Chapter 4 - Medical Assistance And Services
CHAPTER 4 - MEDICAL ASSISTANCE AND SERVICES
ARTICLE 1 - IN GENERAL
42-4-101. Short title.
Thischapter may be cited as the "Wyoming Medical Assistance and ServicesAct". The program and services provided pursuant to this chapter andTitle XIX of the federal Social Security Act may be cited as"Medicaid" or the "Medicaid program".
42-4-102. Definitions.
(a) As used in this chapter:
(i) "Categorically eligible" means any individual inneed of medical assistance authorized by the legislature and by Title XIX ofthe federal Social Security Act to be covered by a state plan for medicalassistance and services;
(ii) "Medical assistance" means partial or fullpayment of the reasonable charges assessed by any authorized provider of theservices and supplies enumerated under W.S. 42-4-103 and consistent withlimitations and reimbursement methodologies established by the department,which are provided on behalf of a qualified recipient, excluding those servicesand supplies provided by any relative of the recipient or for cosmetic purposesonly;
(iii) "Qualified" means any categorically eligibleindividual satisfying eligibility criteria imposed by this chapter, the stateplan for medical assistance and services and by rule and regulation of thedepartment;
(iv) "Relative" means any person as defined bydepartment rule and regulation;
(v) "Resident" means any individual residing in thisstate, including any individual temporarily absent from this state;
(vi) "Institutionalized spouse" means as defined bythe Medicare Catastrophic Coverage Act of 1988, P.L. 100-360;
(vii) "Department" means the state department ofhealth;
(viii) "Direct patient care personnel" means only:
(A) Certified nursing assistants;
(B) Licensed practical nurses;
(C) Registered nurses.
(ix) "Skilled nursing home extraordinary care" meansskilled nursing home services clearly exceeding standard skilled nursing homeservices and meeting the criteria established by the department pursuant toW.S. 42-4-104(d);
(x) "Intermediate care facility for people withintellectual disability" means "intermediate care facility for thementally retarded" or "ICFMR" or "ICFs/MR" as thoseterms are used in federal law and in other laws, rules and regulations.
42-4-103. Authorized services and supplies.
(a) Services and supplies authorized for medical assistanceunder this chapter include:
(i) Inpatient hospital services;
(ii) Outpatient hospital services;
(iii) Laboratory and x-ray services;
(iv) Skilled nursing home services;
(v) The professional services of a licensed and certifiedphysician or osteopathic physician;
(vi) Home health services;
(vii) Family planning services;
(viii) Services provided by an authorized rural health careclinic;
(ix) Nurse midwife services;
(x) Early and periodic screening, diagnosis and treatment forindividuals who have not attained the age of twenty-one (21) years inaccordance with Title XIX of the federal Social Security Act;
(xi) Premiums, deductibles and coinsurance under federal MedicarePart A, hospital insurance, and Part B, supplemental medical insurance;
(xii) The professional services of a licensed optometrist;
(xiii) Prescription drugs and oxygen;
(xiv) Prosthetic devices which are necessary to replace a missingportion of the body or assist in correcting a dysfunctional portion of the bodyincluding training required to implement the use of the device but excludingdental prostheses;
(xv) Licensed rehabilitation center services and if specificallyprescribed by a licensed physician, outpatient services of a privately operatedlicensed occupational, speech, audiology or physical therapy center and theprofessional services of a licensed occupational therapist, licensed speechpathologist, licensed audiologist or a licensed physical therapist;
(xvi) Services provided by an institution for mental illnesses;
(xvii) Services provided under a federal home and community basedwaiver;
(xviii) The professional services of a licensed dentist which maybe legally and alternatively performed by a licensed physician or osteopathicphysician and except as provided under paragraph (a)(x) of this section, whichare not primarily provided for the care, treatment or replacement of teeth orstructures directly supporting teeth;
(xix) Services provided by a freestanding ambulatory surgicalcenter;
(xx) Services provided by a certified mental health center orclinic and certified mental health services furnished to qualified recipientsby a licensed physician or under the direction of a physician if an individualtreatment plan is established in writing, approved and periodically reviewed bya licensed physician. The department of health shall by rule and regulation orwithin the state plan for medical assistance and services, define thoseservices qualifying as mental health services under this paragraph and,pursuant to W.S. 9-2-102, establish standards for certification under thisparagraph;
(xxi) Services provided by intermediate care facilities;
(xxii) Services provided by an intermediate care facility asdefined under 42 U.S.C. 1396d(d);
(xxiii) Services provided by freestanding end stage renal dialysisclinics or centers;
(xxiv) Services provided by advanced practitioners of nursing;
(xxv) Hospice care as defined in W.S. 35-2-901(a)(xii) andauthorized under 42 U.S.C. 1396a(a)(10)(ii)(VII);
(xxvi) Tuberculosis ambulatory care authorized under 42 U.S.C. 1396a(a)(10)(A)(ii)(XII);
(xxvii) Targeted case management services, which shall be serviceswhich will assist targeted individuals eligible under the state plan in gainingaccess to needed medical, social, educational and other services;
(xxviii) Skilled nursing home extraordinary care in accordance withW.S. 42-4-104(d);
(xxix) Bone marrow, kidney and liver transplant services;
(xxx) Programs and services provided under the school healthprogram.
