ACA Medicaid andExchange AID CODE List ‐‐ with Pre ACA …

1 ACAM edicaidandExchangeAIDCODEList withPre January31,20142014 ProgramsCategoryAid CodeSub-CategoriesFPLMAGI ScopeFundingSourceFMAP RateTraceabilityInstalledRelated Pre-ACA Aid CodeParents/Caretaker RelativesM3 Parent/Caretaker Relative: Citizen/Lawfully Present0%-109%YesFullTitle XIX50/50 MCED 24647/27/20133N (1931(b) parents/caretaker relative)M4 Parent/Caretaker Relative: Undocumented0%-109%YesRestrictedTitle XIXT itle XXI50/5065/35 MCED 24647/27/20133V (1931(b) parents/caretaker relative)Adults 19-64 Year OldM1 Adult 19 to 64 Yrs: Citizen/Lawfully Present0%-138%YesFullTitle XIX100/0 MCED 24647/27/2013L1 (Post transition, annual renewal)M2 Adult 19 to 64 Yrs.

2 Undocumented0%-138%YesRestrictedTitle XIX100/0 MCED 24647/27/2013N/A (No Pre-ACA aid code)E3 New Adult Group LTC (To be developed if CMS requires asset test)N/AN/ALimited - LTCT itle XIXTBDNo QuestionnaireNoTo Be DeterminedState Inmates 19-64 Year OldN5 Limited Scope Medi-Cal No SOC State Adult Inmate 0%-138%YesLimitedTitle XIX100/0 MCED 23745/28/2013N9 (Post transition, annual renewal)N6 Restricted Scope Medi-Cal No SOC State Adult Inmate 0%-138%YesRestrictedTitle XIX100/0 MCED 23745/28/2013N/A (No Pre-ACA aid code)County Inmates 19-64 Year OldN7 Limited Scope Medi-Cal No SOC Cty Adult Inmate0%-138%YesLimitedTitle XIX100/0 MCED 23745/28/2013N0 (Post transition, annual renewal)N8 Restricted Scope Medi-Cal No SOC Cty Adult Inmate 0%-138%YesRestrictedTitle XIX100/0 MCED 23745/28/2013N/A (No Pre-ACA aid code)Pregnant WomenM9 Pregnant Women: Citizen/Lawfully Present60%-213%YesLimited -- Pregnancy ServicesTitle XIX50/50 MCED 24645/28/201344 (Percent program pregnant women)M7 Pregnant Women: Citizen/Lawfully Present0%-60%YesFullTitle XIX50/50 MCED 24645/28/20133N (1931(b) pregnant women)M0 Pregnant Women.

3 Undocumented60%-213%YesLimited -- Pregnancy Services/Emergency Pregnancy ServicesTitle XIXT itle XXI50/5065/35 MCED 24645/28/201348 (Percent program pregnant women)M8 Pregnant Women: Undocumented0%-60%YesLimited -- Pregnancy Services/Emergency Pregnancy Services/ Non-Pregnancy Emergency ServicesTitle XIXT itle XXI50/5065/35 MCED 24645/28/20133V (1931(b) pregnant women)0 DImplemented, but not utilized by MRMIB----------------------------OD (Aim pregnant women)Page1of5 ACAM edicaidandExchangeAIDCODEList withPre January31,20142014 Programs CategoryAid CodeSub-CategoriesFPLMAGI ScopeFunding SourceFMAP RateTraceabilityInstalledRelated Pre-ACA Aid CodeChildrenM5 Expansion Child from 6 to 19 Yrs.

4 Citizen/Lawfully Present108%-133%YesFullTitle XXI65/35 MCED 24645/28/2013N/A (No Pre-ACA aid code)M6 Expansion Child from 6 to 19 Yrs: Undocumented108%-133%YesRestrictedTitle XXI65/35 MCED 24645/28/2013N/A (No Pre-ACA aid code)P5 ACA Child 6-19 Yrs: Citizen 0%-133%YesFullTitle XIX 50/50 MCED 24679/27/20133N/7A/8R (1931(b)/Percent program for children)H4/5C (OTLIC, age 6-19 above 100% -133%)P6 ACA Child 6-19 Yrs: Undocumented0%-133%YesRestrictedTitle XIX Title XXI50/5065/35 MCED 24679/27/20133V/7C/8T (1931(b)/Percent program for children)P7 ACA Child 1-6 Yrs: Citizen0%-142%YesFullTitle XIX 50/50 MCED 24679/27/20133N/72/8P (1931(b)/Percent program for children)P8 ACA Child 1 to 6 Yrs: Undocumented0%-142%YesRestrictedTitle XIX 50/50 MCED 24679/27/20133V/74/8N (1931(b)/Percent program for children)P9 ACA Infants 0-1 Yrs: Citizen0%-208%YesFullTitle XIX 50/50 MCED 24679/27/20133N/47 (1931(b)/Percent program for infants)P0 ACA Infants 0-1 Yrs.

