CurrentMaryland Medicaid (Maryland Department of Health)Policy N/A

Quick Reference to Medical Care Program Coverage Groups and HealthChoice Eligibility (Updated April 2025)

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A one-page quick reference listing Maryland Medicaid Medical Care Program coverage groups, income eligibility thresholds, special categories (e.g., presumptive eligibility, waivers, foster care), and notes on HealthChoice eligibility; intended for Maryland Medicaid/HealthChoice administrators and providers.

Policy Summary

PayerMaryland Medicaid (Maryland Department of Health)

PolicyQuick Reference to Medical Care Program Coverage Groups and HealthChoice Eligibility (Updated April 2025)

Policy CodePolicy N/A

Change TypeNo material coverage changes

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionEnter FPPE by trained Title X clinic staff only.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20coverage group lines listed (approx.)

Up to 264% FPLhighest explicit FPL threshold shown

No spend-downnewly eligible adults

4 monthsHealthy Babies postpartum duration

Medicaid Coverage Groups & Eligibility

Coverage groups and eligibility criteria

Summary of major coverage categories and eligibility rules shown in the quick reference.

Adults: Codes A02, A03, A04: Adults ages 19 to <65, no Medicare; income up to 138% FPL. Note: no spend-down for newly eligible adults.

Parents & Caretaker Relatives: Codes F05, F99: Low‑income parents/caretaker relatives, any age; Medicare permitted up to 123% FPL; Medically Needy with spend‑down available for parents and primary caretakers of children.

Pregnant Women: Codes P02 and P11: Pregnant women covered up to 189% FPL (P02) and 190%–264% FPL (P11); Healthy Babies Act provides prenatal and 4 months postpartum coverage up to 264% FPL.

Children: Multiple child codes (e.g., P06, P07, F98): Newborns of eligible mothers/children <1 year up to 199% FPL; ages 1–5 up to 143% FPL; ages 6–19 up to 138% FPL; ages 19–20 up to 123% FPL.

Foster Care & Subsidized Adoptions: E‑series codes (E01–E05): IV‑E or SSI foster care, non‑IV‑E foster care, special needs subsidized adoptions/guardianship, state‑funded foster care and subsidized adoptions; former foster youth aged 18–26 included.

Aged, Blind, or Disabled (ABD): S‑series codes (S01–S99): SSI recipients, Medicare Savings Programs (QMB/SLMB/QI), Pickle/1634 categories, EID, QDWI, DAC, medically needy ABD with spend‑down options and related temporary/transition categories.

Home & Community‑Based Waivers & PACE: Codes H01, H02, H98: HCBS waiver and PACE participants, HCBS participants on E&E, and participants losing SSI.

Presumptive Eligibility categories: Includes Correctional Presumptive Eligibility (C13 series), Hospital Presumptive Eligibility (C13M/P), and Family Planning Presumptive Eligibility (C10).

Family Planning Presumptive Eligibility (FPPE): Code C10: Family Planning Presumptive Eligibility for any age or gender. NOTE: FPPE must be entered by trained Title X clinic staff only; some category flags (E&E, MMIS only) are noted on MMIS.

Emergency & Non‑eligible Aliens / Refugee Assistance: Emergency medical services for aliens (X02/X03) provide emergency‑only coverage; refugee medical assistance codes (G01, G02, G98, G99) and related post‑RCA options with spend‑down noted.

Highlighted Codes & Income Thresholds

Highlighted coverage group codesmixed

A02,A03,A04	Adult MAGI-related coverage group codes referenced for adults ages 19 to <65
E01-E05	Foster care & subsidized adoption group codes
S01-S99	Aged, Blind, or Disabled (ABD) group code series

Income eligibility examples

AdultsA02/A03/A04 — Adults ages 19 to <65, no Medicare; income eligibility up to 138% FPL (includes adults with children 124%–138% FPL; disabled adults up to 77% FPL, not newly eligible).

Pregnant womenP02 — Pregnant women up to 189% FPL; P11 — Pregnant women 190%–264% FPL.

Healthy Babies (CHIP)X11/X12 — Healthy Babies Act prenatal and postpartum coverage up to 264% FPL; postpartum coverage provided for 4 months.

Children (age-tier examples)P06/P07/F98 — Newborns up to 199% FPL; children 1–5 up to 143% FPL; children 6–18 up to 138% FPL; ages 19–20 up to 123% FPL.

Presumptive Eligibility & Provider Entry Notes

Documentation Required

Presumptive Eligibility (FPPE) entry and MMIS-only categories

Enter FPPE (Family Planning Presumptive Eligibility) only through trained Title X clinic staff; note that some coverage categories are recorded on MMIS only.

FPPE is entered by trained Title X clinic staff only.
Some categories are marked “On MMIS Only” and exist only on the Medicaid Management Information System.

Key Terms and Abbreviations

E&E — Eligibility Determined in E&E

DefinitionEligibility Determined in E&E indicates eligibility determined in the Eligibility & Enrollment (E&E) process.

ContextApplied to categories noted in the quick reference to indicate the determination was made through the state E&E workflow.

