease is effective from October 1, 2015 to September 30, Title XXI Aid Codes - FMAP crease of 23% to total 88% for MCHIP Aid Codes. The crease is effective October 1, 2015 to September 30, 2019 except for E2, E4 and E5 which are active. Code Benefits SOC Program/Description MHS MEG DMC SD/MC SB75 Effective Date E1 Restricted to pregnancy and/or emergency services Unverified citizens. Covers eligible unverified citizen children. One Month Medi-Cal to Healthy Families Bridge. Prenatal and Emergency Services Only. Covers services only to eligible children ages 0-19, who are unverified citizens Effective Dates EPSDT MCHIP E2 CHIP 2101(f) Citizen/Lawfully Present MCHIP 1/1/14 6/30/14 (Age 0-19, premiums) E4 Restricted CHIP 2101(f) Undocumented (Age MCHIP 1/1/14 6/30/14 019, premiums) Restricted to emergency and pregnancy related services, and state-funded long term care services. E5 CHIP 2101(f) Citizen/Lawfully Present MCHIP 1/1/14 6/30/14 (Age 1-19, With premiums) E6 AIM fant above 213% to 266% MCHIP 1/1/14 E7 AIM fant above 250% to 300% MCHIP 1/1/14 H0 Hospital Presumptive Eligibility for Children age 6-19 (FPL above 108 percent up to and cludg 266 percent FPL). MCHIP 1/1/14 Page 41 of 66 Rev. 11/17/16

42 Title XXI Aid Codes - FMAP crease of 23% to total 88% for MCHIP Aid Codes. The crease is effective October 1, 2015 to September 30, 2019 except for E2, E4 and E5 which are active. Code Benefits SOC Program/Description MHS MEG DMC SD/MC SB75 Effective Date E1 Restricted to pregnancy and/or emergency services Unverified citizens. Covers eligible unverified citizen children. One Month Medi-Cal to Healthy Families Bridge. Prenatal and Emergency Services Only. Covers services only to eligible children ages 0-19, who are unverified citizens Effective Dates EPSDT MCHIP E2 CHIP 2101(f) Citizen/Lawfully Present MCHIP 1/1/14 6/30/14 (Age 0-19, premiums) E4 Restricted CHIP 2101(f) Undocumented (Age MCHIP 1/1/14 6/30/14 019, premiums) Restricted to emergency and pregnancy related services, and state-funded long term care services. E5 CHIP 2101(f) Citizen/Lawfully Present MCHIP 1/1/14 6/30/14 (Age 1-19, With premiums) E6 AIM fant above 213% to 266% MCHIP 1/1/14 E7 AIM fant above 250% to 300% MCHIP 1/1/14 H0 Hospital Presumptive Eligibility for Children age 6-19 (FPL above 108 percent up to and cludg 266 percent FPL). MCHIP 1/1/14 Page 42 of 66 Rev. 11/17/16

43 Title XXI Aid Codes - FMAP crease of 23% to total 88% for MCHIP Aid Codes. The Effective Dates crease is effective October 1, 2015 to September 30, EPSDT Code Benefits SOC Program / Description MHS MEG DMC SD/MC SB75 Effective Date H1 Targeted Low Income FPL for fants. Provides full scope, no-cost Medi-Cal for fants who are U.S. citizens, have satisfactory immigration status, or unverified citizenship**. Coverage is up to the month of their first birthday or contues beyond one year, when an patient status that began before the first birthday. Family come is above 200 percent up to 250 percent of the FPL. MCHIP 1/1/13 H2 Medi-Cal Targeted Low-Income FPL for Children Program. Provides full scope, no-cost Medi-Cal coverage to children with U.S. citizenship, satisfactory immigration status, or unverified citizenship; ages one through the month of the 6 th birthday or contues when an patient status which began before the 6 th birthday for family come at or below 133 up to 150 percent of federal poverty level. MCHIP 1/1/13 Page 43 of 66 Rev. 11/17/16

