Other individuals

AZ | AZBH | CA | CO | DE | DC | FL | FLMH | HI | HIBH | IL | IN | IA | IABH | KS | KY | ME | MD | MABH
MI | MN | MO | MT | NE | NEBH | NV | NJ | NM | NY | NC | ND | OH | OK | OR | PA | PABH | RI | SC
TN | UTMH | VA | WA | WV

"TITLE XXI MEMBER
Member eligible for acute care services under Title XXI of the Social security Act, referred to in federal legislation as the 'Children's Health Insurance Program' (CHIP). The Arizona version of CHIP is referred to as 'KidsCare'. " Arizona Contract, page 8.

"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 Qualified Medicare Beneficiary program and other Medicare cost sharing programs, and the Title XXI program.

Arizona's 15 Counties
Each County determines eligibility for the Medically Needy/Medically Indigent (MN/MI)…and the State Emergency Services State Programs." Arizona Contract, pages 18-19.

"Native Americans: Native Americans eligible under any coverage group other than MN/MI, on or off reservation, have a choice to receive services from Indian Health Service (IHS), a PL 93-638 tribal facility or any available contractor...

Native Americans may change from IHS to a contractor or from a contractor to IHS at any time. Native American Title XXI members must make a choice prior to being determined eligible." Arizona Contract, page 20.

"64. KIDSCARE
On November 1, 1998, AHCCCSA implemented a Title XXI Children's Health Insurance Program, referred to as 'KidsCare'. KidsCare provides health care coverage statewide to eligible children 18 and younger and is provided through the existing AHCCCS health plans, state employee HMOs that elect to participate, and tribal facilities or Indian Health Service for Native Americans who elect to receive services through them…

The KidsCare service package is established by the legislature and approved by HCFA through the State Plan...

Title XXI Parent/Guardian Health Insurance Coverage: ARS §36.2984 mandates that the Contractor offer health insurance coverage to the parent(s) or legal guardian(s) of a child who is eligible for Title XXI...

Title XXI Parent/Guardian Health Insurance Coverage: ARS 36.2984 mandates that the Contractor offer health insurance coverage to the parent(s) or legal guardian(s) of a child who is eligible for Title XXI. The Contractor shall establish rates for this coverage which must be approved by AHCCCSA, Office of Managed Care, prior to implementation. Title XXI funds or any other federal or state funds shall not be used to subsidize family coverage. The full cost of the premium shall be paid by the parent or legal guardian who elects this coverage…" Arizona Contract, page 54.

AZBH

"SECTION B: CAPITATION RATES...
AHCCCSA will pay monthly capitation to ADHS in accordance with the terms of this contract at the following rates: ...

Title XIX eligible children, under the age of 18 (represents the cost of providing covered behavioral health services to children)...

Title XIX eligible adults, age 18 and older (represents the cost of providing covered behavioral health services to SMI adults): ...

Title XIX eligible adults, age 18 and older (represents the cost of providing covered behavioral health services to non SMI adults): ...

Title XXI eligible adults age 18 (represents the cost of providing covered behavioral health services to SMI and non-SMI adults): …" Arizona Behavioral Health Contract, page 2.

"TITLE XXI MEMBER
Member eligible for acute care services under Title XXI of the Social Security Act, referred to in federal legislation as the 'Children's Health Insurance Program' (CHIP). The Arizona version of CHIP is referred to as 'KidsCare'." Arizona Behavioral Health Contract, page 8.

"SCOPE OF SERVICES...
Laws of 1999. Chapter 313. This revision of the AHCCCS/ADHS contract is believed to contain the necessary revisions from Laws of 1999, Chapter 313 which gives responsibility to ADHS for the provision of medically necessary covered behavioral health services to non-SMI 18 year old Title XXI (KidsCare) and Title XIX non-SMI 18, 19 and 20 year olds.

Eligibility: Covered behavioral health services are available to all enrolled Title XXI and acute care Title XIX members...

2. COVERED SERVICES FOR NATIVE AMERICANS
ADHS shall ensure that covered services are available to all Title XIX and Title XXI eligible Native Americans, whether they live on or off reservation…" Arizona Behavioral Health Contract, pages 10-11.

"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...

1. Individuals who have been approved by the Medi-Cal Field Office or the California Children Services Program for bone marrow, heart, heart-lung, liver, lung, combined liver and kidney, or combined liver and small bowel transplants.

2. Individuals who elect and are accepted to participate in the following Medi-Cal waiver programs: ... the Model Waiver Program, the Acquired Immune Deficiency (AIDS) and AIDS Related Conditions Waiver Program, and the Multipurpose Senior Services Waiver Program...

4. Individuals who have commercial or Medicare HMO coverage, unless the Medicare HMO is a provider under this Contract and DHS has agreed, as a term of the HMO's Contract, that these individuals may be enrolled, and DHS and the Medicare HMO have negotiated an appropriate rate for these individuals. Individuals with Medicare fee-for-service coverage are not excluded from enrolling under this Contract." California Contract, page 6.

"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:
b. Qualified Medicare Beneficiaries...
c. Clients who are known members of a Medicare-funded health maintenance organization or competitive plan other than such a plan offered by the Contractor, and
d. Clients with a comprehensive health coverage other than Medicaid." Colorado Contract, page 12.

"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...
(e) Certain two-parent families when the head of the household is unemployed...

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 RFP, pages I.2-I.4.

"G. ENROLLMENT, EDUCATION, AND OUTREACH
1. Classes of person eligible for enrollment...
(2) infants born to women who are enrolled with Provider shall be automatically enrolled from the date of birth until disenrolled; and
(3) other actuarially equivalent individuals that might become eligible for Medicaid through expansions as allowed by the Balanced Budget Act of 1997 or through Medicaid waivers.