(b) In addition to other payments authorized under thischapter, the department may provide payments to skilled nursing homes which areproviding services covered under this chapter if:
(i) The nursing home demonstrates that one hundred percent(100%) of the additional amount received will be expended upon direct patientcare personnel salaries and benefits; and
(ii) The nursing home agrees to provide sufficient data to thedepartment substantiating compliance with paragraph (i) of this subsection.
42-4-104. Powers and duties of department of health.
(a) The department of health shall:
(i) Administer this chapter;
(ii) Develop a state plan for medical assistance and servicesprovided to qualified recipients under this chapter and otherwise providing forthe effective administration of this chapter;
(iii) Maintain records on the administration of this chapter,report to the federal government as required by federal law and regulation andwithin limitations imposed under W.S. 42-4-112, may provide for theavailability of information on the administration of this chapter to interestedpersons;
(iv) Adopt, amend and rescind rules and regulations on theadministration of this chapter following notice and public hearing inaccordance with the Wyoming Administrative Procedure Act.
(b) In carrying out subsection (a) of this section, thedepartment may:
(i) Advise, consult and cooperate with any state agency orpolitical subdivision, any other state, the federal government, privateindustry and other interested persons;
(ii) Negotiate and enter into contract with other public andprivate agencies and persons as necessary to administer this chapter;
(iii) Directly or by contract and through one (1) or more fiscalintermediaries, provide payments to providers of services and supplies formedical assistance authorized by this chapter in the manner and amount providedby this chapter;
(iv) Receive funds from any source for purposes of carrying outthis chapter;
(v) Establish reasonable limits on services and suppliesauthorized under W.S. 42-4-103;
(vi) Conduct pilot projects pursuant to W.S. 42-4-107(c);
(vii) Provide for part or all of the services and suppliesauthorized under W.S. 42-4-103 for some or all categorically eligibleindividuals through health care insurance or through contracts with networks ofhealth care providers;
(viii) Purchase stop gap insurance;
(ix) Enter into intergovernmental transfer arrangements withqualifying facilities in which all federal funding received as a result of theintergovernmental transfer arrangements shall be distributed to participatingfacilities.
(c) Subject to limitations imposed under this subsection, thedepartment shall, at least once every five (5) years but not more than once inany three (3) year period, establish a new base period to be used incalculating all skilled nursing homes' medical assistance per diem base ratereimbursable under this chapter, using the most recent cost report informationprovided to the department. For purposes of medical assistance reimbursableunder this chapter, the department shall reimburse each eligible provider ofskilled nursing home services the greater of the following amounts:
(i) Medical assistance computed on the per diem base rate underthe new base period established pursuant to this subsection; or
(ii) For the state fiscal year beginning July 1, 2003 and endingJune 30, 2004, medical assistance computed on the per diem base rate existingprior to the establishment of the new base period under this subsection.
(d) The department shall establish by rule the conditions andrequirements for skilled nursing home extraordinary care. The requirementsshall include, but are not limited to the following:
(i) The care shall be previously authorized by the departmentfor each individual and subject to continual audit by the department;
(ii) The cost for the care shall clearly exceed the standardskilled nursing home per diem rate;
(iii) The cost shall be excluded from the nursing home's costreport to the department; and
(iv) No extraordinary care payment shall be made for equipmentowned by the nursing home in providing the care.
42-4-105. Repealed by Laws 1991, ch. 221, 3.
42-4-106. Application for assistance; determination of eligibility;assignment of benefits; resources and income allowances defined forinstitutionalized spouse.
(a) Any Wyoming resident may apply for medical assistance underthis chapter by filing an application with the field office located in thecounty in which the individual resides. A determination of eligibility formedical assistance shall be based upon the application. Medical assistanceshall be provided on behalf of a qualified applicant with reasonablepromptness.
(b) Upon signing an application for medical assistance underthis chapter, an applicant assigns to the department any right to medicalsupport or payment for medical expenses from any other person on his behalf oron behalf of any relative for whom application is made. The assignment iseffective upon a determination of eligibility. Application for medicalassistance shall contain an explanation of the assignment provided under thissubsection.
(c) In determining the eligibility of an institutionalizedspouse for medical assistance under this chapter, the resources of thenoninstitutionalized spouse shall not be considered available to theinstitutionalized spouse to the extent the amount of his resources does notexceed the maximum authorized by the Medicare Catastrophic Coverage Act of1988, P.L. 100-360. For purposes of determining the amount of aninstitutionalized spouse's monthly income to be applied towards payment ofinstitutional care costs, the maximum amount of allowance authorized by theMedicare Catastrophic Coverage Act of 1988, P.L. 100-360 shall be deducted fromhis monthly income.
(d) In any assistance program under this chapter for whichincome is the criterion or one (1) of the criteria for assistance payments,compensation received for a veteran's service connected disability shall not becounted in determining income if that compensation on an annual basis is notmore than the poverty level for the applicant as determined by the federaloffice of management and budget.
42-4-107. Uniform application throughout state; discriminationprohibited; pilot projects authorized.
(a) This chapter and the state plan for medical assistance andservices developed under W.S. 42-4-104(a)(ii) shall be uniformly applied withinall political subdivisions of the state.
(b) The provision of medical assistance to any applicant orqualified recipient shall not be denied or delayed and the administration ofthis chapter shall not otherwise discriminate against any applicant orrecipient on the basis of race, creed, color, national origin, sex or mental orphysical handicap.