ImplicationUse E&E determination as the authoritative eligibility status when present on case records and MMIS entries.

MMIS Only

DefinitionMMIS Only indicates the coverage category exists only on the Medicaid Management Information System (MMIS).

Operational noteCategories marked "On MMIS Only" may not have a corresponding entry in other program lists and should be managed through MMIS workflows.

Provider actionVerify MMIS entries for billing and eligibility checks when a category is listed as MMIS Only.

FPPE — Family Planning Presumptive Eligibility

DefinitionFPPE (Family Planning Presumptive Eligibility) — coverage category C10 for family planning services available regardless of age or gender.

Entry requirementFPPE must be entered by trained Title X clinic staff only.

ScopeFPPE provides presumptive family planning eligibility as noted in the quick reference and is distinct from other presumptive categories (e.g., hospital or correctional).

Policy Summary

PayerMaryland Medicaid (Maryland Department of Health)

PolicyQuick Reference to Medical Care Program Coverage Groups and HealthChoice Eligibility (Updated April 2025)

Policy CodePolicy N/A

Change TypeNo material coverage changes

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionEnter FPPE by trained Title X clinic staff only.

SourceLink

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Quick Reference to Medical Care Program Coverage Groups and HealthChoice Eligibility (Updated April 2025)

Customize your policy alerts

Sign up for all Maryland Medicaid (Maryland Department of Health) policy alerts

Know when Maryland Medicaid (Maryland Department of Health) releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medicaid Coverage Groups & Eligibility

Coverage groups and eligibility criteria

Summary of major coverage categories and eligibility rules shown in the quick reference.

Adults: Codes A02, A03, A04: Adults ages 19 to <65, no Medicare; income up to 138% FPL. Note: no spend-down for newly eligible adults.

Pregnant Women: Codes P02 and P11: Pregnant women covered up to 189% FPL (P02) and 190%–264% FPL (P11); Healthy Babies Act provides prenatal and 4 months postpartum coverage up to 264% FPL.

Children: Multiple child codes (e.g., P06, P07, F98): Newborns of eligible mothers/children <1 year up to 199% FPL; ages 1–5 up to 143% FPL; ages 6–19 up to 138% FPL; ages 19–20 up to 123% FPL.

Home & Community‑Based Waivers & PACE: Codes H01, H02, H98: HCBS waiver and PACE participants, HCBS participants on E&E, and participants losing SSI.

Presumptive Eligibility categories: Includes Correctional Presumptive Eligibility (C13 series), Hospital Presumptive Eligibility (C13M/P), and Family Planning Presumptive Eligibility (C10).

Highlighted Codes & Income Thresholds

Highlighted coverage group codesmixed

A02,A03,A04	Adult MAGI-related coverage group codes referenced for adults ages 19 to <65
E01-E05	Foster care & subsidized adoption group codes
S01-S99	Aged, Blind, or Disabled (ABD) group code series

Income eligibility examples

AdultsA02/A03/A04 — Adults ages 19 to <65, no Medicare; income eligibility up to 138% FPL (includes adults with children 124%–138% FPL; disabled adults up to 77% FPL, not newly eligible).

Pregnant womenP02 — Pregnant women up to 189% FPL; P11 — Pregnant women 190%–264% FPL.

Healthy Babies (CHIP)X11/X12 — Healthy Babies Act prenatal and postpartum coverage up to 264% FPL; postpartum coverage provided for 4 months.

Children (age-tier examples)P06/P07/F98 — Newborns up to 199% FPL; children 1–5 up to 143% FPL; children 6–18 up to 138% FPL; ages 19–20 up to 123% FPL.

Presumptive Eligibility & Provider Entry Notes

Documentation Required

Presumptive Eligibility (FPPE) entry and MMIS-only categories

Enter FPPE (Family Planning Presumptive Eligibility) only through trained Title X clinic staff; note that some coverage categories are recorded on MMIS only.

FPPE is entered by trained Title X clinic staff only.
Some categories are marked “On MMIS Only” and exist only on the Medicaid Management Information System.

Key Terms and Abbreviations

E&E — Eligibility Determined in E&E

DefinitionEligibility Determined in E&E indicates eligibility determined in the Eligibility & Enrollment (E&E) process.

ContextApplied to categories noted in the quick reference to indicate the determination was made through the state E&E workflow.

ImplicationUse E&E determination as the authoritative eligibility status when present on case records and MMIS entries.

MMIS Only

DefinitionMMIS Only indicates the coverage category exists only on the Medicaid Management Information System (MMIS).

Operational noteCategories marked "On MMIS Only" may not have a corresponding entry in other program lists and should be managed through MMIS workflows.

Provider actionVerify MMIS entries for billing and eligibility checks when a category is listed as MMIS Only.

FPPE — Family Planning Presumptive Eligibility

DefinitionFPPE (Family Planning Presumptive Eligibility) — coverage category C10 for family planning services available regardless of age or gender.

Entry requirementFPPE must be entered by trained Title X clinic staff only.

ScopeFPPE provides presumptive family planning eligibility as noted in the quick reference and is distinct from other presumptive categories (e.g., hospital or correctional).