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DBHR Crosswalk for Provider One (ACES) Coverage Group Codes and theTARGET Entry The appropriate Modality, Contract Type and Fund Source should be chosen based on previous guidance provided by DBHR.The only change is that ADATSA Contract Type is no longer active.New Alternative Benefit Plan (ABP) clients (formerly ADATSA and Disability Lifeline eligibles) will use the “AdultResidential” Contract Type for Residential Treatment; or “Adult Outpatient” for Outpatient TreatmentThe column “ACES” in this document refers to the group code found in Provider One (populated by ACES) which is attachedto each person eligible for State Medical Services. Use this group code to cross reference eligibility with Public Funding TypeSSI and SSI RelatedACESSSI and SSI relatedalso calledAged/Blind/DisabledcategoryS01S02Disability isdetermined by SSAor by NGMA referralto DDDSSSI RecipientsS03ABD Categorically NeedyQMB Medicare Savings Program (MSP) Medicare premiumand Medicare co paymentsS04QDWI Medicare Savings ProgramS05S06S07SLMB Medicare Savings Program. Medicare Premium onlyS95S99SSI RelatedLiving in an alternateliving facility (nonmedical institution)adult family home,boarding home orDESCRIPTIONQI-1 (ESLMB) Medicare Savings ProgramUndocumented Alien. Emergency Related Service OnlyMedically Needy no spend downG03Medically Needy with spend downNon Institutional Medical in ALF CN-P Income under the SILplus under state rate x 31 days 38.84G95Medically Needy Non Institutional in ALF no spend downG99Medically Needy Non Institutional in ALF with spend downTARGET Public Funding Type– CD Services CoverageSCOPECN50%CN50%MSPN/AN/A – not covered for CDMSPN/AN/A – not covered for CDMSPN/AN/A – not covered for CDN/A – not covered for CDSupplemental SecurityIncome (SSI)Supplemental SecurityIncome (SSI)Medical Assistance OnlyMSPN/AERSON/AMNN/AMNN/ACN50%N/A – not covered for CDMNN/AN/A – not covered for CDMNN/ASupplemental SecurityIncome (SSI)Supplemental SecurityIncome (SSI)N/A – not covered for CDFMAP
DDD group home.SSI RelatedHealthcare forWorkers w/disabilityINSTITUTIONALHCBS Waivers(HCS/DDD) andHospiceSSI LSSI RelatedResiding in a medicalinstitution 30 days enTANF relatedincome/resourcerulesPREGNANCYK01Healthcare for Workers with Disability CN-P Premium basedprogram. Substantial Gainful Activity (SGA) not a factor inDisability determination.Categorically Needy DDD/HCS Waiver or Hospice on SSICategorically Needy DDD/HCS Waiver or Hospice – grossincome under the SILUndocumented Alien/Non-Citizen LTC - residential placement.Must be preapproved by ADSA program manager. EmergencyRelated Service Only (45 slots)Medically Needy Hospice in Medical Institution. Income overthe SIL-no spend downMedically Needy Hospice in Medical Institution. With spenddownSSI recipient in a Medical Institution - Residing in a medicalinstitution 30 days or moreSupplemental SecurityIncome (SSI)CNMedical Assistance OnlyCNERSO – CNscope50%N/A – not covered for CDMNN/AN/A – not covered for CDMNN/AMedical Assistance OnlyCN50%SSI related CN-P in a Medical Institution Income under the SILUndocumented Alien/Non-Citizen LTC must be pre-approvedby ADSA program manager. Emergency Related Service Only(45 slots)Medical Assistance OnlyRefugee AssistanceCN50%ERSO – CNscope50%SSI related Medically Needy no Spend downIncome over the SIL. Income under the state rate.SSI related Medically Needy with Spend downIncome over the SIL. Income over the state rate but under theprivate rate. Locks into state NF rateSupplemental SecurityIncome (SSI)Supplemental SecurityIncome (SSI)MN50%MN50%Temporary Assistance forNeedy Families (TANF)N/A – not covered for CDCN50%ERSON/AN/A – not covered for CDMNN/AN/A – not covered for CDMNN/ATemporary Assistance forNeedy Families (TANF)Temporary Assistance forCN50%CN scope50%K95K99Family LTC Medically Needy with Spend downIn Medical institutionP02P0450%Medical Assistance OnlyCategorically Needy Family in Medical InstitutionUndocumented Alien Family in Medical institutionEmergency Related Service OnlyFamily LTC Medically Needy no Spend down in MedicalinstitutionK0350%Pregnant 185 FPL & Postpartum ExtensionUndocumented Alien Pregnant Woman
