Common use of Enrollment Exclusions Clause in Contracts

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 non-Medicare individual health plan determined to be cost-effective according to Minnesota Statutes, § 256B.69, subd. 4 (b)(9). Women receiving Medical Assistance through the Breast and Cervical Cancer Control Program. Persons eligible for the Minnesota Family Planning Program (MFPP) in accordance with Minnesota Statutes, § 256B.78. Persons participating in the Navigator Pilot in Minnesota Statutes, § 254B.13. Persons participating in the Continuum of Care Pilot in Minnesota Statutes,‌ § 254B.14.

Enrollment Exclusions. All persons who receive Medical Assistance and reside in the Service Area will participate in managed carePMAP, except for Beneficiaries Recipients who are members of the following Medical Assistance populations: Beneficiaries : (1) Recipients receiving Medical Assistance due to blindness or disability as determined by the U.S. Social Security Administration or the State Medical Review Team (SMRT)Team, except if sixty-five (65) years of age or older. Beneficiaries . (2) Medical Assistance Recipients receiving the Refugee Assistance Program pursuant to 8 USC U.S.C. § 1522(e). Beneficiaries . (3) Medical Assistance Recipients 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(E6.1.21(C). Beneficiaries . (4) Medical Assistance Recipients 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 part of the PMAP MCO. (5) Individuals who are Qualified Medicare Beneficiaries (QMB), as defined in § 1905(p) of the Social Security Act, 42 U.S.C. § 1396d(p), who are not otherwise receiving Medical Assistance. (6) Individuals who are Service Limited Medicare Beneficiaries (SLMB), as defined in § 1905(p) of the Social Security Act, 42 U.S.C. §§ 1396a(a)(10)(E)(iii) and 1396d(p), and who are not otherwise receiving Medical Assistance. (7) Non-citizen Recipients who only receive emergency Medical Assistance under Minnesota Statutes, § 256B.06, subd. 4. (8) Recipients receiving Medical Assistance on a Network Provider in the MCO. Beneficiaries medical Spenddown basis. (9) Recipients, who at the time of notification of mandatory enrollment in managed carePMAP, have a communicable disease whose prognosis is terminal and whose primary physician is not a Network Participating 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(p10) 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 Recipients with private health care coverage through a HMO certified under‌ under Minnesota Statutes, Chapter 62D. Such Beneficiaries Recipients 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 . (11) Medical Assistance Recipients 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 4(b)(9). (b)(9). 12) Medical Assistance Recipients who are eligible while receiving care and services from a non-profit center established to serve victims of torture. (13) Women receiving Medical Assistance through the Breast and Cervical Cancer Control Program. Persons eligible for the Minnesota Family Planning Program (MFPP) in accordance with Minnesota Statutes, § 256B.78. Persons participating in the Navigator Pilot in Minnesota Statutes, § 254B.13. Persons participating in the Continuum of Care Pilot in Minnesota Statutes,‌ § 254B.14.

Enrollment Exclusions. All persons who receive Medical Assistance and reside ‌ The following Beneficiaries are excluded from enrollment in the Service Area will participate in managed careMCO’s program [Minnesota Statutes, except §256B.69, subd. 4; Minnesota Rules, Part 9500.1452]: 3.1.5.1 Both MSC+ and MSHO: (1) Beneficiaries eligible 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). . (2) 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 state regional treatment centers or a placement which is courtstate-ordered within the terms described in section 6.1.27(E). Beneficiaries owned long term care facility. (3) Individuals who are terminally ill Qualified Medicare Beneficiaries (QMB), as defined in Minnesota Rules§1905(p) of the SSA, Part 9505.0297, subpart 2, item N42 USC §1396d(p), and whowho 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, at the time enrollment in PMAP would occur42 USC §1396a(a)(10)(E)(iii) and §1396d(p), have an established relationship with a primary physician and who is are not a Network Provider in the MCO. Beneficiaries otherwise eligible for Medical Assistance. (5) Beneficiaries, who at the time of notification of mandatory enrollment in managed care, 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. Beneficiaries who are Qualified Medicare Beneficiaries . (QMB), as defined in § 1905(p6) 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. . (7) Non-citizen Beneficiaries who receive emergency medical assistance under Minnesota Statutes, §256B.06, subd.4. Beneficiaries receiving Medical Assistance on a medical Spenddown basis. . (8) Beneficiaries with private health care coverage through a HMO certified under‌ under Minnesota Statutes, Chapter 62D. 62D, not including Medicare Supplements. Such Beneficiaries may enroll in PMAP MSC+ on a voluntary basis if the private HMO is the same as the MCO the person will select under PMAP. MSC+. (9) Beneficiaries with cost cost-effective employer-sponsored private health care coverage, coverage or who are enrolled in a non-Medicare individual health plan determined to be cost-effective according effective, pursuant to Minnesota Statutes, § . §256B.69, subd. 4 4, (b)(9). (10) 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. Women Covered services for these Enrollees are paid by FFS. (11) Incarcerated persons; see section 3.5.3.1(14). 3.1.5.2 The following exclusions apply to MSHO only: • Individuals who have Medicare coverage through United Mine Workers. 3.1.5.3 The following exclusions apply to MSC+ only: (1) Beneficiaries who are terminally ill as defined in Minnesota Rules, Part 9505.0297, subpart 2, item N. and who, at the time enrollment in MSC+ would occur, have an established relationship with a primary physician who is not a Network Provider in the MSC+ MCO. (2) For MSC+, Beneficiaries receiving Medical Assistance through the Breast and Cervical Cancer Control Program. Persons eligible for the Minnesota Family Planning Program (MFPP) in accordance with Minnesota Statutes, § 256B.78. Persons participating in the Navigator Pilot in Minnesota Statutes, § 254B.13. Persons participating in the Continuum of Care Pilot in Minnesota Statutes,‌ § 254B.14on a Medical Spenddown basis.

