Common use of Excluded Populations Clause in Contracts

Excluded Populations. Medicaid/CHIP eligibles who cannot voluntarily enroll with a CCN including: • Individuals receiving hospice services; • Individuals Residing in Nursing Facilities (NF) or Intermediate Care Facilities for the Developmentally Disabled (ICF/DD); • Individuals with Medicare dual eligibles: • Individuals who have been diagnosed with tuberculosis, or suspected of having tuberculosis, and receiving tuberculosis- related services through the Tuberculosis Infected Individual Program; • Individuals receiving services through any 1915(c) Home and Community-Based Waiver including, but not limited to: o Adult Day Health Care (ADHC) - Direct care in a licensed adult day health care facility for those individuals who would otherwise require nursing facility services; o New Opportunities Waiver (NOW) - Individuals who would otherwise require ICF/DD services; o Elderly and Disabled Adult (EDA) - Services to persons aged 65 and older or disabled adults who would otherwise require nursing facility services; o Children’s Choice (CC) - Supplemental support services to disabled children under age 18 on the NOW waiver registry; o Residential Options Waiver (ROW) - Individuals living in the community who would otherwise require ICF/DD services; o Supports Waiver – Individuals 18 years and older with mental retardation or a developmental disability which manifested prior to age 22; and o Other HCBS waivers as may be approved by CMS. • Individuals under the age of 21 otherwise eligible for Medicaid who are listed on the Office for Citizens with Developmental Disabilities’ Request for Services Registry, also known as ▇▇▇▇▇▇▇▇ Class Members; • Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE), a community-based alternative to placement in a nursing facility that includes a complete “managed care” type benefit combining medical, social and long-term care services; • Individuals with a limited eligibility period including: o Spend-down Medically Needy Program - An individual or family who has income in excess of the prescribed income standard can reduce excess income by incurring medical and/or remedial care expenses to establish a temporary period of Medicaid coverage (up to three months); and o Emergency Services Only - Emergency services for aliens who do not meet Medicaid citizenship/ 5-year residency requirements; • Individuals enrolled in the LaCHIP Affordable Plan Program (LaCHIP Phase V) that provides benchmark coverage with a premium to uninsured low-income children under age 19 who do not otherwise qualify for Medicaid or other LaCHIP programs and • Individuals enrolled in and receiving Family Planning services only in the Take Charge Program which provides family planning services to uninsured women ages 19 – 44 who are not otherwise eligible for any another Medicaid program.

Excluded Populations. Medicaid/CHIP eligibles Individuals eligible for Medicaid who cannot voluntarily enroll with a CCN including: • Individuals receiving hospice services; • Individuals Residing in Nursing Facilities (NF) or Intermediate Care Facilities for the Developmentally Disabled (ICF/DD); • Individuals with Medicare dual Medicare(dual eligibles: ): • Individuals who have been diagnosed with tuberculosis, or suspected of having tuberculosis, and receiving tuberculosis- tuberculosis-related services through the Tuberculosis Infected Individual Program; • Individuals receiving services through any 1915(c) Home and Community-Based Waiver including, but not limited to: o Adult Day Health Care (ADHC) - Direct care in a licensed adult day health care facility for those individuals who would otherwise require nursing facility services; o New Opportunities Waiver (NOW) - Individuals who would otherwise require ICF/DD services; o Elderly and Disabled Adult (EDA) - Services to persons aged 65 and older or disabled adults who would otherwise require nursing facility services; o Children’s Choice (CC) - Supplemental support services to disabled children under age 18 on the NOW waiver registry; o Residential Options Waiver (ROW) - Individuals living in the community who would otherwise require ICF/DD services; o Supports Waiver – Individuals 18 years and older with mental retardation or a developmental disability which manifested prior to age 22; and o Other HCBS waivers as may be approved by CMS. • Individuals under the age of 21 otherwise eligible for Medicaid who are listed on the Office for Citizens with Developmental Disabilities’ Request for Services Registry, also known as ▇▇▇▇▇▇▇▇ Class Members; • Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE), a community-based alternative to placement in a nursing facility that includes a complete “managed care” type benefit combining medical, social and long-term care services; • Individuals with a limited eligibility period including: o Spend-down Medically Needy Program - An individual or family who has income in excess of the prescribed income standard can reduce excess income by incurring medical and/or remedial care expenses to establish a temporary period of Medicaid coverage (up to three months); and o Emergency Services Only - Emergency services for aliens who do not meet Medicaid citizenship/ 5-year residency requirements; • Individuals enrolled in the LaCHIP Affordable Plan Program (LaCHIP Phase V) that provides benchmark coverage with a premium to uninsured low-income children under age 19 who do not otherwise qualify for Medicaid or other LaCHIP programs and • Individuals enrolled in and receiving Family Planning services only in the Take Charge Program which provides family planning services to uninsured women ages 19 – 44 who are not otherwise eligible for any another Medicaid program.