5 Undocumented0%-208%YesRestrictedTitle XIX 50/50 MCED 24679/27/20133V/69 (1931(b)/Percent program for infants)7 JCEC - Full Scope N/AMAGI /Non-MAGIFullTitle XIX50/50 Existing aid codeYes7J (CEC) citizen7 KCEC - Restricted (Undocs) N/AMAGI /Non-MAGIR estrictedTitle XIXT itle XXI50/5065/35 Existing aid codeYes7K (CEC) undocumented8 EAccelerated Enrollment of ChildrenN/AYesFullTitle XIX50/50 Existing aid codeYes8E (Accelerated enrollment children)E2 Under age 19 ACA Section 2101(f) Protection Citzen/Lawful N/AYesFullTitle XXI65/35 MCED 2707 Installed but not utilizing E2, providing protection under Medi-Cal10/25/2013N/A (No Pre-ACA aid code)E4 Under age 19 ACA Section 2101(f) Protection UndocumentedN/AYesRestrictedTitle XXI65/35 MCED 2707 Installed but not utilizing E4, providing protection under Medi-Cal10/25/2013N/A (No Pre-ACA aid code)E51 yr to age 19 ACA Section 2101(f) Protection (Premiums)N/AYesFullTitle XXI65/35 MCED 2707 Installed but not utilizing E5, providing protection under Medi-Cal10/25/2013N/A (No Pre-ACA aid code)E6 AIM Infant (OTLIC)213%-266%YesFullTitle XXI65/35 Need Aid Code Memo /QuestionnaireNoOC (AIM infant 200%-250% FPL)

6 E7 AIM Infant267%-322%YesFullTitle XXI65/35 MCED 266612/27/2013OC (AIM Infant 250%-300% FPL)Page2of5 ACAM edicaidandExchangeAIDCODEList withPre January31,20142014 ProgramsCategoryAid CodeSub-CategoriesFPLMAGI ScopeFundingSourceFMAP RateTraceabilityInstalledRelated Pre-ACA Aid CodeOTLICT1 Child from 6 to 19 Yrs: Citizen(OTLIC - Premium)160%-266%YesFullTitle XXI65/35 MCED 24909/25/2013H5/5D (OTLIC, age 6-19 at or above 150%)T2 Child from 6 to 19 Yrs: Citizen (OTLIC) 133%-160%YesFullTitle XXI65/35 MCED 24909/25/2013H4/5C (OTLIC, age 6-19 above 133% -149%)T3 Child from 1 to 6 Yrs: Citizen (OTLIC - Premium) 160%-266%YesFullTitle XXI65/35 MCED 24909/25/2013H3/5D (OTLIC, age 1-6)T4 Child from 1 to 6 Yrs: Citizen (OTLIC) 142%-160%YesFullTitle XXI65/35 MCED 24909/25/2013H2/5C (OTLIC, age 1-6)T5 Infant up to 1 Yr: Citizen (OTLIC)208%-266%YesFullTitle XXI65/35 MCED 24909/25/2013H1/5C (OTLIC, infants)T6 Child from 6 to 19 Yrs: Undocumented (OTLIC - Premium)160%-266%YesRestrictedTitle XXI65/35 MCED 24909/25/2013N/A (No Pre-ACA aid code)T7 Child from 6 to 19 Yrs: Undocumented (OTLIC) 133%-160%YesRestrictedTitle XXI65/35 MCED 24909/25/2013N/A (No Pre-ACA aid code)T8 Child from 1 to 6 Yrs.

