reglab/statecodes huggingface dataset:
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 1 - WYOMING COLORECTAL CANCER SCREENING PROGRAM › Section 1-7 - Covered Services

Current through July 13, 2024
(a) For a client enrolled in the WCCSP, the
				Department shall cover the costs related to an evidence-based colorectal cancer
				screening, according to the following provisions:
(i) The Department shall reimburse a
				participating healthcare provider only for the services and at the rates
				identified on the WCCSP's Current Procedural Terminology (CPT) codes list which
				is publicly available on the program's website; and
(ii) The Department may not reimburse a
				participating healthcare provider for:
(A)
				Services related to adverse events; and
(B) Follow-up surgery or additional care
				needed if cancer or another condition requiring additional medical care is
				found.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 1 - WYOMING COLORECTAL CANCER SCREENING PROGRAM › Section 1-8 - Provider Eligibility, Reimbursement, and Billing

Current through July 13, 2024
(a) A healthcare provider may automatically
				participate in the WCCSP if they are approved as a Wyoming Medicaid provider
				with a qualifying taxonomy code.
(b) A participating healthcare provider may
				not receive reimbursement for covered services rendered to a client enrolled in
				the WCCSP unless the provider submits the appropriate clinical documentation
				for the services performed, in the form and manner prescribed by the
				Department.
(c) The Department
				shall reimburse a participating healthcare provider for covered services
				rendered to a client enrolled in the WCCSP at the current Wyoming Medicaid
				allowable rates for the date of service.
(d) A participating healthcare provider shall
				accept the Department's payment for covered services as paid in full.
(e) A participating healthcare provider may
				not bill the client, or any member of the client's family, for services covered
				by the WCCSP. This prohibition includes imposing additional charges for covered
				services.
(f) A participating
				healthcare provider may bill a client enrolled in WCCSP if services provided
				are not covered by the WCCSP, and, prior to providing services, the provider
				informs the client in writing that the service is non-covered and the client is
				responsible for those charges.
(g)
				For persons who are underinsured, the program shall only pay for expenses not
				covered by insurance.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 15 - GENERAL PROVISIONS › Section 15-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Wyoming Department of
				  Health pursuant to the Wyoming Administrative Procedure Act at W,S. §
									
										16-3-101, etseq., and the various provisions
				  of W.S. §
									
										35-25-204, which authorizes the Department to
				  establish the Wyoming Colorectal Cancer Screening Program
				  (WCCSP).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 15 - GENERAL PROVISIONS › Section 15-3 - General Provisions

Current through July 13, 2024
(a) These rules
				shall provide for the following:
(i) Case
				management services to Wyoming men and women enrolled in the WCCSP;
				and
(ii) Public education and
				outreach services to educate Wyoming men, women, and provider about colorectal
				cancer and evidence-based screening guidelines, as well as to promote the
				WCCSP.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 15 - GENERAL PROVISIONS › Section 15-4 - 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 such is the intent, words in the singular number shall
				  include the plural and vice versa. For the purpose of the rules, the following
				  shall apply:
(a) "Adverse Event" is an
				injury or complication resulting from the colonoscopy procedure.
(b) "Colonoscopy" is an endoscopic medical
				procedure that uses a long, flexible, lighted, tubular instrument called a
				colonoscope to view the rectum and the entire inner lining of the colon (large
				intestine).
(c) "Case Management"
				means the provision of educational and emotional support and/or clinical
				navigation services for program enrolled clients by the program nurse to ensure
				compliance with screening protocols.
(d) "Contractor" means an entity that has
				executed a contract for professional services with the WCCSP.
(e) "Departmenf" means the Wyoming Department
				of Health.
(f) "Enrollment
				Start-Date" is the date the application is approved by the WCCSP.
(g) "Federal Poverty Level" means the set
				minimum amount of income that a family needs for food, clothing,
				transportation, shelter and other necessities. In the United States, this level
				is determined by the United States Department of Health and Human
				Services.
(h) "Team Member" refers
				to the WCCSP staff, as well as any other representative given authority to make
				decisions on behalf of the WCCSP by the Program Manager or person serving as
				acting Program Manager.
(i) "CPT
				Code List" refers to a list created by the WCCSP that identifies various
				colonoscopy-related codes that are reimbursable by the program. The most
				current version of the list will be posted on the program website and
				accessible to all providers.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 16 - PROGRAM APPLICANT ELIGIBILITY AND ENROLLMENT REQUIREMENTS › Section 16-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Wyoming Department of
				  Health pursuant to the Wyoming Administrative Procedure Act at W.S. §
									