(c) Notwithstanding any other provision of this act, thedepartment, in providing services and supplies authorized by this act, mayconduct pilot projects pertaining to some or all categorically eligibleindividuals.
42-4-108. Administrative hearings.
Inaccordance with the Wyoming Administrative Procedure Act, the department shallprovide opportunity for a hearing to any individual denied medical assistanceunder this chapter or otherwise aggrieved by the administration of thischapter.
42-4-109. Renumbered and Repealed.
(a) Renumbered as 42-4-207(a) by Laws 1994, ch. 73, 2.
(b) Renumbered as 42-4-207(b) by Laws 1994, ch. 73, 2.
(c) Repealed by Laws 1994, ch. 73, 3.
(d) Renumbered as 42-4-207(f) by Laws 1994, ch. 73, 2.
42-4-110. Charges for inpatient hospital services.
Acost deduction, cost sharing or other similar charge shall not be imposed uponany recipient of medical assistance for inpatient hospital services provided onhis behalf pursuant to this chapter.
42-4-111. Providing or obtaining assistance by misrepresentation;penalties.
(a) No person shall knowingly make a false statement ormisrepresentation or knowingly fail to disclose a material fact in providingmedical assistance under this chapter.
(b) A person violating subsection (a) of this section is guiltyof:
(i) A felony punishable by imprisonment for not more than ten(10) years, a fine of not more than ten thousand dollars ($10,000.00), or both,if the value of medical assistance is five hundred dollars ($500.00) or more;or
(ii) A misdemeanor punishable by imprisonment for not more thansix (6) months, a fine of not more than seven hundred fifty dollars ($750.00),or both, if the value of medical assistance is less than five hundred dollars($500.00).
(c) No person shall knowingly make a false statement ormisrepresentation or knowingly fail to disclose a material fact in obtainingmedical assistance under this chapter. A person violating this subsection isguilty of a misdemeanor punishable by imprisonment for not more than six (6)months, a fine of not more than seven hundred fifty dollars ($750.00), or both.
(d) Each violation of subsection (a) of this section is aseparate offense.
42-4-112. Confidentiality of records; penalty for disclosure;authorized disclosure.
(a) Any application, information and record obtained, compiledand maintained for an applicant or qualified recipient of medical assistanceunder this chapter is confidential and shall not be disclosed or used for anypurpose other than the administration of this chapter.
(b) A violation of subsection (a) of this section is amisdemeanor.
(c) Notwithstanding subsection (a) of this section and anyother provision of law to the contrary, and for purposes of ensuring anymedical assistance under this act does not duplicate any benefit payment madeby another state agency, insurer, group health plan, third party administrator,health maintenance organization or similar entity, the department may uponrequest of the state agency, insurer or similar entity, disclose informationlimited to a recipient's name, social security number, amount of payment,charge for services, date of services and services rendered relating to medicalassistance payments made under this act. A state agency, insurer, group healthplan, health maintenance organization or similar entity shall, upon request ofthe department, disclose the same limited information to the department. Information received under this subsection shall be used only for the purposeauthorized by this subsection and shall otherwise be confidential and the stateagency, insurer, group health plan, health maintenance organization or otherrecipient entity shall be subject to the confidentiality restrictions imposedby law upon information received to the extent required of the department. Anyviolation of this subsection is a misdemeanor punishable by imprisonment fornot more than six (6) months, a fine of not more than seven hundred fiftydollars ($750.00), or both.
(d) Prior to receipt of any payment under this act, thedepartment shall require an applicant for or recipient of assistance under thisact to sign a waiver authorizing the release of information limited toassistance payment information to state agencies, insurers, group health plans,third party administrators, health maintenance organizations or similarentities for purposes specified by subsection (c) of this section.
42-4-113. Eligibility criteria; irrevocable burial trusts.
(a) The department shall not consider as assets available to anapplicant seeking medical assistance the corpus of a Medicaid qualifying trust:
(i) That is irrevocable;
(ii) In which the trustee and trustor retain no discretion withrespect to distributions to the applicant;
(iii) In which the income from the trust shall be transferred tothe applicant at least annually;
(iv) In which the trust corpus shall not exceed five thousanddollars ($5,000.00); and
(v) In which the trust corpus is specifically and irrevocablydesignated, assigned, or pledged for payment of the applicant's burialexpenses.
(b) If any of the trust corpus remains after payment of burialexpenses, that remainder shall be transferred to the department to be used inthe medical assistance program.
42-4-114. Cooperative agreements authorized.
Thedepartment may enter into a cooperative agreement and may contract with privateattorneys to provide legal services and legal representation necessary toassist the department in enforcing its right to reimbursement created underarticle 2 of this chapter. The department and its contract attorneys shall havean unconditional right to intervene in any action by or on behalf of arecipient or former recipient against any third party who may be legally liableto reimburse any medical assistance provided under the Wyoming Medicaidprogram. If no action has been brought, the department and its contractattorneys may initiate and prosecute an independent action on behalf of thedepartment against any third party that may be liable to the person to whom thecare was furnished. If the department elects not to contract with privateattorneys to provide legal services and representation under this section, theattorney general, or an appropriate county attorney, shall provide the legalservices and representation.
42-4-115. Work incentives improvement option; purchase of services;eligibility criteria; definition.
(a) The department may amend the state plan for medicalassistance and services developed under W.S. 42-4-104(a)(ii) to allowindividuals with countable income not to exceed three hundred percent (300%) ofthe supplemental security income level to receive services authorized underW.S. 42-4-103(a), provided that:
(i) Repealed by Laws 2002, Ch. 31, 2.