44 Title XXI Aid Codes - FMAP crease of 23% to total 88% for MCHIP Aid Codes. The crease is effective October 1, 2015 to September 30, Effective Dates EPSDT Code Benefits SOC Program / Description MHS MEG DMC SD/MC SB75 Effective Date H3 Medi-Cal Targeted Low-Income FPL for Children Program. Provides full scope, Medi-Cal coverage with a premium payment to children with U.S. citizenship, satisfactory immigration status, or unverified citizenship; ages one through the month of their 6 th birthday or contues when an patient status which began before the 6 th birthday, with family come above 150 percent up to 250 percent of the FPL. MCHIP 1/1/13 H4 Medi-Cal Targeted Low-Income FPL for Children Program. Provides full scope, no-cost Medi-Cal coverage to children with U.S. citizenship, satisfactory immigration status, or unverified citizenship; ages six through the month of the 19th birthday or contues when an patient status which began before the 19th birthday for family come above 100 up to 150 percent of federal poverty level. MCHIP 1/1/13 Page 44 of 66 Rev. 11/17/16

45 Title XXI Aid Codes - FMAP crease of 23% to total 88% for MCHIP Aid Codes. The crease is effective October 1, 2015 to September 30, Effective Dates EPSDT Code Benefits SOC Program / Description MHS MEG DMC SD/MC SB75 Effective Date H5 H6 H9 M5 Medi-Cal Targeted Low-Income FPL for Children Program. Provides full scope, Medi-Cal coverage with premium payment to children with U.S. citizenship, satisfactory immigration status, or unverified citizenship; ages six through the month of the 19th birthday or contues when an patient status which began before the 19th birthday, with family come above 150 percent up to 250 percent of FPL. Hospital Presumptive Eligibility for fants (FPL above 208 percent up to and cludg 266 percent FPL). Hospital Presumptive Eligibility for Children age 1-6 (FPL above 142 percent up to and cludg 266 percent FPL). Expansion Child from 6 to 19 Yrs., 108% through 133% FPL: Citizen/Lawfully Present. M6 Restricted Expansion Child from 6 to 19 Yrs., 108% through133% FPL: Undocumented Restricted to pregnancy related, emergency, and long term care. MCHIP 1/1/13 MCHIP 1/1/14 MCHIP 1/1/14 MCHIP 5/1/16 MCHIP Page 45 of 66 Rev. 11/17/16

46 Title XXI Aid Codes - FMAP crease of 23% to total 88% for MCHIP Aid Codes. The Effective Dates crease is effective October 1, 2015 to September 30, EPSDT Code Benefits SOC Program / Description MHS MEG DMC SD/MC SB75 Effective Date T0 Restricted Infant up to 1 Yr. Undocumented MCHIP 208%-266% FPL (TLIC). Restricted to emergency and state funded long term care services. T1 Child from 6 to 19 Yrs. Citizen MCHIP 5/1/16 160%-266% FPL (TLIC Premiums). T2 Child from 6 to 19 Yrs., Citizen MCHIP 5/1/16 133%160% FPL (TLIC). T3 Child from 1 to 6 Yrs., Citizen MCHIP 5/1/16 160%266% FPL (TLIC Premiums). T4 Child from 1 to 6 Yrs., Citizen MCHIP 5/1/16 142%160% FPL (TLIC). T5 Infant up to 1 Yr. Citizen 208%-266% MCHIP 5/1/16 FPL (TLIC). T6 Restricted Child from 6 to 19 Yrs., MCHIP Undocumented 160%-266% FPL (TLIC Premiums). Restricted to emergency and pregnancy related services, and state funded long term care services. T7 Restricted Child from 6 to 19 Yrs., MCHIP Undocumented 133%-160% FPL (TLIC). Restricted to emergency and pregnancy related services, and state funded long term care services. T8 Restricted Child from 1 to 6 Yrs., Undocumented 160%-266% FPL (TLIC Premiums). Restricted to emergency and state funded long term care services. MCHIP Page 46 of 66 Rev. 11/17/16

47 Title XXI Aid Codes - FMAP crease of 23% to total 88% for MCHIP Aid Codes. The crease is effective October 1, 2015 to September 30, Effective Dates EPSDT Code Benefits SOC Program / Description MHS MEG DMC SD/MC SB75 Effective Date T9 Restricted Child from 6 to 19 Yrs., MCHIP Undocumented 142%-160% FPL (TLIC). Restricted to emergency services and state funded long term care services. 5C Medi-Cal Presumptive Eligibility, Title XXI, HFP Transitional Children Provides no-cost, full scope, Medi-Cal coverage with no premium payment, to children with family come at or below 150 percent of the federal poverty level durg the transition period until the annual eligibility review. MCHIP 1/1/13 5D 7X Medi-Cal Presumptive Eligibility, Title XXI, HFP Transitional Children Provides full scope Medi-Cal coverage with a premium payment, to children with family come above 150 percent and up to 250 percent of the federal poverty level durg the transition period. One-Month Healthy Families (HF) Bridge (FFP). Provides one additional calendar month of health care benefits with no Share of Cost, through the same health care delivery system, to Medi-Cal-eligible children meetg the criteria of the HF Bridgg Program. MCHIP 1/1/13 MCHIP 5/1/16 Page 47 of 66 Rev. 11/17/16

