Common use of Excluded Populations Clause in Contracts

Excluded Populations. A TANF beneficiary or Medicaid recipient in the following programs may not enroll in a frail/elderly component of a Medicaid HMO: a. An Aged and Adult disabled Waiver; b. The Channeling Waiver; c. Developmental Disabilities Waiver; or d. The Assisted Living for the Elderly Waiver Enrollment in the Frail/Elderly Program. This provision replaces Attachment II, Section III, Eligibility and Enrollment, Item B.2.b. as follows: In order for enrollment to occur, the Health Plan must maintain and document the following information on file and provide it at the Agency’s request: (1) A current CARES assessment completed within the past twelve (12) months. (2) An agreement in writing from the recipient’s Medicare or Medicaid PCP, whichever is applicable, that the provider would participate as part of the multidisciplinary treatment team and would provide input, review, data etc. related to the care of the recipient . (3) A voluntary consent form signed by the recipient documenting the recipients request to enroll in the frail/elderly program. This form must be approved by BMHC prior to use. The disenrollment requirements listed below must be met in addition to those specified in Attachment II, Section III, Eligibility and Enrollment, unless otherwise noted below. a. The Health Plan may request the Agency to disenroll an enrollee if the enrollee is institutionalized in a long term nursing facility at the conclusion of the state fiscal year and the Health Plan furnishes written documentation based upon a CARES assessment or written assurance from the enrollee’s PCP or the administrator of the nursing facility where the enrollee is placed that the nursing home placement is permanent and not temporary. AHCA Contract No. , Attachment II, Exhibit 3, Page 11 of 97 EXHIBITS, 5-11-12 Draft Health 2012 Plan Contract Attachment II b. All disenrollments for institutionalized enrollees must have prior written approval by the Agency and be submitted as involuntary disenrollments on the first available transmission to the fiscal agent after receiving Agency approval of the request. 1. Mandatory Populations There are no mandatory populations for the HIV/AIDS Specialty Plan. 2. Voluntary Populations In addition to meeting the eligibility requirements listed in Attachment II, Section III, Eligibility and Enrollment, A., Eligibility, sub-items 1. and 2., and notwithstanding Attachment II, Section III, Eligibility and Enrollment, B., Enrollment, sub-item 1.c., in order to be eligible for enrollment, the recipient must either: a. Have been screened as clinically eligible for the HIV/AIDS Specialty Plan using an Agency-approved method or b. Be a member of the household of a clinically-eligible HIV/AIDS member enrolled in this specialty plan. 3. Excluded Populations A member of the household of a clinically-eligible HIV/AIDS recipient who is no longer enrolled in this specialty plan or a recipient who otherwise meets a requirement of an excluded population as specified in Attachment II, Section III, A.3., of this Contract.

Excluded Populations. A TANF beneficiary or Medicaid recipient in the following programs may not enroll in a frail/elderly component of a Medicaid HMO: a. An Aged and Adult disabled Waiver; b. The Channeling Waiver; c. Developmental Disabilities Waiver; or d. The Assisted Living for the Elderly Waiver Section Enrollment in the Frail/Elderly Program. This provision replaces Attachment II, Section III, Eligibility and Enrollment, Item B.2.bB.3.b. as follows: In order for enrollment to occur, the Health Plan must maintain and document the following information on file and provide it at the Agency’s request: (1) A current CARES assessment completed within the past twelve (12) months. (2) An agreement in writing from the recipient’s Medicare or Medicaid PCP, whichever is applicable, that the provider would participate as part of the multidisciplinary treatment team and would provide input, review, data etc. related to the care of the recipient recipient. (3) A voluntary consent form signed by the recipient documenting the recipients request to enroll in the frail/elderly program. This form must be approved by BMHC prior to use. use AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract The disenrollment requirements listed below must be met in addition to those specified in Attachment II, Section III, Eligibility and Enrollment, unless otherwise noted below. a. The Health Plan may request the Agency to disenroll an enrollee if the enrollee is institutionalized in a long term nursing facility at the conclusion of the state fiscal year and the Health Plan furnishes written documentation based upon a CARES assessment or written assurance from the enrollee’s PCP or the administrator of the nursing facility where the enrollee is placed that the nursing home placement is permanent and not temporary. AHCA Contract No. , Attachment II, Exhibit 3, Page 11 of 97 EXHIBITS, 5-11-12 Draft Health 2012 Plan Contract Attachment II . b. All disenrollments for institutionalized enrollees must have prior written approval by the Agency and be submitted as involuntary disenrollments on the first available transmission to the fiscal agent after receiving Agency approval of the request. 1. Mandatory Populations There are no mandatory populations for the HIVAMERIGROUP Florida, Inc. d/AIDS Specialty Plan. 2. Voluntary Populations In addition to meeting the eligibility requirements listed in Attachment II, Section III, Eligibility b/a Medicaid Non-Reform and Enrollment, A., Eligibility, sub-items 1. and 2., and notwithstanding Attachment II, Section III, Eligibility and Enrollment, B., Enrollment, sub-item 1.c., in order to be eligible for enrollment, the recipient must either: a. Have been screened as clinically eligible for the HIV/AIDS Specialty Plan using an Agency-approved method or b. Be a member of the household of a clinically-eligible HIV/AIDS member enrolled in this specialty plan. 3. Excluded Populations A member of the household of a clinically-eligible HIV/AIDS recipient who is no longer enrolled in this specialty plan or a recipient who otherwise meets a requirement of an excluded population as specified in Attachment II, Section III, A.3., of this Reform AMERIGROUP Community Care HMO Contract.