Refugee MADCFS/JRA MedicalFoster CareFamily Related Family Planning Service OnlyTake Charge family Planning onlyMedically Needy Pregnant Women & Postpartum ExtensionRefugee cash and Medical (ENDS 09/30/13)Transitional 4 Month ExtensionRefugee Categorically NeedySSI Recipient FC/AS/JRA Categorically NeedyFC/AS/JRA Categorically NeedyTitle IV-E federal foster care – und34 26TANF cash and Medicaid (ENDS 09/30/13)Transitional MedicaidPost TANF Child/Spousal Support (4 months max only) (ENDS12/31/13)TANF RelatedNewbornCategorically Needy Medical Children (Effective 1/1/09, thismay be CN Medicaid children or CN State funded children)Needy Families (TANF)N/A – not covered for CDFAMILYPLANNINGN/AN/A – not covered for CDN/A – program endedRefugee AssistanceMedical Assistance OnlyMedical Assistance OnlyMedical Assistance OnlyMedical Assistance OnlyN/A – not covered for CDTemporary Assistance forNeedy Families (TANF)N/A – not covered for CDMNN/ACNN/A - endedCN50%CN50%CN50%CN50%CN50%CNN/A - endedCN50%CNN/ATemporary Assistance forNeedy Families (TANF)Medical Assistance OnlyTemporary Assistance forNeedy Families (TANF)Medical Assistance OnlyCN50%CN50%CN50%CN S-CHIPNOTMEDICAIDStateFundedCN scope ofcareERSON/A – NotMedicaidCN50%MNN/ACN50%CN50%Children’s Health Insurance ProgramMedical Assistance OnlyF08F09F10F99MAGI FamilyRelated MAN01N02Undocumented Alien Children (this coverage group ends12/31/08 and is merged with the F06 group)Undocumented Alien- Emergency Related Service OnlyInterim Categorically Needy (2 months max only)Medically Needy no Spend downMAGI Parent/Caretaker Medicaid; adult12 month Transitional MAGI Parent/Caretaker Medicaid; adultN/A – not covered for CDMedical Assistance OnlyN/A – not covered for CDTemporary Assistance forNeedy Families (TANF)Temporary Assistance forN/A – statefundedN/A
N03N05N10N11N13N21N23N25N31MAGI PregnancyMAGI adult Medicaid; income 133% (Medicaid Expansion)MAGI Newborn Medical birth to one yearMAGI Children's Medicaid/age under 19,MAGI Children's Health Insurance Program (CHIP) Childrenunder 19; premium payment programMAGI Parents/Caretaker; Emergency only; AEMMAGI Pregnancy; not lawfully presentMAGI adult Medicaid; non-citizen- income 133% (MedicaidExpansion) AEMNeedy Families (TANF)Temporary Assistance forNeedy Families (TANF)Alternative Benefit Plan (newcategory)Temporary Assistance forNeedy Families (TANF)Medical Assistance OnlyMedical Assistance OnlyADATSA Medical-State Funded (ENDS 12/31/13)ADATSAW02ADATSA Medical Care-State Funded (ENDS 12/31/13)Detox Medical-State Funded (ENDS 12/31/13)ADATSAMedical CareServices100% FederalCN50%CN50%CN65% Federal,35% StateN/AN/A – not covered for CDERSORefugee AssistanceStateFundedCN scope ofcareStateFundedCN scope ofcareSTATEFUNDED100% StateFunded OnlySTATEFUNDEDSTATEFUNDEDN/A - endedSTATEFUNDED100% StateFundedMAGI Children's Health Insurance Program (CHIP): under 19;premium payment program, non-citizenW01ABPERSOMAGI Children's medical; under 19; non-citizenADATSA –StateProgram Drug &Alcohol TX program50%N/A – not covered for CDRefugee AssistanceRefugee AssistanceN33CNN/A – program endedN/A – program endedN/A – program endedCN65% Federalpre-natal, 50%labor anddelivery, 100%state only postpartumN/A100% StateFunded OnlyN/A - endedN/A - endedW03G01MCS Medical Care ServicesMedical Assistance Only
andABD Cash with CNMedicaidMental HealthInstitutionalBreast and CervicalCancer programTake ChargePsychiatricinpatientG02ABD cash plus either: (ENDS 12/31/13)ABD-X Presumptive SSI Federally Funded CN-P Medicaid(ENDS 12/31/13)ABD-A Federally Funded CN-P -AGEDABD-D Federally Funded CN-P- NGMA disabilitydeterminationI01In Patient Psychiatric (Mental Health) (ENDS 12/31/13)S30Breast and Cervical Cancer (Health Department approval)P06Family Planning (Take Charge)Psychiatric Indigent Inpatient spend down(MI prior to 7/03)Mental Health ONLY. (ENDS 12/31/13)M99Aging, Blind or Disabled(new category)CN50%N/A – program endedCNN/A - endedMedical Assistance OnlyCN50%N/A – not covered for CDFAMILYPLANNINGSTATEN/AN/A – program endedN/A - ended
DBHR Crosswalk for Provider One (ACES) Coverage Group Codes and the TARGET Entry The appropriate Modality, Contract Type and Fund Source should be chosen based on previous guidance provided by DBHR. The only change is that ADATSA Contract Type is no longer active.File Size: 267KB
