CO
| FL | FLMH | HI
| HIBH | IL | IA
| IABH | KS | KY
| ME | MD | MI |
MN | MO | NE | NEBH
NJ
| NM | NY | NC
| ND | OH | OK |
PA | UT | UTMH
| VA | WV | WI
CO
"II. ELIGIBILITY AND ENROLLMENT…
2. To be eligible to Enroll
as a Covered Person under this Contract, a person must be a Colorado Medicaid
Client and be a resident of the Contractor’s Service Area. The following
Clients are not eligible to be Enrolled under this Contract:
a. Clients
who, at the time of application for Enrollment and/or at the time of Enrollment,
are domiciled or residing in an institution including intermediate care
facilities for the mentally retarded, state mental hospitals or state correctional
institutions…" Colorado Contract, page 12.
FL
"7. Eligible Recipients…Residents who are residents of Assisted Living Facilities (ALFs) and not enrolled in an ALF waiver program are eligible for enrollment in the plan...
8. Ineligible
Recipients. The following categories describe recipients whom the plan
shall not enroll under this contract:
a. Medicaid eligible
recipients who, at the time of application for enrollment and/or at the
time of enrollment, are domiciled or residing in an institution, including
nursing facilities, intermediate care facilities for persons with developmental
disabilities, state hospitals or correctional institutions..." Florida
Contract, page 9.
FLMH
"2.13 Persons Eligible
for Enrollment: ...
B. Ineligible Recipients.
The following categories describe recipients not eligible for enrollment
under the plan: ...
2. Medicaid eligible
recipients who, at the time of enrollment, are domiciled or residing in
an institution including nursing homes, intermediate care facilities for
the mentally retarded." Florida Mental Health RFP, pages 34-35.
HI
“All ABD recipients, with
the exception of the following:
1) residents of nursing
homes;
2) recipients wait
listed for nursing home bed placement...
4) residents of intermediate
care facilities for mentally retarded...will be enrolled into a QUEST plan...”
Hawaii RFP, unnumbered page.
“20.120 Hawaii QUEST (QUEST)...
ABD recipients who will
remain in Medicaid’s fee-for-service program and will not be enrolled into
QUEST include persons who:
1) reside in
nursing homes (ICF and SNF level of care);
2) are wait listed
in hospitals for nursing home bed placement...
4) reside in
intermediate care facilities for mentally retarded (ICF-MR)...” Hawaii
RFP, page 5.
“40.110 Basic Criteria
All recipients must meet
the following basic eligibility criteria: ...
* Not reside in a
public institution, including correctional facilities and the Hawaii State
Hospital.” Hawaii RFP, page 43.
“40.230 Categorical
Requirements...
ABD participants residing
in nursing homes, are wait listed in hospitals for nursing home bed placement...residing
in intermediate care facilities for mentally retarded (ICF-MR)...will be
excluded from the QUEST program and remain in fee-for-service...” Hawaii
RFP, page 43.
“b) For ABD recipients who reside in nursing homes and require acute hospitalization from time to time, will they continue under Medicaid’s fee-for-service program, or will they have to qualify for QUEST during the acute hospitalization stay? The same question applies to ICF-MR recipients.
ANSWER: ...
ABD recipients residing
in nursing homes and wait listed for placement in long-term care facilities
at the time of the conversion will not be enrolled in QUEST. When
these recipients require acute hospitalization, they will be covered under
fee-for- service. This is true for those residing in ICF-MR
facilities.” Hawaii RFP, Q&A, page 2.
HIBH
"20.500 HCFA Contingency...
ABD members who will remain
in Medicaid's fee-for-service program and will NOT be enrolled in QUEST
include persons who:
1) reside in nursing
facilities (ICF and SNF level of care);
2) are waitlisted
in hospitals for nursing facility bed placement;
3) are PACE participants…"
Hawaii Behavioral Health RFP, page 7.
"20.700 Eligible BHMC Plan
Members...