										16-3-101, et seq., and the various provisions
				  of W.S. §
									
										35-25-204, which authorizes the Department to
				  establish the Wyoming Colorectal Cancer Screening Program
				  (WCCSP).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 16 - PROGRAM APPLICANT ELIGIBILITY AND ENROLLMENT REQUIREMENTS › Section 16-3 - Eligibility Guidelines

Current through July 13, 2024
A completed and signed application must be submitted to the
				  WCCSP for approval. The following eligibility criteria must be met before an
				  application may be approved for enrollment:
(a) Residency. Applicant must have been a
				resident of the State of Wyomhig for at least one (1) year immediately prior to
				making application to the program. Applicant shall swear to an oath of
				residency when completing the application for enrollment.
(b) Age. Applicant must be age fifty (50) or
				over, unless an exception is requested by a healthcare provider indicating the
				need for earlier screening and the exception meets the program's evidence based
				guidelines. A minimum age requirement of age eighteen (18) is necessary to be
				screened through the program.
(c)
				Insurance. Applicant must not already be enrolled in the federal Medicare
				program or Wyoming Medicaid.
(d)
				Income. Applicant's gross income (before taxes) at the time of application must
				be at or below 250% of the Federal Poverty Level.
(e) Provider, Applicant, upon approval, must
				receive their' colonoscopy from a provider contracted with the WCCSP,
(f) Ten-Year Rule. Upon approval of
				application for enrollment, applicant will be eligible for one (1) colonoscopy
				every ten (10) years, counting any colonoscopy completed before July 1, 2007,
				or before the applicant became a Wyoming resident. However, the WCCSP on a
				case-by-case basis may authorize follow-up screening when medically indicated
				based on national evidence-based guidelines.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 16 - PROGRAM APPLICANT ELIGIBILITY AND ENROLLMENT REQUIREMENTS › Section 16-4 - Enrollment Guidelines

Current through July 13, 2024
The following are guidelines the WCCSP adheres to with
				  regard to client enrollment and the processes for approval or denial of
				  applications.
(a) Enrollment Period. A
				client who is enrolled in the WCCSP will remain in the program until they are
				eligible for Medicare or until adequate insurance coverage becomes available to
				the client. Clients who do not obtain a screen within three (3) months of
				initial enrollment approval will be notified in writing that enrollment
				approval may be terminated if screening is not obtained within the next ninety
				(90) calendar days. If provider capacity is insufficient at the time of
				enrollment approval, an extension may be given at the Department's sole
				discretion.
(b) Decision-Making
				Process. Upon receipt of an application, it will be reviewed and approved or
				denied by WCCSP team members. If a decision is complex and cannot be determined
				by the team members the case will be referred to a WDH staff physician for
				enrollment decision.
(c)
				Notification to Applicants of Approval or Denial. Eligibility is not determined
				online, in person, or over the telephone. Applicants are informed in writing
				whether their application has been approved or denied. Reasons for denial will
				be specified in the letter.
(d)
				Review Process. Applicants who are denied enrollment may submit a written
				letter explaining their situation or they may request that their healthcare
				provider submit a written letter supporting the request. These documents shall
				be submitted to the Program Manager. A review team will be formed within the
				Department to respond to the appeals. The Department will make every effort to
				respond to the appeals within thirty (30) business days.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 17 - PROVIDER ELIGIBILITY, SCREENING METHODS, AND REIMBURSEMENT GUIDELINES › Section 17-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Wyoming Department of
				  Health pursuant to the Wyoming Administrative Procedure Act at W.S. §
									
										16-3-101, et seq., and the various provisions
				  of W.S. §
									
										35-25-204, which authorizes the Department to
				  establish the Wyoming Colorectal Cancer Screening Program
				  (WCCSP).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 17 - PROVIDER ELIGIBILITY, SCREENING METHODS, AND REIMBURSEMENT GUIDELINES › Section 17-2 - Statement of Purpose

Current through July 13, 2024
The following rules and regulations are adopted to establish
				  provider eligibility, screening methods, and reimbursement
				  guidelines.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 17 - PROVIDER ELIGIBILITY, SCREENING METHODS, AND REIMBURSEMENT GUIDELINES › Section 17-3 - Eligibility

