Assigning Category of Eligibility 510-03-30-15

(Amended 2/8/2024 ML #3773)

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There are six (6) major Categories of Eligibility (COE), each of which have related categories that fall under them. The six major categories are:

  1. Children Under age 21;
  1. Optional Children's Group (CHIP);
  1. Parents, caretaker relatives and their spouses;
  1. Pregnant Women;
  1. Adults.
  1. Former Foster Care Children

The following rules determine how to assign the COE for eligible individuals:

 

  1. Children Under Age 21
     
COE

COE 

Description

 Rule to Assign COE
61 Extended ACA Children

The Child:

  • Is under age 18 (through the month the child attains age 18)
  • Is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a parent;
  • Resides with one or both natural or adoptive parents, or one non-parent caretaker relative;
  • Not eligible under the ACA Medicaid Children Poverty Levels; AND

The child’s parent(s) or caretaker relative:

  • Lost eligibility under the Parents and Caretaker Relative and their spouses Category due to increased alimony or spousal support; and
  • Was eligible under the Parent, Caretaker Relative and their Spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category.
67 Children ages 0 thru 18 (including month turn age 19) -- other than MOE, Foster Care, Transitional, Extended, Med Needy or Optional Children's Group

The Child:

  • Is age 0 to 6 (including the month the child attains age 6);
  • Was found eligible for ACA Medicaid with income at or below 152% of the Federal Poverty Level (FPL).

OR

  • Is age 6 (month following month attains age 6) thru age 18 (including the month the child attains age 19);
  • Was found eligible for ACA Medicaid with income at or below 138% of the Federal Poverty Level (FPL).
67A Children ages 0 to 1(through the month prior to turning 1) – other than MOE, Foster Care, Transitional, Extended, Med Needy, or Optional Children’s Group
  • The child’s mother is determined eligible for Medicaid as of the last day of pregnancy;
  • The child is age 0 to 1 (through the month prior to turning 1)

OR

  • Who fail under ACA Categorically Needy Coverage Group and who have met the Client Share for the birth month under Medically Needy Group.

87

ACA

Transitional

Children

The Child:

  • Is under age 18 (through the month the child attains age 18)
  • Resides with one or both natural or adoptive parents, or one non-parent caretaker relative;
  • Not eligible under the ACA Medicaid Children Poverty Levels;

AND

The child's parent(s) or caretaker relative:

  • Lost eligibility under the Parents and Caretaker Relative and their spouses category due to increased earned income or hours of employment;
  • Was eligible under the Parent, Caretaker Relative and their Spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category.
95

Maintenance of Effort Child Absence Deprived (Age 6 to 19)

The Child:

  • Is age 6 to 19 (month following month attains age 6 through the end of the month the child attains age 19);
  • Was found eligible for ACA Medicaid with income between 111% and 133% of the FPL.
98 State or Tribal Foster Care (Non-IV-E)

The Child:

  • Meets the definition of a Foster Care Child;
  • Is eligible under regular Foster Care (non-Title IV-E, tribal or state-funded).
03 Child Age 0 to 21 (Medically Needy)

The Child:

  • Is age 0 to 21 (including the month the child attains age 21);
  • Has income above 152% of the FPL;
  • Has a medical need that exceeds the calculated Client Share (Recipient Liability);
09

Child Age 0 to 21

(Medically Needy)

The Child is:

  • Non-Deprived
  • Is age 0 to 21 (including the month the child attains age 21);
  • Has income above 152% of the FPL;
  • Has a medical need that exceeds the calculated Client Share (Recipient Liability).

 

 

  1. Optional Children's Group
     
COE

COE 

Description

 Rule to Assign COE
78

Optional Children's Group

The Child is:

  • Age 0 through age 18 (through the last day of the month in which child turns age 19);
  • Is not eligible for full Medicaid Coverage;
  • Does not have current creditable health insurance coverage;
  • Has income between 152% and 205% of the FPL

 

  1. Parents, Caretakers and their Spouses
     
COE

COE 

Description

 Rule to Assign COE
63

Parents, Caretaker Relatives (& their Spouses) of Deprived Children

The Parent(s) or Caretaker:

  • Is the natural or adoptive parent, or a caretaker/relative within the 5th degree of relationship to a child under age 18 (through the month the child attains age 18);
  • Has a child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a parent;
  • Has income below 46% of the FPL.
86

ACA

Transitional Parents

and Caretakers

The Parent(s) or Caretaker relative:

  • Has at least one child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a child under age 18 (through the month the child attains age 18);
  • Lost eligibility under the Parents and Caretaker Relative and their Spouses category due to increased earned income or hours of employment; and
  • Was eligible under the Parent, Caretaker Relative and their Spouses category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category.
88 ACA Extended Parents, Caretaker Relatives (& their Spouses) of Deprived Children