The following Medicaid eligible
who will not be enrolled in the BHMC plan include persons who are:
• Residing in a hospital
who are waitlisted for a nursing facility;
• Participating in
PACE;…" Hawaii Behavioral Health RFP, page 8.
"20.760 Involuntary
Commitment
The BHMC plan shall be responsible
for providing all required services to members who have been involuntarily
committed for inpatient or ambulatory evaluation and treatment under provisions
of Chapter 334, HRS, to the extent that these services are deemed necessary
by the plan's utilization review procedures...
20.770 Criminal Commitment
Adult members who have been
criminally committed for evaluation or treatment in an inpatient setting
or ambulatory mental health care settings under the provisions of Chapter
706, HRS, shall be disenrolled from all QUEST plans and become the clinical
and financial responsibility of the appropriate State agency. The
BHMC plan shall be relieved of its responsibility for providing behavioral
health services." Hawaii Behavioral Health RFP, pages 11-12.
"40.100 Eligibility
40.110 Basic Criteria
All members must meet the
following basic eligibility criteria:
• Be a U.S. citizen
or legal resident alien
• Intend to reside
in the State of Hawaii
• Provide a verified
Social Security Number (SSN)
• Not reside in a
public institution, including correctional facilities and the Hawaii State
Hospital
40.200 QUEST Eligibility...
40.230 Categorical
Requirements...
ABD participants residing
in nursing facilities…participating in the PACE program…will be excluded
from the QUEST program and remain in fee-for-service…" Hawaii Behavioral
Health RFP, page 36.
IL
"Eligible Enrollee means
a Client or KidCare Participant except one who: ...
• is residing in a
long term care facility including state operated facilities..." Illinois
HMO Contract, pages 2-3.
IA
"Medicaid eligible recipients
will be excluded from enrollment with a HMO if they: ...
2. Are residing in
a nursing facility or ICF/MR…" Iowa Contract, page 11.
IABH
"ATTACHMENT ON IOWA PLAN
ENROLLMENT CRITERIA...
The following beneficiaries
are excluded from enrollment:
* Persons who reside
in Glenwood State Hospital School or Woodward State Hospital School..."
Iowa Behavioral Health Contract, page 77.
KS
"A. DETERMINE MEDICAID
ELIGIBILITY...
Beneficiaries Excluded From
the Contract
The following categories
of TAF and PLE Medicaid beneficiaries are excluded from receiving services
under this contract: …
• Beneficiaries residing
in a nursing facility, nursing facility for the mentally ill, ICF/MR or
head injury rehabilitation facility…" Kansas Contract, pages 40-41.
KY
"VI. ENROLLMENT AND
DISENROLLMENT
A. Eligibility
The Contractor shall
follow eligibility procedures and requirements in accordance with Sections
7.10.1 through 7.10.6 and Attachment X of the RFA…" Kentucky Contract,
page 25.
"Listed below are categories
of Medicaid recipients who are not eligible to enroll in the Partnership's
Network: ...
Individuals currently
Medicaid eligible and have been in a nursing facility for more than thirty-one
(31) days...
Individuals in a
psychiatric facility, excluding a PRTF." Kentucky RFA, Attachment
X, page 95.
ME
"II. DEFINITIONS.
A. The following terms
used in this Contract shall be interpreted as defined herein, except to
the extent that the context may clearly require otherwise: …
25. Excluded Recipients
are Medicaid recipients who are not in the target population because they
fall within one of the following exclusions:
a. recipients
residing in a nursing facility or intermediate care facility for people
with mental retardation (ICF/MR)...
d. recipients
residing in jails or State mental institutions...
26. Exempt Recipients
are Medicaid recipients, otherwise in the target population, who the Department
may determine will remain in the fee-for-service Medicaid system instead
of being enrolled in a managed care program because they qualify for one
of the following exemptions: ...
i. individuals
receiving hospice care at the time of enrollment; and
j. individuals
residing in a private non-medical institution." Maine Contract, pages
2, 5.