(ii) Repealed By Laws 2002, Ch. 31, 2.
(iii) The individual is eligible to buy into the Wyoming MedicalAssistance and Services Act under the federal Ticket to Work and Work IncentiveImprovement Act of 1999 and subsequent similar federal enactments and thefederal government is not restricted from paying its proportionate share of theindividual's eligible medical expenses;
(iv) Provided that the individual's earnings do not exceed thelevel specified in section 201(a)(3) of the Federal Ticket to Work and WorkIncentive Improvement Act of 1999; and
(v) The individual pays to the department a premium of sevenand one-half percent (7.5%) of his total gross earnings from work and seven andone-half percent (7.5%) of his unearned income in excess of six hundred dollars($600.00) per year, provided that:
(A) The total paid in premiums under this section does notexceed the yearly premium as calculated pursuant to W.S. 42-4-116; and
(B) The individual is not liable for more than the full premiumcalculated pursuant to W.S. 42-4-116.
(b) If the federal government does not allow a state planamendment containing the expense limitations provided in paragraphs (a)(i) and(ii) of this section or provisions with similar fiscal effects, the state planamendment authorized by this section shall not be implemented without specificlegislative authorization.
(c) With respect to the premium received pursuant to subsection(a) of this section, the department shall deduct and forward to the federalgovernment any amount owed under federal regulations. Any overpaid premiumshall be refunded to the individual and the balance shall be deposited in thegeneral fund. The sum of all amounts deposited under this section shall bereported in the biennial budget submissions to the joint appropriations interimcommittee as premium earned to offset the expenses of the program.
(d) Notwithstanding W.S. 37-2-302, any person earning more thanone hundred eighty-five percent (185%) of the federal poverty level andreceiving benefits under the Medical Assistance and Services Act pursuant tothis section shall not thereby be eligible for assistance under the telephoneassistance program pursuant to W.S. 37-2-301 through 37-2-306.
(e) Repealed by Laws 2002, Ch. 31, 2.
(f) Repealed By Laws 2002, Ch. 31, 2.
42-4-116. Premium calculation.
(a) The calculation of premium for services under W.S. 42-4-115shall be as follows:
(i) Determine the total expenses of the Medicaid program forthe most recent state fiscal year and the total number of clients in theMedicaid program served in that period;
(ii) Deduct from the totals in paragraph (i) of this subsectionthe clients over the age of sixty-five (65) years and the expenses associatedwith those clients;
(iii) Divide the resulting expenses calculated pursuant toparagraph (ii) of this subsection by the clients remaining after the deductionpursuant to paragraph (ii) of this subsection. The result is the basic annualpremium;
(iv) Add to the basic premium a risk factor of fifty percent (50%)of the basic premium to recover additional costs incurred by the populationeligible to be served pursuant to W.S. 42-4-115; and
(v) The premium shall be the sum of the basic annual premiumcalculated pursuant to paragraph (iii) of this subsection and the risk factorcalculated pursuant to paragraph (iv) of this subsection.
42-4-117. End stage renal dialysis program; rulemaking; funding.
(a) Effective July 1, 2001, the department shall expandcoverage for services authorized under W.S. 42-4-103(a)(xxiii) for qualifiedindividuals in need of end stage renal dialysis to the extent funding isavailable.
(b) The department shall by rule and regulation establishreasonable limits on services and supplies authorized under this section,including establishing eligibility criteria for receipt of services. Inestablishing eligibility criteria, the department shall consider financialability of the individual or his family to contribute to the services, severityof the illness, the critical need for the services and the ability of theprogram to meet the needs of the individual.
42-4-118. Prescription drug assistance program created; eligibilitycriteria; benefits provided; coverage of medications.
(a) There is created a prescription drug assistance program toassist residents of the state. The program shall be a state funded program toprovide prescription drug assistance, in addition to the services providedunder the Wyoming Medical Assistance and Services Act. Effective July 1, 2002,the prescription drug assistance program shall replace the minimum medicalprogram. Eligibility for assistance under the program created by this section shallnot constitute an entitlement and services shall be provided under this sectiononly to the extent funds are available.
(b) Residents of the state may apply for the prescription drugassistance program in the manner provided in W.S. 42-4-106. Upon a determinationof eligibility, the applicant remains eligible for assistance under theprescription drug assistance program as provided in this section. If arecipient ceases to be a resident of the state, his eligibility under theprogram shall terminate. The department shall by rule and regulation establishincome eligibility guidelines no later than July 1 of each year based on thefederal poverty levels in effect on January 1 of that calendar year. Personswith family income of one hundred percent (100%) of the federal poverty levelor less shall be eligible under this section. The rules shall take intoconsideration family size up to four (4) individuals. Eligibility for familiesconsisting of more than four (4) individuals shall be determined on the basisof the income of a family of four (4) individuals. Persons eligible forprescription drug assistance under other state or federal programs, except thestate high risk health insurance pool, shall be ineligible for assistance underthe prescription drug assistance program.
(c) Except as provided by this subsection, an eligibilitydetermination made under subsection (b) of this section shall be valid for one(1) year. A recipient whose monthly income changes by more than one-third(1/3), shall report the change in income to the department. The recipient isentitled to a redetermination if his income has declined and may, at the optionof the department, be subject to a redetermination if his income has increased.
