CA

"4.4.2   Definitions
For purposes of Section 4.4, Enrollment Processing, the following definitions shall apply: ...

C. Mandatory Plan Beneficiary shall not include any Eligible Beneficiary who:
   (i) is eligible to receive Covered Services on a Fee-for-Service basis because her/his MEDS eligibility for  managed care plan enrollment is interrupted due to aid code, ZIP code or county code changes; or
   (ii) becomes eligible for enrollment in a managed care plan on a retroactive basis.

4.4.3  DHS Enrollment Obligations
A. DHS shall receive applications for enrollment from its enrollment contractor and shall verify the current eligibility of applicants for enrollment in Contractor’s plan under this Contract. ..

B. DHS or its enrollment contractor shall assign Eligible Beneficiaries meeting the enrollment criteria...

C. Notwithstanding any other provision in this Contract, A and B above shall not apply to:
1. Eligible Beneficiaries previously eligible to receive Medi-Cal services from a Prepaid Health Plan or Primary Care Case Management plan and such plan's contractor with DHS expires, terminates, or is assigned or transferred to Contractor;

2. Members who are enrolled into another managed care plan on account of assignment, assumption, termination, or expiration of this Contract;

3. Eligible Beneficiaries covered by a new mandatory aid code, added to this Contract after October 1, 1998;

4. Eligible Beneficiaries meeting the criteria of Title 22, CCR, Section 53845(b) prior to October 1, 1998, who subsequently meet the criteria of Title 22, CCR, Section 53845(a) due solely to DHS designating a prior voluntary aid code as a new mandatory aid code;

5. Eligible Beneficiaries residing in a County that is not a fully Converted County; or

6. Eligible Beneficiaries without a current valid deliverable address or with an address designated as a County post office box for homeless beneficiaries."  California Contract, pages 53-55.

NE

"9.5.1 Blind/Disabled Clients:
A client, who is blind/disabled, will be excluded from auto-assignment…"  Nebraska Contract, page 34.

"9.5.2 Departmental Wards/Foster Care Clients: ...
A Department Ward/Foster care client will be excluded from auto-assignment…"  Nebraska Contract, page 35.

NJ

"ARTICLE 6
ENROLLMENT EXCLUSIONS AND EXEMPTIONS...
6.2  The following individuals are excluded from the Automatic Assignment process described in Article 7:
  A.  Individuals whose Medicaid eligibility will terminate within 3 months or less after the projected date of effective enrollment.
  B.  Individuals who live in a county where mandatory enrollment is not required.
  C.  Individuals already enrolled in an HMO with a Medicaid contract or private HMO which does not have a contract with the Department to provide Medicaid services.
  D.  Individuals in the Pharmacy Lock-in or Hospice programs.
  E.  Individuals in eligibility categories other than AFDC or AFDC-related New Jersey Care populations or NJ KidCare Plan A.
  F.  Individuals eligible through the Division of Youth and Family Services.
  G.  Individuals participating in NJ KidCare-Plan B, Plan C and Plan D…"  New Jersey Contract, pages 37-38.

"ARTICLE 7
ENROLLMENT
7.1  Enrollment shall be voluntary.  However, certain Medicaid eligible persons who reside in enrollment areas that have been designated for mandatory enrollment, who qualify for AFDC and AFDC-related New Jersey Care eligibility categories, and who do not voluntarily choose enrollment in the contractor's plan, will be assigned automatically by DMAHS to a Health Maintenance Organization.

  A.  Applicants for the NJ KidCare Program must enroll in a HMO which has a contract with DHS in order to receive services under the NJ KidCare program.  Auto assignment is not applicable to NJ KidCare Plan B, C and D participants."  New Jersey Contract, pages 37-38, 40.

PABH

"3.  Phase-in...
a.  Phase-In of HealthPass Members
  The HealthPass 1915 (b) waiver will expire on December 31, 1996, or with the implementation of the HealthChoices Program, whichever is first.  At that time, SSI, GA and Healthy Horizons eligibles currently enrolled in the HealthPASS Program will not be required to remain enrolled in a managed care plan.  These recipients will not be mandated into the HealthChoices Program until July 1, 1997.  However, these recipients will be permitted to participate in the HealthChoices Program on a voluntary basis…"  Pennsylvania Behavioral Health RFP, page 43.

