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| Home > Members &
Applicants > Enrollment Categories |
Some individuals who receive Medicaid are EXEMPT, which means they can remain in traditional fee-for-service
Medicaid or join a health plan.
EXEMPTION CATEGORIES
- Individuals who are HIV+
- MetroPlus has a special program called Partnership in Care for individuals who are HIV+ Click here
to learn more about MetroPlus Partnership in Care Program
- Individuals who are Seriously or Persistently Mentally Ill or Seriously Emotionally Disturbed
- Individuals for whom a managed care provider is not geographically accessible
- Pregnant women receiving prenatal care from a provider not participating in any Medicaid Managed Care plan
- Individuals with chronic medical conditions who have been under active treatment for at least six
months with a sub-specialist who is not a network provider for any Medicaid managed care plan in the
service area or whose request has been approved by the SDOH Medical Director because of unusually severe
chronic care needs
- Individuals with End Stage Renal Disease (ESRD)
- Residents of Intermediate Care Facilities for the mentally retarded
- Individuals with characteristics and needs similar to those who are residents of an ICF/MR
- Individuals already scheduled for a major surgical procedure (within 30 days of scheduled enrollment)
with a provider who is not a participant in the network of any Medicaid managed care plan in the service area
- Individuals with a developmental or physical disability receiving services through a Medicaid home and
community based services waiver
- Individuals with a developmental or physical disability whose needs are similar to participants receiving
services through a Medicaid home and community based services waiver
- Participants in the Medicaid Model Waiver (Care-at-home) Programs
- Individuals whose needs are similar to participants receiving services through the Medicaid Model waiver
(Care-at-Home) programs
- Residents of alcohol/substance abuse long term residential treatment programs
- All homeless individuals
- Native Americans
- Individuals who cannot be served by a managed care provider due to a language barrier
- Individuals temporarily residing out of district
- SSI and SSI related
Some individuals are EXCLUDED from joining a Medicaid managed care plan. If an individual
who is excluded from Medicaid managed care has already been enrolled into a health plan,
they will be disenrolled.
EXCLUSION CATEGORIES
- Persons who are dually eligible for Medicare/Medicaid.
- Persons who become eligible for Medicaid only as spend-downs.
- Persons who are residents of State-operated psychiatric facilities or State-certified or voluntary
treatment facilities for children and youth.
- Persons who are residents of residential and health care facilities.
- Persons enrolled in managed long-term care demonstrations.
- Medicaid-eligible infants living with incarcerated mothers.
- Infants weighing less than 1,200 grams at birth.
- Other infants under 6 months of age who meet the criteria for SSI or SSI-related category.
- Persons with access to comprehensive private health coverage, including a managed care organization.
- Foster children in the placement of a voluntary agency.
- Youths in the care and custody of the Commissioner of New York State Office of Children and Family Services.
- Certified blind or disabled children living or expected to be living separate and apart from the parent
for 30 days or more.
- Foster children in direct care.
- Persons in receipt of long-term care services through Long-Term Home Health Care programs or child care
facilities.
- Persons eligible for medical assistance benefits only with respect to TB-related services.
- Persons placed in State Office of Mental Health licensed family care homes.
- Persons enrolled in the Restricted Recipient Program.
- Persons with a "County of Fiscal Responsibility" code of 99 or 97 or 98
- Persons admitted to a Hospice program at time of enrollment.
A MetroPlus Member Services Representative will be more than happy to answer questions about who is exempt
or excluded. Feel free to call MetroPlus Member Services at 1-800-303-9626.
You can find out more about who is exempt or excluded by calling New York Medicaid CHOICE at 1-800-505-5678.
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