Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS
Section 46-7 - Clinical Eligibility Diagnoses

Universal Citation: WY Code of Rules 46-7

Current through September 21, 2024

(a) An individual is not eligible for waiver services pursuant to Section 4 of this Chapter unless the individual meets one of the following clinical eligibility diagnoses:

(i) A diagnosis of an intellectual disability, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), which is incorporated by reference, and is determined by a Medicaid enrolled psychiatrist, neurologist, or clinical psychologist who is licensed in Wyoming and is free of conflicts with other providers chosen by the participant.
(A) The diagnosis shall be verified in a written and signed psychological evaluation that is submitted to the Division.

(B) The psychological evaluation shall reflect adaptive behavior scores as determined through a standard measurement of adaptive behavior using a validated test of adaptive functioning such as the most current form of the Vineland Adaptive Behavior Scales or Adaptive Behavior Assessment System.

(C) A child applicant who takes an Intelligence Quotient test shall meet a qualifying clinical diagnosis like an adult. A child too young to complete an Intelligence Quotient test may meet the criteria of a developmental disability as described in subsection (a)(i)(B) through medical records of a related condition using a standardized test of development, such as the Bayley Scales of Infant and Toddler Development or other similar instrument.

(ii) A developmental disability or a related condition determined by a Medicaid enrolled licensed medical professional, neurologist, or clinical psychologist who is licensed in Wyoming and is free of conflicts with other providers chosen by the participant.
(A) Determination shall include verification in medical records and a written psychological evaluation, which includes assessment scores. The evaluation or records shall be submitted to the Division and shall identify a severe, chronic disability, which:
(I) Manifested before the person turned age twenty-two;

(II) Reflects the need for a combination and sequence of special services, which are lifelong or of extended duration;

(III) Is attributable to a cognitive or physical impairment, other than mental illness;

(IV) Is likely to continue indefinitely; and

(V) Results in substantial functional limitations in three (3) or more of the following major life activity areas: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency.

(B) Individuals with a diagnosis of Autism Spectrum Disorder (ASD) shall submit a current autism evaluation accepted by the Division, which demonstrates the diagnosis of ASD. The autism evaluation shall be completed by a Medicaid enrolled psychiatrist, neurologist, or clinical psychologist who is licensed in Wyoming and is free of conflicts with other providers chosen by the participant.

(iii) An Acquired Brain Injury (ABI), as defined by Chapter 1 of the Department of Health's Medicaid Rules. An individual with an ABI shall:
(A) Be between the ages of twenty-one (21) and sixty-four (64); and

(B) Have received a qualifying score on at least one of the evaluations accepted by the Division, which shall be completed by a Medicaid enrolled psychiatrist, neurologist, or clinical psychologist who is licensed in Wyoming and is free of conflicts with other providers chosen by the participant. Accepted evaluations, which shall be submitted to the Division to confirm the diagnosis, include:
(I) A score of 42 or more on the Mayo Portland Adaptability Inventory (MPAI);

(II) A score of 40 or less on the most current version of the California Verbal Learning Test Trials 1-5 T; or

(III) A score of 4 or more on the Supervision Rating Scale.

(b) A participant shall be reassessed for clinical eligibility at least annually or more frequently should a change in circumstances occur, which requires a participant to receive a higher level of services or support to ensure the participant's health, safety, and welfare.

(i) A subsequent psychological evaluation, which shall be approved by the Division prior to scheduling, must be necessary due to the participant's change in condition or as determined by the Division.

(ii) A subsequent neuropsychological evaluation, which shall be approved by the Division prior to scheduling, shall be performed every five (5) years.

(iii) Psychological and neuropsychological reassessments shall be completed by a Medicaid enrolled psychiatrist, neurologist, or clinical psychologist who is licensed in Wyoming and is free of conflicts with other providers chosen by the participant.

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.