Excluded Populations. The following categories describe Medicaid recipients who are not eligible to enroll in a Health Plan:
a. Pregnant women who have not enrolled in Medicaid prior to the effective date of their SOBRA eligibility;
b. Medicaid recipients who, at the time of application for enrollment and/or at the time of enrollment, are living in an institution, including a nursing facility (and have been CARES assessed), Statewide Inpatient Psychiatric (SIPP) facility for individuals under the age of 21, an Intermediate Care Facility/Developmentally Disabled (ICFDD), a state mental health hospital or a correctional facility;
c. Medicaid recipients whose Medicaid eligibility was determined through the Medically Needy program;
d. Qualified Medicare Beneficiaries (QMBs), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s);
e. Medicaid recipients who have other creditable health care coverage, such as TriCare or a private commercial health plan;
f. Medicaid recipients who reside in the following:
(1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ);
(2) Residential group care operated by the Family Safety & Preservation Program of Department of Children and Families (DCF); AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract
(3) Children’s residential treatment facilities purchased through the Substance Abuse & Mental Health District (SAMH) Offices of DCF (also referred to as Purchased Residential Treatment Services — PRTS);
(4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and
(5) Residential Level I and Level II substance abuse treatment programs. (See ss. 65D-30.007(2)(a) and (b), F.A.C.);
g. Medicaid recipients participating in the Family Planning Waiver;
h. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network;
i. Women eligible for Medicaid due to breast and/or cervical cancer;
j. Individuals eligible under a hospice-related eligibility group or receiving hospice services;
k. Individuals enrolled in the Nursing Home Diversion Program or the Program of All Inclusive Care for the Elderly (PACE);
l. For non-Reform populations, individuals enrolled in the PAC Waiver; and
m. For Reform populations and non-Reform HMO populations, Medicaid recipients who are members of the Florida Assertive Community Treatment Team (FACT team) unless they disenroll fro...
Excluded Populations. The following populations are ineligible for enrollment in Medicaid managed care.
a) Individuals who are Dually Eligible for Medicare/Medicaid.
b) Individuals who become eligible for Medicaid only after spending down a portion of their income (Spend-down).
c) Individuals who are residents of State-operated psychiatric facilities or residents of State-certified or voluntary treatment facilities for children and youth.
d) Individuals who are residents of Residential Health Care Facilities ("RHCF") at the time of Enrollment, and Enrollees whose stay in a RHCF is classified as permanent upon entry into the RHCF or is classified as permanent at a time subsequent to entry.
e) Individuals enrolled in managed long term care demonstrations authorized under Article 4403-f of the New York State PHL.
f) Medicaid-eligible infants living with incarcerated mothers.
g) Infants weighing less than 1200 grams at birth and other infants under six (6) months of age who meet the criteria for the SSI or SSI related category (shall not be enrolled or shall be disenrolled retroactive to date of birth).
h) Individuals with access to comprehensive private health care coverage including those already enrolled in an MCO. Such health care coverage, purchased either partially or in full, by or on behalf of the individual, must be determined to be cost effective by the local social services district.
i) Xxxxxx children in the placement of a voluntary agency.
j) Certified blind or disabled children living or expected to be living separate and apart from the parent for thirty (30) days or more.
k) Individuals expected to be eligible for Medicaid for less than six (6) months, except for pregnant women (e.g., seasonal agricultural workers).
Excluded Populations. The following children and/or young adults are excluded from participation in RIte Smiles: • Children and/or young adults residing in a nursing home or an intermediate care facility for the persons with intellectual/developmental disabilities (ICF/1/DD); • Children and/or young adults with third-party coverage for dental benefits; and, • Children and/or young adults residing outside of Rhode Island. These children and/or young adults will continue to access their benefits through the State's Medicaid fee-for-service system.
Excluded Populations. A TANF beneficiary or Medicaid recipient in the following programs may not enroll in a frail/elderly component of a Medicaid HMO:
a. An Aged and Adult disabled Waiver;
b. The Channeling Waiver;
c. Developmental Disabilities Waiver; or
Excluded Populations. A member of the household of a clinically-eligible HIV/AIDS recipient who is no longer enrolled in this plan or a recipient who otherwise meets a requirement of an excluded population as specified in Attachment II, Section III, A.3., of this Contract.
Excluded Populations. The following Eligibles will be excluded from enrollment in SoonerSelect Dental: • Dual Eligible Individuals; • Individuals enrolled in the Medicare Savings Program, including Qualified Medicare Beneficiaries (QMB), Specified Low Income Medicare Beneficiaries (SLMB), Qualified Disabled Workers (QDW) and Qualified Individuals (QI); • Persons with a nursing facility or ICF-IID level of care, with the exception of Dental Health Plan Enrollees with a pending level of care determination. • Individuals during a period of Presumptive Eligibility; • Individuals infected with tuberculosis eligible for tuberculosis-related services under 42 C.F.R. § 435.215; • Individuals determined eligible for SoonerCare on the basis of needing treatment for breast or cervical cancer under 42 C.F.R. § 435.213; • Individuals enrolled in a §1915(c) Waiver; • Undocumented persons eligible for Emergency Services only in accordance with 42 C.F.R. § 435.139; • Insure Oklahoma Employee Sponsored Insurance (ESI) dependent children in accordance with the Oklahoma Title XXI State Plan; • Coverage of Pregnancy-Related Services under Title XXI for the benefit of unborn children (‘Soon- to-be-Sooners’), as allowed by 42 C.F.R. § 457.10; and • Individuals determined eligible for Medicaid on the basis of age, blindness, or disability.
