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BEM 101 1 of 15 MA DESK AIDS BPB 2017-008 4-1-2017

BRIDGES ELIGIBILITY MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

EXHIBIT I - LIST OF SSI-RELATED MA CATEGORIES

MA Category

BEM Item Unique Nonfinancial Eligibility Factor

Program Code Financial Eligibility Group Automatic MA Eligibility SSI Recipients 150 Aged, blind or disabled A, B, E 1 Yes Appealing SSI Termination 150 Appealing SSI termination M, O, P 1 No 503 Individuals 155 Aged, blind or disabled M, O, P 1 No Early Widow(er)s 157 Blind or disabled O, P 1 No DAC 158 Aged, blind or disabled M, O, P 1 No AD-Care 163 Aged or disabled M, P 1 No Extended-Care 164 Aged, blind or disabled M, O, P 1 No Medicare Savings Programs 165 Medicare Part A M, O, P - No Group 2 Aged, Blind and Disabled 166 Aged, blind or disabled M, O, P 2 No QDWI 169 Type of Medicare P - No Home Care Children 170 Disabled P 1 No Children’s Waiver 171 Disabled P 1 No Breast and Cervical Cancer Prevention and Treatment Program

173 Health department cancer screening

O

1

No

EXHIBIT II - SSI-RELATED MA CODING

Eligible for: Case

Recipient

Regular MA BEM MSP PT * SC * PT * ES * AD-Care 163 Full QMB 0 1F 4 4 AD-Care 163 None 0 1F/1E 5 4 Extended-Care 164 Full QMB 8 1F 0 4 Extended-Care 164 Limited QMB (SLMB) 1 1F 1 4 Extended-Care 164 None 1 1F/1E 0 4 Group 2 166 Full QMB 9 2F 0 3 Group 2 166 Limited QMB (SLMB) 0 2F 2 3