Common use of Exempt Populations Clause in Contracts

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 characteristics and needs similar to those who are residents of - ICF/MRs based on criteria cooperatively established by the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and the SDOH. i) Individuals already scheduled for a major surgical procedure (within thirty (30) days of scheduled enrollment) with a provider who is not a participant in the network of a Medicaid MCO under contract with the LDSS. This exemption will only apply until such time as the individual's course of treatment is complete. j) Individuals with a developmental or physical disability who receive services through a Medicaid Home-and-Community-Based Services Waiver or Medicaid Model Waiver (care-at-home) through a Section 1915c waiver, or individuals having characteristics and needs similar to such individuals (including individuals on the waiting list), based on criteria cooperatively established by OMRDD and SDOH. k) Individuals who are residents of Alcohol and Substance Abuse or

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 III 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 provider 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 Rental Disease (ESRD). g) Individuals who are residents of Intermediate Care Facilities for the Mentally Retarded ("ICF/MR"). h) Individuals with characteristics and needs similar to those who are residents of - ICF/MRs based on criteria cooperatively established by the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and the SDOH. i) Individuals already scheduled for a major surgical procedure (within thirty (30) days of scheduled enrollment) with a provider who is not a participant in the network of a Medicaid MCO under contract with the LDSS. This exemption will only apply until such time as the individual's course of treatment is complete. j) Individuals with a developmental or physical disability who receive services through a Medicaid Home-and-and Community-Based Services Waiver or Medicaid Model Waiver (care-at-home) through a Section 1915c waiver, or individuals having characteristics and needs similar to such individuals (including individuals on the waiting list), based on criteria cooperatively established by OMRDD and SDOH. k) Individuals who are residents of Alcohol and Substance Abuse or

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 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 provider 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 characteristics and needs similar to those who are residents of - ICF/MRs based on criteria cooperatively established by the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and the SDOH. i) Individuals already scheduled for a major surgical procedure (within thirty (30) days of scheduled enrollment) with a provider who is not a participant in the network of a Medicaid MCO under contract with the LDSS. This exemption will only apply until such time as the individual's course of treatment is complete. j) Individuals with a developmental or physical disability who receive services through a Medicaid Home-and-Community-Based Services Waiver or Medicaid Model Waiver (care-at-home) through a Section 1915c waiver, or individuals having characteristics and needs similar to such individuals (including individuals on the waiting list), based on criteria cooperatively established by OMRDD and SDOH. k) Individuals who are residents of Alcohol and Substance Abuse oror Chemical Dependence Long Term Residential Treatment Programs. l) In New York City, all homeless individuals are exempt. In areas outside of NYC, exemption of homeless individuals residing in the shelter system is at the discretion of the local district. - See Section 5.1 (b). m) Native Americans n) Individuals who cannot be served by a managed care provider due to a language barrier which exists when the individual is not capable of effectively communicating his or her medical needs in English or in a secondary language for which PCPs are available within the Medicaid managed care program. Individuals with a language barrier will be deemed able to be served if they have a choice, within time and distance standards, of three (3) PCPs who are able to communicate in the primary language of the eligible individual or who have a person on his/her staff capable of translating medical terminology. Individuals will be eligible for an exemption when: i) The individual has a relationship with a Medicaid fee-for-service Primary Care Provider who: A) has the language capability to serve the individual;

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 III 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-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 provider 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" disenrollmentrequests. 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 characteristics and needs similar to those who are residents of - ICF/MRs based on criteria cooperatively established by the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and the SDOH. i) Individuals already scheduled for a major surgical procedure (within thirty (30) days of scheduled enrollment) with a provider who is not a participant in the network of a Medicaid MCO under contract with the LDSS. This exemption will only apply until such time as the individual's course of treatment is complete. j) Individuals with a developmental or physical disability who receive services through a Medicaid Home-and-Community-Based Services Waiver or Medicaid Model Waiver (care-at-home) through a Section 1915c waiver, or individuals having characteristics and needs similar to such individuals (including individuals on the waiting list), based on criteria cooperatively established by OMRDD and SDOH. k) Individuals who are residents of Alcohol and Substance Abuse or

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 provider 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 characteristics and needs similar to those who are residents of - ICF/MRs based on criteria cooperatively established by the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and the SDOH. i) Individuals already scheduled for a major surgical procedure (within thirty (30) days of scheduled enrollment) with a provider who is not a participant in the network of a Medicaid MCO under contract with the LDSS. This exemption will only apply until such time as the individual's course of treatment is complete. j) Individuals with a developmental or physical disability who receive services through a Medicaid Home-and-Community-Based Services Waiver or Medicaid Model Waiver (care-at-home) through a Section 1915c waiver, or individuals having characteristics and needs similar to such individuals (including individuals on the waiting list), based on criteria cooperatively established by OMRDD and SDOH. k) Individuals who are residents of Alcohol and Substance Abuse or

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 III 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 provider 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 characteristics and needs similar to those who are residents of - ICF/MRs based on criteria cooperatively established by the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and the SDOH. i) Individuals already scheduled for a major surgical procedure (within thirty (30) days of scheduled enrollment) with a provider who is not a participant in the network of a Medicaid MCO under contract with the LDSS. This exemption will only apply until such time as the individual's course of treatment is complete. j) Individuals with a developmental or physical disability who receive services through a Medicaid Home-and-Community-Based Services Waiver or Medicaid Model Waiver (care-at-home) through a Section 1915c waiver, or individuals having characteristics and needs need similar to such individuals (including individuals on the waiting list), based on criteria cooperatively established by OMRDD and SDOH. k) Individuals who are residents of Alcohol and Substance Abuse or

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 provider 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 '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 characteristics and needs similar to those who are residents of - ICF/MRs based on criteria cooperatively established by the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and the SDOH. i) Individuals already scheduled for a major surgical procedure (within thirty (30) days of scheduled enrollment) with a provider who is not a participant in the network of a Medicaid MCO under contract with the LDSS. This exemption will only apply until such time as the individual's course of treatment is complete. j) Individuals with a developmental or physical disability who receive services through a Medicaid Home-and-Community-Based Services Waiver or Medicaid Model Waiver (care-at-home) through a Section 1915c waiver, or individuals having characteristics and needs similar to such individuals (including individuals on the waiting list), based on criteria cooperatively established by OMRDD and SDOH. k) Individuals who are residents of Alcohol and Substance Abuse or

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 I11 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 provider 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 characteristics and needs similar to those who are residents of - ICF/MRs based on criteria cooperatively established by the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and the SDOH. i) Individuals already scheduled for a major surgical procedure (within thirty (30) days of scheduled enrollment) with a provider who is not a participant in the network of a Medicaid MCO under contract with the LDSS. This exemption will only apply until such time as the individual's course of treatment is complete. j) Individuals with a developmental or physical disability who receive services through a Medicaid Home-and-and Community-Based Services Waiver or Medicaid Model Waiver (care-at-home) through a Section 1915c waiver, or individuals having characteristics and needs similar to such individuals (including individuals on the waiting list), based on criteria cooperatively established by OMRDD and SDOH. k) Individuals who are residents of Alcohol and Substance Abuse or