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If the member has more complex medical needs and requires an exemption longer than two months, the HMO Enrollment Specialist will refer the member to the State Nurse Consultant. In addition, a longer continuity of care exemption can be granted for a pregnant individual who wants to see a nurse midwife/practitioner of their choosing who is not part of the HMO’s provider network. For a pregnant individual, the exemption can be applied at any time starting from the month of request through two months after the estimated due date. Distance This exemption may be granted for a one- to -two-month period when a member has moved out of an HMO’s service area while their eligibility has not yet been updated to reflect the change in address AND the member needs immediate care in the area that is not covered by their current HMO. HIPP Determination in progress or enrollment in the HIPP program This exemption may be granted if the member is pending an eligibility determination for the HIPP program or is enrolled in the HIPP program, and the employer-sponsored insurance plan limits the member to a restricted provider network that does not align with the HMO’s provider network. Long Term Complex Care The state Nursing Consultant may apply this exemption for up to 12 months for individuals who have complex needs and may need specialized care outside of a member’s HMO network. Low Birth Weight The state Nurse Consultant may apply this exemption to newborns with a low birth weight (birth weight less than 2,500 grams or 5 lbs. 8 oz.). Native American, American Indian, Alaskan Native or member of a federally recognized Tribe If the member attests they are a Native American, American Indian, Alaskan Native, or a member of a federally recognized tribe, they are not required to enroll in an HMO. The member can choose to remove this exemption at any time to enroll into an HMO. Care4Kids Extension This exemption applies to children in BadgerCare Plus who are still receiving services under the Care4Kids 12-month extension after being discharged from out-of-home care. Care4Kids is a specialized managed care program for children in out-of- home care in Kenosha, Ozaukee, Milwaukee, Racine, Washington, and Waukesha counties. Transplants The member had a stem cell or bone marrow transplant or the member is receiving sickle cell disease gene therapy. Members undergoing stem cell or bone marrow transplants will be permanently exempted from HMO enrollment effective the first of the month in which the surgery is performed. Members undergoing sickle cell disease gene therapy will be permanently exempted from HMO enrollment effective the first of the month in which successful apheresis is performed. Transplant exemption requests may be made by the HMO or the member and are directed to the state Nurse Consultant. This page last updated in Release Number: 26-02 Release Date: 04/15/2026 Effective Date: 02/23/2026