Enrollment Exclusions. All persons who receive Medical Assistance and reside in the Service Area will participate in managed care, except for Beneficiaries who are members of the following Medical Assistance populations: Beneficiaries receiving Medical Assistance due to blindness or disability as determined by the U.S. Social Security Administration or the State Medical Review Team (SMRT), except if sixty-five (65) years of age or older. Beneficiaries receiving the Refugee Assistance Program pursuant to 8 USC § 1522(e). Beneficiaries who are residents of State institutions, unless the placement has been approved by the MCO. For the purposes of this Contract, approval by the MCO would include a placement which is court-ordered within the terms described in section 6.1.27(E). Beneficiaries who are terminally ill as defined in Minnesota Rules, Part 9505.0297, subpart 2, item N, and who, at the time enrollment in PMAP would occur, have an established relationship with a primary physician who is not a Network Provider in the MCO. Beneficiaries who at the time of notification of mandatory enrollment in managed care, have a communicable disease whose prognosis is terminal and whose primary physician is not a Network Provider in the MCO, and that physician certifies that disruption of the existing physician-patient relationship is likely to result in the patient becoming noncompliant with medication or other health services. Beneficiaries who are Qualified Medicare Beneficiaries (QMB), as defined in § 1905(p) of the Social Security Act, 42 USC § 1396d(p), who are not otherwise receiving Medical Assistance. Beneficiaries who are Specified Low-Income Medicare Beneficiaries (SLMB), as defined in § 1905(p) of the Social Security Act, 42 USC §§ 1396a(a)(10)(E)(iii) and 1396d(p), and who are not otherwise receiving Medical Assistance. Beneficiaries who are eligible while receiving care and services from a non-profit center established to serve victims of torture. Non-citizen Beneficiaries who receive emergency medical assistance under Minnesota Statutes, §256B.06, subd.4. Beneficiaries receiving Medical Assistance on a medical Spenddown basis. Beneficiaries with private health care coverage through a HMO certified under Minnesota Statutes, Chapter 62D. Such Beneficiaries may enroll in PMAP on a voluntary basis if the private HMO is the same as the MCO the person will select under PMAP. Beneficiaries with cost effective employer-sponsored private health care coverage, or who are enrolled in a...
Enrollment Exclusions. The following populations, both SNBC SNP and non-SNP, are excluded from enrollment in the MCO under the SNBC program [Minnesota Statutes, §256B.69, subd. 4; Minnesota Rules, Part 9500.1452]:
3.1.4.1 Beneficiaries eligible for the Refugee Assistance Program pursuant to 8 USC §1522(e).
3.1.4.2 Persons up to eighteen (18) years of age, or sixty-five (65) years of age and over. Enrollees who turn sixty-five (65) will no longer remain enrolled in SNBC.
3.1.4.3 Beneficiaries who are residents of state regional treatment centers or a state-owned long term care facility.
3.1.4.4 Beneficiaries who are eligible while receiving care and services from a non-profit center established to serve victims of torture.
3.1.4.5 Beneficiaries eligible for the emergency Medical Assistance program.
3.1.4.6 Non-citizen Beneficiaries who only receive emergency medical assistance under Minnesota Statutes, §256B.06, subd. 4.
3.1.4.7 Women receiving Medical Assistance through the Breast and Cervical Cancer Control Program.
3.1.4.8 Persons eligible for the Minnesota Family Planning Program (MFPP) in accordance with Minnesota Statutes, §256B.78.
3.1.4.9 Beneficiaries, who at the time of notification of enrollment in managed care, have a communicable disease whose prognosis is terminal and whose primary physician is not a Network Provider in the MCO, and that physician certifies that disruption of the existing physician-patient relationship is likely to result in the patient becoming noncompliant with medication or other health services.
3.1.4.10 Beneficiaries who are terminally ill as defined in Minnesota Rules, Part 9505.0297, subpart 2, item N (hospice) and who, at the time enrollment in SNBC would occur, have an established relationship with a primary physician who is not a Network Provider in the SNBC MCO.
3.1.4.11 Beneficiaries with private health care coverage through a HMO certified under Minnesota Statutes, Chapter 62D, not including Medicare Supplements.
3.1.4.12 Beneficiaries with cost effective employer-sponsored private health care coverage, or who are enrolled in a non-Medicare individual health plan determined to be cost-effective according to Minnesota Statutes, §256B.69, subd. 4 (b)(9).
3.1.4.13 Enrollees who are absent from Minnesota for more than thirty (30) consecutive days but who are still deemed a resident of Minnesota by the STATE. Covered services for these Enrollees are paid by FFS.
3.1.4.14 Individuals who are Qualified Medicare Beneficiaries (QMB), as define...
Enrollment Exclusions. The following Beneficiaries are excluded from enrollment in the MCO’s program [Minnesota Statutes, §256B.69, subd. 4; Minnesota Rules, Part 9500.1452]:
3.1.5.1 Both MSC+ and MSHO:
(1) Beneficiaries eligible for the Refugee Assistance Program pursuant to 8 USC §1522(e).
(2) Beneficiaries who are residents of state regional treatment centers or a state-owned long term care facility.
(3) Individuals who are Qualified Medicare Beneficiaries (QMB), as defined in §1905(p) of the SSA, 42 USC §1396d(p), and who are not otherwise eligible for Medical Assistance.
(4) Individuals who are Specified Low-Income Medicare Beneficiaries (SLMB) as defined in §1905(p) of the SSA, 42 USC §1396a(a)(10)(E)(iii) and §1396d(p), and who are not otherwise eligible for Medical Assistance.
