GIS 15 MA/012: Medicaid Managed Care Exemptions and Exclusions

To: Local District Commissioners, Medicaid Directors

From: Jason Helgerson, Medicaid Director - Office of Health Insurance Programs

Subject: Medicaid Managed Care Exemptions and Exclusions

Effective Date: Immediately

Contact Person: Managed Care
(518) 473-1134

The purpose of this General Information System (GIS) message is to advise local departments of social services (LDSS) that an annual review of managed care exemption (91) and exclusion (90) Restrictive/Exception (R/E) entered codes should take place. With most Medicaid populations transitioning into mandatory managed care, it is important that 90/91 R/E codes are end dated, if no longer applicable, so as not to impede enrollment into a managed care health plan. One example of a 90/91 R/E code to be end dated is when District A entered the R/E code but the consumer now has eligibility in District B.

Most exempt and excluded populations have distinct system identifications to prevent consumers from being enrolled or auto assigned into a managed care health plan. Therefore, additional entry of 90/91 R/E code is not needed (please see attached Exempt/Excluded desk aids). We also ask the districts when a 90/91 R/E code needs to be entered, to enter an end date no longer than one year in the future as an annual review should be made on active 90/91 R/E codes. A monthly exemption/exclusion report that is available on the Health Commerce System (HCS), m49mmdd.txt, and BICS, CSPROD*MUP970-RPT99 to assist local districts to identify consumers with active Restriction/Exception (R/E) codes. If you have any questions, please contact managed care at mcsys@health.ny.govor your local district liaison.