WI

"D. EXEMPTIONS FROM ENROLLMENT IN ANY HMO AND DISENROLLMENT FOR PATIENTS OF CERTIFIED NURSE MIDWIVES OR NURSE PRACTITIONERS - Enrollees may be eligible for exemption from enrollment in any HMO or for disenrollment if:
1.  They reside in a service area of a certified nurse midwife or nurse practitioner, and
2.  They choose to receive their care from a certified nurse midwife or nurse practitioner, and
3.  The certified nurse midwife or nurse practitioner is not affiliated with any HMO in the service area, or
4.  The certified nurse midwife or nurse practitioner is not independently certified as a provider of any HMO within the service area...

E. EXEMPTION FROM ENROLLMENT IN ANY HMO AND DISENROLLMENT FOR AIDS OR HIV-POSITIVE WITH ANTI-RETROVIRAL DRUG TREATMENT - Enrollees with a confirmed diagnosis of AIDS, as indicated by an ICD-9-CM diagnosis code or HIV-Positive who are on anti-retroviral drug treatment approved by the Federal Food and Drug Administration are eligible for exemption from enrollment in any HMO and for disenrollment...

F. EXEMPTIONS FROM ENROLLMENT IN ANY HMO and DISENROLLMENT FOR PATIENTS OF FEDERALLY QUALIFIED HEALTH CENTERS - Enrollees may be eligible for exemption from enrollment in any HMO and disenrollment if:
1.  they reside in the service area of an FQHC,
2.  they choose to receive their primary care from the FQHC, and
3.  the FQHC is not affiliated with any HMO within the service area...

H.  EXEMPTIONS FROM ENROLLMENT IN ANY HMO AND DISENROLLMENT FOR RECIPIENTS WITH COMMERCIAL HMO INSURANCE or COMMERCIAL INSURANCE WITH A RESTRICTED PROVIDER NETWORK-Enrollees who have commercial HMO insurance may be eligible for exemption from enrollment in any HMO or disenrollment, if the commercial HMO does not participate in Medicaid. In addition, enrollees who have commercial insurance which limits enrollees to a restricted provider network (e.g., PPOs, PHOs, etc.) may be eligible for an exemption from enrollment in any HMO or disenrollment...

I. EXEMPTION FROM ENROLLMENT IN ANY HMO AND DISENROLLMENT FOR FAMILIES WHERE ONE OR MORE MEMBERS ARE SSI ELIGIBLE - Families may be Eligible for exemption from enrollment in any HMO and disenrollment if:
1.  There are one or more members in the family who are SSI eligible, and
2.  The SSI eligible members are in fee-for-service Medicaid, or
3.  The SSI eligible members have commercial HMO insurance and the commercial
HMO is either not participating in Medicaid or is a different HMO from that of the HMO eligible family."  Wisconsin Contract, pages 55-56.

"11. EXEMPTION PRIVILEGE DEFINED - For Medicaid recipients who are eligible for HMO enrollment under the terms of Article V of this Contract, and who are thought to meet one or more of the criteria in 12, the AFDC case head shall be given the option of enrolling the recipient who meets one or more criteria in an HMO or applying to have the affected person remain in the Medicaid fee-for-service system...
The AFDC case head shall be given the option of having the affected person remain in the HMO or applying to be exempted at any point during the terms of this Contract...

12. CRITERIA FOR EXEMPTION - The HMO shall not be liable, at the point in time commencing with the month for which the recipient's voluntary exemption becomes effective, except as provided in 9 above, for providing contract services to Medicaid cases in which there is an HMO enrollee who meets one or more of the following criteria as provided in requirement 11 of this addendum:
 a.  a person with recurrent or persistent psychosis and/or a major disruption in mood, cognition or perception;
 b.  a child from birth through two years of age (i.e., including 2 year olds), who is severely developmentally disabled or suspected of a severe developmental delay, or who is admitted to a 0-3 program;
 c.  a person participating in a methadone treatment program, or who has been determined to need methadone treatment unless the person declines to receive such treatment;
 d.  a person who has extensive non-medical programming needs which the 51.42, 51.437, and social/human services system are typically best equipped to provide or coordinate."  Wisconsin Contract, Addendum II, page 83.