Excluded Populations. A TANF beneficiary or Medicaid recipient in the following programs may not enroll in a frail/elderly component of a Medicaid HMO:
a. An Aged and Adult disabled Waiver;
b. The Channeling Waiver;
c. Developmental Disabilities Waiver; or
d. The Assisted Living for the Elderly Waiver Enrollment in the Frail/Elderly Program. This provision replaces Attachment II, Section III, Eligibility and Enrollment, Item B.2.b. as follows: In order for enrollment to occur, the Health Plan must maintain and document the following information on file and provide it at the Agency’s request:
(1) A current CARES assessment completed within the past twelve (12) months.
(2) An agreement in writing from the recipient’s Medicare or Medicaid PCP, whichever is applicable, that the provider would participate as part of the multidisciplinary treatment team and would provide input, review, data etc. related to the care of the recipient .
(3) A voluntary consent form signed by the recipient documenting the recipients request to enroll in the frail/elderly program. This form must be approved by BMHC prior to use. The disenrollment requirements listed below must be met in addition to those specified in Attachment II, Section III, Eligibility and Enrollment, unless otherwise noted below.
a. The Health Plan may request the Agency to disenroll an enrollee if the enrollee is institutionalized in a long term nursing facility at the conclusion of the state fiscal year and the Health Plan furnishes written documentation based upon a CARES assessment or written assurance from the enrollee’s PCP or the administrator of the nursing facility where the enrollee is placed that the nursing home placement is permanent and not temporary. AHCA Contract No. , Attachment II, Exhibit 3, Page 11 of 97 EXHIBITS, 5-11-12 Draft Health 2012 Plan Contract Attachment II b. All disenrollments for institutionalized enrollees must have prior written approval by the Agency and be submitted as involuntary disenrollments on the first available transmission to the fiscal agent after receiving Agency approval of the request.
1. Mandatory Populations There are no mandatory populations for the HIV/AIDS Specialty Plan.
2. Voluntary Populations In addition to meeting the eligibility requirements listed in Attachment II, Section III, Eligibility and Enrollment, A., Eligibility, sub-items 1. and 2., and notwithstanding Attachment II, Section III, Eligibility and Enrollment, B., Enrollment, sub-item 1.c., in order to be eligible fo...
Excluded Populations. Individuals eligible for Medicaid who cannot voluntarily enroll with a CCN including: • Individuals receiving hospice services; • Individuals Residing in Nursing Facilities (NF) or Intermediate Care Facilities for the Developmentally Disabled (ICF/DD); • Individuals with Medicare(dual eligibles): • Individuals who have been diagnosed with tuberculosis, or suspected of having tuberculosis, and receiving tuberculosis-related services through the Tuberculosis Infected Individual Program; • Individuals receiving services through any 1915(c) Home and Community-Based Waiver including, but not limited to: o Adult Day Health Care (ADHC) - Direct care in a licensed adult day health care facility for those individuals who would otherwise require nursing facility services; o New Opportunities Waiver (NOW) - Individuals who would otherwise require ICF/DD services; o Elderly and Disabled Adult (EDA) - Services to persons aged 65 and older or disabled adults who would otherwise require nursing facility services; o Children’s Choice (CC) - Supplemental support services to disabled children under age 18 on the NOW waiver registry; o Residential Options Waiver (ROW) - Individuals living in the community who would otherwise require ICF/DD services; o Supports Waiver – Individuals 18 years and older with mental retardation or a developmental disability which manifested prior to age 22; and o Other HCBS waivers as may be approved by CMS. • Individuals under the age of 21 otherwise eligible for Medicaid who are listed on the Office for Citizens with Developmental Disabilities’ Request for Services Registry, also known as Xxxxxxxx Class Members; • Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE), a community-based alternative to placement in a nursing facility that includes a complete “managed care” type benefit combining medical, social and long-term care services; • Individuals with a limited eligibility period including: o Spend-down Medically Needy Program - An individual or family who has income in excess of the prescribed income standard can reduce excess income by incurring medical and/or remedial care expenses to establish a temporary period of Medicaid coverage (up to three months); and o Emergency Services Only - Emergency services for aliens who do not meet Medicaid citizenship/ 5-year residency requirements; • Individuals enrolled in the LaCHIP Affordable Plan Program (LaCHIP Phase V) that provides benchmark coverage with a premium to...
Excluded Populations. Beneficiaries in Excluded Populations may not enroll in PHPs and will continue to receive Medicaid services through Fee-for-Service and LME/MCOs (as applicable).
Excluded Populations. Medicaid populations that cannot participate in Medicaid managed care include:
2.4.6.1 Adults (age 21 and older) residing in Intermediate Care Facilities for People with Developmental Disabilities (ICF/DD);
2.4.6.2 Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE), a community-based alternative to placement in a nursing facility that includes a complete “managed care” type benefit combining medical, social and long-term care services;
2.4.6.3 Refugee Cash Assistance;
2.4.6.4 Refugee Medical Assistance;
2.4.6.5 Take Charge Plus;
2.4.6.6 SLMB only;
2.4.6.7 QI-1;
2.4.6.8 LTC Co-Insurance;
2.4.6.9 QDWI;
2.4.6.10 QMB only; and
2.4.6.11 Individuals with a limited eligibility period including:
