Individuals Who Are HIV+ or who have AIDS

Medicare/Medicaid Dually Eligibles [these persons may only join a qualified Medicaid Advantage Plan as long as they enroll in the same plan’s Medicare Advantage product]

Individuals Who Are Seriously & Persistently Mentally Ill or Seriously Emotionally Disturbed. This exemption does not apply to NYC residents with SSI or who are certified blind or disabled.

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

Individuals with End Stage Renal Disease (ESRD)

Residents of Intermediate Care Facilities for the Mentally Retarded (ICF/MR)

Individuals with Characteristics and Needs Similar to Those Who Are Residents of an ICF/MR

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 Service 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

Individuals who are eligible for the Medicaid buy-in for the working disabled and are not required to pay a premium

Individuals Who Become Eligible for Medicaid Only After Spending Down a Portion of Their Income

Residents of State Psychiatric Facilities or Residents of State Certified or Voluntary Treatment Facilities for Children and Youth

Patients in Residential Health Care Facilities at Time of Enrollment and Residents in a RHCF Who Are Classified as Permanent

Participants in Capitated Long Term Care Demonstration Projects

Medicaid-Eligible Infants Living with Incarcerated Mothers

Infants Weighing Less Than 1200 Grams at Birth and Other Infants Less Than 6 Months Who Meet the Criteria for SSI-Related Categories

Individuals with Access to Comprehensive Private Health Insurance if Cost Effective

All Children in Foster Care

Certified Blind or Disabled Children Living or Expected to Live Separate and Apart from Their Parents for 30 Days or More

Individuals Expected to be Medicaid Eligible for Less Than Six Months (Except for Pregnant Women)

Individuals Receiving Long-Term Care Services Through Long-Term Home Health Care Programs, or Child Care Facilities (Except ICF Services for the Developmentally Disabled)

Individuals Eligible for Medical Assistance Benefits Only with Respect to Tuberculosis Related Services

Individuals Placed in OMH Licensed Family Care Homes

Individuals Enrolled in the Restricted Recipient Program

Individuals with a "County of Fiscal Responsibility" Code 99 in MMIS

Individuals Receiving Hospice Services (at Time of Enrollment)

Individuals with a "County of Fiscal Responsibility" Code of 97 (OMH in MMIS) or 98 (OMRDD in MMIS)

Youth in the Care and Custody of the Commissioner of the Office of Family & Children Services

Individuals Eligible for Medical Assistance Benefits Only with Respect to Family Planning Services and Whose Net Available Income Is 200% or Less of FPL

Individuals under sixty-five years of age (screened and require treatment) in CDC Breast and/or Cervical Cancer Early Detection Program and need treatment for breast or cervical cancer, and are not otherwise covered under creditable health coverage

Individuals who are eligible for the Medicaid buy-in for the working disabled and are required to pay a premium

Individuals eligible for the Colorectal and Prostate Cancer Program

Medicare/Medicaid dually eligible individuals are ineligible for enrollment in a mainstream Medicaid managed care plan. If not otherwise excluded, they may only enroll in qualified Medicaid Advantage Product as long as they also enroll in the same plan’s Medicare Advantage product