Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 18 - MEDICAID ELIGIBLITY
Section 18-8 - Aged, Blind or Disabled Eligibility

Universal Citation: WY Code of Rules 18-8

Current through September 21, 2024

(a) Eligibility Requirements for the Aged, Blind or Disabled.

(i) Age sixty-five (65) or over;

(ii) Legally blind as certified by an optical professional or the Social Security Administration (SSA); or

(iii) An individual who is determined disabled by the SSA or the Department.

(b) The following individuals are eligible for Medicaid:

(i) Individuals entitled to Supplemental Security Income (SSI).

(ii) Any aged, blind, or disabled individual who loses eligibility for SSI benefits due to an increase in income, but who would be eligible for SSI if the Cost of Living Adjustments (COLA) received since the SSI termination were disregarded.

(iii) Individuals who lose SSI benefits due to the entitlement of SSA widow/widower benefits, as defined in Section 1634(b) of the Social Security Act.

(iv) Individuals who are Aged, Blind or Disabled and reside in a Medical institution, receive hospice services in accordance with a voluntary election, or receive Home and Community Based Services under a waiver and have income at or below three hundred percent (300%) of the payment standard. Individuals shall reside in a medical institution for thirty (30) consecutive days or more, unless the individual is eligible for SSI or dies before completion of the thirty (30) consecutive.

(c) Treatment of Income.

(i) Income of a spouse is not available to the other spouse when applying for Inpatient Hospital Care, Employed Individuals with Disabilities, Nursing Home, Hospice, or Home and Community Based Services under a waiver, pursuant to Section 1915(c) of the Social Security Act.

(ii) A parent's income is available to a child until the month after the child attains age eighteen (18) if the child lives in the parent's home. A parent's income is not available to a child if the child is married, institutionalized for more than thirty (30) days, or if the child applies for assistance under a Home and Community Based Services waiver or the Employed Individuals with Disabilities program.

(iii) To qualify for an Income Trust exception the trust shall be treated in accordance with Section 1917(d)(4)(B), [42 U.S.C. 1396p], and be:
(A) Irrevocable.

(B) Composed only of pension, Social Security, and other income to the individual and accumulated income in the trust.

(C) Provide that the Department will receive all amounts remaining in the trust upon the death of the individual up to the amount equal to the total amount of medical assistance paid on behalf of the beneficiary.

(D) Allow a monthly distribution of three hundred percent (300%) of the SSI payment standard for programs with no patient contribution, reasonable costs of administering the trust, and a Community Spouse allowance.

(E) Allow a monthly distribution to pay towards the cost of nursing facility services, less allowable deductions. Deductions shall be allocated, as specified in 42 C.F.R. § 435.725, except the trust may provide that the trustee pay any reasonable costs of administering the trust; and

(F) Not allow any portion of the principal to be available to the individual.

(G) Penalties for transferred resources shall not apply to resources transferred into an Income Trust.

(d) Treatment of Resources.

(i) Resources shall be determined to be available to the individual when the individual has the legal right, authority, or power to liquidate.

(ii) Resources shall be determined to be unavailable to the individual when there is a legal barrier that prevents the access or right to dispose of the resource. The individual shall pursue reasonable steps to overcome the legal barrier unless it is determined by the Department that the cost of pursuing legal action would exceed the resource value of the property or that it is unlikely the individual would succeed in the legal action.

(iii) A home, as defined by Chapter 1 of the Wyoming Medicaid Rules, is an excluded resource.

(iv) Medicaid may disregard any resources claimed by an individual in an amount equal to or less than the benefits paid on behalf of the individual by a Qualified LongTerm Care Partnership Policy as defined by W.S. § 42-7-102(a)(v).

(v) Resources shall not exceed the SSI resource limits, as specified in 20 C.F.R. § 416.1205. Individuals who are Aged, Blind or Disabled and reside in a medical institution, receive Hospice Services, or receive Home and Community Based Services under a waiver shall receive an additional Community Spouse allowance as specified in Section 1924 of the of the Social Security Act.

(vi) Treatment of Trusts.
(A) Revocable and Irrevocable Trusts shall be treated in accordance with W. S. §§ 42-2-402 and 42-2-403 and Sec. 1917(d)(3) [42 U.S.C. 1396p].

(B) Resources within a Special Needs Trust that is established in accordance with W. S. § 42-2-402, 42-2-403 and Section 1917(d)(4)(A) [42 U.S.C. 1396p] shall be considered an excluded resource.
(I) The Trustee shall obtain the consent of the Department prior to early termination of a Special Needs Trust pursuant to W.S. § 4-10-412. The Department shall consent to termination of a Special Needs Trust prior to the individual's death when a court order is entered providing that the Department shall be fully reimbursed from the Special Needs Trust. The Department shall be joined as a party to any such proceedings and served with a copy of all pleadings.