Current through July 13, 2024
A physician must be licensed to practice medicine as
				  determined by the credentialing state's Board of Medicine to be an eligible
				  provider for reimbursement of colorectal cancer screening services (i.e.,
				  colonoscopy) by the WCCSP.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 17 - PROVIDER ELIGIBILITY, SCREENING METHODS, AND REIMBURSEMENT GUIDELINES › Section 17-4 - Reimbursement for Services

Current through July 13, 2024
Pursuant to W.S. §
									
										35-25-204, the WCCSP will reimburse providers
				  for the costs relating to colonoscopy screening. If a colonoscopy screening is
				  unsuccessful and cannot be completed, an alternate screening method will be
				  considered for reimbursement on a case-by-case basis as determined by the
				  Department's staff physician.
(a)
				Services covered by the WCCSP. Reimbmrsement is paid for services listed on the
				program's CPT code list. The CPT-code list is located on the program's web
				site.
(b) Services not covered by
				the WCCSP.
(i) There will be no reimbursement
				to providers for colonoscopies or related costs performed prior to the WCCSP
				enrollment start date. The applicant/patient must have a WCCSP payment voucher
				to present to the provider prior to the procedure, unless otherwise approved by
				WCCSP. If applicant/patient does not have proper enrollment approval, the
				applicant/patient will assume responsibility for any costs relating to
				procedures performed prior to enrollment approval,
(ii) Reimbursement for adverse events is not
				covered by the WCCSP.
(iii) The
				WCCSP shall not reimburse for follow-up surgery or additional care needed if an
				actual cancer or other condition requiring additional medical care is
				found.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 17 - PROVIDER ELIGIBILITY, SCREENING METHODS, AND REIMBURSEMENT GUIDELINES › Section 17-5 - Payment Policy

Current through July 13, 2024
Screening by the WCCSP will be paid by the program at the
				  current Wyoming Medicaid allowable rates for the date of service. For
				  cirucumstances where multiple biopsy/removal techniques are used during one
				  colonoscopy, the program will pay 100 percent for the allowable Medicaid
				  reimbursement amount for the service of the highest cost, then 50 percent of
				  the allowable Medicaid reimbursement amount for the second service, and 25
				  percent of the allowable Medicaid reimbursement amount for the third and
				  sequential techniques.
(a) The
				Contractor must accept as payment in full the current Medicaid allowable charge
				in effect on the date of the covered service as identified on the WCCSP OPT
				code set.
(b) The Contractor is
				prohibited from making additional charge(s) to the client or any member of the
				client's family for those services covered by the WCCSP.
(c) The Contractor shall have and/or retain
				the expressed right to bill clients enrolled in WCCSP for any services not
				covered by the WCCSP.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 18 - PROGRAM EVALUATION AND REPORTING › Section 18-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Wyoming Department of
				  Health pursuant to the Wyoming Administrative Procedure Act at W.S. §
									
										16-3-101, et seq., and the various provisions
				  of W.S. §
									
										35-25-204, which authorizes the Department to
				  establish the Wyoming Colorectal Cancer Screening Program
				  (WCCSP).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0063 - Wyoming Cancer Program › Chapter 18 - PROGRAM EVALUATION AND REPORTING › Section 18-3 - Data Collection and Reporting

Current through July 13, 2024
The program shall establish and maintain an appropriate data
				  collection system.
(a) Program
				participating healthcare providers are required to submit the colonoscopy
				report or other approved procedure reports and pathology report(s) (if biopsy
				performed) for ah procedures requested for reimbursement.
(b) The WCCSP is responsible for the
				collection and analysis of client demographic data, clinical outcome data,
				program process and outcome data and reimbursement cost related data,
(c) The WCCSP will produce data reports and
				other program reports as requested and on an as needed basis.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-1 - Authority

Current through July 13, 2024
This Chapter is promulgated pursuant to the Child Health
				  Insurance Program Act at W.S. §
									
										35-25-108 and the Wyoming Administrative
				  Procedure Act at W.S. §
									
										16-3-102.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter
				shall apply to and govern Kid Care CHIP. This Chapter shall become effective
				for Kid Care CHIP services provided on or after January 1, 2014.
(b) The requirements of 42 C.F.R. Ch. IV,
				Subch. D, Pt. 457 and Ch. VII, Subch. XX, Division A and Title XXI of the
				social Security Act also apply to Kid Care CHIP and are incorporated by this
				reference as of the effective date of this Chapter, and may be cross-referenced
				throughout this Chapter where applicable. This incorporation by reference does
				not include any later amendments or editions of the incorporated matter. The
				incorporated matter may be viewed at http://www.ecfr.gov/cgi-bin/ECFR and
				http://www.ssa.gov, or may be obtained at cost from the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-3 - General Provisions

