EXCLUSION/RESTRICTION CODES & MLTC PLAN ENROLLMENT – SEPTEMBER 2013
CODE #
02
03
04
05
06
08
09
10
11
12
13
15
20
21
22
23
24
25
30
35
DESCRIPTION
RRP PODIATRY
RRP DENTAL
RRP DME
RRP PHARMACY
RRP PHYSICIAN
RRP CLINIC
RRP INPATIENT HOSPITAL
RRP DENTAL CLINIC
RRP PHYSICIAN GROUP
RRP PHYSICIAN ASSISTANT/NURSE PRACTITIONER
RRP ALTERNATIVE PHARMACY
Restricted to one primary Pharmacy and Physician
HIV ENROLLEE IN SPECIAL NEEDS MC PLAN
AIDS ENROLLEE IN SPECIAL NEEDS MC PLAN
MEDICARE PART D-GOOD CAUSE AUTO- CLOSING
OMH CHILDREN’S WAIVER & COMMUNITY
CHRONIC ILLNESS DEMONSTRATION PROJECT (CIDP)
SUBCHAPTER A OPWDD EXCEPTION
MLTC ENROLLMENT STATUS
For #s 2 – 15
LONG TERM HOME HEALTH CARE PROGRAM (LTHHCP)
LTHHCP participants in mandatory counties must enroll in
MLTC.
Can Enroll in MLTC plan (EXCEPT PACE – PACE must
provide documented confirmation that the PACE will be
providing the service via a contract with the consumer's
current CMCM provider.)
Cannot Enroll in MLTC.
Can Enroll in MLTC.
For #s 41 - 43
Can Enroll in MLTC (codes not in use)
Comprehensive Medicaid Case Management Program
(CMCM)
38
39
UT EXEMPT
AID CONTINUING
41
42
ICF DD EXPENSE LEVEL
HOSPITAL/SNF EXPENSE LEVEL
HOSPITAL IFC/DD EXPENSE LEVEL
43
Cannot Enroll in MLTC
Plan to Plan transfer. Consumer can opt into MLTC if
otherwise eligible.
Can Enroll in MLTC if otherwise eligible.
Cannot Enroll in MLTC.
Can Enroll in MLTC
Can Enroll in MLTC only if opt out of OPWDD Program.
44
45
46
47
48
49
50
51
53
55
56
58
59
OPWDD HCBS AT HOME RESIDENTIAL HABILITATION
OPWDD HCBS AT HOME RESIDENTIAL HABILITATION
INTENSIVE BEHAVIORAL SERVICES (IBS)
OPWDD HOME & COMMUNITY BASED SERVICES
WAIVER (PURE WAIVER)
OPWDD SUPERVISED CR (Inactive as of 1/1/10)
OPWDD SUPPORTIVE IRAs AND CRs
OPWDD SUPERVISED IRA AND CR - Residential
Habitation
PRENATAL CONNECT
For #s 44 - 49
Cannot Enroll in MLTC
46, 47, 48, 49 indicate consumer is enrolled in OPWDD
HCBS WAIVER. 47, 48, 49 indicate consumer may reside
in a supervised Community Residence, supportive
Community Residence, supportive Individual Residential
Alternative or supervised Individual Residential
Alternative.
CONNECT
Cannot Enroll in MLTC
HR Recipient in area with no MC Program
Code not in use
MCCP PHARMACY
For #s 55 - 59
Cannot Enroll in MLTC
MCCP PHYSICIAN
MCCP CLINIC
MCCP INPATIENT
NURSING HOME TRANSITION AND DIVERSION WAIVER
60
62
63
64
65
66
67
68
69
70
71
72
73
74
CARE AT HOME 1 (CAH 1)
CAH II
CAH III
CAH IV
CAH V
CAH VI
CAH VII
CAH VIII
CAH IX
CAH X
B2H SED
B2H DD
B2H MedF
Cannot Enroll in MLTC
Consumer can enroll in MLTC if he/she chooses to
disenroll from NHTD. Consumer must be educated re:
service differentials including housing support.
For 62 – 71
Cannot Enroll in MLTC
For 72 – 74
Cannot Enroll in MLTC
Bridges to Health Waiver
75
76
77
78
81
82
83
84
85
86
90
91
92
93
94
LTC D/D ASSET PROTECTION
LTC TOTAL ASSET PROTECTION
LTC INSURANCE-NON PARTNERSHIP
TARGETED CASE MANAGEMENT
TRAUMATIC BRAIN INJURY (TBI)
For 75 – 77
Cannot Enroll in MLTC
RESTRICTED RECIPIENT IN MC
Identifies a consumer in the Restricted Recipient program
who is enrolled in a Managed Care Plan.
ALCOHOL & SUBSTANCE ABUSE (ASA)
OMH BASE/COMMUNITY REHAB & SUPPORT (CRS)
WITH CLINICAL TREATMENT
OMH BASE/COMMUNITY REHAB & SUPPORT (CRS)
WITHOUT CLINICAL TREATMENT
OMH INTENSIVE REHAB & ONGOING REHAB SERVICES
(IR/OR)
MANAGED CARE EXCLUDED
MANAGED CARE EXEMPT
Cannot Enroll in MLTC
For #s 84 – 86 – Identifies Personalized Recovery
Oriented Services (PROS)
Codes can remain on case file.
GENERAL MANAGED CARE EXEMPTION
Express need for services in the home
OMH EXEMPT
OPWDD WAIVERED SERVICES LOOK-ALIKES
Can Enroll in MLTC
Must enroll in MLTC
Can Enroll in MLTC
Excluded from MLTCP enrollment; cannot Enroll in MLTC
unless code is end dated by OPWDD. Consumer/family
must decide if OPWDD provides required specialized
services or if MLTCP enrollment is preferred.
SPMI SED
DUR-WMS/EMEVS DUR USE
Can Enroll in MLTC
Can Enroll in MLTC
95
96
98
Cannot Enroll in MLTC
Cannot Enroll in MLTC - 81 code is put up by LDSS.
Consumer can Enroll in MLTC plan (EXCEPT PACE)
90 cannot enroll in MLTC; requires notification to NYSDOH
to lift restriction. 91 can enroll voluntarily in MLTC; does
not require lifting of restriction by NYSDOH.