Managed Care Category/Program Status Code HCBP (HealthCare Benefit Package)

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Pierce Lane
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1 APPENDIX N

2 (HealthCare Benefit Package) 1 of 4 Category A recipient in any category 50-Healthy Plus could request to Opt Out to 40-Healthy A 00 SSI Aged N/A I* A 44 SSI Aged State Supplement for SSI recipients (Known as sandwich Group) N/A I* A 45 SSI Aged Nursing Home State Supplement for SSI recipients N/A I* A 46 SSI Aged Recipients who receive a Mandatory SSP will by SSA N/A I* A 60 SSI Aged Individual Receiving Dom Care Supplement N/A I* A 62 SSI Aged Individual Receiving PCBH Supplement N/A I* A 64 SSI Aged State Supplement for SSI recipients w/flac B N/A I* ACX 00 Act 150 (Ages 18-59) N/A N/A N/A E B 00 State Blind N/A E B 80 State Blind Pension N/A E C 00 TANF , 50 I* C 04 TANF alien (Subject to 5 year bar) , 50 I* C 06 TANF Timeout , 50 I* C 07 Extended TANF - Contingency , 50 I* C 08 Extended TANF , 50 I* C 09 Extended TANF - DV , 50 I* C 47 1 Month TANF Diversion N/A N/A N/A E C 48 2 Month TANF Diversion N/A N/A N/A E C 49 3 Month TANF Diversion N/A N/A N/A E C 53 TANF Work Support (Disabled) 30 N/A 40, 50 I* C 57 TANF Work Support (Extended TANF) 30 N/A 40, 50 I* C 58 TANF Work Support (Extended TANF) 30 N/A 40, 50 I* C 71 TANF Transitional Cash Assistance - EMC , 50 I* C 72 TANF Transitional Cash Assistance - Non-EMC , 50 I* D 02 GA RRP/RCA (Refugee Cash Assist) , 50 I* D 05 Repatriated National , 50 I* E 00 Emergency Assistance (Federal Fund) N/A N/A N/A E EIX 00 Early Intervention N/A N/A N/A E EIX 01 Early Intervention Preschool N/A N/A N/A E J 00 SSI Disabled I* J 31 SSI Disabled Federal Foster Care 30 N/A 50 N/A 50 I* J 32 SSI Disabled Federal Adoption Assist 30 N/A 50 N/A 50 I* J 33 SSI Disabled State Foster Care 30 N/A 50 N/A 50 I* J 34 SSI Disabled State Adoption Assistance P P P P J 35 SSI Adoption Foster Care Other State 30 N/A 50 N/A 50 I* J 36 Out of State Adoption Assistance 30 N/A 50 N/A 50 I* J 37 SSI SPLC 30 N/A 50 N/A 50 I* J 44 SSI Disabled State Supplement for SSI Recipients (known as sandwich group) I* J 45 SSI Disabled Nursing Home State Supplement for SSI Recipients I* J 46 SSI Disabled Recipients who Received a Mandatory SSP will by SSA I* J 60 SSI Disabled individual Receiving Dom Care Sup I* J 62 SSI Disabled Individual Receiving PCBH Sup I* J 64 SSI Disabled State Supplement for SSI Recipients w/flac B I* M 00 SSI Blind I* M 44 SSI Blind State Supplement for SSI Recipients (Known as the sandwich group) I* M 45 SSI Blind Nursing Home State Supplement for SSI Recipients I* M 46 SSI Blind