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: ...
(4) individuals who have been restricted to a specific provider by the District..." District of Columbia Contract, page 15.

"7. Eligible Recipients…Title XXI MediKids are eligible for enrollment in the plan in accordance with Section 409.8132, F.S. ...

8. Ineligible Recipients. The following categories describe recipients whom the plan shall not enroll under this contract: ...
b. Medicaid eligible recipients who are receiving services through a hospice program, the Medicaid AIDS waiver (Project AIDS Care) program, the assisted living waiver program, a prescribed pediatric extended care center, or Children's Medical Services..." Florida Contract, page 9.

"AMENDMENT 001...
1. Attachment I, A.9. is added to read:
Except as otherwise specified in this contract, Title XXI MediKids eligible participants are entitled to the same conditions and services as currently eligible Title XIX Medicaid recipients…" Florida Contract, Amendment 001, page 1.

FLMH

"2.13 Persons Eligible for Enrollment: The contractor shall only enroll those Area 6 Medicaid recipients in the authorized categories specified in this section and having the eligibility program codes specified in Attachment 4...

Only recipients not enrolled in a Medicaid HMO are eligible to participate. Eligible Medicaid recipients will either be enrolled in MediPass or in a Medicaid HMO. Medicaid recipients enrolled in MediPass will receive their mental health services through the prepaid mental health plan. The contractor will receive an enrollment report that lists each recipient’s MediPass physician. Eligible recipients include the following Medicaid recipients: ...

3. Emergency Shelter. These are recipients eligible for Medicaid because they are in the care and control of the state..." Florida Mental RFP, pages 34-35.

"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... state mental hospitals or correctional institutions.
3. Medicaid eligible recipients who are receiving services through a hospice program.
4. Medicaid eligible recipients who are members of a Medicaid HMO or prepaid health plan.
5. Medicaid eligible recipients who are eligible due to meeting a share of their medical costs through the Medically Needy Program...
8. Newly eligible AFDC recipients who have not completed the Medicaid enrollment process." Florida Mental Health RFP, pages 34-35.

“All ABD recipients, with exception of the following: ...5) ABD recipients with spend down requirements... will be enrolled into a QUEST plan...” Hawaii RFP, unnumbered page.

“20.120 Hawaii QUEST (QUEST)...
QUEST includes the individuals in the: ...
* General Assistance (GA) Program
* Former State Health Insurance Program (SHIP)...

ABD recipients who will remain in Medicaid’s fee-for service program and will NOT be enrolled into QUEST include persons who: ...5) are ABD recipients with spend down requirements...” Hawaii RFP, pages 4-5.

“40.230 Categorical Requirements
Currently, QUEST includes the... GA financial recipients, former SHIP participants and other eligibles who are not aged, blind or disabled, meet the financial asset and income limitations and are not eligible for employer-sponsored insurance...
ABD participants...having spend down requirements will be excluded from the QUEST program and remain in fee-for-service.

40.240 Employer-Based Health Coverage
Working adults, except for recipients of financial assistance, who have or are eligible for insurance coverage under the Hawaii Prepaid Health Care Act are excluded from participating in QUEST. Their dependents and spouses will be allowed to participate in QUEST.” Hawaii RFP, pages 43-44.

“40.330 Additional QUEST-Net Requirements
To be eligible for QUEST-Net, recipients must currently be enrolled in QUEST or the ABD FFS program. Recipients who qualify for QUEST or ABD may voluntarily choose QUEST-Net to obtain lower out-off-pocket costs. Recipients who are enrolled or eligible for any type of medical coverage, including Medicare, VA, or Champus, are not eligible for QUEST-Net…

40.400 Enrollment into a Health Plan...
Individuals not subject to the enrollment limitation and open application period are...individuals who lose employer sponsored health coverage due to loss of employment within 45 days prior to application. There is no enrollment cap for QUEST-Net.” Hawaii RFP, page 45.

HIBH

"20.300 Hawaii QUEST (QUEST)...
QUEST currently includes the individuals in the: ...
• General Assistance (GA) Program; and
• Former State Health Insurance Program (SHIP)" Hawaii Mental Health Contract, page 4.

"20.400 QUEST-Net
QUEST-Net is a safety-net program implemented on April 1, 1996, providing limited medical, dental and behavioral health services which do not require utilization of the managed care concept. This program was developed primarily for current QUEST and ABD members who become ineligible because their assets exceed the allowable retention limitations…

20.500 HCFA Contingency...
The dual eligibles (i.e., participants with both Medicaid and Medicare coverage) will have the option of enrolling in the QUEST program. All medically needy adults who have the option of enrolling in the QUEST program. All medically needy adults who are SMI and who have spend-down requirements will also have the option of enrolling in the BHMC plan. All other ABD eligibles will be enrolled in a QUEST managed care plan...

20.700 Eligible BHMC Plan Members...
The following Medicaid eligibles who will not be enrolled in the BHMC plan include persons who are: ...
* Receiving Medicaid and Medicare (Dual eligible) and choose to remain in the FFS program (Refer to Subsection 20.750);
* Medically needy (with spend-down) and choose to remain in the FFS program (Refer to Subsection 20.750)...
* Persons committed for evaluation or treatment under chapter 706, HRS (Refer to Subsection 20.770)." Hawaii Behavioral Health RFP, pages 6-8.

"40.100 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...
40.210 Asset Limits
Asset limits of $2,000 for an household of one (1), $3,000 for an household of two (2), and $250 for each additional person in the household, have been established to qualify for QUEST.
40.220 Income Limits
The individual or family gross income cannot exceed 300% of the federal poverty level for current QUEST members.
40.230 Categorical Requirements
Currently, QUEST includes the AFDC, AFDC-related and GA financial members…who are not aged, blind or disabled, meet the financial asset and income limitations and are not eligible for employer-sponsored insurance…" Hawaii Behavioral Health RFP, page 36.

