Medical Services

Managed Care

State Plan Amendment - Title XIX of the Social Security Act

Supplement 1 - Mandatory and Excluded Populations

Mandatory populations

  • Section 1931 Children and Related Poverty Level Populations (TANF/AFDC)
  • Section 1931 Adults and Related Poverty Level Populations, including pregnant women (TANF/AFDC)
  • Blind/Disabled Adults and Related Populations (SSI)
  • Title XXI CHIP

Excluded populations

  • Medicare recipients
  • Nursing home residents
  • Recipients residing in an Intermediate Care Facility for the Mentally Retarded (ICF/MR)
  • Participants in a home and community-based waiver program
  • Have an eligibility period that is only retroactive
  • Enrollees under age 19 with special needs that are
    1. Eligible for SSI
    2. Determined to be Children with Special Health Care Needs (CSHCN) through Title V
    3. Eligible under a Maternal Child Health Services Block Grant
  • Foster care children
  • Subsidized adoption

Optional populations (State approval for exemption required)

  • Full-time students residing out-of-state and other recipients where the State determines that access to care is severally limited through PCCM participation.
  • Recipients currently receiving care within a case management system
    • Institutionalized recipients including Adjustment Training Center residents
    • Recipients residing at boarding schools
    • Recipients considered medically fragile