Recipients who receive a Mandatory SSP will by SSA I* M 60 SSI Blind Indv Receiving Dom Care Sup I* M 62 SSI Blind Indv Receivign PCBH Sup I* M 64 SSI Blind State Supplement for SSI Recipients w/flac B I* MG 00 MAGI Pregnant Woman/Infant/Child/Youth I* MG 17 MAGI Presumptive Eligibility Former Foster/Infant/Child/Youth/Caretaker E MG 18 MAGI NMP SMA/Income Ineligible Pregnant Woman/Newborn I* Status w/ D)

3 (HealthCare Benefit Package) 2 of 4 A recipient in any category 50-Healthy Plus could request to Opt Out to 40-Healthy MG 19 MAGI Youth (Newly Eligible) 30 N/A 50 N/A 40 I* MG 27 MAGI Infant/Child/Youth/Caretaker (Below TANF/NMP Limit) I* MG 71 MAGI TMA Infant/Child/Youth/Caretaker I* MG 91 Newly Eligible MA I* MG 92 Former MNO MA I* MG 93 Gap Coverage MA to PCO N/A N/A 40 E MG 94 Former MNO PCO Gap Coverage N/A N/A 40 E MHX 00 County Funded Mental Health Services N/A N/A N/A E MRX 00 OMR Base N/A N/A N/A E PA 00 NMP Aged N/A I* PA NMP Aged Spend Down (Monthly Auth) N/A E PA 22 NMP Aged Spend Down (Ongoign Auth) N/A I* PA 81 Aged Disabled Adult Child N/A I* PA 84 "Pickle" Aged N/A I* PA 85 Disabled Employment Aged N/A I* PA 86 Qualified Disabled Working Individual Aged N/A 50 N/A E PAN 00 Aged Long Term Care (NMP) N/A I* PAN 66 Aged Long Term Care W/Buy-In (NMP) N/A 50 N/A I* PAN 80 Aged Long Term Care W/Buy-In (NMP) N/A 50 N/A I* PAW 00 Aged Waiver Program (NMP) N/A I* PAW 66 Aged Waiver Program W/Buy-In (NMP) N/A 50 N/A I* PAW 80 Aged Waiver Program W/Buy-In (NMP) N/A 50 N/A I* PAW 81 Special SSI Waiver-Aged-DAC N/A I* PAW 84 Special SSI Waiver-Aged-Pickle N/A I* PAW 85 Special SSI Waiver-Aged-Dis-Emp N/A I* PC 02 NMP TANF Refugee (RMA) , 50 I* PC 03 NMP TANF Rep Unaccompanied Minor 30 N/A 50 N/A 40 I* PC 30 Release from YDC 30 N/A 50 N/A 50 I* PC 31 NMP TANF Federal Foster Care 30 N/A 50 N/A 40 I* PC 32 NMP TANF Fed Adoption Assistance 30 N/A 50 N/A 40 I* PC 33 NMP TANF State Foster Care 30 N/A 50 N/A 40 I* PC 34 NMP TANF State Adoption Assistance 30 N/A 50 N/A 40 I* PC 35 Adoption Asst Foster Care Other State 30 N/A 50 N/A 40 I* PC 36 Out of State Adoption Assistance 30 N/A 50 N/A 40 I* PC 37 NMP SPLC (Subsidized Permanent Legal Custodianship) 30 N/A 50 N/A 40 I* PC 38 NMP TANF SCI Inmates E PC 39 NMP TANF County Inmates E PC 40 MAGI Former Foster Care , 50 I* PCN 02 Refugee Nursing Home 30 N/A 50 N/A 40 I* PCN 31 LTC-NMP Fed Foster Care 30 N/A 50 N/A 50 I* PCN 32 LTC-Fed Adop Assistance 30 N/A 50 N/A 50 I* PCN 33 LTC - NMP State Foster Care 30 N/A 50 N/A 50 I* PCN 34 LTC-NMP Sta Adop Assis Recip in Fac 30 N/A 50 N/A 50 I* PCN 35 LTC - NMP Out of State Foster Care 30 N/A 50 N/A 50 I* PCN 36 LTC - NMP Out of State Adop