"Eligible Enrollee means a Client or KidCare Participant except one who:
• is receiving Medical Assistance under Aid to the Aged, Blind and Disabled;
• is eligible only through the Transitional Assistance or Refugee Assistance Programs;
• is age 18 or older and eligible only through the State Family and Children Assistance Program;
• is a ward of the Department of Children and Family Services;
• is residing in a long term care facility including state operated facilities;
• has Medicare coverage;
• has significant medical coverage through a third party for Clients or any medical coverage through a third party for KidCare Phase II Participants;
• is eligible only through the Healthy Start program;
• is eligible for Medical Assistance only through meeting a spend-down obligation; or
• is a non-citizen receiving only emergency Medical Assistance." Illinois HMO Contract, pages 2-3.

"3.1.2 Medicaid Eligibility
The Indiana Medicaid program arranges for and administers medical assistance to more than 450,000 individuals. This includes the categorically needy population (those individuals eligible for, or receiving, federal financial assistance or those deemed categorically needy) and those eligible for services under federally-authorized waiver programs. Indiana law does not authorize a medically needy program.

The following categorical groups, which are subject to income and asset limitations, are covered by the Indiana Medicaid program:
* Persons who are age 65 years or older.
* Persons who are blind within the definition set forth in Indiana law.
* Persons who are disabled within the definition set forth in Indiana law.
* TANF (Temporary Assistance for Needy Families), which includes caretakers and children under 18 years receiving TANF.
* Pregnant women who do not receive TANF. The full scope of benefits are available to women who meet strict income and resource criteria, and pregnancy-related coverage is provided to women whose income is below 150% of poverty without regard to their resources.
* Children whose families do not receive TANF but who are under age 21 and meet the eligibility requirements, without regard to resources.
* Children who are wards of county offices of the Division of Family and Children.
In addition, limited Medicaid benefits are available to certain population groups, including:
* Qualified Medicare Beneficiaries (QMBs)
* Pregnant women whose family income exceeds TANF, but are at or below one hundred and fifty percent (150%) of the Federal poverty level. Children in families whose income exceeds TANF, but are at or below one hundred and fifty percent (150%) of the Federal poverty level receive the full range of benefits.
* Qualified Disabled Working Individuals (QDWIs) who have lost Medicare Part A due to their employment status
* Specified Low Income Medicare Beneficiaries (SLIMBs)
* Undocumented or illegal aliens (emergency services only)…" Indiana RFP, pages 3-2 - 3-3.

"1.3 Definitions...
- Recipient - person who receives Medicaid in accordance with the State Plan as defined in 441--75.1 (249A) of the Iowa Administrative Code." Iowa Contract, pages 6, 10.

"ELIGIBLE GROUPS
Medicaid eligibility groups eligible for enrollment in a HMO under this Contract are as follows: ...
37-4 RRP, CMAP...
06-0 RRP, adult receiving cash payment
06-1 RRP, family receiving cash payment
06-3 RRP, adult or family eligible for but not receiving cash payment, medical only...

Medicaid eligible recipients will be excluded from enrollment with a HMO if they:
1. have Medicare or other insurance...
3. are enrolled in another managed care program other than Iowa's prepaid health plan known as the Iowa Plan;
4. live in an area excluded from the waiver;
5. have an eligibility period that is only retroactive;
6. are eligible as medically needy…" Iowa Contract, pages 139-140.

IABH

"31.0 RISK RESPONSIBILITY
This Contract is a risk-based contract for Medicaid mental health and substance abuse services in which the Contractor will be responsible for assuring, arranging, monitoring, and reimbursing all necessary and appropriate mental health and substance abuse services and supports for all enrolled Medicaid beneficiaries as specified in this Contract.

The Contractor also will be at risk in administering services for persons with a mental health indicator who are designated as members in the State Payment Program (SPP) and for assuring, arranging, monitoring, and reimbursing all necessary and appropriate mental health services for persons determined eligible for SPP." Iowa Behavioral Health Contract, page 16.

"36.3 STATE PAYMENT PROGRAM
At the end of each calendar month, DHS will provide to the Contractor a list of State Payment Program members for whom the Contractor will have responsibility for the management of mental health services during the following month and prior member months.

36.4 DPH PARTICPANTS SERVED THROUGH DPH SUBSTANCE ABUSE TREATMENT FUNDING
Licensed substance abuse treatment programs will be responsible for making eligibility determinations for the Non-Medicaid population based upon poverty level guidelines provided by DPH. Persons, who are Iowa residents, who are not Medicaid enrollees, and who are at or below 300% of the poverty guidelines may be eligible for substance abuse treatment services based on this sliding fee scale, so long as there is no other payor available. Medicaid enrollees may not be considered DPH participants during any month of enrollment with the Iowa Plan…

37.0 IOWA PLAN ELIGIBLES NOT ELIGIBLE FOR IOWA PLAN SERVICES
A person who is an inmate of a non-medical public institution such as a public jail or other type of public penal institution is not eligible for Medical Assistance or DPH funded treatment services and thus is not eligible for services through the Iowa Plan…

40.0 STATE PAYMENT PROGRAM
The Contractor shall be responsible to assure, arrange, monitor and reimburse the delivery of State Payment Program (SPP) services to those persons with state case status who carry a mental health indicator (MI and CMI) as determined by the DHS Division of Mental Health/Developmental Disabilities. The Contractor shall make available to an SPP member all services which are available to such members pursuant to the county management plan which covers that person. The Division will retain responsibility to determine applicants' eligibility and to designate those persons whose services are to be managed by the Contractor." Iowa Behavioral Health Contract, pages 25-26.

