Common use of Excluded Populations Clause in Contracts

Excluded Populations. The following categories describe Medicaid Recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid 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 (and have been CARES assessed), sub-acute inpatient psychiatric facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICF-DD); c. Medicaid Recipients whose Medicaid eligibility was determined through the medically needy program. d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s). e. Medicaid Recipients who have other creditable health-care coverage, such as TriCare or a private health maintenance organization (HMO). f. Medicaid Recipients who reside in the following: (1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ); (2) Residential group care operated by the Family Safety & Preservation Program of the DCF; (3) Children's residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as Purchased Residential Treatment Services - "PRTS"); (4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and (5) Residential Level I and Level II substance abuse treatment programs. (See Sections 65D- 30.007(2)(a) and (b), F.A.C.) g. Medicaid Recipients participating in the Family Planning waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network. j. Women eligible for Medicaid due to breast and/or cervical cancer. k. Individuals eligible under a hospice-related eligibility group. l. Medicaid Recipients who are members of the Florida Assertive Community Treatment Team (FACT team).

Excluded Populations. The following categories describe Medicaid Recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid 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 (and have been CARES assessed), sub-acute inpatient psychiatric facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICF-DD); c. Medicaid Recipients whose Medicaid eligibility was determined through the medically needy program. d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 ▇▇▇▇▇ ▇ (QI-1s▇▇-▇▇). e. Medicaid Recipients who have other creditable health-care coverage, such as TriCare or a private health maintenance organization (HMO). f. Medicaid Recipients who reside in the following: (1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ); (2) Residential group care operated by the Family Safety & Preservation Program of the DCF; (3) Children's residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as Purchased Residential Treatment Services - "PRTS"); (4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and (5) Residential Level I and Level II substance abuse treatment programs. (See , as described in Sections 65D- 30.007(2)(a65D-30.007(2)(a) and (b), F.A.C.) g. Medicaid Recipients participating in the Family Planning waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network. j. Women eligible for Medicaid due to breast and/or cervical cancer. k. Individuals eligible under a hospice-related eligibility group. l. Medicaid Recipients who are members of the Florida Assertive Community Treatment Team (FACT team).

Excluded Populations. The following categories describe Medicaid Recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid 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 (and have been CARES assessed), sub-acute inpatient psychiatric facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICF-DD); c. Medicaid Recipients whose Medicaid eligibility was determined through the medically needy program. d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s). e. Medicaid Recipients who have other creditable health-care coverage, such as TriCare or a private health maintenance organization (HMO). f. Medicaid Recipients who reside in the following: (1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ); (2) Residential group care operated by the Family Safety & Preservation Program of the DCF; (3) Children's residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as Purchased Residential Treatment Services - "PRTS"); (4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and (5) Residential Level I and Level II substance abuse treatment programs. (See Sections 65D- 30.007(2)(a) and (b), F.A.C.) g. Medicaid Recipients participating in the Family Planning waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Children‘s Medical Services Network. j. Women eligible for Medicaid due to breast and/or cervical cancer. k. Individuals eligible under a hospice-related eligibility group. l. Medicaid Recipients who are members of the Florida Assertive Community Treatment Team (FACT team).

Excluded Populations. The following categories describe Medicaid Recipients recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid Recipients recipients who, at the time of application for Enrollment enrollment and/or at the time of Enrollmentenrollment, are domiciled or residing living in an institution, including a nursing facilities facility (and have been CARES assessed), sub-acute inpatient psychiatric Statewide Inpatient Psychiatric (SIPP) facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICF-DDICFDD), a state mental health hospital or a correctional facility; c. Medicaid Recipients recipients whose Medicaid eligibility was determined through the medically needy Medically Needy program.; d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s).; e. Medicaid Recipients recipients who have other creditable health-health care coverage, such as TriCare or a private commercial health maintenance organization (HMO).plan; f. Medicaid Recipients recipients who reside in the following: (1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ); (2) Residential group care operated by the Family Safety & Preservation Program of the Department of Children and Families (DCF;); AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract (3) Children's ’s residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as Purchased Residential Treatment Services - "— PRTS"); (4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and (5) Residential Level I and Level II substance abuse treatment programs. (See Sections 65D- 30.007(2)(ass. 65D-30.007(2)(a) and (b), F.A.C.); g. Medicaid Recipients recipients participating in the Family Planning waiver.Waiver; h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network.; j. i. Women eligible for Medicaid due to breast and/or cervical cancer.; k. j. Individuals eligible under a hospice-related eligibility group.group or receiving hospice services; k. Individuals enrolled in the Nursing Home Diversion Program or the Program of All Inclusive Care for the Elderly (PACE); l. For non-Reform populations, individuals enrolled in the PAC Waiver; and m. For Reform populations and non-Reform HMO populations, Medicaid Recipients recipients who are members of the Florida Assertive Community Treatment Team (FACT team)) unless they disenroll from the FACT team. These recipients are allowed to enroll in non-Reform PSNs.