Assistance 30 N/A 50 N/A 50 I* PCN 37 LTC - NMP SPLC Child 30 N/A 50 N/A 50 I* Status w/ D) PCO 91 Newly Eligible PCO N/A N/A 60 E - PCO Plan Only PCO 92 Former MNO PCO N/A N/A 60 E - PCO Plan Only PCO 99 Pregnant PCO Enrollee N/A N/A 60 E - PCO Plan Only PCW 02 Special Groups Waiver Programs 30 N/A 50 N/A 50 I* PD 00 NMP GA Chronically Needy N/A N/A 40 E PD NMP GA Chron Need Spend-Down (Monthly) N/A N/A 40 E PD 22 NMP GA Chron Need Spend-Down (Ongoing) N/A N/A 40 E

4 (HealthCare Benefit Package) 3 of 4 A recipient in any category 50-Healthy Plus could request to Opt Out to 40-Healthy PD 38 NMP GA Disabled SCI Inmates N/A E PD 39 NMP GA Disabled County Inmates N/A E PG 00 Elderly Med Cost Sharing Healthy Horizon N/A E PH 00 Category Needy Healthy Horizon 30 N/A 50 I* PH 20 Breast & Cervical Cancer I* PH 38 SSA Disabled SCI Inmates E PH 39 SSA Disabled County Inmates E PH 80 Category Needy Healthy Horizon W/Buy-In N/A I* PH 95 Category Needy Child Special Needs 30 N/A 50 N/A 50 I* PH 97 SSI Pending/Child Special Needs (1yr-18yrs) 30 N/A 50 N/A 50 I* PI 00 Medically Improved MAWD I* PI 66 Med Improved MAWD Eligible for SLMB N/A I* PI 80 Med Improved MAWD Elig for Buy-In N/A I* PJ 00 NMP Disabled I* PJ NMP Disabled Spend-Down (Monthly) E PJ 22 NMP Disabled Spend-Down (Ongoing) I* PJ 81 Disabled Adult Child I* PJ 83 Disabled Special SSI Group Widows/Widowers Age N/A I* PJ 84 Disabled "Pickle" Aged Age 0-64 N/A I* PJ 85 Disabled Employment Aged Age I* PJ 86 Qualified Disabled Working Individual Aged N/A N/A N/A E PJN 00 Disabled Long Term Care (NMP) I* PJN 66 Disabled Long Term Care w/buy-in (NMP) N/A I* PJN 80 Disabled Long Term Care w/buy-in (NMP) N/A I* PJW 00 Disabled Waiver Program (NMP) I* PJW 66 Disabled Waiver Program W/Buy-In (NMP) N/A I* PJW 80 Disabled Waiver Program W/Buy-In (NMP) N/A I* PJW 81 Special SSI Waiver-Dis-DAC Age I* PJW 83 Special SSI Waiver -Disabled widow(er) N/A I* PJW 84 Special SSI Waiver - Disabled Pickle Age I* PJW 85 Special SSI Waiver Disabled Emp Age I* PM 00 NMP Blind I* PM NMP Blind Spend-Down (Monthly) E PM 22 NMP Blind Spend-Down (Ongoing) I* PM 81 Blind Disabled Adult Child I* PM 84 Blind "Pickle" Individual I* PM 85 Blind Disabled Employment Age I* PM 86 Blind Qualified Disabled Working Individual N/A N/A N/A E PMN 00 Blind Long Term care (NMP) I* PMN 66 Blind Long Term Care W/Buy-In (NMP) N/A I* PMN 80 Blind Long Term Care W/Buy-In (NMP) N/A I* PMW 00 Blind Waiver Program (NMP) I* PMW 66 Blind Waiver Program w/buy-in (NMP) N/A I* PMW 80 Blind Waiver Program W/Buy-In (NMP) N/A I* PMW 81 Special SSI Waiver-Blind DAC Age I* PMW 84 Special SSI Waiver-Blind Pickle Age I* PMW 85 Speical SSI Waiver-Blind Employment Age I* PS 17 NMP SMA Presumptive Eligibility N/A E PSF 00 Select Plan for Women E PSF 10 MAGI Select Plan for Women E PVN 00 VA Nursing Home N/A E PVN 66 VA Nursing Home w/buy-in (NMP) N/A 50 N/A E PVN 80 VA Nursing Home w/buy-in (NMP) N/A 50 N/A E Status w/ D)