7 Undocumented (OTLIC - Premium) 160%-266%YesRestrictedTitle XXI65/35 MCED 24909/25/2013N/A (No Pre-ACA aid code)T9 Child from 1 to 6 Yrs: Undocumented (OTLIC) 142%-160%YesRestrictedTitle XXI65/35 MCED 24909/25/2013N/A (No Pre-ACA aid code)T0 Infant up to 1 Yr: Undocumented (OTLIC)208%-266%YesRestrictedTitle XXI65/35 MCED 24909/25/2013N/A (No Pre-ACA aid code)Former Foster Care Children4 MUnder age 26, were in foster care under responsibility of the State or Tribe and enrolled in Medicaid upon attaining age 18. No IncomeN/AFullTitle XIX50/50 Age Ediit WRIF submitted to ITSD 6/27/1307/0820134M (Former foster care)Hospital PEFPLs update 7/30/13P1 Hospital PE for Infant age 0-1 0%-208%N/AFullTitle XIX50/50 MCED 2606 12/26/2013N/A (New PE gateway)P2 Hospital Presumptive Eligibility Parent-Caretaker 0%-109%N/AFullTitle XIX50/50 MCED 2606 12/26/2013N/A (New PE gateway)P3 Hospital Presumptive Eligibility for Adults 19-640%-138%N/AFullTitle XIX50/50 MCED 260612/26/2013N/A (New PE gateway)

8 P4 Hospital PE Pregnant Women 0%-213%N/ALimited to ambulatory prenatalTitle XIX50/50 MCED 260612/26/2013N/A (New PE gateway)H6 Hospital PE Infants 0-1 208%-266%N/AFullTitle XXI65/35 MCED 2606 12/26/2013N/A (New PE gateway)H7 Hospital PE Child 1-6 0%-142%N/AFullTitle XIX50/50 MCED 260612/26/2013N/A (New PE gateway)H8 Hospital PE Child 6-19 0%-133%N/AFullTitle XIX50/50 MCED 2606 12/26/2013N/A (New PE gateway)H9 Hospital PE Child 1-6 142%-266%N/AFullTitle XXI65/35 MCED 260612/26/2013N/A (New PE gateway)H0 Hospital PE Child 6-19 133%-266%N/AFullTitle XXI65/35 MCED 2606 12/26/2013N/A (New PE gateway)4 EHospital Presumptive Eligibility for Former Foster Care Children up to age 26.

9 No income testNo IncomeN/AFullTitle XIX50/50 MCED 2606 12/26/2013N/A (New PE gateway)Page3of5 ACAM edicaidandExchangeAIDCODEList withPre January31,20142014 ProgramsCategoryAid CodeSub-CategoriesFPLMAGI ScopeFundingSourceFMAP RateTraceabilityInstalledRelated Pre-ACA Aid CodeCovered CaliforniaX1 Covered CA - Subsidized Coverage250%-400%YesTracking onlyN/AN/AMCED 24237/26/2013N/A(New Exchange Aid Code)X2 Covered CA - Subsidized Coverage 100%-150%YesTracking onlyN/AN/AMCED 24237/26/2013N/A(New Exchange Aid Code)X3 Covered California Subsidized Coverage151%-200%YesTracking onlyN/AN/AMCED 24237/26/2013N/A(New Exchange Aid Code)X4 Covered California Subsidized Coverage201%-250%YesTracking onlyN/AN/AMCED 24237/26/2013N/A(New Exchange Aid Code)X5 Covered CA - Cost Sharing Waiver 100%-300%YesTracking onlyN/AN/AMCED 24237/26/2013N/A(New Exchange Aid Code)X6 Covered CA - AI/AN CSR Only No Income TestN/AYesTracking onlyN/AN/AMCED 24237/26/2013N/A(New Exchange Aid Code)X7 Covered CA Unsubsidized Coverage Above 400%NoTracking onlyN/AN/AMCED 24237/26/2013N/A(New Exchange Aid Code)X8 Covered CA - Lawful Present/MC ineligibleBelow 100%YesTracking onlyN/AN/AMCED 24237/26/2013N/A(New Exchange Aid Code)

10 X9N/A, development halted 9/27/2013N/AN/AN/AN/AN/AMCED 2449 Implementation haltedNoN/A(New Exchange Aid Code)Medi-Cal Transitional3 TTransitional Medi-Cal Undoc No Income Test No IncomeN/ARestrictedTitleXIX/XXI50/5065/3 5 Existing aid codeN/A3T (TMC) undocumented39 Transitional Medi-Cal No Income Test No IncomeN/AFull Title XIX50/50 Existing aid codeN/A39 (TMC) citizen5 TContinuing TMC - Undoc Final FPL: TBD TBDYesRestrictedTitleXIX/XXI50/5065/35 Existing aid codeN/A5T (Continuing TMC) undocumented59 Continuing TMC Final FPL: TBD TBDYesFullTitle XIX 50