"IOWA PLAN FOR BEHAVIORAL HEALTH MEDICAID CAPITATION RATE...
CATEGORY OF ASSISTANCE AND AGE RANGE ...
Dual Eligibles (Medicaid & Medicare) Age 0-64." Iowa Behavioral Health Contract, page 64.

"ATTACHMENT ON IOWA PLAN ENROLLMENT CRITERIA...
Medicaid beneficiaries in the following categories of eligibility will be enrolled with in the Iowa Plan unless excluded: ...
* Dual eligible (Medicaid & Medicare)

The following beneficiaries are excluded from enrollment:
* Persons eligible for Medicaid as a result of spending downs excess income (Medically needy with a cash spenddown)...
* Persons whose Medicaid benefit package is limited, such as:
     Qualified Medicare Beneficiaries (QMB),
     Specified Low Income Medicare Beneficiaries (SLMB),
     Home Health SLMB...
     Presumptive Eligible,
     Illegal Aliens,
     Others not entitled to the full range of mental health and substance abuse treatment included in the Iowa Medicaid fee-for-service program." Iowa Behavioral Health Contract, page 77.

"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 with Medicare coverage...
• Beneficiaries enrolled in another Medicaid managed care program;
• Beneficiaries enrolled in a Medicaid administrative 'lock-in' program;
• Beneficiaries who have an eligibility period that is only retroactive; and…
• Health Insurance Premium Payment System (HIPPS) participants" Kansas Contract, pages 40-41.

"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.

"7.10.1 Persons Eligible For Enrollment
To be eligible to enroll in The Partnership Program established pursuant to this RFA, a person must be a recipient of medical assistance under one of the aid categories as defined in Attachment X and must appear on the Partnership's member listing...

Newborns are eligible beginning with the first day of their birth month and unemployed parent program recipients are eligible beginning with the date the definition of 'unemployment' or 'underemployment' is met." Kentucky RFA, pages 76-77.

"Eligibility For Enrollment
Listed below are categories of Medicaid recipients who are eligible to enroll in the Partnership's Network: ...
Pass through...
Under the age of twenty-one (21) years and in a psychiatric residential treatment facility (PRTF)...

Listed below are categories of Medicaid recipients who are not eligible to enroll in the Partnership's Network: ...
Individuals who must spend down to meet eligibility income criteria
Qualified Medicare beneficiaries (QMBs), specified low income Medicare beneficiaries (SLMBs) or qualified disabled working individuals (QDWIs)
Individuals in an intermediate care facility for mentally retarded (ICF-MR)." Kentucky RFA, Attachment X, pages 94-95.

"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: ...
c. recipients eligible for both Medicaid and Medicare;
d. recipients residing in jails or State mental institutions;
e. recipients having only an eligibility period that is retroactive or that is less than three (3) months;
f. recipients living in areas excluded from the waiver; and
g. recipients with other forms of comprehensive insurance.

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: ...
b. migrant farm workers or their dependents...
d. recipients with a terminal illness (as defined by Medicare) who have an established relationship with a qualified health provider who is not within an accessible HMO;
e. recipients with chronic, debilitating conditions who have established relationships with a qualified health provider who is not within an accessible HMO;
f. recipients with specific language barriers or cultural needs that may not be addressed within the available HMOs. Culturally appropriate care is care that is provided with sensitivity, understanding, and respect for the Enrollee's culture;
g. recipients who have to travel more than thirty (30) minutes to obtain primary care services;
h. individuals receiving care in a hospital on the date of enrollment. Such individuals will have effective enrollment periods after hospital discharge..." Maine Contract, pages 2, 5.

"Chapter 63 Maryland Medicaid Managed Care Program: Eligibility and Enrollment
.01 Eligibility.
A. Criteria. Except as provided in §B of this regulation, a Program recipient shall be enrolled in the Maryland Medicaid Managed Care Program, described in this chapter, if the recipient is eligible for receipt of Medical Assistance benefits by qualifying:
(1) As categorically needy or medically needy under COMAR 10.09.24, unless the recipient is:
(a) Eligible to receive Medicare benefits,
(b) Determined medically needy under a spend down, or
(c) Otherwise certified for a period of less than 6 months…" Maryland COMAR 10.09.63.01.

"10.09.69.01...
J. An individual who becomes eligible for REM while enrolled in an MCO may elect to remain in the MCO by notifying the Department in writing of the election.

K. When an REM-eligible individual elects to remain in an MCO, the Department, in consultation with the MCO and the REM-eligible individual, may determine whether the MCO can appropriately meet the individual's medical needs within the parameter of the Program benefit package as described in COMAR 10.09.67.

L. If the Department determines that the MCO cannot appropriately meet the individual's medical needs, it shall issue a written determination to the individual and the MCO, which includes:
(1) The reason for its determination; and
(2) An explanation of the individual's right to appeal the determination according to the procedures set forth in COMAR 10.09.72." Maryland COMAR 10.09.69.01.

MABH

"A. DEFINITIONS...
The following definitions shall be amended or added: ...

3. 'Excluded Recipient' shall be amended by deleting the definition in its entirety and replacing it with the following:
'Excluded Recipient' shall mean any individual who is excluded from participate in the Division's managed care options pursuant to Division regulations at 130 CMR 501et seq." Massachusetts MH/SAP Contract, Amendment 2, pages 1-2.

"II-E MEDICAID ELIGIBILITY AND CHCP ENROLLMENT...
1. Medicaid Eligible Groups Who Must Enroll in the CHCP: ...
*Persons receiving Medicaid for caretaker relatives and families with dependent children who do not receive FIP...

2. Medicaid Eligible Groups Who May Voluntarily Enroll in the CHCP: ...
*Native Americans
*Persons in the Traumatic Brain Injury program...