Excluded Populations. The following categories describe Medicaid Recipients recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid Recipients recipients who, at the time of application for Enrollment enrollment and/or at the time of Enrollmentenrollment, are domiciled or residing living in an institution, including a nursing facilities facility (and have been CARES assessed), sub-acute inpatient psychiatric Statewide Inpatient Psychiatric (SIPP) facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICF-DD), a state mental health hospital or a correctional facility; c. Medicaid Recipients recipients whose Medicaid eligibility was determined through the medically needy Medically Needy program.; d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s).; e. Medicaid Recipients recipients who have other creditable health-health care coverage, such as TriCare or a private commercial health maintenance organization (HMO).plan; f. Medicaid Recipients recipients who reside in the following: (1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ); (2) Residential group care operated by the Family Safety & Preservation Program of the Department of Children and Families (DCF;); WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform Contract (3) Children's ’s residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as Purchased Residential Treatment Services - "– PRTS"); (4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and (5) Residential Level I and Level II substance abuse treatment programs. (See Sections 65D- 30.007(2)(ass. 65D-30.007(2)(a) and (b), F.A.C.); g. Medicaid Recipients recipients participating in the Family Planning waiver.Waiver; h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network.; j. i. Women eligible for Medicaid due to breast and/or cervical cancer.; k. j. Individuals eligible under a hospice-related eligibility group.group or receiving hospice services; k. Individuals enrolled in the Nursing Home Diversion Program or the Program of All Inclusive Care for the Elderly (PACE); l. For non-Reform populations, individuals enrolled in the PAC Waiver; and m. For Reform populations and non-Reform HMO populations, Medicaid Recipients recipients who are members of the Florida Assertive Community Treatment Team (FACT team)) unless they disenroll from the FACT team. These recipients are allowed to enroll in non-Reform PSNs.

Excluded Populations. The following categories describe Medicaid Recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid 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 (and have been CARES assessed), sub-acute inpatient psychiatric facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICF-DD); c. Medicaid Recipients whose Medicaid eligibility was determined through the medically needy program. d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 L▇▇▇▇ ▇ (QI-1s▇▇-▇▇). e. Medicaid Recipients who have other creditable health-care coverage, such as TriCare or a private health maintenance organization (HMO). f. Medicaid Recipients who reside in the following: (1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ); (2) Residential group care operated by the Family Safety & Preservation Program of the DCF; (3) Children's residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as Purchased Residential Treatment Services - "PRTS"); (4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and (5) Residential Level I and Level II substance abuse treatment programs. (See , as described in Sections 65D- 30.007(2)(a65D-30.007(2)(a) and (b), F.A.C.) g. Medicaid Recipients participating in the Family Planning waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network. j. Women eligible for Medicaid due to breast and/or cervical cancer. k. Individuals eligible under a hospice-related eligibility group. l. Medicaid Recipients who are members of the Florida Assertive Community Treatment Team (FACT team).

Excluded Populations. The following categories describe Medicaid Recipients recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid Recipients recipients who, at the time of application for Enrollment enrollment and/or at the time of Enrollmentenrollment, are domiciled or residing living in an institution, including a nursing facilities facility (and have been CARES assessed), sub-acute inpatient psychiatric Statewide Inpatient Psychiatric (SIPP) facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICF-DD), a state mental health hospital or a correctional facility; c. Medicaid Recipients recipients whose Medicaid eligibility was determined through the medically needy Medically Needy program.; d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s).; e. Medicaid Recipients recipients who have other creditable health-health care coverage, such as TriCare or a private commercial health maintenance organization (HMO).plan; f. Medicaid Recipients recipients who reside in the following: (1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ); (2) Residential group care operated by the Family Safety & Preservation Program of the Department of Children and Families (DCF;); HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract (3) Children's ’s residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as Purchased Residential Treatment Services - "– PRTS"); (4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and (5) Residential Level I and Level II substance abuse treatment programs. (See Sections 65D- 30.007(2)(ass. 65D-30.007(2)(a) and (b), F.A.C.); g. Medicaid Recipients recipients participating in the Family Planning waiver.Waiver; h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network.; j. i. Women eligible for Medicaid due to breast and/or cervical cancer.; k. j. Individuals eligible under a hospice-related eligibility group.group or receiving hospice services; k. Individuals enrolled in the Nursing Home Diversion Program or the Program of All Inclusive Care for the Elderly (PACE); l. For non-Reform populations, individuals enrolled in the PAC Waiver; and m. For Reform populations and non-Reform HMO populations, Medicaid Recipients recipients who are members of the Florida Assertive Community Treatment Team (FACT team)) unless they disenroll from the FACT team. These recipients are allowed to enroll in non-Reform PSNs.

