Common use of Excluded Populations Clause in Contracts

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 from the FACT team. These recipients are allowed to enroll in non-Reform PSNs.

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 (ICFDDICF-DD), 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:: WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (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. Rule 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 Waiver except for those enrolled in the non-Reform HMO populations, HMOs that specialize in HIV/AIDS; m. Medicaid recipients who are members of the Florida Assertive Community Treatment Team (FACT team) unless they disenroll from the FACT team. These ; and n. Medicaid recipients are allowed to enroll participating in non-Reform PSNsthe state’s Health Insurance Premium Payment program (HXXX).

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 (ICFDDICF-DD), 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 WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO 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 from the FACT team. These recipients are allowed to enroll in non-Reform PSNs.

Excluded Populations. The following categories describe Medicaid recipients Recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid recipients Recipients who, at the time of application for enrollment Enrollment and/or at the time of enrollmentEnrollment, are living domiciled or residing in an institution, including a nursing facility facilities (and have been CARES assessed), Statewide Inpatient Psychiatric (SIPP) sub-acute inpatient psychiatric facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICFDDICF-DD), a state mental health hospital or a correctional facility; c. Medicaid recipients Recipients whose Medicaid eligibility was determined through the Medically Needy medically needy program;. d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 Lxxxx 0 (QI-1sXX-0x);. e. Medicaid recipients Recipients who have other creditable health health-care coverage, such as TriCare or a private commercial health plan;maintenance organization (HMO). f. Medicaid recipients 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 (the DCF); AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract; (3) Children’s 's residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the 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. , as described in Sections 65D-30.007(2)(a) and (b), F.A.C.); g. Medicaid recipients Recipients participating in the Family Planning Waiver;waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network;. i. j. Women eligible for Medicaid due to breast and/or cervical cancer;. j. k. 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 from the FACT team. These recipients are allowed to enroll in non-Reform PSNsgroup.

Excluded Populations. The following categories describe Medicaid recipients Recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid recipients Recipients who, at the time of application for enrollment Enrollment and/or at the time of enrollmentEnrollment, are living domiciled or residing in an institution, including a nursing facility facilities (and have been CARES assessed), Statewide Inpatient Psychiatric (SIPP) sub-acute inpatient psychiatric facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICFDDICF-DD), a state mental health hospital or a correctional facility; c. Medicaid recipients Recipients whose Medicaid eligibility was determined through the Medically Needy medically needy program;. d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 Xxxxx 0 (QI-1sXX-0x);. e. Medicaid recipients Recipients who have other creditable health health-care coverage, such as TriCare or a private commercial health plan;maintenance organization (HMO). f. Medicaid recipients 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 (the DCF); AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract; (3) Children’s 's residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the 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. , as described in Sections 65D-30.007(2)(a) and (b), F.A.C.); g. Medicaid recipients Recipients participating in the Family Planning Waiver;waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network;. i. j. Women eligible for Medicaid due to breast and/or cervical cancer;. j. k. 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 from the FACT team. These recipients are allowed to enroll in non-Reform PSNsgroup.

Excluded Populations. The following categories describe Medicaid recipients Recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid recipients Recipients who, at the time of application for enrollment Enrollment and/or at the time of enrollmentEnrollment, are living domiciled or residing in an institution, including a nursing facility facilities (and have been CARES assessed), Statewide Inpatient Psychiatric (SIPP) sub-acute inpatient psychiatric facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICFDDICF-DD), a state mental health hospital or a correctional facility; c. Medicaid recipients Recipients whose Medicaid eligibility was determined through the Medically Needy 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 Recipients who have other creditable health health-care coverage, such as TriCare or a private commercial health plan;maintenance organization (HMO). f. Medicaid recipients 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 (the DCF); AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract; (3) Children’s 's residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the 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)(aSections 65D- 30.007(2)(a) and (b), F.A.C.); g. Medicaid recipients Recipients participating in the Family Planning Waiver;waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Children‘s Medical Services Network;. i. j. Women eligible for Medicaid due to breast and/or cervical cancer;. j. k. 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);group. l. For non-Reform populations, individuals enrolled in the PAC Waiver; and m. For Reform populations and non-Reform HMO populations, Medicaid recipients Recipients who are members of the Florida Assertive Community Treatment Team (FACT team) unless they disenroll from the FACT team. These recipients are allowed to enroll in non-Reform PSNs).

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 (ICFDDICF-DD), 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 HealthEase of Florida, Inc. d/b/a Medicaid HMO 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 from the FACT team. These recipients are allowed to enroll in non-Reform PSNs.

Excluded Populations. The following categories describe Medicaid recipients Recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid recipients Recipients who, at the time of application for enrollment Enrollment and/or at the time of enrollmentEnrollment, are living domiciled or residing in an institution, including a nursing facility facilities (and have been CARES assessed), Statewide Inpatient Psychiatric (SIPP) sub-acute inpatient psychiatric facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICFDDICF-DD), a state mental health hospital or a correctional facility; c. Medicaid recipients Recipients whose Medicaid eligibility was determined through the Medically Needy 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 Recipients who have other creditable health health-care coverage, such as TriCare or a private commercial health plan;maintenance organization (HMO). f. Medicaid recipients 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 (the DCF); AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract; (3) Children’s 's residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the 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)(aSections 65D- 30.007(2)(a) and (b), F.A.C.); g. Medicaid recipients Recipients participating in the Family Planning Waiver;waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network;. i. j. Women eligible for Medicaid due to breast and/or cervical cancer;. j. k. 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);group. l. For non-Reform populations, individuals enrolled in the PAC Waiver; and m. For Reform populations and non-Reform HMO populations, Medicaid recipients Recipients who are members of the Florida Assertive Community Treatment Team (FACT team) unless they disenroll from the FACT team. These recipients are allowed to enroll in non-Reform PSNs).

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 (ICFDDICF-DD), 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:: WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (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. Rule 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 Waiver except for those enrolled in the non-Reform HMO populations, HMOs that specialize in HIV/AIDS; m. Medicaid recipients who are members of the Florida Assertive Community Treatment Team (FACT team) unless they disenroll from the FACT team. These ; and n. Medicaid recipients are allowed to enroll participating in non-Reform PSNsthe state’s Health Insurance Premium Payment program (XXXX).