Following are the populations excluded from Medicaid managed care effective 7/1/19. (There are some differences between integrated health and dental.)
Integrated health (medical) managed care – Include all active (status = AC) Medicaid recipients except:
1. Clients age 19 and older who have excess income (or a premium due or a spend down/share of cost amount). Exceptions note: These recipients ARE enrolled in managed care when they receive HCBS waiver services (SPI Code A, B, C, D, I, O, P, Q, R, V, W, X, Y or Z) and do not have reason closed code 400 or 450, OR they have the following living arrangements and do not have reason closed code 400 or 450. (Reason closed code 400 and 450 indicate the client needs to meet spend down every month to be eligible.) The included living arrangements are:
01 - Halfway House
09 - Board and room
10 - Licensed Mental Health Center, or Assisted Living – Waiver
12 - Nursing facility ICF/DD
18 - Licensed Residential Care Facility, or Assisted Living
20 - Certified Adult Family Home
32 - Licensed Drug Treatment Center
2. Clients with a waiver of managed care enrollment in MMIS
3. Clients with living arrangement 37 (correctional facility)
4. Clients with SPI codes H, M or 1
5. Clients enrolled in PACE
Dental managed care – Include all active (status = AC) Medicaid recipients except:
1. Clients age 19 and older who have excess income (or a premium due or a spend down/share of cost amount). Exceptions note: These recipients ARE enrolled in managed care when they receive HCBS waiver services (SPI Code A, B, C, D, I, O, P, Q, R, V, W, X, Y or Z) and do not have reason closed code 400 or 450, OR they have the following living arrangements and do not have reason closed code 400 or 450. (Reason closed code 400 and 450 indicate the client needs to meet spend down every month to be eligible.) The included living arrangements are:
01 - Halfway House
09 - Board and room
10 - Licensed Mental Health Center, or Assisted Living – Waiver
12 - Nursing facility ICF/DD
18 - Licensed Residential Care Facility, or Assisted Living
20 - Certified Adult Family Home
32 - Licensed Drug Treatment Center
2. Clients with a waiver of managed care enrollment in MMIS
3. Clients with living arrangement 37 (correctional facility)
4. Clients with SPI codes H, M or 1
5. Clients enrolled in PACE
6. 599 CHIP clients (PAE 4090 + SPI Code K)
7. Clients with a physical address outside of Nebraska (county code of 99)
8. Clients with PAE 6045 (pregnancy presumptive)
(08-2019)