AZ
| CA | DE | DC |
HIBH | KS | KY
| ME |
MD | MN
MO
| MT | NEBH | NM
| ND | OH | PA |
SC
| TN | VA
AZ
"6. ENROLLMENT AND
DISENROLLMENT...
Eligibility for the various
AHCCCS coverage groups is determined by one of the following agencies:
…
AHCCCSA
AHCCCSA determines eligibility
for the SSI/MAO groups, including...The Arizona Long Term Care System (ALTCS)..."
Arizona Contract, page 18.
CA
"ARTICLE II - DEFINITIONS...
CC. Eligible Beneficiary
means any Medi-Cal beneficiary who is residing in Contractor's Service
Area with one of the following aid codes... with the following exclusions:
...
2. Individuals who elect and are accepted to participate in the following Medi-Cal waiver programs: In-Home Medical Care Waiver Program, the Skilled Nursing Facility Waiver Program, the Model Waiver Program...
3. Individuals determined by the Medi-Cal Field Office to be in need of long term care and residing in a Skilled Nursing Facility (SNF) for 30 days past the month of admission…" California Contract, page 6.
DE
"1.3 Contracting Agency
Background...
(a) Pregnant women and infants
less than one (1) year to one hundred and eighty five-percent (185) of
the FPL...
(f) Persons who require
institutional long-term care services are eligible if their incomes are
below two hundred and fifty (250) percent of the Supplemental Security
Income (SSI) Federal Benefit Rate
Under the Diamond State Health Plan, all adults at or below one hundred (100) percent of the FPL would be eligible for those services in the basic benefits package. Adults at or below one hundred (100) percent of the FPL who are not included within categories (a) through (f) above will be referred to as the ‘expansion population.’...
Delaware Medicaid operates three additional waivers, an AIDS waiver and other home and community-based waivers. Participants in these waivers are excluded from the DHSSHP. Delaware does not have a Medically Needy Program." Delaware RFP, pages I.2-I.4.
DC
"G. ENROLLMENT, EDUCATION,
AND OUTREACH
1. Classes
of person eligible for enrollment...
b. Individuals
who meet the requirements of paragraph 'a' of this section and are included
in one or more of the following categories, are excluded from enrollment
under this contract: ...
(5) residents
of a long-term care facility (nursing facility, intermediate care facility
for the mentally retarded, residential treatment center, Hospital for Sick
Children, and mental institution)." District of Columbia Contract,
pages 15-16.
HIBH
"20.500 HCFA Contingency...
ABD members who will remain
in Medicaid's fee-for-service program and will NOT be enrolled into QUEST
include persons who:…2) are waitlisted in hospitals for nursing facility
bed placement…" Hawaii Behavioral Health RFP, page 7.
"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, are waitlisted in hospitals for nursing facility
bed placement…will be excluded from the QUEST program and remain in fee-for-service…"
Hawaii Behavioral Health RFP, page 36.
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 enrolled
in any Home and Community Based Services (HCBS) Waiver Program…"
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 served
under the alternate intermediate services, mental retardation or developmental
disabilities (AIS-MR-DD), home and community-based, or other Medicaid waivers."
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:
b. recipients covered
under home and community-based waivers, specifically those for mental retardation,
the aged, and the disabled..." 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…"
Maryland COMAR 10.09.63.01.
MN
"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: ...
c. Individuals
eligible under ME Code 41 (MA ICF-MR Poverty) residing in a State Mental
Institution or an Intermediate Care facility for the Mentally Retarded
(ICF/MR)." Missouri RFP, page 16.
MT
"ELIGIBLE GROUPS
The eligibility subtypes
targeted for the HMO program are: ...
RECIPIENTS of home and community-based
waiver services for the developmentally disabled
People in these subtypes are not eligible to enroll in HMOs if they have...are in a nursing home...are RECIPIENTS of home and community based waiver services for the aged or disabled…" Montana Contract, Attachment 4, page 63.
NEBH
"9.2.5 Excluded Clients:
The following clients are excluded from the NHC (based on the information
known to the HHS eligibility system): ...
(h) Clients receiving services
through the following home and community-based waivers pursuant to Title
480 NAC for:
(1) Adults
with mental retardation or related conditions;
(2) Aged
persons or adults or children with disabilities;
(3) Children
with mental retardation and their families;
(4) Infants
and toddlers with disabilities (also known as the Early Intervention Waiver);
(5) Clients
receiving Developmental Disability Targeted Case Management Services; and
(6) Any
other group for whom the Department has received approval of a 1915(c)
waiver of the Social Security Act…" Nebraska Behavioral Health Contract,
pages 33-34.
NM
"2.A.5.a.vi Coordination With Waiver Programs. The CONTRACTOR shall provide all covered benefits to members who are waiver participants. There are four home and community-based waiver programs..." New Mexico Contract, page 16.
ND
"ATTACHMENT F: ELIGIBLE
GROUPS...
2. Individuals in
the aid categories and subcategories are not eligible to enroll in the
HMO if: ...
D. They are recipients
of home and community-based waivered services for the elderly or the disabled."
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... home and community-based
waiver program ADMINISTERED BY ODHS, ODMR-DD, or ODA, 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
PA
"H. Coordination with
Out-of-Plan Services
11. The Home and Community
Based Waiver Program for Nursing Facility Residents With Other Related
Conditions (OSP/OBRA Waiver)
The Department's Office of Social Programs currently operates a Home and Community Based Waiver which provides services to inappropriately placed nursing facility and special rehabilitation facility residents with other related conditions who need specialized services...
MA recipients receiving these
home and community based services through the OSP/OBRA Waiver may be enrolled
in the HealthChoices Program. The HMO is responsible for providing medically
necessary services to these individuals;
however, all services
covered under the OSP/OBRA Waiver are not the responsibility of the HMO.
12. The Home and Community
Based Waiver Program for Attendant Care Services (OSP/AC Waiver)
The Department's Office
of Social Programs currently operates a Home and Community Based Services
Waiver which provides attendant care to mentally alert adults eighteen
(18) through fifty-nine (59) years of age with physical disabilities who
require nursing facility level of care but who choose to remain in their
own home or community living arrangement.
MA recipients receiving these home and community based services through the OSP/AC Waiver may be enrolled in the HealthChoices Program. The HMO is responsible for providing medically necessary services to these individuals; however, all services covered under the OSP/AC Waiver are not the responsibility of the HMO... " Pennsylvania RFP, pages 51-63.
SC
"MARKETING, ENROLLMENT, AND
MEMBER EDUCATION POLICY AND PROCEDURES...
* HMO's should clearly
state that this program is limited to certain Medicaid eligibles who:
- are not in a nursing
home...
- are not Home and
Community Based Waiver recipients;
- are not Hospice
recipients…" South Carolina Contract, Appendix J, page 1.
TN
"2-3 Benefit/Service Requirements
Limitations…
h. Institutional Services
and Alternatives to Institutional Services
Long term care institutional
services of a nursing home, a nursing facility for the mentally retarded
or the Home and Community Based Services (HCBS) alternative for these institutional
services are not covered by this Agreement and shall remain the responsibility
of TENNCARE. Enrollees requiring long term care institutionalization
or the HCBS alternative shall be eligible for participation in the plan
for all covered services and such services shall be the CONTRACTOR's responsibility."
Tennessee Contract, pages 7-19.
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: ...
d. Individuals who
are participating in Federal waiver programs for home and community-based
Medicaid coverage…" Virginia Contract, pages 21-22.