Excluded Populations. The following categories describe Medicaid Recipients recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid Recipients recipients who, at the time of application for Enrollment enrollment and/or at the time of Enrollmentenrollment, are domiciled or residing living in an institution, including a nursing facilities facility (and have been CARES assessed), sub-acute inpatient psychiatric Statewide Inpatient Psychiatric (SIPP) facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICF-DD), a state mental health hospital or a correctional facility; c. Medicaid Recipients recipients whose Medicaid eligibility was determined through the medically needy Medically Needy program.; d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s).; e. Medicaid Recipients recipients who have other creditable health-health care coverage, such as TriCare or a private commercial health maintenance organization (HMO).plan; f. Medicaid Recipients recipients who reside in the following:: WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ); (2) Residential group care operated by the Family Safety & Preservation Program of the Department of Children and Families (DCF); (3) Children's ’s residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as Purchased Residential Treatment Services - "– PRTS"); (4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and (5) Residential Level I and Level II substance abuse treatment programs. (See Sections 65D- 30.007(2)(aRule 65D-30.007(2)(a) and (b), F.A.C.); g. Medicaid Recipients participating in the Family Planning waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network.; j. i. Women eligible for Medicaid due to breast and/or cervical cancer.; k. j. Individuals eligible under a hospice-related eligibility group.group or receiving hospice services; k. Individuals enrolled in the Nursing Home Diversion Program or the Program of All Inclusive Care for the Elderly (PACE); l. For non-Reform populations, individuals enrolled in the PAC Waiver except for those enrolled in the non-Reform HMOs that specialize in HIV/AIDS; m. Medicaid Recipients recipients who are members of the Florida Assertive Community Treatment Team (FACT team) unless they disenroll from the FACT team; and n. Medicaid recipients participating in the state’s Health Insurance Premium Payment program (H▇▇▇).

Excluded Populations. The following categories describe Medicaid Recipients recipients who are not eligible to enroll in a Health Plan: a. Pregnant women who have not enrolled in Medicaid Reform prior to the effective date of their SOBRA eligibility; b. Medicaid Recipients recipients who, at the time of application for Enrollment enrollment and/or at the time of Enrollmentenrollment, are domiciled or residing living in an institution, including a nursing facilities facility (and have been CARES assessed), sub-acute inpatient psychiatric Statewide Inpatient Psychiatric (SIPP) facility for individuals under the age of 21, or an Intermediate Care Facility/Developmentally Disabled (ICF-DD), a state mental health hospital or a correctional facility; c. Medicaid Recipients recipients whose Medicaid eligibility was determined through the medically needy Medically Needy program.; d. Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s).; e. Medicaid Recipients recipients who have other creditable health-health care coverage, such as TriCare or a private commercial health maintenance organization (HMO).plan; f. Medicaid Recipients recipients who reside in the following:: WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (1) Residential commitment programs/facilities operated through the Department of Juvenile Justice (DJJ); (2) Residential group care operated by the Family Safety & Preservation Program of the Department of Children and Families (DCF); (3) Children's ’s residential treatment facilities purchased through the Substance Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as Purchased Residential Treatment Services - "– PRTS"); (4) SAMH residential treatment facilities licensed as Level I and Level II facilities; and (5) Residential Level I and Level II substance abuse treatment programs. (See Sections 65D- 30.007(2)(aRule 65D-30.007(2)(a) and (b), F.A.C.); g. Medicaid Recipients participating in the Family Planning waiver. h. Participants in the Sub-acute Inpatient Psychiatric Program ("SIPP"). i. Title XXI-funded children with chronic conditions who are enrolled in Children’s Medical Services Network.; j. i. Women eligible for Medicaid due to breast and/or cervical cancer.; k. j. Individuals eligible under a hospice-related eligibility group.group or receiving hospice services; k. Individuals enrolled in the Nursing Home Diversion Program or the Program of All Inclusive Care for the Elderly (PACE); l. For non-Reform populations, individuals enrolled in the PAC Waiver except for those enrolled in the non-Reform HMOs that specialize in HIV/AIDS; m. Medicaid Recipients recipients who are members of the Florida Assertive Community Treatment Team (FACT team) unless they disenroll from the FACT team; and n. Medicaid recipients participating in the state’s Health Insurance Premium Payment program (▇▇▇▇).