(d) A recipient shall be required to pay a copayment perprescription of ten dollars ($10.00) for generic drugs and twenty-five dollars($25.00) for brand name drugs.
(e) The department shall project costs of the program createdby this section at least quarterly and compare those projected costs againstthe funds appropriated for the program. If the funds available to the programare insufficient to meet the projected costs of the program, the departmentshall take action to prevent the program from incurring costs beyond availablefunds, including taking any of the following actions:
(i) Imposing a moratorium on new enrollments in the program;
(ii) Reducing the gross family income eligibility levelspecified in subsection (b) of this section;
(iii) Imposing higher prescription drug copayments not to exceedtwenty-five dollars ($25.00) per prescription;
(iv) Eliminating specified drugs from eligibility under theprogram;
(v) Carrying claims for payment into the next biennium if theamount of claims are less than one twenty-fourth (1/24) of the appropriationthat has been enacted for the next biennium.
42-4-119. Pharmacy plus program; eligibility criteria; rulemaking;termination of program.
(a) The department may apply for a demonstration waiver undersection 1115 of the federal Social Security Act to allow individuals withincome or assets in excess of limits generally established in the state plan toreceive services under a pharmacy plus program provided that:
(i) The individual is a beneficiary under the federal Medicareprogram who has not been determined to be eligible for full Medicaid benefitsunder the state plan;
(ii) The total family income of the individual does not exceedone hundred seventy-five percent (175%) of the federal poverty level in effecton April 1 of that calendar year;
(iii) The total family net assets of the individual do not exceedthree hundred fifty thousand dollars ($350,000.00); and
(iv) An individual determined eligible to receive services underthis section shall not be eligible for other services under W.S. 42-4-103,unless the individual otherwise qualifies for the services. Eligibility forassistance under the program created by this section shall not constitute anentitlement and services shall be provided under this section only to theextent funds are available.
(b) The department is directed to negotiate the terms andconditions of the waiver with the United States secretary of health and humanservices as necessary to implement this section.
(c) Upon approval of the final terms and conditions by theUnited States secretary of health and human services and the legislature of thewaiver applied for under this section, the department shall implement thepharmacy plus program to assist eligible individuals with payment andmanagement of prescription drug costs. In implementing the pharmacy plusprogram, the department may use private sector benefit management approaches,including pharmacy benefit managers, preferred drug lists, prior authorization,pharmacist consultation, provider education, disease state management andvariable enrollee cost sharing in the form of annual or monthly premiumassessments, per prescription copayment requirements, coinsurance, deductiblesand coverage limits. The department shall establish through rules andregulations variable enrollee cost sharing provisions under this subsection ona graduated basis, taking into consideration the differing income levels ofenrollees and the funding available to the program.
(d) If the federal Medicare program is amended to providepharmaceutical benefits for recipients under that program, the pharmacy plusprogram authorized under this section shall terminate upon implementation ofthe federal Medicare pharmaceutical benefits program.
(e) The department shall project costs of the program createdby this section at least quarterly and compare those projected costs againstthe funds appropriated for the program. If the funds available to the programare insufficient to meet the projected costs of the program, the departmentshall take action to prevent the program from incurring costs beyond availablefunds, including taking any of the actions specified in W.S. 42-4-118(e).
42-4-120. Contracts for waiver services; authority of department;emergency case services; cost based payments.
(a) The department is authorized to enter into contracts withproviders of services under a federal home and community based waiver and toenforce the provisions of this section.
(b) The department shall adopt and enforce reasonable rules andregulations for the certification of home and community based waiver services,and shall include minimum certification standards for each category of serviceprovider.
(c) Before entering into a contract with a provider of servicesunder this section, the department shall ascertain that the provider is incompliance with applicable regulations regarding health care providers adoptedpursuant to W.S. 35-2-908, with all applicable professional licensing statutesand regulations and with regulations adopted pursuant to subsection (b) of thissection.
(d) In addition to other remedies, in the event of a chronicfailure to provide services or services that fail to meet the applicablestandard of care for the profession involved or a continuing condition creatingserious detriment to the health, safety or welfare of recipients of home andcommunity based waiver services, the department may impose a civil penalty uponthe provider. For each day of continuing violation, the civil penalty shallnot exceed one thousand dollars ($1,000.00) or one percent (1%) of the amountpaid to the provider during the previous twelve (12) months, whichever isgreater, and any administrative penalty assessed under this section shall bepaid over to the state treasurer who shall remit the monies to the countytreasurer to the credit of the public school fund of the county in which theviolation occurred, except as otherwise provided by federal law for Medicaidcertified nursing facilities.
(e) The department shall have the same authority to placeconditions upon a provider, to impose a monitor or to revoke a certificationissued under this section in the manner described in W.S. 35-2-905.
(f) The department, not later than April 1, 2008, shallpromulgate rules under which an emergency case shall be determined to existwith respect to eligibility for federal home and community based waiverservices for persons with developmental disabilities or adult brain injuryunder this act. Upon a finding by the department that an emergency existsunder this subsection, the department in accordance with its rules andregulations shall make necessary expenditures for the recipient from theemergency contingency account established for that purpose. Expenditures fromthe emergency contingency account shall be limited to those services necessaryto provide authorized customary services as provided by home andcommunity-based waivers for persons with developmental disabilities or adult braininjury in response to the emergency situation until the emergency no longerexists or eligibility under this act can be determined and any necessaryservices provided from nonemergency funding sources. The developmentaldisabilities division of the department of health shall submit an accounting tothe joint appropriations interim committee and the joint labor, health andsocial services interim committee by October 1 of each year regarding totalexpenditures and the number of persons provided emergency services pursuant tothis subsection.