(II) All Special Needs Trusts shall have a valid Spendthrift provision that complies with the laws of every state in which the individual has received Medicaid benefits.

(III) The Department is a Qualified Beneficiary defined in W.S. § 4-10-103(a)(xv)(E).

(IV) Distributions.
(1.) Distributions shall be for the sole benefit of the disabled individual and shall be used to provide for the individual's special needs; and

(2.) Distributions for funeral expenses shall not be paid after the beneficiary's death until the Department and all other state Medicaid agencies are fully reimbursed.

(3.) Distribution shall only be allowed for the individual's basic needs when the Trustee has proven to the Department that the disabled individual's basic needs are not adequately being provided for by government assistance programs.

(V) All contributions from third parties to a Special Needs Trust shall be deemed an irrevocable gift to the disabled individual, and the third party shall not be able to redirect resources transferred to the trust, or otherwise exert any interest or control over the resources in the trust.

(VI) When the Special Needs Trust has or will receive annuity payments, structured settlement payments, or any other periodic payments, the payments shall be titled in the name of the trust.

(VII) The trustee shall provide an annual accounting of the trust income and expenditures to the Department. The Department may request more frequent accountings at its discretion.

(VIII) All distributions to or for the benefit of the beneficiary, unless paid directly to a third party, shall be income to the beneficiary.

(IX) No portion of the principal shall be available to the beneficiary.

(X) When the beneficiary dies or the trust is terminated, the trustee shall notify the Department and provide a sworn affidavit with an accounting within two (2) months after the individual's death.

(C) Pooled Trusts shall be established in accordance with W.S. § 42-2-403(f)(iii) and Section 1917(d)(4)(C) [42 U.S.C. 1396p].
(I) The Pooled Trust shall be established for the sole benefit of an individual who is under age sixty-five (65) and disabled according to the criteria set forth in 42 U.S.C. § 1382c(a)(3), by the individual, parent, grandparent, legal guardian of the disabled individual, or by a court.

(II) The Pooled Trust shall provide that upon the death of the beneficiary or termination of the trust during the beneficiary's lifetime, whichever is sooner, the Department receives any amount, up to the amount of medical assistance benefits paid on behalf of the beneficiary, remaining in the beneficiary's trust account after deduction for reasonable administrative fees and expenses, and an additional remainder amount.

(III) All distributions from the Pooled Trust shall be for the sole benefit of the beneficiary and shall be used to provide for the beneficiary's special needs.
(1.) Any distribution from the trust paid directly to the beneficiary shall be considered income available to the beneficiary.

(2.) Distributions for funeral expenses shall not be paid after the beneficiary's death until the Department and all other Medicaid agencies in other states are fully reimbursed.

(IV) Penalties for transferred resources shall not apply to resources transferred into a Pooled Trust, except that all amounts transferred to the Pooled Trust by the beneficiary or beneficiary's spouse after the beneficiary turns age sixty-five (65) shall be subject to a transfer penalty as specified in subsection (h) below.

(vii) Real property shall be considered unavailable to the individual for purposes of resource determinations when:
(A) Bona Fide Effort To Sell Agreement when the client has been eligible for Medicaid for six months or more, or

(B) Conditional Benefits Agreement when the individual has been eligible for Medicaid for less than six months.

(e) Personal Care Contracts

(i) A "Personal Care Contract" (PCC) is an agreement between a caregiver and an aged, blind or disabled individual to provide caregiver services for fair market value. Payments made to family members through a PCC to delay or prevent entrance into a long term care facility are considered transfers for fair market value only if the agreement meets the requirements in this Section and documentation is provided to the Department upon request.

(ii) The PCC shall be a detailed writing that includes:
(A) The date the care begins;

(B) A detailed description of the services to be provided;

(C) How often services will be provided;

(D) How much the caregiver will be compensated;

(E) When the caregiver will be compensated;

(F) How long the agreement is to be in effect;

(G) A statement that the terms of the agreement can be modified only by mutual agreement of the parties and approved by the Department;

(H) The location where services will be provided; and

(I) The notarized signature of both parties.

(iii) The following services may be provided through a PCC when the individual is receiving unduplicated services at home and are not in a facility: preparing meals, shopping, medication management, transportation to medical appointments, paying bills, light housekeeping, and assistance with activities of daily living.

(iv) No services shall be provided under a PCC while an individual resides in a long term care facility or receives services under a Waiver program. A caregiver shall not duplicate services provided by a home health aide, nurse, medical professional, or other care provider hired to assist the individual regardless of whether the individual resides in a long term care facility or receives services within their home.

(v) "Advocating for services" shall not be an allowable service under a PCC.

(vi) The Department shall verify the fair market value of these services through the use of the U.S. Department of Labor, Bureau of Labor Statistics, Occupational Outlook Handbook see https://www.bls.gov/ooh/healthcare/home-health-aides-and-personal-care-aides.htm?view_full.