Enrollment Exclusions. All persons who receive Medical Assistance and reside ‌ The following Beneficiaries are excluded from enrollment in the Service Area will participate in managed careMCO’s program [Minnesota Statutes, except §256B.69, subd. 4; Minnesota Rules, Part 9500.1452]: 3.1.5.1 Both MSC+ and MSHO: (1) Beneficiaries eligible 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). . (2) 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 state regional treatment centers or a placement which is courtstate-ordered within the terms described in section 6.1.27(E). Beneficiaries owned long term care facility. (3) Individuals who are terminally ill Qualified Medicare Beneficiaries (QMB), as defined in Minnesota Rules§1905(p) of the SSA, Part 9505.0297, subpart 2, item N42 USC §1396d(p), and whowho 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, at the time enrollment in PMAP would occur42 USC §1396a(a)(10)(E)(iii) and §1396d(p), have an established relationship with a primary physician and who is are not a Network Provider in the MCO. Beneficiaries otherwise eligible for Medical Assistance. (5) Beneficiaries, who at the time of notification of mandatory enrollment in managed care, 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. Beneficiaries who are Qualified Medicare Beneficiaries . (QMB), as defined in § 1905(p6) 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. . (7) Non-citizen Beneficiaries who receive emergency medical assistance under Minnesota Statutes, §256B.06, subd.4. Beneficiaries receiving Medical Assistance on a medical Spenddown basis. . (8) Beneficiaries with private health care coverage through a HMO certified under‌ under Minnesota Statutes, Chapter 62D. 62D, not including Medicare Supplements. Such Beneficiaries may enroll in PMAP MSC+ on a voluntary basis if the private HMO is the same as the MCO the person will select under PMAP. MSC+.‌‌ (9) Beneficiaries with cost cost-effective employer-sponsored private health care coverage, coverage or who are enrolled in a non-Medicare individual health plan determined to be cost-effective according effective, pursuant to Minnesota Statutes, § . §256B.69, subd. 4 4, (b)(9). (10) 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. Women receiving Medical Assistance through the Breast and Cervical Cancer Control Program. Persons eligible Covered services for the Minnesota Family Planning Program these Enrollees are paid by FFS. (MFPP11) in accordance with Minnesota Statutes, § 256B.78. Persons participating in the Navigator Pilot in Minnesota Statutes, § §254B.13. Persons participating , if applicable. (12) Incarcerated persons; see section 3.5.3.1(14).‌‌ 3.1.5.2 The following exclusions apply to MSHO only: (1) Individuals who have Medicare coverage through United Mine Workers. (2) Individuals with a diagnosis of End Stage Renal Disease (ESRD) prior to enrollment in the Continuum of Care Pilot MCO. See also 3.1.8(2) below.‌‌ 3.1.5.3 The following exclusions apply to MSC+ only: (1) Beneficiaries who are terminally ill as defined in Minnesota Statutes,‌ § 254B.14Rules, Part 9505.0297, subpart 2, item N. and who, at the time enrollment in MSC+ would occur, have an established relationship with a primary physician who is not a Network Provider in the MSC+ MCO. (2) For MSC+, Beneficiaries receiving Medical Assistance on a Medical Spenddown basis.