(g) The department shall establish by rule and regulation acost based reimbursement system to pay providers of services and supplies underhome and community based waiver programs for persons with developmental disabilitiesor acquired brain injury. The payment system shall:
(i) Use information provided to the department, including butnot limited to:
(A) Provider cost data;
(B) Provider claims data;
(C) Participant needs assessment data;
(D) Other relevant regional and national data.
(ii) Establish a new base period to be used in calculatingreimbursement rates to providers for subsequent budget periods at least onceevery four (4) years but not more than once in any two (2) year period. When anew base period is established, the department shall submit a biennial orsupplemental budget request to adjust provider reimbursement rates based on themost current base period;
(iii) Be developed following consultation with Wyomingdevelopmental disability and acquired brain injury waiver program serviceproviders, developmental disability waiver program clients and their familiesand an expert in cost based waiver program payment systems, which thedepartment is authorized to retain by contract following competitive bidding;
(iv) Be implemented for services and supplies provided underindividual budget amounts established on and after July 1, 2008;
(v) Be contingent upon approval by the center for Medicare andMedicaid services of the United States department of health and human services;
(vi) Require service and supply providers to provide actual costof service and supply data to the department and to submit to reasonable auditsof the submitted data, if requested by the department.
42-4-121. Program of all-inclusive care for the elderly.
(a) The department, as an optional services program of theMedicaid program, may develop and implement a program of all-inclusive care forthe elderly (PACE) in accordance with section 4802 of the Balanced Budget Actof 1997, P.L. 105-33, as amended, and 42 C.F.R. part 460.
(b) The department may contract with approved PACEorganizations to provide, in the manner and to the extent authorized by federallaw, comprehensive, community based acute and long term care services for olderMedicaid eligible participants who are at least fifty-five (55) years old,living in a PACE service area, certified by the department as eligible for longterm care facility placement and who elect to participate in the PACE program. Services provided through a PACE organization shall include all necessarymedical and related care required by the PACE participant, including but notlimited to physician and other health care provider visits, regular check ups,prescription drugs, rehabilitation services, home and personal care services,medically necessary transportation, hospitalization and skilled nursingfacility services.
(c) The objective of the PACE program is to provide prepaid,capitated, quality comprehensive health care services that are designed to:
(i) Enhance the quality of life and autonomy for frail, olderadults;
(ii) Maximize dignity of, and respect for, older adults;
(iii) Enable frail, older adults to live in the community as longas medically and socially feasible;
(iv) Preserve and support the older adult's family unit.
(d) The department shall adopt rules as necessary to implementthis section. In adopting rules, the department shall:
(i) Provide application procedures for organizations seeking tobecome a PACE program provider;
(ii) Establish the capitation rate for Medicaid participantselecting to participate in the PACE program instead of receiving Medicaidservices on a fee for service basis. The capitation rate shall be no less thanninety percent (90%) of the fee for service equivalent cost, including thedepartment's cost of administration, that the department estimates would bepayable for all services covered under the PACE organization contract if all ofthose services were to be provided on a fee for service basis;
(iii) Provide application procedures, including acknowledgment ofinformed consent, for Medicaid participants electing to participate in the PACEprogram in lieu of receiving fee for service Medicaid benefits.
(e) PACE provider organizations shall be public or privateorganizations providing or having the capacity to provide, as determined by thedepartment, comprehensive health care services on a risk based capitated basisto PACE patients.
(f) To demonstrate capacity as required by subsection (e) ofthis section, the department shall consider evidence such as an organization'sinsurance, reinsurance, cash reserves, letters of credit, guarantees ofcompanies affiliated with the organization or a combination of thosearrangements.
(g) PACE organizations shall assume responsibility for allcosts generated by PACE program participants, and shall create and maintain arisk reserve fund that will cover any cost overages for any participant. APACE organization is responsible for the full financial risk that the cost ofservices required by a program participant might exceed the Medicaid capitatedfee for that participant.
(h) The department shall develop and implement a coordinatedplan to promote the PACE program among prospective Medicaid long term carepatients in the service areas of approved PACE organizations.
(j) As soon as practicable after July 1, 2010, the departmentshall submit to the federal centers for Medicare and Medicaid services anamendment to the state Medicaid plan authorizing the state to implement theprogram of all-inclusive care for the elderly pursuant to this section. Thedepartment shall not enter into a contract with any PACE provider organizationuntil all necessary state plan amendments or waivers are approved. Anadditional amendment to the state Medicaid plan shall not be required each timethe department enters into a contract with a new PACE provider organization.
(k) Nothing in this section shall be construed to require aPACE organization to hold a certificate of authority as an insurer or a healthmaintenance organization under title 26 of the Wyoming statutes.
(m) The department shall provide a report to the joint labor,health and social services interim committee no later than October 1, 2011, andannually thereafter, with respect to the program established by this section,including the number of PACE organizations authorized, the administrativestructure of the program, the number of Medicaid eligible persons receivingservices under the program and the historical annual actual and next bienniumprojected savings to the Medicaid program from the PACE program. As used inthis section "PACE" means a program of all-inclusive care for theelderly meeting the requirements of this section.