(vii) Caregivers shall not receive payment in advance of services performed. Prepayments made to caregivers shall be considered a transfer for less than fair market value.

(viii) A PCC shall not be retroactive and shall be considered a transfer for less than fair market value in accordance with subsection (h) of this Chapter.

(f) Patient Contribution.

(i) Deductions from the individual's gross income shall be allowed in determining the amount of the individual's monthly contribution to be paid toward the cost of care in a medical facility.

(ii) Allowable deductions shall be applied in accordance with the Social Security Act, 42 § C.F.R. 435.725 and the Medicaid State Plan.

(iii) An individual temporarily in an institution shall be allowed a maintenance deduction not to exceed one hundred fifty dollars ($150.00) per month for up to six (6) months to maintain the home, except:
(A) The deduction shall not be allowed when a physician verifies the individual will not be able to return to the home within six (6) months; or

(B) The deduction is not allowed if the individual has a spouse who is not institutionalized.

(iv) Deductions for a community spouse who lives in the community when the married partner lives in a medical institution, receives services under a Home & Community Based Services Waiver, or Hospice Care, shall be applied in the manner prescribed in Title XIX of the Social Security Act, 42 C.F.R. 435.725 and the Medicaid State Plan.

(g) Benefits begin:

(i) After completion of thirty (30) consecutive days in a medical institution or thirty (30) days after a hospice election.

(ii) The first day of the month during which the plan of the care is approved by the Department for the Home and Community Based Services Waiver Program, and after all eligibility requirements are met.

(h) Transfer penalties:

(i) A transfer penalty shall be imposed for nursing facility or home and community based services when an individual or the individual's spouse disposes of income or resources for less than fair market value on or after the look-back period, as prescribed in Section 1917(c) of the Social Security Act, [42 U.S.C. § 1396p(c)], and W.S. § 42-2-402.

(A) It is presumed that a transfer for less than fair market value was made for the purpose of qualifying for Medicaid in the following circumstances.
(I) An inquiry about Medicaid benefits was made, by or on behalf of the individual, to any person before the date of the transfer, or;

(II) A transfer was made by the individual or on the individual's behalf to a relative of the individual, a relative of the individual's spouse, or to the individual's fiduciary.

(B) The fair market value of real property shall be based on an appraisal or market analysis of the property at the time of the sale or transfer of the property. The individual has the obligation to provide the Department with an appraisal or market analysis. Failure to provide the requested documentation shall result in a denial of eligibility.

(C) For a resource to be considered transferred for fair market value or to be considered to be transferred for valuable consideration, the compensation received for the resource shall be in a tangible form with intrinsic value A transfer for love and consideration is not considered a transfer at fair market value. Services provided for free at the time performed were intended to be provided without compensation.
(I) A transfer to a relative for care provided without compensation in the past is a transfer for less than fair market value.

(II) An individual can rebut this presumption with tangible evidence that is acceptable to the Department. Such evidence shall be in writing at the time services were provided to be considered by the Department.

(D) A transfer penalty shall be reduced in the amount of returned resources to the individual or paid directly to a provider on behalf of the individual. The amount of returned resources shall be determined using fair market value.
(I) A return of resources to pay for attorney fees during a contested case shall not reduce the penalty period for the individual. Attorney fees are the sole responsibility of the individual.

(II) A request for an undue hardship shall be made in writing and include documentation to support and demonstrate an undue hardship in accordance with Section 8.

(E) Undue hardship will be considered if the transfer penalty would deprive the individual of food, clothing, shelter, or other necessities of life or medical care such that the individual's health or life would be endangered, verified with the Medicaid Hardship Exception Request and Physician Statement and one of the following has occurred:
(I) It is determined that the person who received the transferred resource cannot be located by the individual, the individual's spouse, the individual's fiduciary, or an agent of the nursing facility, after all attempts to locate the person have been exhausted; or

(II) The resource transferred was due to theft, fraud, or financial exploitation of the individual or their spouse, which has been reported and pursued through Adult Protective Services or law enforcement; or

(III) The individual or their fiduciary has exhausted all reasonable legal means to recover or regain possession or obtain fair market value of the transferred resource or income. "Exhausting all reasonable legal means to recover" may include seeking the advice of an attorney and pursuing legal or equitable remedies, such as asset freezing, assignment, or injunction; seeking modification, avoidance, or nullification of a financial instrument, promissory note, mortgage, or other transfer agreement; cooperating with any attempt to recover the transferred asset; making a referral to Adult Protective Services; filing a police report; and seeking recovery through the court.

(i) Individuals shall be responsible for reporting to the Department any changes in the following:

(i) Income;

(ii) Resources;

(iii) Household size;

(iv) Health insurance; and

(v) Address.

Disclaimer: These regulations may not be the most recent version. Wyoming may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.