Current through July 13, 2024
(a) This Chapter is
				intended to be read in conjunction with the Child Health Insurance Program Act
				at W.S. §§
									
										35-25-101 through
				35-25-111,
				42 U.S.C.
				§
										1397 aa through 139711, andHHS
				Regulations at 42 C.F.R. Part 457.
(b) Nothing in this Chapter shall be
				construed as providing an individual with an entitlement to Kid Care
				CHIP.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-4 - Definitions

Current through July 13, 2024
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 all Chapters of Kid Care CHIP Rules, the
				  following shall apply:
(a) "Act" shall
				mean the "Child Health Insurance Program Act," as enacted by the Wyoming
				Legislature and codified at W.S. §§
									
										35-25-101 through
				35-25-111.
(b) "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
				14
				or a change in federal or state law, including an amendment to this Chapter.
				"Adverse action" does not include the denial of services because they are not
				covered services or other issues about the scope of covered services.
(c) "Alaska Native" shall mean an Eskimo,
				Aleut, or other Alaska Native enrolled by the United States Secretary of the
				Interior.
(d) "Alien" shall mean a
				person residing in Wyoming who is not a citizen of the United States of
				America.
(e) "American Indian"
				shall mean a person who is an enrolled member of a federally recognized Indian
				tribe, band, or group, or a first or second degree descendent of such
				person.
(f) "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 ehgibility.
(g) "Application" shall mean the form,
				specified by the Department, on which an applicant indicates in writing the
				desire to receive benefits.
(h)
				"Application date" shall mean the date an application for Kid Care CHIP is
				noted as received by the Department.
(i) "Basic level of benefits" shall mean the
				level of benefits established by the Health Benefits Plan Committee pursuant to
				Chapter 3.
(j) "Benefits" shall
				mean the health insurance coverage through Kid Care CHIP.
(k) "Benefit year" shall mean January to
				December of each year, so long as the insured remains eligible.
(1) "Change in circumstances" shall mean a
				change in an insured's address or health insurance coverage.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-5 - Payments Only to Participating Insurance Companies

Current through July 13, 2024
(a)
				Payments for premiums shall be made only to participating insurance companies.
				No person or entity that furnishes a health insurance plan to an insured shall
				receive Kid Care CHIP funds unless the health insurance plan is offered by or
				through a participating insurance company.
(b) Submission of invoices. Any person or
				entity that submits an invoice for premiums, deductibles, or co-insurance,
				shall be deemed to have agreed to be bound by these rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-6 - Participating Insurance Company

Current through July 13, 2024
(a) No insurance
				company may participate in Kid Care CHIP, unless it offers a health insurance
				plan which meets or exceeds the basic level of benefits established pursuant to
				Chapter 3 Rules and Regulations for Kid Care CHIP and the insurance company has
				entered into a contract with the Department.
(b) The Department shall notify the
				participating insurance company of the identity of its participants and shall
				make premium payments on behalf of those participants directly to the
				company.
(c) The participating
				insurance company shall submit invoices to the Department in the manner
				specified by the Department to request reimbursement for premiums.
(d) When an insured seeks services, the
				provider must verify the individual's eligibility with the participating
				insurance company using the procedures established by the company. If a
				provider fails to verify eligibility, the Department shall not be responsible
				for paying such services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-7 - Payment and Submission of Invoices

Current through July 13, 2024
(a) Payment in full
				of covered services. If the service is a covered service, a participating
				insurance company may not request, receive, or attempt to collect any payment
				from the insured or the insured's family for the service, except for
				co-payments, pursuant to Chapter 4.
(b) Payment for non-covered services. A
				provider that provides a non-covered service to an insured may seek payment
				from the insured's parent or guardian, if the provider informed the parent or
				guardian, in writing, of the insured's potential liability before providing the
				service, and the parent or guardian agreed in writing to pay for such services
				before they were furnished.
(c)
				Submission of invoices.
(i) Invoices shall be
				submitted to the Department in the manner and form specified by the
				Department;
(ii) The invoice is
				considered submitted on the date the invoice is received by the
				Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-8 - Recovery of Overpayments

Current through July 13, 2024
The Department may recover overpayments pursuant to Chapter
				  16 of the Medicaid rules. All references in that Chapter to "Medicaid" shall be
				  replaced with "Kid Care CHIP" for purposes of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-9 - Reconsideration and Administrative Hearings