48 Title XXI Aid Codes - FMAP crease of 23% to total 88% for MCHIP Aid Codes. The crease is effective October 1, 2015 to September 30, Effective Dates EPSDT Code Benefits SOC Program/Description MHS MEG DMC SD/MC SB75 Effective Date 8X Medically Indigent (MI)-Accelerated MCHIP Enrollment (AE)-CHDP Gateway for Healthy Families. Provides for the preenrollment of CHILDREN to the Medi-Cal program that is Screened as Probable Healthy Families Eligibles. Provides Temporary, full scope MediCal benefits with no SOC. 8N Restricted Excess Property Child-ESO FPL 133% MCHIP 8P 133 Percent Program. Child United States Citizen (with excess property), Permanent Resident Alien/PRUCOL Alien (FFP). Provides full-scope Medi- Cal benefits to children ages 1 up to 6 and beyond 6 years when patient status, which began before 6th birthday, contues, and family come is at or below 133 percent of the federal poverty level. 8T Restricted to pregnancy and/or emergency services 100 Percent Program. Child Undocumented / nimmigrant Status / (IRCA Amnesty Alien [with excess property]). MCHIP 5/1/16 MCHIP Page 48 of 66 Rev. 11/17/16

49 Title XIX Emergency 50 % FFP & Title XXI Pregnancy 65% FFP Page 49 of 66 Rev. 11/17/16

50 Title XIX (EMERGENCY) FFP 50% and XXI (PREGNANCY) Enhanced FFP 65% Effective Dates EPSDT Other Code Benefits SOC Program/Description MHS MEG DMC SD/MC 1U 5J 5R Restricted to pregnancy and/or emergency services Restricted to pregnancy and/or emergency services Restricted to pregnancy and/or emergency services 55 Restricted to pregnancy and/or emergency services Restricted Federal poverty level Aged (Restricted FPL Aged) Provides emergency and pregnancy-related benefits (no Share of Cost) to qualified aged dividuals/couples who do not have satisfactory immigration status Pendg disability Program. Covers recipients whose lkage has to be redetermed under Senate Bill 87 (SB87) requirements. Services restricted due to unsatisfactory immigration status. Recipients have a potential new lkage of disability with no SOC. Pendg disability Program. Covers recipients whose lkage has to be redetermed under Senate Bill 87 (SB87) requirements. Services restricted due to unsatisfactory immigration status. Recipients have a potential new lkage of disability with a SOC. Aid to Undocumented Aliens LTC t PRUCOL. Covers undocumented aliens LTC not Permanently Residg Under Color of Law (PRUCOL). LTC services: State-only funds; Emergency and pregnancy-related services: State and federal funds. Recipients will rema this aid code even if they leave LTC. Other Other Other Page 50 of 66 Rev. 11/17/16

51 Title XIX (EMERGENCY) FFP 50% and XXI (PREGNANCY) Enhanced FFP 65% Effective Dates EPSDT Other Code Benefits SOC Program/Description MHS MEG DMC SD/MC C1 C2 D2 D3 D5 Restricted to pregnancy and/or emergency services Restricted to pregnancy and/or emergency services Restricted to pregnancy and/or emergency services Restricted to pregnancy and/or emergency services Restricted to pregnancy and/or emergency services Aid to the Aged Medically Needy (FFP). Covers persons 65 years of age or older who do not wish or are not eligible for a cash grant, but are eligible for Medi-Cal only. Aid to the Aged Medically Needy, SOC (FFP). Covers persons 65 years of age or older who do not wish or are not eligible for a cash grant, but are eligible for Medi-Cal only. SOC required Aid to the Aged LTC (FFP) Covers persons 65 years of age or older who are medically needy and LTC status Aid to the Aged LTC (FFP) Covers persons 65 years of age or older who are medically needy and LTC status Aid to the Bld LTC Status (FFP). Covers persons who meet the federal criteria for bldness, are medically needy, and are LTC status. Other Other Other Disab led Page 51 of 66 Rev. 11/17/16