(n) No PACE organization shall withhold any necessary medicalor nonmedical services to any PACE participant in order to increase theorganization's profit from the Medicaid capitated payment.
(o) PACE participants may disenroll from the PACE program atany time. A PACE organization shall promptly report the identity of alldisenrolled participants to the department.
ARTICLE 2 - MEDICAID BENEFIT RECOVERY
42-4-201. Action against third party; notice; subrogation.
(a) If a person who is or becomes an applicant or recipient formedical assistance under this chapter receives an injury under circumstancescreating a legal liability in some third party, the applicant or recipientshall not be deprived of any medical assistance for which he is entitled underthis chapter. He may also pursue his remedy at law against the third party. Ifthe applicant or recipient recovers from the third party in any manner,including judgment, compromise, settlement or release, the state is entitled tobe reimbursed for all payments made, or to be made, on behalf of the applicantor recipient under this chapter.
(b) The department shall be served by certified mail, returnreceipt requested, with a copy of the complaint within seven (7) days of itsfiling in any suit initiated pursuant to subsection (a) of this section. Anyattorney who knowingly fails to serve the complaint on the department shall bereported to the state board of professional responsibility for the Wyomingstate bar. The department shall be notified in writing by certified mail returnreceipt requested of any judgment, compromise, settlement or release enteredinto by any person who has been an applicant for or recipient of medicalassistance under this chapter after the date of injury. If there is asettlement, compromise or release entered into by the parties the attorneygeneral representing the director shall be made a party in all negotiations forsettlement, compromise or release. The department, for purposes of facilitatingcompromise and settlement, may in a proper case authorize acceptance by thestate of less than the state's claim for reimbursement under this section forall current and future assistance under this chapter. Any reimbursement rightcreated pursuant to this article shall remain in effect until the state is paidthe amount authorized under this section. In addition the person paying thesettlement remains liable to the state's reimbursement right unless the statethrough the attorney general signs the release prior to payment of an agreedsettlement.
(c) If the injury causes death of the recipient, the rights andremedies in this section inure to, and the obligations are binding upon thepersonal representative of the deceased recipient for the benefit of hisdependents.
(d) Repealed By Laws 2002, Ch. 39, 2.
(e) If, after notice is provided in accordance with thissection, the department states in writing that it will neither file anindependent action nor intervene in an existing action as allowed by W.S.42-4-114, the department's reimbursement right shall be reduced by not morethan thirty-three percent (33%) for attorney's fees together with the amount ofits proportionate share of costs. If the department does not provide thiswritten statement, its right to reimbursement shall not be reduced by any shareof the recipient's attorney's fees or costs.
42-4-202. Third party liability; authority; enforcement; notice;costs.
(a) When the department provides, pays for or becomes liablefor medical care, it shall have a lien for the cost of the medical assistanceprovided upon any and all causes of action which accrue to the person to whomthe care was furnished, or to the person's legal representatives, as a resultof the injuries which necessitated the medical care.
(b) The department may perfect and enforce its lien byfollowing the procedures set forth in W.S. 29-1-301 and 29-1-302, and itsverified lien statement shall be filed with the appropriate clerk in the countyof financial responsibility. The verified lien statement shall contain thefollowing:
NOTE: Effective7/1/2011, this section will read as follows:
(b) The department may perfect and enforce its lien byfollowing the procedures set forth in W.S. 29-1-312 and 29-1-313, and itsverified lien statement shall be filed with the appropriate clerk in the countyof financial responsibility. The verified lien statement shall contain thefollowing:
(i) The name and address of the person to whom medical care wasfurnished;
(ii) The date of injury;
(iii) The name and address of the vendor or vendors furnishingmedical care;
(iv) The dates of the service;
(v) The amount claimed to be due for the care;
(vi) To the best of the department's knowledge, the names andaddresses of all persons, firms or corporations claimed to be liable fordamages arising from injuries.
(c) This section shall not affect the priority of anyattorney's lien. The department shall not be subject to any limitations periodreferred to in title 1 or 29 of the Wyoming statutes to file its verified lienstatement.
(d) The department shall be given notice of monetary claimsagainst a person, firm or corporation that may be liable to pay part or all ofthe cost of medical care when the department has paid or become liable for thecost of that care. Notice shall be given as follows:
(i) Applicants for medical assistance shall notify the state orlocal agency of any possible claims when they submit the application. Recipients of medical assistance shall notify the department of any possibleclaims when those claims arise. A recipient's noncooperation in providinginformation to the department to assist in pursuing liable third parties shallresult in denial or termination of eligibility per federal law;
(ii) An enrolled medicaid provider shall notify the departmentwhen the person has reason to believe that a third party may be liable forpayment of the cost of medical care. If the person providing medical careservices fails to notify the department when a third party is liable forpayment of the cost of medical care and the department, because of lack ofnotice from the provider, does not receive reimbursement for the cost ofmedical care, the department may adjust the value of those claims from futurepayments to that provider;
(iii) An attorney representing an applicant for or a recipient ofmedical assistance in a claim upon which the department may have areimbursement right under this chapter shall notify the department of itspotential claim for reimbursement before filing a claim, commencing an action,or negotiating a settlement. Any attorney who fails to notify the departmentof any settlement or fails to ensure the state is reimbursed, to the extent ofits reimbursement right, from the proceeds of any settlement or judgment underthis section shall be reported to the state board of professionalresponsibility for the Wyoming state bar. If the attorney knowingly failed toreport and insure reimbursement to the state, the department shall have a claimfor relief against the attorney for the amount of the reimbursement right underthis chapter;
(iv) Insurers shall not disburse any settlement payment for apersonal injury claim made to a recipient of medical assistance under this actuntil seven (7) working days after the department has received written noticefrom the insurer of the proposed settlement or judgment and failed to provide awritten objection to the insurer. Failure to provide notice under thisparagraph shall commence the tolling of any applicable statute of limitations.