3. Medicaid Eligible Groups Excluded From Enrollment in the CHCP:
*Persons without full Medicaid coverage, including those in the State Medical Program or PlusCare
*Persons with Medicaid who reside in an ICF/MR (intermediate care facilities for the mentally retarded), or a State psychiatric hospital...
*Persons being served under the Home & Community Based Elderly Waiver Persons enrolled in Children's Special Health Care Services (CSHCS)
*Persons with commercial HMO coverage, including Medicare HMO coverage.
*Persons in PACE (Program for All-inclusive Care for the Elderly)
*Spend-down clients...
*Persons in the Repatriate Assistance Program…" Michigan Contract, pages 16-17.

"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 2.33. Medically Needy means a category of PMAP Enrollees used as a factor to determine the Rate Cell of an individual Enrollee. The Medically Needy category includes those Enrollees who are under age 21, who would not be eligible for AFDC or Statewide MFIP even if their income or assets were below the AFDC or Statewide MFIP program standards." Minnesota Contract, page 14.

"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...

6) MA and GAMC Recipients with private health care coverage through a HMO licensed under Minnesota Statutes, Chapter 62D. Such Recipients may enroll in PMAP and PGAMC on a voluntary basis if the private HMO is the same as the health plan the person will select under PMAP or PGAMC...

7) MA and GAMC Recipients who are terminally ill as defined in Minnesota Rules, Part 9505.0297, Subpart 2(N) and who, at the time enrollment in PMAP would occur, have an established relationship with a primary physician who is not part of a PMAP health plan.

8) Individuals who are Qualified Medicare Beneficiaries (Q.M.B.), as defined in Section 1905(p) of the Social Security Act, 42 U.S.C. 1396d(p), who are not otherwise receiving MA.

9) Individuals who are Service Limited Medicare Beneficiaries (S.L.M.B.), as defined in Section 1905(p) of the Social Security Act, 42 U.S.C. 1396a(a)(10)(E)(iii) and 1396d(p), and who are not otherwise receiving MA.

10) Non-documented alien Recipients who only receive emergency MA under Minnesota Statutes, Section 25613.06, Subdivision 4 or emergency GAMC under Minnesota Statutes, Section 256D.03, Subdivision 3(f).

11) Recipients receiving MA or GAMC on a non-institutional Spenddown basis.

12) Recipients, who at the time of notification of mandatory enrollment in PMAP or PGAMC have a communicable disease whose prognosis is terminal and whose primary physician is not a Participating Provider in the HEALTH PLAN, and that physician certifies that disruption of the existing physician patient relationship is likely to result in the patient becoming noncompliant with medication or other health services.

14) American Indians who are receiving MA or GAMC and who are living on the Indian reservation, if the tribal government of that reservation chooses to exclude these persons…

D. The following MA and/or GAMC populations are excluded on the effective date of this Contract, but may become eligible for mandatory enrollment (or voluntary enrollment for the population described in paragraph 5) during the term of this Contract.

3) Children who prior to enrollment in PMAP are determined to be in need of protection and are receiving MA services through a provider who is not a Participating Provider in PMAP.

4) MA and GAMC Recipients who have private health care coverage through an HMO licensed under Minnesota Statutes, Chapter 62D.

5) Non-institutionalized Recipients who are eligible for MA and GAMC on a monthly Spenddown basis may voluntarily enroll in PMAP or PGAMC." Minnesota Contract, pages 17-19.

"1.4.4 Parent's Fair Share Under Title XIX
a. Covered Groups
Certain uninsured non-custodial parents actively participating in the Missouri's Parent's Fair Share program will be eligible for Medicaid under this waiver amendment...

To be eligible for Parent's Fair Share the non-custodial parent must meet the following requirements:
1) Must reside in the State of Missouri
2) Must have one child receiving TANF benefits, food stamps, or Title XIX benefits in the State of Missouri (the child cannot reside with the non-custodial parent);
3) Must be the legal or presumed parent of the child (paternity cannot be in question); and
4) Must be unemployed or underemployed (working fewer than 40 hours a week at minimum wage or less)…" Missouri RFP, pages 13-14.

"1.4.5 Uninsured Custodial Parents Below 100 Percent Under Title XIX
a. Covered Groups
Uninsured custodial parents with income up to 100 percent of the federal poverty level will be eligible for Medicaid." Missouri RFP, page 14B.

"1.7.2 Not Covered Under the Managed Care Plan: ...
e. Individuals eligible under ME Codes 2, 3, 12, and 15 (Aid to the Blind and Blind Pension).
f. Individuals eligible under ME Code 09 (General Relief).
g. AIDS Waiver participants (individuals over twenty-one (21) years of age).
h. Any individual eligible and receiving either or both Medicare Part A and Part B benefits." Missouri RFP, page 16.

"Group Eligibility Criteria...
Adoption Subsidy...
Adoption Subsidy-Homeless,
Dependent, Neglected Children (HDN)...
CWS Health Initiative Fund
CWS Health Initiative Fund...
Child Welfare-HIF…" Missouri RFP, Attachment One.

"2.1.5 Notification of Medicare and TPL Eligibility Medicare/Medicaid dual eligibles will not be eligible to join the CONTRACTOR'S plan. The CONTRACTOR shall contact the State's ADMINISTRATIVE CONTRACTOR FOR MANAGED CARE if it becomes aware that an ENROLLEE has become eligible for Medicare while on Medicaid. It shall also notify the State's ADMINISTRATIVE CONTRACTOR FOR MANAGED CARE if it becomes aware of insurance coverage which differs from the health coverage information forwarded to the CONTRACTOR by the DEPARTMENT via the 'Contractor Enrollment Information.'" Montana Contract, page 31.

