MEDICAID MANAGED CARE: EXCLUSIONS and EXEMPTIONS
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| POPULATION | MMC EXCLUDED | MMC EXEMPT | BENEFIT PACKAGE AVAILABLE TO PERSON AGED 21 YEARS AND OLDER HARP EXCLUDED |
BENEFIT PACKAGE AVAILABLE TO PERSON AGED 21 YEARS AND OLDER HARP EXEMPT |
EMEDNY SYSTEM IDENTIFIER | MEDICAID ELIGIBILITY RESPONSE EPACES |
|---|---|---|---|---|---|---|
| Office for People with Developmental Disabilities (OPWDD) Eligible Individuals who are qualified and identified by OPWDD to receive program services through OPWDD. |
X | X | R/E Code 95 | Exception code 95 | ||
| Residents of Intermediate Care Facilities for the Developmentally Disabled A resident of an Intermediate Care Facility (ICF/DD) has a developmental disability and lives in a residence which is operated by the State or by a private agency such as ARC. At this residence, the personreceives room and board, ongoing healthservices, and training in skills which encourage independence. |
X | X | PP Code 02, 04, may have R/E 38 | Exception code 38 | ||
| Office for People with Developmental Disabilities (OPWDD) Home and Community Based Services (HCBS) Waiver An individual has a developmental disability, is eligible for an ICF/DD level of care and has chosen HCBS 1915(c) waiver services over institutional care. |
X | X | OPWDD waiver codes 44-49 | Exception codes 44-49 | ||
| Individuals with chronic medical conditions being treated by a specialist not participating in any Medicaid managed care plan in the service area *Exemption limited to 6 months Individual who is not currentlyenrolledin a Medicaidmanagedcare health plan that has a medical condition and is currently under the care of a physician specialist, and there is at least a 6- month treatment plan for ongoing care. This includes individuals scheduled for surgery within 30 days of enrollment with a surgeon that does not participate with any MCO. See the Exemption Request Form for criteria to meet this exemption. |
X | X | May have R/E 91 | May have Exception code 91 | ||
| Residents of Title 14 NYCRR Part 819 Chemical Dependence Long Term Residential Program Individuals residing in a facility including drug-free residential communities (therapeutic communities), recovery homes, community residences, supportive living facilities. A letter from residence Director or Program Supervisor on program letterhead that verifies that the individual is a resident is required. Exemption applies only until individual leaves residence. |
X | X | May have R/E 91 | May have Exception code 91 | ||
| Native American (NA) or Alaskan Native (AN) Individuals who have Native American or Alaska Native heritage. Individual needs only to attest to this heritage. |
X | X | May have R/E 91 | May have Exception code 91 | ||
| Nursing Home Transition and Diversion Medicaid Waiver (NHTD) Individuals aged 18-64 with a physical disability, or age 65 and older upon application to the waiver. All individuals need to be assessed to need nursing home level of care and choose to live in the community rather than in a nursing facility. |
X | X | R/E Code 60 | Exception code 60 | ||
| Traumatic Brain Injury Medicaid Waiver (TBI) Individuals aged 18-64 with a primary diagnosis of TBI or similar non-degenerative condition that results in deficits similar to a TBI such as stroke or anoxia. All individual need to be assessed to need nursing home level of care and choose to live in the community rather than in a nursing facility. |
X | X | R/E Code 81 | Exception code 81 | ||
| Residents of Office of Mental Health (OMH) State Operated Psychiatric Center Inpatient Facilities and 21-64 Years of Age. | X | X | PP Code 06 Medicaid District 97 | Medicaid District 97 | ||
| Resident of Office of Mental Health (OMH) State Operated Psychiatric Center Inpatient Facilities and 21-64 Years of Age. Individuals in receipt of inpatient services at OMH State Operated psychiatric facilities. Local District Medicaid is suspended with Coverage Code 25 throughout the State Operated Psychiatric Center admission and is reinstated in the Local District at the corresponding discharge. |
X | X | Coverage Code 25 May have R/E 90 | Coverage Code 25 May have Exception Code 90 Eligible Only Inpatient Services | ||
| Residents of Office of Mental Health (OMH) State Operated Psychiatric Center Community Residences or Family Care Homes | X | X | May have Aid Category 28 Medicaid District 97 | Medicaid District 97 | ||
| Residents of state certified, voluntary operated Residential Treatment Facilities (RTFs) for children Medical facilities certified, but not operated by OMH, which provide for long term psychiatric care for persons 21 years of age and younger |
X | X | PP Code 10 May have R/E 90 | Fiscal District 97 May have R/E 90 | ||