MD
"Chapter 63 Maryland
Medicaid Managed Care Program: Eligibility and Enrollment
.01 Eligibility...
B. A recipient is
not eligible for the Maryland Medicaid Managed Care Program if the recipient:
(1) Has been,
or is expected to be, continuously institutionalized for more than 30 successive
days in:
(a) A long-term
care facility, or
(b) An IMD;
(2) Is institutionalized
in an intermediate care facility for mentally retarded persons…"
Maryland COMAR 10.09.63.01.
MI
"II-E MEDICAID ELIGIBILITY
AND CHCP ENROLLMENT...
3. Medicaid Eligible Groups
Excluded From Enrollment in the CHCP: ...
*Persons receiving long
term care (custodial care) in a licensed nursing facility…" Michigan
Contract, page 16.
MN
"Section 2.24. Institutionalized means a category of Enrollees used as a factor to determine the Rate Cell of an individual who resides in a Nursing Facility or intermediate care facility for the mentally retarded (ICF/MR)." Minnesota Contract, page 12.
"Section 3.1.1. Eligibility…
C. Eligibility Determinations
for MA and GAMC. Eligibility for MA and GAMC and eligibility for participation
in PMAP and PGAMC will be determined by the Local Agency. All persons who
receive MA or GAMC and reside in the Service Area will participate in PMAP
or PGAMC, except for Recipients who are members of the following MA and
GAMC populations...
5) MA and GAMC Recipients who are residents of state institutions, unless the placement has been approved by the HEALTH PLAN." Minnesota Contract, page 17.
MO
"1.7.2 Not Covered
Under the Managed Care Plan: ...
b. Individuals eligible
under ME Code 14 (Nursing Care-OAA) residing in a nursing home and
who are receiving cash to apply toward their nursing home costs or a vendor
payment directly to a nursing home for their care through the Medicaid
program." Missouri RFP, page 16.
NE
"9.2.5 Excluded Clients:
The following clients shall be excluded from the NHC (based on the information
known to the HHS eligibility system): ...
(b) Clients residing
in nursing facilities and receiving custodial care pursuant to Section
9.20 of this contract…" Nebraska Contract, page 32.
NEBH
"9.2.5 Excluded Clients:
The following clients are excluded from the NHC (based on the information
known to the HHS eligibility system): ...
(b) Clients
residing in nursing facilities and receiving custodial care pursuant
to 471 NAC 12-000;
(c) Clients
residing in intermediate care facilities for the mentally retarded (ICF/MR)
pursuant to 471 NAC 31-000…" Nebraska Behavioral Health Contract,
page 33.
NJ
"ARTICLE 6
ENROLLMENT EXCLUSIONS AND
EXEMPTIONS
6.1 The following
persons are excluded from enrollment in the contractor's plan: ...
C. Individuals
who are institutionalized in a long term care or residential facility.
However, individuals who are eligible through DYFS and are institutionalized
in a DYFS residential center/facility are not excluded from enrolling in
the contractor's plan…" New Jersey Contract, page 37.
"APPENDIX A...
INSTITUTIONAL FEE-FOR-SERVICE
BENEFITS
NO CASE MANAGEMENT BY THE
CONTRACTOR...
Medicaid recipients participating
in a waiver or demonstration program or admitted for long term care treatment
in one of the following shall be disenrolled from the contractor's plan
on the date of admission to institutionalized care.
- Nursing
Facility care
- Residential
Treatment Center care...
- Intermediate
Care Facility/Mental Retardation…" New Jersey Contract, Appendix
A, page 170.
NM
"All Medicaid eligible clients
are required to participate in the Medicaid managed care program except
for the following: ...
2.B.1.b Institutionalized
clients i.e., those residing for greater than thirty (30) days in nursing
facilities...
2.B.1.c Clients residing
in intermediate care facilities for the mentally retarded: ..." New
Mexico Contract, page 22.