Current through July 13, 2024
(a) A participating
				insurance company may request that the Department reconsider a decision to
				recover overpayments. Such request shall be mailed to the Department by
				certified mail, return receipt requested, within twenty (20) days of the date
				of the notice of overpayment. The reconsideration provisions of Chapter 16 of
				the Medicaid rules, shall govern all aspects of the reconsideration and any
				administrative hearings shall be governed by Chapter 4 of the Medicaid
				rules.
(b) Eligibility
				determinations and redeterminations. An applicant or insured who is denied
				eligibility or terminated from eligibility may request an administrative
				hearing pursuant to Chapter 4 of the Medicaid rules. Chapter 4 of the Medicaid
				rules shall govern administrative hearings involving Kid Care CHIP eligibility
				issues in all respects, except that a request for hearing on issues involving
				eligibility for Kid Care CHIP shall be mailed or hand-delivered to the
				Department within thirty (30) days from the date of the notice of adverse
				action,
(c) Denial of services or
				other coverage issues. An insured who is denied services or has any other
				complaint regarding covered services shall be entitled to review of that
				decision pursuant to the procedures provided by the participating insurance
				company. Such action is not adverse action, and the insured shall not be
				entitled to reconsideration or an administrative hearing regarding such
				decision pursuant to this Section or Chapter 4 of the Medicaid rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-11 - Contingent on Funding

Current through July 13, 2024
(a) In accordance
				with Program Expenditure provisions of the Act, payment to participating
				insurance companies shall be contingent on the availability of Kid Care CHIP
				funds.
(b) Monitoring and
				projecting program expenditures. The Department shall:
(i) Monitor program expenditures to ensure
				that the expenditures do not exceed program funds;
(ii) Make monthly projections of expenditures
				for the remainder of the biennium based on program expenditures for the most
				recent six (6) calendar months, trended forward for the remainder of the
				biennium, and including utilization trends and the estimated amount of unpaid
				invoices.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-12 - Financial Audits

Current through July 13, 2024
The Department may audit a participating insurance company's
				  financial records at any time to determine the accuracy and appropriateness of
				  invoices submitted to the Department. The Department may recover any
				  overpayments pursuant to Section
				  8.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-13 - Interpretation of Chapter

Current through July 13, 2024
The order in which the provisions of this Chapter appear is
				  not to be construed to mean that any one provision is more or less important
				  than any other provision. The text of this Chapter shall control the titles of
				  its various provisions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 1 - GENERAL PROVISIONS › Section 1-15 - Severability

Current through July 13, 2024
If any portion of this Chapter is found to be invalid or
				  unenforceable, the remainder shall continue in effect. If any portion of this
				  Chapter is inconsistent with the provisions required by CMS, as part of the
				  State plan, the State Plan shall control.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-1 - Authority

Current through July 13, 2024
This Chapter is promulgated pursuant to the Child Health
				  Insurance Program Act at W.S. §
									
										35-25-108 and the Wyoming Administrative
				  Procedure Act at W.S. §
									
										16-3-102.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter
				shall provide uniform procedures for determining eligibility for Kid Care CHIP.
				This Chapter shall become effective for Kid Care CHIP services provided on or
				after January 1, 2014.
(b) The
				requirements of 42 C.F.R. Ch. IV, Subch. C, Pt. 435 also apply to Kid Care CHIP
				and are incorporated by this reference as of the effective date of this
				Chapter, and may be cross-referenced throughout this Chapter where applicable.
				This incorporation by reference does not include any later amendments or
				editions of the incorporated matter. The incorporated matter may be viewed at
				http://www.ecfr.gov/cgi-bin/ECFR and http://www.ssa.gov or may be obtained at
				cost from the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-3 - Application Process

Current through July 13, 2024
When an individual makes a request for Kid Care CHIP, the
				  following apply:
(a) An application
				form shall be provided upon request;
(b) A separate application shall be required
				for each family, and the applicant shall be notified, in writing, of the
				result;
(c) The application may be
				mailed, delivered personally, faxed or submitted on-line to the
				Department;
(d) The application
				shall be accepted when complete and noted as received;
(e) Applicants shall be informed of the
				eligibility criteria, services available under the program, and their rights
				and responsibilities;
(f) An
				application shall be approved if the applicant is found to be eligible;
				or
(g) An application shall be
				denied if the applicant:
(i) is found to be
				ineligible;
(ii) does not provide
				all required information;
(iii) has
				withdrawn the application;
(iv) is
				an inmate of a public institution;
(v) is a resident in an institution for
				mental disease;
(vi) is a dependent
				of a state employee eligible for health insurance benefits;
(vii) has insurance or has willingly dropped
				insurance within thirty (30) days before the application was submitted;
				or
(viii) is age nineteen (19) or
				older.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-4 - Applicant Rights

