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 5-3 - Definitions

(i) "Act" shall mean the Child Health Insurance Program Act at W.S. 35-25-101 through 35-25-108.

(ii) "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 12 or a change in federal or state law, including an amendment to this Chapter. "Adverse action" does not include program reduction or termination, or the denial of eligibility due to a moratorium or the denial of services because they are not covered services.

(iii) "Alien" shall mean a person residing in Wyoming who is not a citizen of the United States of America.

(iv) "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 eligibility.

(v) "Application" shall mean the single, streamlined application form that is used by the State in accordance with 42 CFR § 457.330.

(vi) "Application date" shall mean the date an application for Kid Care CHIP is received by the Department.

(vii) "Benefit year" shall mean a year of benefits coverage that begins January 1 of each year and ends December 31 of the same year.

(viii) "Child" shall mean an individual who has not yet reached the nineteenth (19th) anniversary of his or her birth.

(ix) "Cost sharing or co-payment" shall mean premium charges, enrollment fees, deductibles, coinsurance, copayments or other similar fees that the enrollee has responsibility for paying.

(x) "Department" shall mean the Wyoming Department of Health.

(xi) "Federal funds" shall mean the Federal funds received by the Department pursuant to 42 C.F.R. § 457 Subpart F.

(xii) "Household" shall mean, for the purposes of eligibility, number of persons counted as members of an individual's household, including the modified adjusted gross income (MAGI) household determinations as defined in 42 CFR § 457.315.

(xiii) "Kid Care CHIP" shall mean the Children's Health Insurance Program created by the Balanced Budget Act of 1997, enacted Title XXI of the Social Security Act, and established pursuant to W.S. 35-25-101 through W.S. 35-25-108, administered by the State to provide child health assistance (insurance) to uninsured, targeted low income children.

(xiv) "Kid Care CHIP funds" shall mean that combination of Federal funds and State funds which is available to the Department per 42 CFR Part 457 Subpart F to make payments to participating insurance companies for child health assistance (insurance) for eligible, enrolled children as well as administrative expenditures, outreach and health initiatives and further defined by W.S. W.S. 35-25-107.

(xv) "Kid Care CHIP State Plan" shall mean the comprehensive written statement submitted by the Department to The Centers for Medicare and Medicaid (CMS) describing the purpose, nature and scope of the Program, as per 42 CFR § 457.50, referenced in W.S. 35-25-108.

(xvi) "Medically necessary" or "medical necessity" shall mean a health service that is required to diagnose, treat, cure, or prevent an illness, injury, or disease which has been diagnosed or is reasonably suspected; to relieve pain; or to improve and preserve health and be essential to life. The service shall be:

(xvii) "Orthodontia medical necessity" shall mean orthodontic condition(s) that must meet specific criteria and determined eligible for services as outlined by Program guidelines.

(xviii) "Services" shall mean medical, mental health and dental services, medical supplies, or medical equipment as described in the Kid Care CHIP State Plan.

(xix) "Targeted low income child" shall mean a child who has a household income, as determined according to 42 CFR § 457.315, at or below 200 percent of the Federal poverty level for a family of the size involved.

(xx) "Well-baby or well-child services" shall mean the regular or preventive diagnostic and treatment services necessary to ensure the health of babies and children.