(e) Notice given to the local agency is not sufficient to meetthe requirements of paragraphs (d)(ii) through (iv) of this section.
(f) Repealed By Laws 1999, ch. 125, 2.
42-4-203. Settlement between recipient and tortfeasor or insurer; liennot discharged; exceptions.
(a) No settlement made by and between the applicant orrecipient and the tortfeasor or insurer shall discharge the right toreimbursement created pursuant to this article, against any money due or owingby such tortfeasor or insurer to the applicant or recipient or relieve thetortfeasor or insurer from liability by reason of the right to reimbursementunless the settlement also provides for the payment and discharge of the rightto reimbursement and the attorney general has signed a written release asprovided by W.S. 42-4-201(b).
(i) Repealed By Laws 2002, Ch. 39, 2.
(ii) Repealed By Laws 2002, Ch. 39, 2.
42-4-204. Department subrogated to right of recovery of applicant orrecipient; utilization of personal health insurance; insurance coverage ofrecipients.
(a) The department shall be subrogated to any right of recoveryor indemnification arising from an accident or occurrence resulting inexpenditures by the department, which an applicant or recipient of medicalassistance or any legally liable party has against an insurer, health insurer,self-insured plan, group health plan, service benefit plan, managed careorganization, pharmacy benefit manager or other party that is, by statute,contract or agreement, legally responsible for payment of a claim for healthcare items or services, including but not limited to hospitalization,pharmaceutical services, physician services, nursing services and other medicalservices, not to exceed the amount expended by the department for the care andtreatment of the applicant or recipient. An applicant or recipient or legallyliable party, by the act of applying for, or recipient receiving medicalassistance, shall be deemed to have made a subrogation assignment and anassignment of claim for benefits to the department. The department shallinform an applicant of the assignments at the time of application. Inaddition, any entitlements from a contractual agreement with an applicant orrecipient or legally liable party, a state or federal program or a claim oraction against any responsible third party for medical services, not to exceedthe amount expended by the department, shall be so assigned. The entitlementsshall be directly reimbursable to the department by third party payors. Thedepartment may assign its right to subrogation or its entitlement to benefitsto a designee or a health care provider participating in the medicaid programand providing services to an applicant or recipient, in order to assist theprovider in obtaining payment for the services. A provider that has receivedan assignment from the department shall notify the insurer of the assignmentupon rendering of services to the applicant or recipient. Failure to so notifythe insurer shall render the provider ineligible for payment from the department. Once the insurer has been billed or notified the provider may not requestpayment through the medicaid program until a payment, denial or otherexplanation of benefits, not including mistakes in billing, is received fromthe insurer. The provider shall notify the department of any request by theapplicant or recipient or his legally liable party or representative forbilling information.
(b) When a recipient of medical assistance has access topersonal health insurance through his employer, payment or part payment of thepremium for the insurance may be made by the department when deemed appropriateby the director of the department.
(c) No individual accident policy, group accident policy,health policy, accident and health policy, medical expense policy or medicalservice plan contract, delivered, issued for delivery or renewed in this stateon or after July 1, 1995, and no self-insured plan, managed care policy orplan, pharmacy benefit management plan or policy or other policy or plan issuedby any other party that is, by statute, contract or agreement legallyresponsible for payment of a claim for items or services, delivered, issued fordelivery or renewed in this state on or after July 1, 2007, shall contain anyprovision denying or limiting insurance benefits because services are renderedto an insured who is eligible for or who received medical assistance under thischapter. This section shall supersede any statutory provision to thecontrary. No such policy, plan or contract, when enrolling an individual,shall take into account the individual's eligibility for medical assistanceunder this chapter. This subsection applies to all such policies, plans andcontracts issued by any person including, but not limited to:
(i) An insurer;
(ii) A group health plan as defined in section 607(1) of theEmployee Retirement Income Security Act of 1974;
(iii) A managed care organization, pharmacy benefit manager orother party that is, by statute, contract or agreement, legally responsible forpayment of a claim for a health care item or service;
(iv) An entity offering a service benefit plan;
(v) A self-insured plan.
(d) Medicaid shall not pay for any services provided under thischapter if the individual eligible for medical assistance has coverage for theservices under an accident or health insurance policy or other source.
(e) In addition to the separate requirements set forth in W.S.42-4-205, all health insurers, including all self-insured plans, group healthplans as defined in section 607(1) of the Employee Retirement Income SecurityAct of 1974, service benefit plans, managed care organizations, pharmacy benefitmanagers, or other parties that are, by statute, contract, or agreement,legally responsible for payment of a claim for a health care item or service,shall agree, as a condition of doing business in the state of Wyoming, to:
(i) Provide, with respect to the individuals who are eligiblefor or are provided medical assistance by the department of health, informationto determine the period during which the individual or the individuals' spousesor depend