048-46 Wyo. Code R. §§ 46-5 - Loss of Eligibility

(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.

Notes

048-46 Wyo. Code R. §§ 46-5

Adopted, Eff. 6/21/2017. Amended, Eff. 7/26/2018. Amended, Eff. 12/20/2019.