048-1 Wyo. Code R. §§ 1-4 - Definitions

The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indicates that such is the intent, words in the singular number shall include the plural and vice versa. Throughout these rules gender pronouns are used interchangeably except where the context dictates otherwise. The drafters have attempted to utilize each gender pronoun in equal numbers in random distribution. Words in each gender shall include individuals of the other gender.

(a) "Act." The Prescription Drug Assistance Act, 2002 Wyoming Senate Bill No. 34, to be codified as W.S. 42-4-118.

(b) "Adverse action." The denial, suspension, or termination of benefits, other than a suspension or termination caused by a suspension of the Program pursuant to Section 12 or a change in State law, including an amendment to this Chapter.

(c) "A lien." A person residing in, and who is not a citizen of, the United States of America.

(d) "Applicant." An individual on whose behalf an application for coverage by the Program has been submitted, but there has been no final determination of eligibility.

(e) "Application." The form, specified by the Department, on which an applicant indicates in writing the desire to receive benefits.

(f) "Application date." The date an application is received and date stamped by DFS.

(g) "Approve." To determine an applicant is eligible for program benefits.

(h) "Assistance unit." The financially responsible persons living together whose income is considered in determining eligibility for program benefits.

(i) "Benefit month." The calendar month for which program eligibility will

be approved.

(j) "Benefits." Coverage under the program.

(k) "Benefit year." The twelve month period following the benefit start date, and each twelve month period thereafter so long as an insured remains eligible.

(l) "Biennium." The period covering two State fiscal years following each regularly scheduled budget session of the Wyoming Legislature.

(m) "Change in income." An increase of one-third or more in the monthly income of an assistance unit.

(n) "Change report." A form, as prescribed by the Department, used to report a change in income to DFS.

(o) "Chapter 1 of the DFS rules." Chapter 1 of the DFS rules.

(p) "Chapter 1 of the Medicaid Rules." Chapter 1, Medicaid Fair Hearings, of the Wyoming Medicaid Rules.

(q) "Chapter 3 of the Medicaid Rules." Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.

(r) "Chapter 16 of the Medicaid Rules." Chapter 16, Medicaid and State Funded Program Integrity, of the Wyoming Medicaid Rules.

(s) "Chapter 39 of the Medicaid Rules." Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid Rules.

(t) "Claim." A request by a provider for payment of PDAP funds for services provided to a recipient.

(u) "Contested case." Contested case as defined in Chapter 1, which definition is incorporated by this reference.

(v) "Copayment." A charge to a recipient for receiving covered services.

(w) "Countable." A category of income, or resources, which is used to determine program eligibility.

(x) "Covered service." Services provided to a recipient that may be reimbursed out of program funds as provided in this Chapter.

(y) "Department." The Wyoming Department of Health, its agent, designee, or successor.

(z) "Department of Family Services (DFS)." The Wyoming Department of Family Services, its agent, designee, or successor.

(aa) "Prescription Drug Assistance Program (PDAP)" The Prescription Drug Assistance Program established by the Act.

(bb) "Prescription Drug Assistance Program (PDAP) allowable payment." The maximum reimbursement for covered services as specified by this Chapter.

(cc) "Prescription Drug Assistance Program (PDAP) funds." That State general funds appropriated by the Wyoming State Legislature and available to the Department to make payments to providers for furnishing covered services to recipients.

(dd) "Effective date of eligibility." A recipient will be covered for services as of the first day of the month in which the recipient submitted an application.

(ee) "Eligible." An applicant who is approved.

(ff) "Excess payments." "Excess payments" as defined in Chapter 39, which definition is incorporated by this reference. Except that the phrase "Medicaid Funds" in Chapter 39 is replaced with "Program funds."

(gg) "Federal poverty level." The poverty line as specified in the federal poverty guidelines as published and updated annually in the Federal Register pursuant to Section 673(2) of OBRA.

(hh) "Financial records." All records, in whatever form, used or maintained by a provider which are necessary to substantiate or understand a claim submitted to the Department.

(ii) "Formulary." "Formulary" as defined in Chapter 10, which definition is incorporated by this reference.

(jj) "Income." Earned income, unearned income, or in-kind payments received from any source, excluding money classified as a resource or exempt income:

(i) Earned income includes:

(A) Any payment received by an employee or agent in cash or in-kind as wages, salary, tips, commissions, or pursuant to a contract.

(B) Net profits received from activities in which the individual is engaged. "Net profits" means the total sum before deductions for personal or employment expenses and excludes the meal allowance used by the Federal Insurance Contribution Act (FICA).

(ii) Exempt income. Money set aside or free from program policy limits and not counted against program income limits. The following income is exempt:

(A) Income which is required to be excluded under a federal statute;

(B) Unearned income paid in-kind to a household member, such as payments made to a third party for food, shelter, clothing, or other needs;

(C) Educational income, such as grants, scholarships, fellowships, education loans, and work-study income paid to a person who is enrolled in an educational program;

(D) Needs-based veteran's benefits;

(E) Reimbursement for expenses incurred by the individual; and

(F) Child care assistance paid under Title XX of the Social Security Act.