"ELIGIBLE GROUPS
The eligibility subtypes targeted for the HMO program are: ...
automatic newborn...
family MEDICAID...
transitional MEDICAID…

People in these subtypes are not eligible to enroll in HMOs if they have Medicare in addition to MEDICIAD coverage, are in a nursing home or are institutionalized, are medically needy, are RECIPIENTS of home and community based waiver services for the aged or disabled, or are children under court ordered absent parent child support." Montana Contract, Attachment 4, page 63.

"9.2.5 Excluded Clients: The following clients shall be excluded from the NHC (based on the information known to the HHS eligibility system):
(a) Clients with Medicare coverage pursuant to 471 NAC 3-000...
(d) Clients who are residing out-of-state (i.e., children who are placed with relatives out-of-state, and who are designated as such by HHS personnel...
(f) Aliens who are eligible for Medicaid for an emergency condition only pursuant to Title 469 NAC...
(i) Clients who have excess income (i.e., spenddown - met or unmet) pursuant to 471 NAC 3-000;
(j) Clients participating in the Subsidized Adoption Program, including those who receive a maintenance subsidy from another state, pursuant to 469 NAC...
(l) Clients eligible during the period of presumptive eligibility pursuant to 471 NAC 28-000;
(m) Transplantation recipients pursuant to 471 NAC 10-000 and Section 9.18 of this contract;
(n) Clients who have received a disenrollment/waiver of enrollment pursuant to Section 9.18 and 9.19 of this contract; and
(o) Clients with private health insurance for medical/surgical benefits determined to be qualified coverage or whose insurance coverage is pending verification. Qualified coverage includes verified standard comprehensive coverage, verified HMO or prepaid plan with specified providers, or verified CHAMPUS. Note: Clients with private health insurance shall be 'excluded' from NHC until the coverage is verified; at that time, clients not having qualified coverage will be required to participate in NHC pursuant to 471 NAC 3-000." Nebraska Contract, pages 32-33.

NEBH

"9.2.5 Excluded Clients: The following clients are excluded from the NHC (based on the information known to the HHS eligibility system): ...
(d) Clients who are residing out-of-state (i.e., children who are placed with relatives out-of-state, and who are designated as such by HHS personnel)…
(i) Clients who have excess income (i.e., spenddown - met or unmet) pursuant to 471 NAC 3-000...
(l) Clients eligible during the period of presumptive eligibility pursuant to 471 NAC 28-000;
(m) Transplantation recipients pursuant to 471 NAC 10-000 and Section 9.8 of this contract; and
(n) Clients who have received a disenrollment/waiver of enrollment pursuant to Section 9.8 of this contract." Nebraska Behavioral Health Contract, pages 33-34.

"45. The Contractor agrees to accept all Medicaid participants enrolled by DHCFP as specified in Attachment C, Section I.B. and I.D…" Nevada Contract, page 13.

"DHR DUTIES AND RESPONSIBILITIES
I. Eligibility

A. Eligibility Determination. DHR will continue to have sole authority for determining whether individuals or families meet Medicaid eligibility criteria and are enrolled with the Contractor. Determination of initial Medicaid eligibility, redetermination of continued eligibility, and ongoing case maintenance (e.g., change of address) will remain the responsibility of NSWD.

As under the current system, individuals will apply for Medicaid at the Welfare District Office (DO) nearest to which he or she resides or, in some cases, at outreach sites. The eligibility certification specialist (ECS) processes the application and determines eligibility. New recipients will receive a Medicaid identification card the week following their eligibility determination. Ongoing recipients will receive a new Medicaid card for each month that he or she continues to be eligible for Medicaid benefits…

C. Medicaid Recipients Excluded From Enrollment. The following recipients eligible for Medicaid will be excluded from enrollment. These individuals will be identified through data matches with other state agencies and self reporting by recipients and parents:
1. Children who are inpatients of a Residential Treatment Facility;
2. Individuals with comprehensive health coverage from another health organization or agency which cannot reimburse the Contractor; and
3. Dual Medicare-Medicaid eligibles…" Nevada Contract, page 46.

"ARTICLE 5
PERSONS ELIGIBLE FOR ENROLLMENT
5.1 Except as specified in Section 6.1, all persons, who are not institutionalized, that are eligible for the following eligibility categories and who reside in any of the enrollment areas... shall be eligible for enrollment in the contractor's plan...
F. Uninsured children up to the age of 19 who qualify for the NJ KidCare Program…" New Jersey Contract, page 36.

"ARTICLE 6
ENROLLMENT EXCLUSIONS AND EXEMPTIONS
6.1 The following persons are excluded from enrollment in the contractor's plan: ...
    A. Individuals in Home and Community-based Waiver program...
    B. Individuals in a Medicaid demonstration program...
    D. Individuals in the Medically Needy, Presumptive Eligibility for Pregnant Women, or Home Care Expansion Program.
    E. Infants of inmates of a public institution living in a prison nursery…

6.3 Exemption Reasons: The contractor should refer those persons who desire to avail themselves of an enrollment Exemption to the Health Benefits Coordinator. Neither the Contractor, its subcontractors, nor agents may coerce individuals to disenroll because of their health care needs which may meet an exemption reason, especially when the enrollees want to remain enrolled. Individuals may be exempted from enrollment in an HMO for the following reasons:

A. Pregnant women, beyond the first trimester, who have an established relationship with an obstetrician who is not a participating provider in the contractor's plan. These individuals will be tracked and enrolled after sixty (60) days postpartum.

B. Individuals with a terminal illness and who have an established relationship with a physician who is not a participating provider in the contractor's plan.

C. Individuals with a chronic, debilitating illness and have received treatment from one physician with whom they have an established relationship.

D. Individuals who do not speak English or Spanish and who have an illness requiring on-going treatment and who have an established relationship with a physician who speaks the same language and there is no available primary care physician in any of the participating managed care plans who speak the client's language. These cases will be reviewed on a case-by-case basis with no automatic exemption from initial enrollment.

