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DOM 063 HCBS Elderly/Disabled Waiver - 1915 (c) Optional DOM 064 HCBS Intellectual Disabilities (ID/DD) Waiver - 1915 (c) Optional DOM 065 HCBS Independent Living Waiver - 1915 (c) Optional DOM 066 HCBS Traumatic Brain Injury Waiver - 1915 (c) Optional Appendix A-4- b Certifying Agency Category of Eligibility (COE) Coverage Group Description Mandatory or Optional DOM 071 Infants to age 1 with income at/below the MAGI-Equivalent (ME) income limit for 185% FPL (ME limit = 194% FPL) Mandatory DOM 072 Children age 1-5 with income at/below the MAGI-Equivalent (ME) income limit for 133% FPL (ME limit = 143% FPL) Mandatory DOM 073 Children age 6-19 with income at/below the MAGI-Equivalent (ME) income limit for 100% FPL (ME limit = 107% FPL) Mandatory DOM 074 Children age 6-19 with income above the MAGI-equivalent income limit for 100% FPL but at/below 133% FPL. Mandatory DOM 075 Parent(s) and needy caretakers of minor children under age 18 Mandatory DOM 088 Preg. Women with income at/below the MAGI-Equivalent income limit for 185% FPL (ME limit = 194% FPL) Mandatory DOM 093 Former SSI Recipients Ineligible due to Cost of Living Increase(s) Mandatory DOM 094 Former SSI Recipient - Disabled Adult Child (DAC) Mandatory DOM 095 Former SSI Recipient - Widow(er) 60+ with no Medicare Mandatory DOM 096 Former SSI Recipient - Widow(er) 50+ with no Medicare Mandatory DOM 099 CHIP children eligible under a separate health plan. Optional * does not receive full benefits

Certifying Agency: SSI = Social Security Administration determines eligibility for SSI (Supplemental Security Income) DOM = Division of Medicaid CPS = Child Protection Services (these COE's may continue to reflect DHS as the certifying agency as this was the state agency with custody prior to creation of CPS) DHS = Department of Human Services Dual Eligibility Indicator (DEI) values (on MMIS) for individuals with both Medicaid & Medicare Q = QMB and/or QMB-dual with income at/below 100% FPL. DOM pays both Medicare Part A & B premiums. S = SLMB and/or SLMB dual with income between 100% - 120% FPL. DOM pays Medicare Part B premiums.