5 (HealthCare Benefit Package) 4 of 4 A recipient in any category 50-Healthy Plus could request to Opt Out to 40-Healthy PW 00 MAWD I* PW 66 MAWD Elig for SLMB N/A I* PW 80 MAWD Elig for Buy-In N/A I* SC 00 Family Works N/A N/A N/A E SC 82 Family Works Preliminary Screening N/A N/A N/A E TA 00 MNO Aged N/A I* TA 22 SSI MNO Aged Spend Down Age 65+ N/A I* TA 65 Spec Low Inc Med Benef. Pt B Buy-In N/A N/A N/A E TA 66 Specif Low Inc Med Benef. Buy-In (MNO) N/A 50 N/A I* TA 67 Qual. Individual (QI-1) Buy-In Only N/A N/A N/A E TA 80 With Buy-In N/A 50 N/A I* TAN 00 Aged Long Term Care (MNO) N/A I* TAN 66 Aged Long Term Care W/Buy-In (MNO) N/A 50 N/A I* TAN 80 Aged Long Term Care W/Buy-In (MNO) N/A 50 N/A I* TAW 00 Aged Waiver Program (MNO) N/A I* TAW 66 Aged Waiver Program W/Buy-In (MNO) N/A 50 N/A I* TAW 80 Aged Waiver Program W/Buy-In (MNO) N/A 50 N/A I* TC 00 MNO TANF I* TC 22 TANF MNO Abs/Inc Spend down < I* TD 00 MNO GA Chronically Needy N/A N/A 40 E TD 22 GA MNO Spend down -64 N/A N/A 40 E TJ 00 MNO Disabled I* TJ 22 SSI MNO Disabled Spend down I* TJ 65 Spec Low Inc Med Benef. Pt B Buy-In N/A N/A N/A E TJ 66 Specif Low Inc Med Benef. Buy-In (MNO) N/A I* TJ 67 Qual. Individual (QI-1) Buy-In Only N/A N/A N/A E TJ 80 With Buy-In N/A I* TJN 00 Disabled Long Term Care (MNO) I* TJN 66 Disabled Long Term Care w/buy-in (MNO) N/A I* TJN 80 Disabled Long Term Care W/Buy-In (MNO) N/A I* TJW 00 Disabled Waiver Program (MNO) I* TJW 66 Disabled Waiver Program W/Buy-In (MNO) N/A I* TJW 80 Disabled Waiver Program W/Buy-In (MNO) N/A I* TU 00 MNO TANF/CU I* TU 22 TANF MNO UPWE Spend down I* TVN 00 VA Nursing Home N/A E TVN 66 VA Nursing Home w/buy-in (MNO) N/A 50 N/A E TVN 80 VA Nursing Home w/buy-in (MNO) N/A 50 N/A E U 00 TANF/CU , 50 I* U 04 TANF/U Alien (Subject to 5 Years bar) , 50 I* U 06 TANF Timeout , 50 I* U 07 Extended TANF-Contingency , 50 I* U 08 Extended TANF , 50 I* U 09 Extended TANF-DV , 50 I* U 47 1 Month TANF Diversion N/A N/A N/A E U 48 2 Month TANF Diversion N/A N/A N/A E U 49 3 Month TANF Diversion N/A N/A N/A E U 53 TANF Work Support (Disabled) , 50 I* U 57 TANF Work Support (Extended TANF) 30 N/A 40, 50 I* U 58 TANF Work Support (Extended TANF) 30 N/A 40, 50 I* U 71 TANF Transitional Cash Assistance - EMC , 50 I* U 72 TANF Transitional Cash Assistance - Non-EMC , 50 I* Status w/ D)

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