The following outlines those clients who are mandatory or
excluded members. The member's status (mandatory or excluded) is determined by
an automated interface between Medicaid's eligibility system and each Heritage
Health plan's system based on information entered on the Medicaid eligibility
system known at the time of the interface.
002.01
HERITAGE HEALTH PLAN
MANDATORY MEMBERS. Unless excluded, the following clients are
required to participate as members in Nebraska Medicaid managed care program
for physical health, behavioral health, and pharmacy benefits:
(A) Families, children, and pregnant women
eligible for Medicaid under Section 1931 of the federal Social Security Act, as
amended ("Section 1931"), or related coverage groups.
(B) Members who are eligible for Medicaid due
to blindness or disability;
(C)
Members who are sixty-five (65) years of age or older and not members of the
blind and disabled population or members of the Section 1931 adult
population;
(D) Low-income children
who are eligible to participate in Medicaid under Title XXI of the federal
Social Security Act, as amended (the "Children's Health Insurance
Program");
(E) Members who are
receiving foster care or subsidized adoption assistance under Title IV-E of the
federal Social Security Act, as amended; are in foster care; or, are otherwise
in an out-of-home placement;
(F)
Members who participate in a Home and Community-Based Waiver Services program.
This includes groups covered by the State's Section 1915(c) waiver under the
federal Social Security Act, as amended;
(G) Individuals who are eligible for Medicaid
through the Breast and Cervical Cancer Prevention and Treatment Act of
2000;
(H) Medicaid beneficiaries
during a period of retroactive eligibility, when mandatory enrollment for
Heritage Health has been determined;
(I) Members eligible during a period of
presumptive eligibility;
(J)
Members eligible for the State Disability program under Neb. Rev. Stat. §
68-1005;
(K) Members eligible for the Refugee
Resettlement program under Title IV of the Immigration and Nationality Act;
and
(L) Members with continuous
eligibility who have a share of cost.
(M) Members who are eligible in the Heritage
Health Adult group as described in 477 Nebraska Administrative Code (NAC) 29
under Section 1902(a)(10)(A)(i)(VIII) of the Social Security Act
002.02
HERITAGE HEALTH
PLAN EXCLUDED POPULATIONS. The following clients are excluded from
the Nebraska Medicaid managed care program:
(A) Non-Citizens-eligible under the Emergency
Medical Services Assistance (EMSA) for non-citizens program;
(B) Clients who have excess income or who are
required to pay a premium, and are intermittently eligible;
(C) Clients who have received a disenrollment
or waiver of enrollment;
(D)
Clients in the Program for All-Inclusive Care for the Elderly;
(E) Clients with Medicare coverage where
Medicaid only pays co-insurance and deductibles; and
(F) Inmates of public institutions.
002.03
DENTAL BENEFITS
MANAGER MANDATORY MEMBERS. Any member required to participate in a
Heritage Health plan must participate as a member in the Dental Benefits
Manager, except for:
(A) Unborn members
eligible for Children's Health Insurance Program (599 CHIP); or
(B) Members who are not physically present in
the State of Nebraska;.
002.04
COVERAGE FOR EXCLUDED
CLIENTS. Medicaid coverage for clients excluded from participation
in managed care or Dental Benefits Manager remains on a fee-for-service basis
for services they are eligible for. Excluded clients cannot voluntarily enroll
in managed care or the Dental Benefits Manager.
002.05
COVERAGE DURING
ENROLLMENT. The Heritage Health plan and Dental Benefits Manager
are responsible for providing services covered by Heritage Health plan and
Dental Benefits Manager for the member as long as the member is enrolled in the
Heritage Health plan and Dental Benefits Manager.