The Parent(s) or Caretaker:

  • Has at least one child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/underemployment of a child under age 18 (through the month the child attains age 18);
  • Lost eligibility under the Parents and Caretaker Relative and their Spouses category as a result of the collection or increased collection of spousal support (alimony).
  • Was eligible under the Parent, Caretaker Relative and their Spouses category in a least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category.
10C Parent/Caretaker Medically Needy
  • Has at least one child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/underemployment of a child under age 18 (through the month the child attains age 18);
  • Meets the Caretaker Relatives policy.
  • Meets the policy for Need;
10P Parent/Caretaker medically Needy
  • Has at least one child residing with them who is non-deprived (intact household);
  • Meets the Parent, Caretaker, and their Spouses category.
  • Meets the policy for Need.

 

  1. Pregnant Women
     
COE

COE 

Description

 Rule to Assign COE
66

Pregnant

Woman

(Categorically

Needy)

A woman who is:

  • Pregnant and through the end of the twelfth month post-partum period;
  • Has income at or below 175% of the FPL.
20F

Pregnant

Woman

(Medically Needy)

A woman who is:

  • Pregnant and through the end of the twelfth month post-partum period;
  • Has income above 175% of the FPL;
  • Has a medical need that exceeds the calculated Client Share (Recipient Liability).

 

  1. Adults
    1. Adult Expansion
     
COE

COE 

Description

 Rule to Assign COE
76

Adult

Expansion

Category

Individual is:

  • Age 21 through age 64 (month following the month attained age 21 and month prior to attaining age 65);
  • Not eligible under the Parent/Caretaker or Pregnant Woman Category;
  • Not eligible under the Adults age 19 and 20 Category;
  • Not eligible as Medically Frail;
  • Has income at or below 138% of the FPL.

 

  1. Adults age 19 and 20
     
COE

COE 

Description

 Rule to Assign COE
62

Adult

Age 19 and 20

The Adult:

  • Must be age 19 or 20 (month following month attains age 19 through the month attains age 21);
  • Is NOT pregnant;
  • Pass the Adult Expansion Group BUT have income less than 90% of FPL
76A

Adult

Age 19 and 20

The Adult:

  • Must be age 19 or 20 (month following month attains age 19 through the month attains age 21);
  • Not eligible under Parent/Caretaker or Pregnant Woman Category;
  • Not eligible under Adult Age 19-20 category with income less than 90% of the FPL;
  • Not eligible as Medically Frail;
  • Has income at or below the 138% of the FPL

 

  1. Medically Frail
     
COE

COE 

Description

 Rule to Assign COE
58

Adults Medically

Frail- Non-institutionalized

The Individual is:

  • Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);
  • Passes the Adult Expansion Group criteria;
  • Determined Medically Frail;
  • Not residing in an Institution;
  • Income at or below 85% of FPL.
59

Adults Medically

Frail- Non-

Institutionalized

Individual is:

  • • Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);
  • Passes the Adult Expansion Group criteria;
  • Determined Medically Frail;
  • Not residing in an Institution;
  • Income above 85% of FPL.
60

Adults

Medically

Frail-

Institutionalized

Individual is:

  • Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);
  • Passes the Adult Expansion Group criteria;
  • Determined Medically Frail;
  • Residing in an Institution;
  • Income at or below 85% of FPL.
65

Adults

Medically

Frail-

Institutionalized

Individual is:

  • Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);
  • Passes the Adult Expansion Group criteria;
  • Determined Medically Frail;
  • Residing in an Institution;
  • Income above 85% of FPL.
77

Adults

Medically

Frail- Non-

Institutionalized

Managed Care

Individual is:

  • Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65) for months prior to January 1, 2022;
  • Age 21 through 64 (month following month attains age 21 through the month prior to the month attains 65) for months on or after January 1, 2022;
  • Passes the Adult Expansion Group criteria;
  • Determined Medically Frail;
  • Not residing in an Institution;
  • Income at or below 85% of FPL.
89

Adults

Medically

Frail- Non-

Institutionalized

Managed Care

Individual is:

  • Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65); for months prior to January 1, 2022;
  • Age 21 through 64 (month following month attains age 21 through the month prior to the month attains 65) for months on or after January 1, 2022;
  • Passes the Adult Expansion Group criteria;
  • Determined Medically Frail;
  • Not residing in an Institution;
  • Income above 85% of FPL.

 

  1. Former Foster Care Children
     
COE

COE 

Description

 Rule to Assign COE
91

Former Foster

Care Child

The Child:

  • Was in foster care (Title IV-E, state-funded (non IV-E or tribal) and on Medicaid, in any state, in the month they turned age 18.
  • Is under age 26 (through the month attaining age 26);

NOTE: An individual age 18 through 21 whom voluntarily sign him/herself back into Foster Care would also be assigned the COE of M091.