E. Individuals who do not have a choice of at least two (2) PCPs within thirty (30) miles of their residence." New Jersey Contract, pages 37-38.

"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: …the Medically Fragile Waiver and the AIDS Waiver. An integral part of each waiver is the provision of case management." New Mexico Contract, pages 16-17.

"Medicaid eligible clients are required to participate in the Medicaid managed care program except for the following:
2.B.1.a Clients eligible for both Medicaid and Medicare, i.e. dual eligibles...
2.B.1.d Clients participating in the Health Insurance Premium (HIP) program...
2.B.1.f Native American who opt-out of Salud..." New Mexico Contract, page 22.

"22. New Article 41 is created and certain provisions of the Agreement are amended to include participants of the State Children Health Insurance Program (SCHIP) as members:
The CONTRACTOR shall enroll as members children who are participants in the SCHIP Program under Title XXI of the Social Security Act." New Mexico Contract, Amendment #1, page 11.

"5. ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS
5.1 Eligible Populations
a) Except as specified in Section 5.1(b) and 5.3 below, all persons in the following Medicaid-eligible beneficiary categories who reside in the service area shall be eligible for enrollment in the Contractor's plan: ...
viii) Transitional Medical Assistance Beneficiaries...

5.2. 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...
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...
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 provider for any MCO participating in the Medicaid managed care program service area...
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...
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...
m) Native Americans...
o) Individuals temporarily residing out of district, (e.g., college students) will be exempt until the last day of the month in which the purpose of the absence is accomplished. The definition of temporary absence is set forth in Social Services regulations 18 NYCRR §360-1.4(p).

5.3 Excluded Populations
The following populations are ineligible for enrollment in Medicaid managed care.
a) Individuals who are Dually Eligible for Medicare/Medicaid.
b) Individuals who become eligible for Medicaid only after spending down a portion of their income (Spend-down)…
e) Individuals enrolled in managed long term care demonstrations authorized under Article 4403-f of the New York State P.H.L.
f) Medicaid-eligible infants living with incarcerated mothers...
h) Individuals with access to comprehensive private health care coverage including those already enrolled in an MCO…" New York Contract, pages 5-1-5-4.

"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...
a. Individuals covered under Section 1931 of the Social Security Act (1931 Group)…" North Carolina Contract, page 5.

"3.2 Persons Ineligible for Enrollment
The following categories of Recipients are not eligible to enroll in the Plan: …
j. Participants in Community Alternatives Programs (CAP/DA, CAP/MR-DD, CAP/AIDS, CAP/C)." North Carolina Contract, page 5.

"2.26 Notification of Medicare and TPL Eligibility
Medicare and Medicaid dual eligibles will not be eligible to join the Contractor's plan during this contract period…" North Dakota Contract, Attachment C, page 25.

"ATTACHMENT F: ELIGIBLE GROUPS
1. Except as provided in subsection 2, the following groups of eligible Medicaid recipients may be enrolled in the HMO program: ...
E. All optional categorically eligible individuals 0 through 20 years of age (AFPU, AFCT, AFCH, AFCU).
2. Individuals in the aid categories and subcategories are not eligible to enroll in the HMO if:
A. They have Medicare coverage in addition to Medicaid coverage...
C. They are medically needy…" North Dakota Contract, Attachment F, page 1.

"APPENDIX D…
Special Enrollment Exclusions...
In rare and unique situations, an individual's health care condition and circumstances may permit exclusion from managed care if, in the best judgment of ODHS, enrollment would result in a significant disruption in health services received by the enrollee.

The criteria for such exclusions are limited and relate to disease complexity, the chronic nature of the condition, and the existence and availability of necessary providers in the Medicaid program's provider service area." Ohio RFP, Appendix D, pages 2-3.

"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 persons eligible under 56 O.S. Supp. 1999, §1010.1;
• The SoonerCare population, which are groups of other eligibles resulting from federal or state mandated categories of eligible persons…" 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 served through a home & community based waiver...
• Individuals who are classified as medically needy..." Oklahoma RFP, page 18.

"11. ENROLLMENT/DISENROLLMENT
A. Enrollment
Enrollment is the process by which DHR signs on with a particular contractor those individuals who have been determined to be eligible for services under the Oregon Health Plan Medicaid Demonstration Project and/or the Childrens' Health Program…" Oregon Contract, page 28.

"C. HealthChoices Program...
3. Phase-In
Contract to operate the HealthChoices Program will become effective in accordance with the following schedule...
Mandatory recipient enrollment for the Second Phase of program eligible groups:
July 1, 1997…General Assistance (GA) (State and Federal)…Migrant Workers...

The six (6) eligible groups are described below...
f. State-Only GA: A state funded program which provides cash grants and MA or MA only (Medically Needy Only and Non-Money Payment) to Pennsylvania individuals and families whose income and resources are below established standards and who do not qualify for the AFDC program.

g. Federally-Assisted MA for GA Recipients: A federal and state funded program which provides MA only (Medically Needy Only and Non-Money payment) to Pennsylvania individuals and families whose incomes and resources are below established standards and who do not qualify for the AFDC program…" Pennsylvania RFP, pages 6-9.

PABH

"2. HealthChoices/Behavioral Health Program Rate Categories
Bidders will be required to develop and submit capitation proposals for seven (7) rate groups, or categories. Specifically:
b. Rate Category 2: Health Beginnings...
e. Rate Category 5: State-Only GA/Categorically Needy
f. Rate Category 6: State-Only GA/Medically Needy Only
g. Rate Category 7: Federal GA" Pennsylvania Behavioral Health RFP, page 32.