NY
"5. ELIGIBLE, EXEMPT
AND EXCLUDED POPULATIONS...
5.3 Excluded Populations
The following populations
are ineligible for enrollment in Medicaid managed care...
c) Individuals who
are residents of State-operated psychiatric facilities or residential treatment
facilities for children and youth.
d) Individuals who
are residents of Residential Health Care Facilities ('RHCF') at the time
of enrollment and individuals who enter a RHCF subsequent to enrollment,
except for short term rehabilitative stays anticipated to be no greater
than thirty (30) days.
e) Individuals enrolled
in managed long term care demonstrations authorized under Article 4403-f
of the New York State P.H.L. …" New York Contract, pages 5-1-5-4.
NC
"3.1 Persons Eligible
for Enrollment
To be eligible to enroll
in the Plan established pursuant to this Contract, a person must be a Recipient
in the North Carolina Medical Assistance (Medicaid) Program in one of the
aid categories listed below; and residing in Mecklenburg County; and not
eligible for Medicare…
g. Adult Care
Home Residents (SAD)…" North Carolina Contract, page 5.
ND
"ATTACHMENT F: ELIGIBLE
GROUPS...
2. Individuals in
the aid categories and subcategories are not eligible to enroll in the
HMO if: ...
B. They are nursing
facility residents, or are otherwise institutionalized in facilities such
as intermediate care facilities for the mentally retarded or residential
treatment centers…" North Dakota Contract, Attachment F, page 1.
OH
"5101:3-26-03 Managed
care plan: Covered services...
(I) Exclusions, limitations
and clarifications.
(1) When an MCP enrollee
has been found by ODHS to meet the criteria for either a skilled intermediate,
or ICF-MR level of care and is then placed in a NF, ICF-MR... ODHS will
disenroll the enrollee from the MCP effective on the last day of the month
prior to the placement, pursuant to procedures specified by ODHS.
ENROLLEES WILL NOT BE ELIGIBLE FOR SUCH DISENROLLMENT IF THEY ARE PLACED
IN A NF FOR A SHORT-TERM REHABILITATIVE STAY AS DETERMINED BY ODHS."
Ohio RFP, Appendix E, OAC 5101:3-26-03, pages 1-2.
**Note: NF refers
to a nursing facility
OK
"1.2 General Information
for Applicants...
1.2.2 Covered Populations
The following categories
of Medicaid and Title XXI beneficiaries in the three urban areas will be
mandatorily enrolled into Health Plans awarded contracts through this procurement:
...
• The populations…excluding
those persons…currently institutionalized…" Oklahoma RFP, page 2.
"2.4.6 Exceptions to
Health Plan Enrollment
The following categories
of members who otherwise qualify will be excluded from participation in
the managed care program: ...
• Individuals who are institutionalized…"
Oklahoma RFP, page 18.
PA
"F. In-Plan Services...
2. Description of
Comprehensive Benefit Package...
i. Intermediate Care Facility
for the Mentally Retarded (ICF/MR)
The HMO is responsible to
provide the full realm of medical services to members residing in ICF/MRs.
The HMO is not responsible to provide any services which are covered under
the facility's per diem payment such as room, board, and treatment. The
HMO is also not responsible to provide any medical services determined
to fall under the scope of behavioral health services, or are the responsibility
of the behavioral health contractor(s).
j. Residential Treatment
Facility (RTF)
The HMO is responsible to
provide the full realm of medical services to members residing in RTFs.
The HMO is not responsible to provide any services which are covered under
the facility's per diem payment such as room, board, and treatment. The
HMO is also not responsible to provide any medical services determined
to fall under the scope of behavioral health services, or are the responsibility
of the behavioral health contractor(s)…" Pennsylvania RFP, pages
37-45.
"H. Coordination with
Out-of-Plan Services...
5. Nursing Homes
The HMO will be responsible
for the payment of members for up to thirty (30) consecutive days if that
member is admitted into a nursing home facility...
