Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 5 - Rules and Regulations for Kid Care CHIP ("Children's Health Insurance Program") › Section 5-3 - Definitions

Current through July 13, 2024
(a) Except as defined in the Act or as
				otherwise specified in this section, the terminology used in this Chapter is
				the standard terminology and has the standard meaning used in health care,
				health insurance, Medicare, and Medicaid. For the purposes of this Chapter, the
				following shall apply:
(i) "Act" shall mean
				the Child Health Insurance Program Act at
				W.S.
				35-25-101 through
				35-25-108.
(ii) "Adverse action" shall mean the denial,
				suspension, or termination of benefits, other than a suspension or termination
				caused by a suspension of Kid Care CHIP, pursuant to Section
				12 or a change in federal or state law,
				including an amendment to this Chapter. "Adverse action" does not include
				program reduction or termination, or the denial of eligibility due to a
				moratorium or the denial of services because they are not covered
				services.
(iii) "Alien" shall mean
				a person residing in Wyoming who is not a citizen of the United States of
				America.
(iv) "Applicant" shall
				mean a child on whose behalf an application for coverage by Kid Care CHIP has
				been submitted, but there has been no final determination of
				eligibility.
(v) "Application"
				shall mean the single, streamlined application form that is used by the State
				in accordance with
				42 CFR §
											457.330.
(vi) "Application date" shall mean the date
				an application for Kid Care CHIP is received by the Department.
(vii) "Benefit year" shall mean a year of
				benefits coverage that begins January 1 of each year and ends December 31 of
				the same year.
(viii) "Child" shall
				mean an individual who has not yet reached the nineteenth
				(19th) anniversary of his or her birth.
(ix) "Cost sharing or co-payment" shall mean
				premium charges, enrollment fees, deductibles, coinsurance, copayments or other
				similar fees that the enrollee has responsibility for paying.
(x) "Department" shall mean the Wyoming
				Department of Health.
(xi) "Federal
				funds" shall mean the Federal funds received by the Department pursuant to 42
				C.F.R. § 457 Subpart F.
(xii)
				"Household" shall mean, for the purposes of eligibility, number of persons
				counted as members of an individual's household, including the modified
				adjusted gross income (MAGI) household determinations as defined in
				42
				CFR §
											457.315.
(xiii) "Kid Care CHIP" shall mean the
				Children's Health Insurance Program created by the Balanced Budget Act of 1997,
				enacted Title XXI of the Social Security Act, and established pursuant to
				W.S.
				35-25-101 through
				W.S.
				35-25-108, administered by the State to
				provide child health assistance (insurance) to uninsured, targeted low income
				children.
(xiv) "Kid Care CHIP
				funds" shall mean that combination of Federal funds and State funds which is
				available to the Department per 42 CFR Part 457 Subpart F to make payments to
				participating insurance companies for child health assistance (insurance) for
				eligible, enrolled children as well as administrative expenditures, outreach
				and health initiatives and further defined by W.S.
				W.S.
				35-25-107.
(xv) "Kid Care CHIP State Plan" shall mean
				the comprehensive written statement submitted by the Department to The Centers
				for Medicare and Medicaid (CMS) describing the purpose, nature and scope of the
				Program, as per
				42 CFR §
											457.50, referenced in
				W.S.
				35-25-108.
(xvi) "Medically necessary" or "medical
				necessity" shall mean a health service that is required to diagnose, treat,
				cure, or prevent an illness, injury, or disease which has been diagnosed or is
				reasonably suspected; to relieve pain; or to improve and preserve health and be
				essential to life. The service shall be:
(A)
				Consistent with the diagnoses and treatment of the insured's
				condition;
(B) In accordance with
				the standards of good medical practice among the provider's peer
				group;
(C) Required to meet the
				medical needs of the insured and undertaken for reasons other than the
				convenience of the insured and the provider; and
(D) Performed in the most cost effective and
				appropriate setting required by the insured's condition.
(xvii) "Orthodontia medical necessity" shall
				mean orthodontic condition(s) that must meet specific criteria and determined
				eligible for services as outlined by Program guidelines.
(xviii) "Services" shall mean medical, mental
				health and dental services, medical supplies, or medical equipment as described
				in the Kid Care CHIP State Plan.
(xix) "Targeted low income child" shall mean
				a child who has a household income, as determined according to
				42
				CFR §
											457.315, at or below 200 percent
				of the Federal poverty level for a family of the size involved.
(xx) "Well-baby or well-child services" shall
				mean the regular or preventive diagnostic and treatment services necessary to
				ensure the health of babies and children.