"4. Health Choices Program Eligible Groups
For purposes of the RFP, the Health Choices Program population is defined to consist of seven different eligible groups, or aid categories...

5) State-Only GA for Categorically Needy: A state funded program which provides cash grants and MA to Pennsylvania individuals and families whose income and resources are below established standards and who do not qualify for the AFDC program.
6) State-Only GA for Medically Needy Only: A state funded program which provides MA only to Pennsylvania individuals and families whose income and resources are below established standards and who do not qualify for the AFDC program.
7) Federally-Assisted MA for GA Recipients: A federal and state funded program which provides MA only (Medically Needy only and Non-Money payment) to Pennsylvania individuals and families whose income and resources are below established standards and who do not qualify for the AFDC program. " Pennsylvania Behavioral Health RFP, pages 44-45.

"2.04.02.03 Rhode Island Certified Family Home Child Care Providers
This group consists of Certified Home Child Care Providers and their family members.

2.04.02.04 Other Medical Assistance Clients In Rite Care Households
In household situations where one or more members are enrolled in the plan through Rite Care, the State may request that the Contractor offer optional enrollment to all other household members who qualify for Medical Assistance…" Rhode Island RFP, page 10.

"MARKETING, ENROLLMENT, AND MEMBER EDUCATION POLICY AND PROCEDURES...
* HMO's should clearly state that this program is limited to certain Medicaid eligibles who:
- do not also have Medicare…
- are not Family planning Waiver recipients...
- do not have an HMO through third party coverage." South Carolina Contract, Appendix J, page 1.

"2-4. Persons Eligible for Enrollment
a. Eligible Persons
Eligibility in TennCare shall be limited to persons who meet the following criteria:
1. Would have been Medicaid-eligible under the Tennessee Medicaid program as administered in State Fiscal Year 92-93;
2. Are unable, because of an existing medical condition, to purchase health insurance; or
3. As of March 1, 1993...did not have coverage under an individual health insurance policy or who did not have (either directly or through a family member) coverage under, or access to, employer-sponsored health insurance or to another government health plan, and continues to lack this access...
4. Other individuals who are uninsured according to the criteria set forth by TENNCARE...

b. Ineligible Persons
Eligibility shall cease when one or more of the following situations exists:
1. The person becomes eligible for participation in an employer sponsored health plan, either directly or indirectly through a family member;
2. The person becomes eligible for participation in Medicare (not dually eligible for Medicare and Medicaid; dually eligible persons remain eligible for TennCare);
3. The person purchases individually funded non-employer health insurance;
4. The person becomes eligible for participation in another government health plan…" Tennessee Contract, pages 31-32.

UTMH

"Article I
DEFINITIONS...

'Enrollee' or 'Medicaid Enrollee' means any Medicaid eligible person whose eligibility has been established within the geographic boundaries of the enrollment area served by the CONTRACTOR, excluding residents of the Utah State Hospital and Utah State Developmental Center...

'Medicaid Eligible Person' means any individual who has been certified by the Utah Department of Health Utah Department of Human Services or the Utah Department of Workforce Services to be eligible for Medicaid benefits. The effective date of eligibility begins on the first day of the month of application and may include the three-month period before the month of application, if so indicated on the official eligibility file...

'Retroactive Medicaid Eligible Person' means a person who is made eligible for Medicaid up to three months prior to the month of application if the client has incurred medical costs during that time and would have been eligible for Medicaid had they applied…" Utah Mental Health Contract, pages 1-2.

"Rate Cells...
Separate rates will be established for each eligible group as follows: ...
8. Medically Needy Child (to age 20)
9. Medically Needy Adult…" Utah Mental Health Contract, page 23.

"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: ...

c. Individuals who are placed on spend-down...

f. Individuals who live outside their area of residence for greater than sixty (60) calendar days, except those individuals placed there for medically necessary services funded by the Contractor or other Medallion II plan;

g. Individuals who enter into a Department-approved hospice program in accordance with Department criteria;

h. Individuals with other comprehensive group or individual health insurance coverage, including Medicare, insurance provided to military dependents, and any insurance purchased through the Health Insurance Premium Payment Program, except as set forth in this Contract...

k. Individuals who have been pre-assigned to the Contractor but have not yet been enrolled, who have been diagnosed with a terminal condition and whose physician certifies a life expectancy of six (6) months or less may request exclusion from Medallion. Requests must be made during the pre-assigned period...

m. Individuals who have been pre-assigned to an HMO but have not yet been enrolled, who are scheduled for surgery which is scheduled to be within thirty (30) days of initial enrollment into the HMO, which requires an inpatient hospital stay, until the first day of the month following discharge." Virginia Contract, pages 21-23.

"AMENDMENT 1
1. The purpose of this amendment is to add coverage for Children's Health Insurance Program (CHIP) clients.
2. The terms and conditions of the department's Request for Qualifications and Quotation (RFQQ) for CHIP, including the amendment and questions and RFQQ answers, are incorporated by reference, except as specifically modified below:
a. CHIP clients will only be required to enroll with a managed care plan if they reside in a county where two plans are available. (This modifies provision 2.21 of Section 3 of the CHIP RFQQ.)
b. CHIP clients residing in counties where one plan is available will have the choice of enrolling with that plan or receiving services under the department's fee-for-service delivery system. (This modifies provision 2.21 of Section 3 of the CHIP RFQQ.)...
4. The following terms and conditions of this contract for Healthy Options do no apply to CHIP members:
a. Section 2.2, Eligible Client Groups. The CHIP RFQQ defines eligibility requirements for CHIP." Washington Contract, Amendment 1, page 1.

"1.1 BACKGROUND
The Medically Needy and Medicare/Medicaid dual eligible populations will be excluded...The feasibility of including these populations during a later phase of the program will be investigated." West Virginia RFA, page 1.