Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER
Section 43-6 - Assessment and Eligibility
Universal Citation: WY Code of Rules 43-6
Current through September 21, 2024
(a) Eligibility under this Chapter is limited to persons who complete the application process and who meet the following requirements for medical determination, clinical eligibility and financial eligibility. In addition, in order to be eligible for the waiver, all persons shall be:
(i) A
United States Citizen as determined by the Department of Family
Services.
(ii) A resident of
Wyoming as determined by the Department of Family Services.
(iii) Aged 21 through 6 4 years.
(b) Medical determination. In order to meet the medical determination criteria for the waiver an applicant shall meet the acquired brain injury definition pursuant to Section 4 of this Chapter as determined by the medical team pursuant to this section.
(c) Clinical eligibility criteria. An applicant is considered clinically eligible if:
(i) The applicant has met the medical
determination criteria pursuant to this section, and
(ii) The neuropsychological or other
evaluations confirm that the applicant meets the following:
(A) Has a score of 42 or more on the Mayo
Portland Adaptability Inventory (MPAI), or
(B) Has a score of 40 or less on the
California Verbal Learning Test II Trials 1-5 T, or
(C) Has a score of 4 or more on the
Supervision Rating Scale, or
(D)
Has an Inventory for Client and Agency Planning (ICAP) service score of 70 or
less, and
(iii) A
completed LT-ABI-105 verifies that the participant or applicant meets the
ICF/MR level of care.
(d) Financial eligibility. Eligibility for covered services is limited to persons who meet the income and resource criteria set forth in the waiver and in the rules and policies of the Wyoming Medicaid program, as determined by the Department of Family Services.
(e) Application process:
(i) A completed application on a form
required by the Division shall be submitted to the Division.
(A) An application is valid for one year.
After that time, if necessary documentation has not been received so that the
Division can determine clinical eligibility, the applicant shall be required to
re-apply.
(B) Once an applicant has
been determined to be clinically eligible and has been placed on a wait list,
he/she does not need to re-apply.
(ii) Selection of individually-selected
service coordinator.
(A) After an applicant
requests services pursuant to this Chapter, the Division shall provide the
applicant with a list of individually-selected service coordinators in the
area(s) he or she wishes to receive service.
(B) The applicant shall select and meet with
an individually-selected service coordinator from that list. Once both the
applicant and the individually-selected service coordinator have agreed to work
together, the individually-selected service coordinator shall notify the
Division of that selection on a form designated by the Division.
(f) Medical determination process.
(i) The
individually-selected service coordinator shall work with the applicant to
identify and compile medical documentation of the brain injury and submit
information to the Division.
(ii)
The medical team coordinated by the Division shall review the medical
documentation of the brain injury to determine if the medical criteria are met.
(A) If the medical team does not feel they
have sufficient information to determine medical eligibility, the ISC shall be
notified as to what types of additional information are needed.
(iii) If medical team agrees that
medical criteria are met, the individually selected service coordinator shall
be notified and shall work with the applicant to determine clinical eligibility
pursuant to (g) of this section.
(iv) If the applicant does not have a
diagnosis of acquired brain injury the applicant does not meet the medical
determination criteria and is not eligible for the waiver.
(v) If an applicant is determined not to meet
the medical determination criteria, the applicant or the applicant's legal
guardian shall be notified in writing within 15 business days of the
determination.
(A) An applicant determined to
not meet the medical criteria requirements, may appeal the decision pursuant to
Chapter 1.
(g) Determination of clinical eligibility. A person shall not receive covered services unless that person is clinically eligible. The determination of a person's clinical eligibility shall be made as follows:
(i) Neuropsychological evaluation.
The individually-selected service coordinator shall schedule a
neuropsychological evaluation for the applicant to determine if the applicant
meets the criteria pursuant to (c) of this section.
(ii) Inventory for Client and Agency
Planning. Upon completion of the neuropsychological exam the individual shall
be assessed pursuant to (c) of this section to determine functional ability
using the Inventory for Client and Agency Planning. Assessments shall be
performed by a third party, under contract to the Division, who is qualified to
perform such assessments using the Inventory for Client and Agency Planning
(ICAP).
(iii) LT-ABI-105. The
individually-selected service coordinator shall complete the LT-ABI-105 that
verifies that the participant or applicant meets the ICF/MR level of
care.
(h) Notification of determination of clinical eligibility.
(i)
The Division shall determine clinical eligibility within 90 calendar days of
receipt of the neuropsychological evaluation. If additional data or review is
needed to determine eligibility, the Division shall notify the applicant in
writing that the process will take an additional 30 calendar days.
(ii) If an applicant is determined not to
meet clinical eligibility criteria, pursuant to (c) of this section, the
applicant or the applicant's legal guardian shall be notified in writing within
15 business days.
(A) An applicant determined
to not meet clinical eligibility requirements may appeal the decision pursuant
to Chapter 1.
(iii) If
an applicant is determined to be clinically eligible, the applicant or
applicant's legal representative will be notified in writing that:
(A) There is a funding opportunity available,
or
(B) There is not a funding
opportunity available but the applicant is placed on the Division's waiting
list, as specified in Section 13 of this Chapter.
(iv) Once an individual is notified that
there is a funding opportunity available, financial eligibility shall be
determined by the Department of Family Services.
(i) Loss of eligibility.
(i) A participant shall be determined to no
longer be eligible when the participant:
(A)
Does not meet clinical eligibility when re-tested, or
(B) Does not meet financial eligibility
requirements as determined by the Department of Family Services, or
(C) Changes residence to another state,
or
(D) Turns the age of
65.
(ii) Services to a
participant determined to not meet clinical eligibility requirements shall be
terminated no more than 45 days after the determination is made.
(A) If an applicant is determined not to meet
clinical eligibility criteria, the applicant or the applicant's legal guardian
shall be notified in writing within 15 business days.
(B) A participant determined to not meet
eligibility requirements may appeal the decision pursuant to Chapter
1.
(iii) A participant
may be denied waiver placement and may be required to reapply when the
participant:
(A) Voluntarily does not receive
any waiver services for 3 consecutive months.
(B) Is in a nursing home, hospital, or
residential treatment facility for 6 consecutive months.
(C) Is in an out-of-state placement for 6
consecutive months.
(iv)
Upon written notification of the denial of waiver placement:
(A) The participant may submit, in writing,
reasons why he/she should still be considered eligible for the
services.
(B) This request shall be
reviewed by the Waiver Manager and the Division Administrator.
(v) If the participant is
determined not to be eligible for services due to one of the criteria in (iii)
of this section, the participant or the participant's legal guardian shall be
notified in writing within 15 business days.
(A) The participant may appeal the decision
pursuant to Chapter 1.
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