Current through July 13, 2024
Applicants shall have the following rights:
(a) To apply without delay at the Kid Care
				CHIP Central Office (at the Department in Cheyenne), either in person, by mail,
				by facsimile, on-line, or by leaving the application at the Central
				Office.
(b) To be accompanied or
				assisted by a person of the applicant's choice in requesting or completing an
				application.
(c) To request
				assistance from the Department in completing an application.
(d) To have the application and all
				personally identifiable information kept confidential and only disclosed as
				necessary to determine or verify eligibility or in accordance with the rules of
				the Department.
(e) To be treated
				with respect and to not be discriminated against, in accordance with applicable
				federal and state laws.
(f) To be
				informed:
(i) Orally or in writing of the
				program eligibility factors and required verifications;
(ii) In writing of the effective date of
				eligibility; and
(iii) In writing
				of their rights and responsibilities.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-5 - Applicant Responsibilities

Current through July 13, 2024
(a) An applicant
				shall complete an application in the form and in the manner specified by the
				Department. The application must be completed, dated and signed by the
				applicant's parent or guardian, or by the child, if the child is an emancipated
				minor.
(b) An applicant shall
				cooperate fully in the process of determining eligibility, including the
				following:
(i) Provide any and all necessary
				information required by the Department; and
(ii) Promptly provide a Change Report to
				reflect a Change in Circumstances.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-6 - Verifications

Current through July 13, 2024
The following information shall be verified, and
				  documentation shall be maintained in the individual's case file:
(a) Qualified alien status;
(b) Birth certificate;
(c) Proof of identity;
(d) Proof of American Indian or Alaska Native
				status; and
(e) Reasons for the
				denial of eligibility.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-8 - Eligibility Determination

Current through July 13, 2024
(a) Eligibility
				shall be determined using the countable income of the family unit, as specified
				in
				42 C.F.R.
				§
										435.603.
(i) Except as specified in paragraph (ii)
				below, eligibility shall be determined based on the child's family's countable
				income during the month in which the application is submitted.
(ii) Income from self-employment or seasonal
				work shall be based on the monthly average of the family's annual countable
				income for the previous twelve (12) month period. Current monthly income may be
				used if income from the previous twelve (12) month period is not representative
				of the family's current financial circumstance.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-9 - Eligibility Redetermination

Current through July 13, 2024
The Department shall conduct a Periodic Review to determine
				  continuing eligibility. Such reviews shall be done on forms and in accordance
				  with procedures developed and specified in manuals or bulletins distributed by
				  the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-10 - Eligibility Letters

Current through July 13, 2024
The Department shall issue "Kid Care CHIP Eligibility
				  Letters" to the parent or guardian of each insured notifying him or her of the
				  approval of eligibility for the program. The letter shall include information
				  about available participating insurance programs and specify which Kid Care
				  CHIP plan the child is enrolled in.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 2 - ELIGIBILITY › Section 2-11 - Duration of Eligibility

Current through July 13, 2024
After being determined eligible, a child shall remain
				  eligible for twelve (12) months following the effective date of eligibility
				  unless the child turns age nineteen (19), enters a public institution, moves
				  out of state, becomes eligible for Medicaid, requests that the Kid Care CHIP
				  policy be closed and/or fails quality control.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 3 - BENEFITS › Section 3-1 - Authority

Current through July 13, 2024
This Chapter is promulgated pursuant to the Child Health
				  Insurance Program Act at W.S. §§
									
										35-25-108 and the Wyoming Administrative
				  Procedure Act at W.S. §
									
										16-3-102.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 3 - BENEFITS › Section 3-3 - Basic Level of Benefits