Individuals who are residing in nursing homes and are subsequently found eligible for MA will not be enrolled in the HealthChoices Program.
Individuals eligible for MA but not mandated into HealthChoices Program when they enter nursing homes or MA recipients who are placed in nursing homes inside the HealthChoices program area who previously resided outside the HealthChoices project area , will not be enrolled in the HealthChoices Program.
MA eligible recipients who are placed into a nursing home from a hospital and were not previously enrolled in HealthChoices Program or individuals who enter a nursing home from a hospital and are then determined eligible for MA will not be enrolled in the HealthChoices program. However, should an individual leave the nursing home to reside in the HealthChoices project area and then be determined mandatory for the HealthChoices Program, they will then be required to enroll into the Program…" Pennsylvania RFP, pages 51-55.
UT
"ATTACHMENT B - Special Provisions
Article I - Definitions...
G. 'Enrollee' means
any Medicaid eligible: (3) who is accepted for enrollment by the
CONTRACTOR according to the conditions set forth in this Contract excluding
residents of the Utah State Hospital, Utah State Developmental Center,
and long-term care facilities except as defined in Attachment C."
Utah Contract, Attachment B, page 1.
UTMH
"Article II
ENROLLMENT...
B. Enrollment Exclusions
1. Medicaid
Enrollees who reside at the Utah State Hospital and the Utah Developmental
Center are not covered under the Contract." Utah Mental Health Contract,
page 2.
"Rate Cells..
Separate rates will be established
for each eligible group as follows: ...
11. Nursing Home Residents"
Utah Mental Health Contract, page 23.
VA
"D. ELIGIBILITY AND
ENROLLMENT...
1. Medicaid and CMSIP
Eligible Individuals Excluded from Medallion II
The Contractor shall cover
all Medicaid and CMSIP eligible individuals, with the exception of individuals
excluded from Medallion II, as defined in 12 VAC 30-120-370. The
Department shall exclude individuals meeting the exclusion criteria listed
below: …
a. Individuals who
are inpatients in the State mental hospitals listed below:
i. Western
State Hospital.
ii. Southwestern
VA Mental Health Institution.
iii. Eastern
State Hospital.
iv. HW Davis
Medical Center.
v. Southern
Virginia Mental Health Institution.
vi Western
State HM&S.
vii. Northern
Virginia Mental Health Institution.
viii. Dejarnette Center.
ix. Central
State Hospital, and
x.
Southwestern State HM&S;
b. Individuals who are approved by the Department as inpatients in long-stay hospitals, nursing facilities, or intermediate care facilities for the mentally retarded...
l. Individuals who have been pre-assigned to an HMO but have not yet been enrolled, who are inpatients in hospitals other than those listed in (a) of this section, until the first day of the month following discharge." Virginia Contract, pages 21-23.
WV
"1.1 BACKGROUND...
The Medically Needy…
populations will be excluded, as will Medicaid-eligible residing in nursing
facilities. The feasibility of including these populations during
a later phase of the program will be investigated." West Virginia
RFA, page 1.
WI
"14. LIVING IN A PUBLIC INSTITUTION-The HMO shall be liable for the cost of providing all medically necessary services to enrollees who are living in a public institution as defined in Article I, during the month in which they first enter the public institution. Enrollees who remain in a public institution after the last day of the month are no longer eligible for Medical Assistance and HMOs are not liable for providing care after the end of the first month.
15. TRANSFER FROM A PUBLIC INSTITUTION TO A MEDICAL FACILITY-Enrollees who are living in a public institution and go directly from the public institution to a medical facility, court ordered or voluntarily, are no longer living in a public institution and remain eligible for Medicaid. The HMO shall be responsible for reimbursing for the provision of medically necessary treatment if treatment is at the HMO's facilities, or if unable to itself provide for such treatment." Wisconsin Contract, Addendum II, page 84.