Current through September 21, 2024
(a) The Division
shall determine a participant has lost eligibility for waiver services when the
participant:
(i) Does not meet clinical
eligibility;
(ii) Does not meet
financial eligibility; or
(iii)
Changes residence to another state.
(b) The Division may terminate a
participant's eligibility when the participant:
(i) Voluntarily does not receive waiver
services for three (3) consecutive months;
(ii) Is in a nursing home, hospital,
residential treatment facility, in-patient hospice, institution, or ICF/IID for
thirty (30) or more consecutive calendar days;
(iii) Is in an out-of-state placement or
residence for six (6) consecutive months or resides out of state for six (6)
consecutive months; or
(iv) Chooses
another waiver outside of the Comprehensive or Supports waiver.
(c) If the participant is
determined not to be eligible for services due to one of the criteria in
subsection (b) of this Section, the participant or the participant's legally
authorized representative shall be notified in writing within fifteen (15)
calendar days.
(d) The Division
shall notify an applicant, participant, or legally authorized representative,
in writing, of the determination of clinical ineligibility or loss of clinical
eligibility within fifteen (15) calendar days of the determination or loss.
(i) Upon written notification of
ineligibility, the applicant, participant, or legally authorized representative
may submit, in writing, a request for reconsideration within thirty (30)
calendar days of the notice of ineligibility, which shall include the reasons
why the participant should still be considered eligible for the
services.
(ii) If the participant
requests reconsideration, the Division Administrator or Designee shall review
the request and make a final determination, in writing, within thirty (30)
calendar days of the request. A participant who is aggrieved or adversely
affected by a reconsideration decision may also request an administrative
hearing within thirty (30) calendar days following the adverse reconsideration
decision.
(iii) Requests for an
administrative hearing will be administered pursuant to Chapter 4 of the
Department of Health's Medicaid Rules.
(iv) Services to a participant determined not
to meet clinical eligibility requirements shall be terminated no more than
forty-five (45) calendar days after the determination is made.
(e) Wyoming Medicaid shall send
written notification of financial ineligibility.
(f) An applicant who is determined
ineligible, or a participant whose eligibility is terminated under this
Section, may reapply at any time.