Current through July 13, 2024
(a) The HHS
				Secretary-approved benefits provided to targeted low-income children eligible
				for Kid Care CHIP shall include, at a minimum, the following services:
(i) Inpatient hospital services
(ii) Outpatient hospital services
(iii) Physician services
(iv) Surgical services
(v) Clinic services and other ambulatory
				health care services
(vi)
				Prescription drugs
(vii) Laboratory
				and radiological services
(viii)
				Prenatal care and pre-pregnancy family planning services and supplies
(ix) Inpatient mental health
				services
(x) Outpatient mental
				health services
(xi) Dental
				services
(xii) Medically necessary
				orthodontia
(xiii) Abortion, only
				if necessary to save the life of the mother or if the pregnancy is the result
				of rape or incest
(xiv) Inpatient
				substance abuse treatment
(xv)
				Outpatient substance abuse treatment
(xvi) Durable medical equipment
(xvii) Preventive care, screening and
				immunization
(xviii) Hospice
				care
(xix) Emergency medical
				transportation
(xx) Vision
				services
(xxi) Any other additional
				or different services required by the Request for Proposal for health benefits,
				and resulting contract.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 4 - COST SHARING › Section 4-1 - Authority

Current through July 13, 2024
This Chapter is promulgated pursuant to the Child Health
				  Insurance Program Act at W.S. §§
									
										35-25-108 and the Wyoming Administrative
				  Procedure ActatW.S. §
									
										16-3-102.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 4 - COST SHARING › Section 4-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter
				shall apply to and govern Kid Care CHIP. This Chapter shall become effective
				for Kid Care CHIP services provided on or after January 1, 2014.
(b) The requirements of 42 C.F.R. Ch. IV,
				Subch. D, Pt. 457 also apply to Kid Care CHIP and are incorporated by this
				reference as of the effective date of this Chapter, and may be cross-referenced
				throughout this Chapter where applicable. This incorporation by reference does
				not include any later amendments or editions of the incorporated matter. The
				incorporated matter may be viewed at http://www.ecfr.gov/cgi-biii/ECFR and
				http://www.ssa.gov or may be obtained at cost from the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 4 - COST SHARING › Section 4-3 - Cost Sharing Maximums and Tracking Requirements

Current through July 13, 2024
(a) Cost
				sharing shall not exceed five percent (5%) of a family's gross income for the
				length of the child's eligibility period as specified in
				42 C.F.R. §
										457.560.
(b) Each family shall be notified of their
				cost sharing maximum for the eligibility period. Families shall track their
				cost sharing expenditures and submit receipts to the Department when they
				believe they have met their total cost sharing maximum for the eligibility
				period.
(c) Families will track
				their benefit year cost sharing expenditures for medical, pharmacy, dental and
				medically necessary orthodontia and submit receipts to the Department when they
				believe they have met the benefit year cost sharing maximum for medical and/or
				pharmacy and/or dental and/or medically necessary orthodontia.
(d) The benefit year cost sharing maximums
				and co-payments for particular medical, pharmacy and dental services shall be
				determined by the Department and insurance contractor. The benefit year cost
				sharing maximums and co-payments may be adjusted at the establishment of a new
				contract or contract extension with the insurance contractor.
(e) If it is determined the family has paid
				more than their five percent (5%) annual cost sharing maximum or medical,
				dental, pharmacy or medically necessary orthodontia co-payment maximum(s) the
				family shall be reimbursed by the insurance contractor.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0064 - Kid Care CHIP › Chapter 4 - COST SHARING › Section 4-4 - Co-payments

Current through July 13, 2024
(a) Co-payment amounts shall be determined
				according the applicable Plan. Enrollment in Plan A, B or C shall be determined
				by the family income reported at the time of application.
(b) The, benefit year maximum amounts for
				medical,, dental, pharmacy and medically necessary orthodontia and particular
				service co-payments shall be contained in the Subscription Agreement developed
				by the Insurance contractor and shall be made available to each CHIP
				enrollee.
(c) Exclusions from
				Co-payments. No co-payment shall be assessed for;
(i) Well-baby and well child
				services;
(ii)
				Immunizations;
(iii) Preventive
				dental services; or
(iv) Services
				provided to American Indians or Alaska Natives.
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 5-1 - Authority

Current through July 13, 2024
This Chapter is promulgated pursuant to Title XXI of the
				  Social Security Act, 42 C.F.R., Part 438, 42 C.F.R., Part 457, and the Child
				  Health Insurance Program Act at Wyoming Statutes
										35-25-101 through
				  35-25-108.
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 5-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter has been adopted to describe
				a Kid Care CHIP applicant, client's rights and responsibilities associated with
				Kid Care CHIP eligibility, and to establish uniform procedures for Kid Care
				CHIP eligibility.
(b) The
				Department may issue manuals and newsletters to interpret this Chapter. Such
				manuals and newsletters shall be consistent with and reflect this Chapter. The
				provisions contained in manuals and newsletters shall be subordinate to this
				Chapter.
(c) Nothing in this
				Chapter shall be construed as providing an individual with an entitlement to
				Kid Care CHIP.
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 5-4 - Application Process, Application Rights and Responsibilities