(5) Beneficiaries, who at the time of notification of mandatory enrollment in MSC+ or voluntary enrollment in MSHO have a communicable disease whose prognosis is terminal and whose primary physician is not a Network Provider in the MCO, and that physician certifies that disruption of the existing physician-patient relationship is likely to result in the patient becoming noncompliant with medication or other health services.
Enrollment Exclusions. A. The following persons shall be excluded from enrollment in the managed care program:
1. Individuals in the following Home and Community-based Waiver programs: Model Waiver I, Model Waiver II, Model Waiver III, Enhanced Community Options Waiver, Aids Community Care Alternative Program (ACCAP), Community Care Program for Elderly and Disabled (CCPED), assisted living programs, ABC Waiver for Children, Traumatic Brain Injury (TBI), and DYFS Code 65 children.
2. Individuals in a Medicaid demonstration program.
3. Individuals who are institutionalized in an inpatient psychiatric institution, long term care nursing facility or in a residential facility including Intermediate Care Facilities for the Mentally Retarded. However, individuals who are eligible through DYFS and are placed in a DYFS residential center/facility or individuals in a mental health or substance abuse residential treatment facility are not excluded from enrolling in the contractor's plan.
4. Individuals in the Medically Needy, Presumptive Eligibility for pregnant women, Presumptive Eligibility for NJ FamilyCare, Home Care Expansion Program, or PACE program.
5. Infants of inmates of a public institution living in a prison nursery.
6. Individuals already enrolled in or covered by a Medicare or private HMO that does not have a contract with the Department to provide Medicaid services.
7. Individuals in out-of-state placements.
8. Full time students attending school and residing out of the country will be excluded from New Jersey Care 2000+ participation while in school.
B. The following individuals shall be excluded from the Automatic Assignment process described in Article 5.4C but may voluntarily enroll:
1. Individuals whose Medicaid eligibility will terminate within three (3) months or less after the projected date of effective enrollment.
2. Individuals in mandatory eligibility categories who live in a county where mandatory enrollment is not yet required based on a phase-in schedule determined by DMAHS.
3. Individuals enrolled in or covered by either a Medicare or commercial HMO will not be enrolled in New Jersey Care 2000+ contractor unless the New Jersey Care 2000+ contractor and the Medicare/commercial HMO are the same.
4. Individuals in the Pharmacy Lock-in or Provider Warning or Hospice programs.
5. Individuals in eligibility categories other than AFDC/TANF, AFDC/TANF-related New Jersey Care, SSI-Aged, Blind and Disabled populations, the Division of Developmental Disabilities Communi...
Enrollment Exclusions. The following Recipients are excluded from enrollment in the MCO’s program:
(1) Both programs: The following exclusions apply to MSC+ and MSHO:
(a) Recipients eligible for the Refugee Assistance Program pursuant to 8 U.S.C. § 1522(e).
Enrollment Exclusions. The following populations are excluded from enrollment in the MCO under the SNBC program:
(A) Recipients eligible for the Refugee Assistance Program pursuant to 8 U.S.C. § 1522(e).
(B) Residents of State Regional Treatment Centers, unless the MCO approves placement. For purposes of this Contract, approval by the MCO would include a placement that is court-ordered within the terms described in section 6.20.
Enrollment Exclusions. The Contractor shall cover all eligible members, with the exception of excluded members as defined in 12 VAC 00-000-000 B. The Department shall have sole responsibility for determining the program exclusion for these individuals. When individuals no longer meet the exclusion criteria, they shall be required to re-enroll in the Medallion 4.0 program. Members enrolled with a MCO that subsequently meets one or more of these criteria during MCO enrollment shall be excluded from MCO participation as appropriate by the Department. The Department shall, upon new state or federal laws, regulations, or Department policy, exclude other members as appropriate. When a member for whom services have been authorized, but not provided as of the effective date of exclusion or disenrollment is excluded or dis-enrolled from the Contractor’s plan and from Medallion 4.0, the Contractor shall provide to the Department or the relevant PCP the history for that member upon request. This prior authorization history shall be provided to the Department or the relevant PCP within five (5) business days of request. The Department shall exclude members who meet at least one of the following exclusion criteria: Inpatient Members in State Mental HospitalsMembers who are approved by the Department as inpatients in Long-Stay Hospitals: The Department recognizes two facilities as long-stay hospitals: Lake Xxxxxx [Norfolk] and Hospital for Sick Children [Washington, DC]), nursing facilities, or intermediate care facilities for the intellectually disabled. Spend Down: Members who are placed on spend-down by the Department of Social Services. Home and Community-Based Waivers: Members who are participating in home and community based Waiver Programs. Commonwealth Coordinated Care (CCC) Plus: Members who are enrolled in the CCC Plus program. Outside Area of Residence: Members, other than students, who continuously live outside their area of residence for greater than sixty (60) consecutive days, except those members placed there for medically necessary services funded by the Contractor or another MCO. Hospice: Members who receive hospice services in accordance with Department criteria. XXXX: Members with insurance purchased through the Health Insurance Premium Payment Program.
Enrollment Exclusions. The following populations are excluded from enrollment in the MCO for MnDHO:
(1) Recipients eligible for the Refugee Assistance Program pursuant to 8 U.S.C. 1522(e).
Enrollment Exclusions. All persons who receive Medical Assistance and reside in the Service Area will participate in managed care, except for Beneficiaries who are members of the following Medical Assistance populations:
Enrollment Exclusions. A. The following persons shall be excluded from enrollment in the managed care program:
1. Individuals in the following Home and Community-based Waiver programs: Model Waiver I, Model Waiver II, Model Waiver III, Enhanced Community Options Waiver, Aids Community Care Alternative Program (ACCAP), Community Care Program for Elderly and Disabled (CCPED), assisted living programs, ABC Waiver for Children, Traumatic Brain Injury (TBI), and DYFS Code 65 children.
