014-2 Wyo. Code R. §§ 2-4 - Eligibility for Medical Assistance Benefit
(a)
To be eligible for the Medical Assistance Benefit a miner shall:
(i) Complete a Board registration
form, have registered as an Eligible Miner as provided in Section 3
and receive a valid Miner's Hospital Program Identification
Card;
(ii) Submit a State
licensed medical provider's written statement that the miner is in
need of the services or benefits described in W.S. 30-6-102,
(iii) The
eligible miner shall provide a State licensed medical provider's
statement of injury and inability to work as miner with Workers
Compensation records; mine personnel records; medical records; Social
Security Records; or any other information which verifies that the
injury occurred and the miner is unable to work due to the
injury.
(b)
The following shall be submitted as evidence of an individual's
eligibility for the benefit:
(i)
Diagnosis of the condition from a State licensed medical provider
that verifies the condition and need for treatment and
(ii) Verification that no other
sources of benefits exist, which may include:
(A) Explanation of Benefits from
the miner's insurance company, Medicaid or Medicare or any other
third-party responsible to pay for treatment received:
(B) A statement from a State
licensed medical provider that other third party sources of payment
have been explored and exhausted or
(C) An affidavit from the claimant
certifying that he or she is not covered by any policy of insurance
that provides coverage of or reimbursement for prescription
medications.
(iii) A statement from a State
licensed medical provider, statement from a health insurance company,
or statement under penalty of perjury from the miner, the miner's
next of kin or personal representative of the amount of out of pocket
expenses incurred.
(c) A miner may be required to
submit additional evidence of eligibility for services or
benefits.
Notes
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