Enrollment Exclusions. All persons who receive Medical Assistance and reside in the Service Area will participate in managed care, except for Beneficiaries Recipients who are members of the following Medical Assistance populations: Beneficiaries : (1) Recipients 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 . (2) Recipients receiving the Refugee Assistance Program pursuant to 8 USC § 1522(e). Beneficiaries . (3) Recipients 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(E6.1.24(D). Beneficiaries . (4) Recipients 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 Participating Provider in the MCO. Beneficiaries . (5) Recipients 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 Participating 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 . (6) Individuals 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 . (7) Individuals 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 . (8) Recipients who are eligible while receiving care and services from a non-profit center established to serve victims of torture. . (9) Non-citizen Beneficiaries Recipients who receive emergency medical assistance under Minnesota Statutes, §256B.06, subd.4. Beneficiaries . (10) Recipients receiving Medical Assistance on a medical Spenddown basis. Beneficiaries . (11) Recipients with private health care coverage through a HMO certified under‌ under Minnesota Statutes, Chapter 62D. Such Beneficiaries Recipients 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 . (12) Recipients with cost effective employer-sponsored private health care coverage, or who are enrolled in a non-Medicare individual health plan determined to be cost-cost- effective according to Minnesota Statutes, § 256B.69, subd. 4 (b)(9). . (13) Women receiving Medical Assistance through the Breast and Cervical Cancer Control Program. . (14) Persons eligible for the Minnesota Family Planning Program (MFPP) in accordance with Minnesota Statutes, § 256B.78. . (15) Persons participating in the Navigator Pilot in Minnesota Statutes, § 254B.13. . (16) Persons participating in the Continuum of Care Pilot in Minnesota Statutes,‌ Statutes, § 254B.14.

Enrollment Exclusions. All persons who receive Medical Assistance and reside ‌ The following Beneficiaries are excluded from enrollment in the Service Area will participate in managed careMCO’s program [Minnesota Statutes, except §256B.69, subd. 4; Minnesota Rules, Part 9500.1452]: 3.1.5.1 Both MSC+ and MSHO: (1) Beneficiaries eligible 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). . (2) 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 state regional treatment centers or a placement which is courtstate-ordered within the terms described in section 6.1.27(E). Beneficiaries owned long term care facility. (3) Individuals who are terminally ill Qualified Medicare Beneficiaries (QMB), as defined in Minnesota Rules§1905(p) of the SSA, Part 9505.0297, subpart 2, item N42 USC §1396d(p), and whowho 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, at the time enrollment in PMAP would occur42 USC §1396a(a)(10)(E)(iii) and §1396d(p), have an established relationship with a primary physician and who is are not a Network Provider in the MCO. Beneficiaries otherwise eligible for Medical Assistance. (5) Beneficiaries, who at the time of notification of mandatory enrollment in managed care, 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. Beneficiaries who are Qualified Medicare Beneficiaries . (QMB), as defined in § 1905(p6) 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. . (7) Non-citizen Beneficiaries who receive emergency medical assistance under Minnesota Statutes, §256B.06, subd.4. Beneficiaries receiving Medical Assistance on a medical Spenddown basis. . (8) Beneficiaries with private health care coverage through a HMO certified under‌ under Minnesota Statutes, Chapter 62D. 62D, not including Medicare Supplements. Such Beneficiaries may enroll in PMAP MSC+ on a voluntary basis if the private HMO is the same as the MCO the person will select under PMAP. MSC+.‌ (9) Beneficiaries with cost cost-effective employer-sponsored private health care coverage, coverage or who are enrolled in a non-Medicare individual health plan determined to be cost-effective according effective, pursuant to Minnesota Statutes, § . §256B.69, subd. 4 4, (b)(9). (10) 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. Women receiving Medical Assistance through the Breast and Cervical Cancer Control Program. Persons eligible Covered services for the Minnesota Family Planning Program these Enrollees are paid by FFS. (MFPP11) in accordance with Minnesota Statutes, § 256B.78. Persons participating in the Navigator Pilot in Minnesota Statutes, § §254B.13. Persons participating , if applicable. (12) Incarcerated persons; see section 3.5.3.1(14).‌‌ 3.1.5.2 The following exclusions apply to MSHO only:  Individuals who have Medicare coverage through United Mine Workers. 3.1.5.3 The following exclusions apply to MSC+ only: (1) Beneficiaries who are terminally ill as defined in Minnesota Rules, Part 9505.0297, subpart 2, item N. and who, at the time enrollment in MSC+ would occur, have an established relationship with a primary physician who is not a Network Provider in the Continuum of Care Pilot in Minnesota Statutes,‌ § 254B.14MSC+ MCO. (2) For MSC+, Beneficiaries receiving Medical Assistance on a Medical Spenddown basis.