(iii) In-kind income. Goods or services received in lieu of cash. In-kind income is countable when the individual has a legal right to liquidate such goods or services to cash.

(iv) Unearned income. Income received which is neit her earned by providing goods or services nor defined as a resource.

(kk) "Income disregard." Income which is not included in countable income. Income disregards shall be determined as follows:

(i) Each working member of a household shall receive a $200.00 per month disregard, except that a married couple shall be entitled to a $400.00 per month disregard;

(ii) All earned income of a full-time high school student under age eighteen (18) who is living with a caretaker relative;

(iii) Twenty-five percent of the assistance unit's gross self-employment income or a deduction of actual business expenses; and

(iv) Fifty ($50.00) dollars of child support per assistance unit.

(ll) "Inmate of a public institution." "Inmate of a public institution" as defined in 42 C.F.R. 435.1009, which definition is incorporated by this reference.

(mm) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act or the Wyoming Medical Assistance and Services Act of 1967, as amended. "Medicaid" includes any successor or replacement program enacted by Congress or the Wyoming Legislature.

(nn) "Medically necessary." Medically necessary as defined by Chapter 3, which definition is incorporated by this reference.

(oo) "Medical records." All records, in whatever form, in the possession of or subject to the control of a provider which describe a recipient's diagnosis, treatment or condition.

(pp) "Medical supplies." Disposable, semi-disposable or expendable medical supplies.

(qq) "Medicare approved Discount Card." A card that provides a discount on prescription drugs specifically for Medicare recipients that is approved by the Centers for Medicare and Medicaid Services.

(rr) "Month." A calendar month.

(ss) "Notice of action." A written notice mailed to a recipient which informs the recipient of intended action affecting eligibility for benefits. The notice shall include the action to be taken, the effective date of the action, and the legal authority for the action. Notice shall be timely if mailed, by first-class United States mail, ten days before the effective date of the intended action.

(tt) "OBRA." The Omnibus Budget Reconciliation Act of 1981, Pub. L. No. 97-35.

(uu) "Overpayments." Program funds received by a provider as the result of fraud or abuse, as those terms are defined in Chapter 16 of the Medicaid Rules, which definitions are incorporated by this reference.

(vv) "Periodic review." A review of a recipient's eligibility. A periodic review shall be conducted every twelve months after the effective date of eligibility. A periodic review is timely if it is conducted within one-month before or one month after the effective date of eligibility.

(ww) "Physician." A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners.

(xx) "Prescription." "Prescription" as defined by Chapter 10, which definition is incorporated by this reference.

(yy) "Program," The Prescription Drug Assistance Program.

(zz) "Provider." A provider as defined by Chapter 3, which definition i s incorporated by this reference.

(aaa) "Recipient." An individual who has been determined and is currently eligible for the program.

(bbb) "Residence." The place a recipient uses as his or her primary dwelling place and intends to continue to use indefinitely for that purpose.

(ccc) "Resident." A person who lives in the State of Wyoming and has the intention of establishing a permanent residence in the State.

(ddd) "Resource." Real or personal property in which an individual has a legal or equitable interest.

(i) Exempt resources. A category of resources not subject to program policy or limits and is not counted. The following resources are exempt:

(A) Any resource for which:

(I) A legal barrier exists; or

(II) A restriction exists, such as:

(1.) The resource is jointly owned and the co-owner (if the co-owner must legally consent to sale) cannot be located;

(2.) The resource is jointly owned and the co-owner (if the co-owner must legally consent to sale) has provided a statement of refusal to sell; or

(3.) Legal documents include a barrier to sale or inability to convert to cash.

(B) Term insurance policies;

(C) The family home or life estate in family home when lived in by the client, client's spouse or dependent relatives;

(D) The household furnishings belonging to the assistance unit;

(E) Trade-in value less than fifteen thousand dollars ($15,000) for one vehicle. Value of each additional vehicle is a countable resource; and

(F) Real property when the client is making a bona fide effort to sell the property.

(G) Vehicles and other resources used for self-employment purposes.

(H) Resources which the assistance unit is making a bona fide effort to sell when:

(I) The bona fide effort to sell was initiated at least fifteen (15) days prior to application; and

(II) The bona fide effort to sell has not lasted more than ninety (90) days.

(eee) "Services." Health or medical services, medical supplies, or medical equipment.

(fff) "State fiscal year." July 1st through June 30th of the following calendar year.

(ggg) "State general funds." The dollar amount of the state funds appropriated by the Wyoming Legislature for the program and available for the Department to reimburse providers for furnishing covered services to recipients.

(hhh) "Termination." To remove a recipient from the program.

(iii) "Utilization controls." The standards and procedures established pursuant to Chapter 16 of the Medicaid rules, which are incorporated by this reference to deter and detect fraud or abuse by beneficiaries or providers.

(jjj) "Usual and customary charge." A provider's charge to the general public for the same or a similar service.

Notes

048-1 Wyo. Code R. §§ 1-4