Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0043 - Prescription Drug Assistance Program › Chapter 1 - PRESCRIPTION DRUG ASSISTANCE PROGRAM › Section 1-4 - Definitions

Current through July 13, 2024
The following definitions shall apply in the interpretation
				  and enforcement of these rules. Where the context in which words are used in
				  these rules indicates that such is the intent, words in the singular number
				  shall include the plural and vice versa. Throughout these rules gender pronouns
				  are used interchangeably except where the context dictates otherwise. The
				  drafters have attempted to utilize each gender pronoun in equal numbers in
				  random distribution. Words in each gender shall include individuals of the
				  other gender.
(a) "Act." The
				Prescription Drug Assistance Act, 2002 Wyoming Senate Bill No. 34, to be
				codified as
				W.S.
				42-4-118.
(b) "Adverse action." The denial, suspension,
				or termination of benefits, other than a suspension or termination caused by a
				suspension of the Program pursuant to Section
				12
				or a change in State law, including an amendment to this Chapter.
(c) "A lien." A person residing in, and who
				is not a citizen of, the United States of America.
(d) "Applicant." An individual on whose
				behalf an application for coverage by the Program has been submitted, but there
				has been no final determination of eligibility.
(e) "Application." The form, specified by the
				Department, on which an applicant indicates in writing the desire to receive
				benefits.
(f) "Application date."
				The date an application is received and date stamped by DFS.
(g) "Approve." To determine an applicant is
				eligible for program benefits.
(h)
				"Assistance unit." The financially responsible persons living together whose
				income is considered in determining eligibility for program benefits.
(i) "Benefit month." The calendar month for
				which program eligibility will
be approved.
(j) "Benefits." Coverage under the
				program.
(k) "Benefit year." The
				twelve month period following the benefit start date, and each twelve month
				period thereafter so long as an insured remains eligible.
(l) "Biennium." The period covering two State
				fiscal years following each regularly scheduled budget session of the Wyoming
				Legislature.
(m) "Change in
				income." An increase of one-third or more in the monthly income of an
				assistance unit.
(n) "Change
				report." A form, as prescribed by the Department, used to report a change in
				income to DFS.
(o) "Chapter 1 of
				the DFS rules." Chapter 1 of the DFS rules.
(p) "Chapter 1 of the Medicaid Rules."
				Chapter 1, Medicaid Fair Hearings, of the Wyoming Medicaid Rules.
(q) "Chapter 3 of the Medicaid Rules."
				Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(r) "Chapter 16 of the Medicaid Rules."
				Chapter 16, Medicaid and State Funded Program Integrity, of the Wyoming
				Medicaid Rules.
(s) "Chapter 39 of
				the Medicaid Rules." Chapter 39, Recovery of Excess Payments, of the Wyoming
				Medicaid Rules.
(t) "Claim." A
				request by a provider for payment of PDAP funds for services provided to a
				recipient.
(u) "Contested case."
				Contested case as defined in Chapter 1, which definition is incorporated by
				this reference.
(v) "Copayment." A
				charge to a recipient for receiving covered services.
(w) "Countable." A category of income, or
				resources, which is used to determine program eligibility.
(x) "Covered service." Services provided to a
				recipient that may be reimbursed out of program funds as provided in this
				Chapter.
(y) "Department." The
				Wyoming Department of Health, its agent, designee, or successor.
(z) "Department of Family Services (DFS)."
				The Wyoming Department of Family Services, its agent, designee, or
				successor.
(aa) "Prescription Drug
				Assistance Program (PDAP)" The Prescription Drug Assistance Program established
				by the Act.
(bb) "Prescription Drug
				Assistance Program (PDAP) allowable payment." The maximum reimbursement for
				covered services as specified by this Chapter.
(cc) "Prescription Drug Assistance Program
				(PDAP) funds." That State general funds appropriated by the Wyoming State
				Legislature and available to the Department to make payments to providers for
				furnishing covered services to recipients.
(dd) "Effective date of eligibility." A
				recipient will be covered for services as of the first day of the month in
				which the recipient submitted an application.
(ee) "Eligible." An applicant who is
				approved.
(ff) "Excess payments."
				"Excess payments" as defined in Chapter 39, which definition is incorporated by
				this reference. Except that the phrase "Medicaid Funds" in Chapter 39 is
				replaced with "Program funds."
(gg)
				"Federal poverty level." The poverty line as specified in the federal poverty
				guidelines as published and updated annually in the Federal Register pursuant
				to Section 673(2) of OBRA.
(hh)
				"Financial records." All records, in whatever form, used or maintained by a
				provider which are necessary to substantiate or understand a claim submitted to
				the Department.
(ii) "Formulary."
				"Formulary" as defined in Chapter 10, which definition is incorporated by this
				reference.
(jj) "Income." Earned
				income, unearned income, or in-kind payments received from any source,
				excluding money classified as a resource or exempt income:
(i) Earned income includes:
(A) Any payment received by an employee or
				agent in cash or in-kind as wages, salary, tips, commissions, or pursuant to a
				contract.
(B) Net profits received
				from activities in which the individual is engaged. "Net profits" means the
				total sum before deductions for personal or employment expenses and excludes
				the meal allowance used by the Federal Insurance Contribution Act
				(FICA).