Exempt Populations. Pursuant to federal law, the Contractor may not collect POWER Account contributions or impose any other cost-sharing, including co-payments for non- urgent use of hospital emergency departments, on members who are pregnant, members who have reached their 5% cost sharing requirement, or members identified as an American Indian/ Alaska Native (AI/AN) pursuant to 42 CFR 136.12. The State will identify all AI/AN members through the eligibility determination process.
Exempt Populations. The following populations are exempt from mandatory enrollment in Medicaid managed care, but may enroll on a voluntary basis, if otherwise eligible.
a) Individuals who are HIV+ or have AIDS.
b) Individuals who are Seriously and Persistently Mentally Ill or Seriously Emotionally Disturbed.
c) Individuals for whom a Managed Care Provider is not geographically accessible so as to reasonably provide services. To qualify for this exemption, an individual must demonstrate that no participating MCO has a provider located within thirty (30) minutes travel time/thirty (30) miles travel distance from the individual's home, who is accepting new patients, and that there is a fee-for-service Medicaid provider available within the thirty (30) minutes travel time/thirty (30) miles travel distance.
d) Pregnant women who are already receiving prenatal care from a provider authorized to provide such care not participating in any Medicaid managed care plan. This status will last through a woman's pregnancy, extend through the sixty (60) day post-partum period and end at the end of the month in which the sixtieth (60th) day occurs.
e) Individuals with a chronic medical condition who, for at least six (6) months, have been under active treatment with a non-participating sub-specialist physician who is not a network provide for any MCO participating in the Medicaid managed care program service area. This status will last as long as the individual's chronic medical condition exists or until the physician joins a participating MCO's network. The SDOH's Office of Managed Care, Medical Director will, upon the request of an individual or his/her guardian or legally authorized representative (health care agent authorized through a health care proxy), review cases of individuals with unusually severe chronic care needs for a possible exemption from mandatory enrollment in managed care if such individuals are not otherwise eligible for an exemption (i.e., meet one of the seventeen (17) criteria listed here. The SDOH's OMC Medical Director may also authorize a plan disenrollment for such individuals. Disenrollment requests SECTION 5 (ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS) October 1, 2004 5-2 should be made in a manner consistent with the overall disenrollment request process for "good cause" disenrollment.
f) Individuals with End Stage Renal Disease (ESRD).
g) Individuals who are residents of Intermediate Care Facilities for the Mentally Retarded ("ICF/MR").
h) Individuals with char...
Exempt Populations. The Contractor shall ensure, in accordance with 42 C.F.R. § 447.56, that copayments are not imposed on any of the following populations:
a) Individuals between ages one (1) and eighteen (18), eligible under 42 C.F.R. § 435.118;
b) Individuals under age one (1), eligible under 42 C.F.R. § 435.118;
c) Disabled or blind individuals under age eighteen (18) eligible under 42 C.F.R. § 435.120 or 42 C.F.R. § 435.130;
d) Children for whom child welfare services are made available under Part B of title IV of the Social Security Act on the basis of being a child in xxxxxx care and individuals receiving Benefits under Part E of that title, without regard to age;
e) Disabled children eligible for Medicaid under the Family Opportunity Act;
f) Pregnant women, during pregnancy and through the postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the sixty (60) day period following termination of pregnancy ends;
g) Any individual whose medical assistance for services furnished in an institution or HCBS setting is reduced by amounts reflecting available income other than required for personal needs;
h) An individual receiving hospice care, as defined in Section 1905(o) of the Social Security Act;
i) An Indian (as defined in Special Contract Exhibit B) who is currently receiving or has ever received an item or service furnished by an IHCP or through referral under contract health services; and
j) Individuals who are receiving Medicaid by virtue of their breast or cervical cancer diagnosis under 42 C.F.R. § 435.213.
Exempt Populations. The following populations are exempt from mandatory enrollment in Medicaid managed care, but may enroll on a voluntary basis, if otherwise eligible.
