Who Does Not Have to Join a Health Plan

See a complete list of who does not have to join a plan or cannot join a plan.

Some Medicaid members cannot join a plan because of their medical needs or other reason. They are ‘excluded’. Others are not required to join a health plan but they can if they want to. They are ‘exempt’. If you have questions, call New York Medicaid Choice. Counselors will be glad to answer your questions. Call: 1-800-505-5678.  TTY: 1-888-329-1541.

Exemptions

You are not required to join a plan but you can if you want to.

• American Indian/Alaskan Native
• Residents of an Article 819 long-term alcohol or substance use facility
• People who live in facilities for the developmentally disabled
• People being treated for a chronic medical condition for 6 months or  longer by a Medicaid specialist who is not in a Medicaid health plan. (This exemption is limited to a 6 month period and for one time only)
• Adults in waiver programs: Nursing Home Transition and Diversion (NHTD), Office of People with Developmental Disabilities (OPWDD), Traumatic Brain Injury (TBI)

Exclusions

You cannot join a plan because of your medical needs or other reason.

• People in a hospice program at the time of enrollment.
• Children or adults who live in state psychiatric or residential treatment facilities
• People who will get Medicaid only after they spend some of their own money for medical needs (spend-down cases)
• People with other full benefit health insurance
• Infants living with their mothers in jail or prison
• Children who are blind or disabled and living apart from their parents for 30 days or more
• People eligible for TB services only
• People eligible for the Medicaid Cancer Treatment Program: Breast, Cervical, Colorectal and Prostate Cancer (MCTP)