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II-C Interpretative Guidelines for the Office Site Evaluation Form | IV-A Medicaid Marketing Guidelines for Medical Service Providers

Appendix III — Healthfirst Commercial Plans and Medicaid Managed Care Exclusions and Exemptions

Medicaid Exclusions

The following persons are excluded from joining a managed care plan:

·     Medicare/Medicaid Dual Eligibles.
·     Individuals who became eligible for Medicaid only after spending down a portion of their income.
·     Residents of State psychiatric facilities and residential treatment facilities for children and youth.
·     Residents of residential healthcare facilities at the time of enrollment and persons who enter a residential healthcare facility subsequent to enrollment, except for short-term rehabilitative stays anticipated to be less than thirty (30) days.
·     Participants in capitated long-term care demonstration projects, including beneficiaries with Medicare.
·     Medicaid-eligible infants living with incarcerated mothers.
·     Comprehensive private health insurance consumers if cost is lower than the State’s.
·     All children in foster care. (Noninstitutional foster care children and institutional foster care children, children enrolled in Brides to Health waiver program – not excluded as of April 1, 2013).
·     Certified blind or disabled children living or expected to live separate from their parents for thirty (30) days or more. (No longer excluded as of April 1, 2013.)ertified blind or disabled children living or expected to live separate from their parents for thirty (30) days or more. (No longer excluded as of April 1, 2013.)
·     Individuals expected to be Medicaid eligible for less than six (6) months (except for pregnant women).
·     Individuals receiving (at the time of enrollment) institutional long-term care services through long-term home healthcare programs, or child care facilities (except ICF Services for the Developmentally Disabled).
·     Individuals eligible for medical assistance benefits only with respect to tuberculosis-related services.
·     Individuals placed in OMH licensed family care homes.
·     Individuals enrolled in the Restricted Recipient Program. (No longer excluded as of August 1, 2012.)
·     Individuals with a “County of Fiscal Responsibility” Code of 99, Code of 97 (OMH in MMIS), or Code of 98 (OMRDD in MMIS).
·     Individuals receiving family planning services who are not otherwise eligible for medical assistance and whose net available income is 200% or less of the federal poverty line.
·     Individuals receiving hospice services (at time of enrollment).
·     Individuals eligible for Medicaid pursuant to the terms of the “Medicaid buy-in for the working disabled.” (No longer excluded as of April 1, 2013.)
·     Individuals who are eligible for medical assistance.

Medicaid Exemptions

The following persons may voluntarily enroll, but are not required to enroll, in a Medicaid managed care plan.

·     Individuals with chronic medical conditions who have been under active treatment for at least six (6) months with a subspecialist who is not a network provider for any Medicaid managed care plan in the service area, or whose request has not been approved by the SDOH medical director because of unusually severe chronic care needs.
·     Residents of Intermediate Care Facilities for the Mentally Retarded (ICF/MR). (No longer exempt as of April 1, 2013.)
·     Individuals with characteristics and needs similar to those who are residents of an ICF/MR. (No longer exempt as of April 1, 2013.)
·     Individuals previously 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 any Medicaid managed care plan in the service area.
·     Persons with developmental or physical disability receiving services through a Medicaid Home- and Community-Based Services Waiver. (No longer excluded as of April 1, 2013.)
·     Individuals whose needs are similar to participants receiving services through a Medicaid Home- and Community-Based Services Waiver.
·     Participants in the Medicaid Model Waiver (Care-At-Home) Program. (No longer excluded as of April 1, 2013.)
·     Individuals whose needs are similar to participants receiving services through the Medicaid Model Waiver (Care-At-Home) Programs. (No longer excluded as of April 1, 2013.)
·     Residents of Alcohol/Substance Abuse Long-Term Residential Treatment Programs.
·     Native Americans.
·     Recipients with a “County of Fiscal Responsibility” Code of 98 (OMRDD in MMIS).
·     Individuals eligible for Medicaid pursuant to the terms of the “Medicaid buy-in for the working disabled.”  (No longer excluded as of April 1, 2013.)

Healthfirst Commercial Plan Exclusions

The following persons are excluded from joining a Healthfirst Commercial plan:
·     Individuals over 65 who are eligible for Medicare.
·     Individuals who are eligible for Medicaid.
·     Individuals who live outside of Bronx, New York, Queens, Kings, Richmond, Suffolk, and Nassau counties.
·     Individuals who are already insured through an employer or through a spouse’s employer.
·     Individuals who are incarcerated.
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