Current through July 13, 2024
(a) Application Process.
(i) Applicants shall submit an application in
				the manner and form prescribed by the Department. The application shall be
				completed, dated, and signed by the applicant or by any person who is assisting
				the applicant as specified in
				42
				CFR §
											435.907(b).
(A) Any individual who knowingly makes a
				false statement or misrepresentation or knowingly fails to disclose a material
				fact in obtaining benefits may be guilty of a misdemeanor or felony, as
				specified in Wyoming Statute §
											
												42-4-111.
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 5-5 - General Eligibility Requirements

Current through July 13, 2024
(a) Applicants shall meet the following
				requirements to be eligible for Kid Care CHIP.
(i) Applicants shall be citizens or qualified
				non-citizens of the United States, and provide documentation of such, as
				specified in
				42 C.F.R. §
											457.320.
(ii) Applicants shall provide proof of
				identity, as specified in
				42 C.F.R.
				§
											435.407.
(iii) Applicants shall reside in Wyoming or
				meet the criteria, as specified in
				42 C.F.R. §
											435.403.
(iv) Applicants who are citizens or nationals
				of the United States shall provide record of a social security number, as
				specified in
				42
				C.F.R. §
											457.340(b).
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 5-6 - Kid Care CHIP Eligibility Requirements

Current through July 13, 2024
(a) Applicants shall meet the following
				additional requirements to be eligible for Kid Care CHIP.
(i) Children must be between the ages of zero
				(0) and age eighteen (18).
(ii)
				Countable family income shall be between one hundred fifty-four percent (154%)
				and two hundred percent (200%) of the Federal Poverty Level (FPL) and
				calculated using the modified adjusted gross income of the household, as
				specified in
				42
				C.F.R. §
											457.315.
(iii) Applicants who are American Indian or
				Alaska Natives shall provide proof of being an enrolled member.
(iv) Applicants cannot be in a public
				institution.
(v) Applicants cannot
				be covered by the State of Wyoming employee health insurance
				coverage.
(vi) Applicants cannot be
				covered by any health insurance plan.
(vii) Applicant cannot have been covered by a
				health insurance plan for one (1) month or more before the date of application
				(unless the plan is ended for a reason considered to be an exception in the
				CHIP State Plan).
(viii) Clients
				shall immediately report changes in any of the following circumstances to the
				Department:
(ix) Income;
(x) Household composition;
(xi) Health insurance;
(xii) Address.
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 5-7 - Basic Level of Benefits

Current through July 13, 2024
(a) The covered services provided to children
				eligible for Kid Care CHIP shall include, at a minimum, the following services:
(i) Inpatient hospital services
(ii) Outpatient hospital services
(iii) Physician services
(iv) Surgical services
(v) Clinic services and other ambulatory
				health care services
(vi)
				Prescription drugs
(vii) Laboratory
				and radiological services
(viii)
				Prenatal care and pre-pregnancy family planning services and supplies
(ix) Inpatient mental health
				services
(x) Outpatient mental
				health services
(xi) Durable
				medical equipment
(xii) Abortion,
				only if necessary to save the life of the mother or if the pregnancy is the
				result of rape or incest
(xiii)
				Dental services
(xiv) Medically
				necessary orthodontia
(xv)
				Inpatient substance abuse
(xvi)
				Outpatient substance abuse treatment services
(xvii) Preventive care, screening and
				immunization
(xviii) Hospice
				care
(xix) Emergency medical
				transportation
(xx) Vision
				services
(xxi) Any other additional
				or different services required by the Request for Proposal for health benefits,
				and resulting contract.
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 5-8 - Cost Sharing Maximums and Tracking Requirements

Current through July 13, 2024
(a) Cost sharing shall not exceed five
				percent (5%) of a family's gross income for the length of the child's
				eligibility period as specified in
				42 C.F.R.
				457.560. Each family shall be notified of
				their cost sharing maximum for the eligibility period as per
				42 CFR
				457.525(b)(1).
(b) Families will be provided resources to
				track their benefit year cost sharing expenditures for medical, pharmacy,
				dental, vision and medically necessary orthodontia and submit receipts to the
				Department when they believe they have met the benefit year cost sharing
				maximum.
(c) If it is determined
				the family has paid more than their five percent (5%) annual cost sharing
				maximum the family shall be reimbursed by the insurance contractor.