| Medicaid eligible infants living with incarcerated mothers in state or local correctional facilities Infants living in correctional facilities (example: Taconic Hills and Bedford Hills) with their mothers, usually up to age 1 |
X | X | May have R/E 90 | May have exception code 90 | ||
| Individuals who are expected to be Medicaid eligible for less than 6 months (except for pregnant women) Medicaid case is closing within 6 months. This does not include cases that are scheduled to renew in 6 months. |
X | X | May have R/E 90 | May have exception code 90 | ||
| Foster Care Children/Youth Children/youth placed in a voluntary foster care agency operating under Article 29-I license, or in the care and custody of the Office of Children and Family Services. Local Districts that utilize foster care voluntary agencies to place children in the community or facilities. |
X | X | May have R/E 90 | May have exception code 90 | ||
| Blind or disabled children living separate from their parents for 30 days or more Children under age 18, Certified Blind or disabled, living in a medical facility/separate residence from parents for 30 days or more |
X | X | May have R/E 90 | May have Exception code 90 | ||
| Adolescents admitted to Residential Rehabilitation Services for Youth (RRSY) The RRSY program serves chemically dependent individuals under age 21. |
X | X | May have R/E 90 | May have Exception code 90 | ||
| Individuals receiving hospice services at time of enrollment Individuals receiving hospice at time of enrollment are excluded. Current enrollees who begin to receive hospice remain enrolled in MMC. |
X | X | May have R/E 90 | May have Exception code 90 | ||
| Persons in receipt of Medicaid/Medicare Persons in receipt of Medicaid/Medicare are excluded from MMC but can enroll in an Integrated Benefits for Dually Eligible Enrollees Program (IB-Dual) or MLTC. Individual is excluded from MMC and HARP unless enrolled in a qualified Managed Care Organization's D-SNP product; as long as consumer does not opt out of the D-SNP, they can remain enrolled in MMC/HARP. *Dully eligible members residing in Long Term Nursing Home Stay are not eligible for the IB-Dual program and therefore excluded from MMC. |
X | X | Medicare shows in eMedNY | Medicare | ||
| Spend-down medically needy Individuals who are requiredto spend some of their own money for medical needs on a monthly basis to receive Medicaid. |
X | X | Outpatient or Provisional coverage, R/E S-1 or R/E 90 | Outpatient Cov'g, No Cov'g, Excess Income, May have R/E S1, 90 | ||
| Individuals in receipt of comprehensive private health insurance Comprehensive insurance covers most medical services; Major Medical, Inpatient, ER, Physician, DME, Clinic, Substance Abuse, Mental Health. |
X | X | TPHI shows in ePACES | Third Party Insurance | ||
| Individuals under 65 years of age, who have been determined eligible by the Medicaid Cancer Treatment Program: Breast, Cervical, Colorectal, Prostate Cancer Medicaid eligibility through District 99. |
X | X | ePACES will show DFR 99 | Fiscal District 99 | ||
| Individuals receiving family planning services only Individuals who are not fully eligible for Medicaid but are eligible to receive family planning services through the Family Planning Benefit Program |
X | X | ePACES will show family planning coverage | Eligible Only Family Planning Services | ||
| Individuals receiving assistance through an Assisted Living Program (ALP) ALPs are jointly licensedas adult care facilities and licensed home care services agencies (LHCSA) and provide room, board, personal care services and medication case management. |
X | X | PP 16 | Exception code AL | ||
| Fiscal responsibility of State Office of Mental Health (OMH), District Code 97 | X | X | ePACES will show DFR 97 | Fiscal District 97 | ||
| Fiscal responsibility of State Office for People with Developmental Disabilities (OPWDD), District Code 98 | X | X | ePACES will show DFR 98 | Fiscal District 98 | ||
| Individuals eligible for Emergency Medicaid only: undocumented immigrants/no citizenship status who are under age 65 are excluded from Medicaid Managed Care (MMC). For HARP and HIV SNP product line, Emergency Medicaid Only: undocumented immigrants/no citizenship status continues to be excluded for all ages. |
X | X | ePACES willshow 07 coverage | Emergency Services Only | ||
| Individuals over age 21 that are permanently placed in a residential health care facility (RHCF) | X | PP Code 01, 03 with R/E N1 through N5 | Exception codes NH, N1, N2, N3 N4, N5, N7, N9 | |||
| Individuals that are temporary residents in a residential health care facility (RHCF) at the time of enrollment. | X | X | PP Code 01, 03 | Exception codes NH, N9 | ||
| Individuals under age 21 who are in Long Term Placement status in a nursing home | X | Not eligible at any age |
Revised 10/8/2025
