048-1 Wyo. Code R. §§ 1-4 - Definitions
Except as defined in the Act or as otherwise specified in this section, the terminology used in this Chapter is the standard terminology and has the standard meaning used in health care, health insurance, Medicare, and Medicaid.
For the purposes of all Chapters of Kid Care CHIP Rules, the following shall apply:
(a) "Act" shall
mean the "Child Health Insurance Program Act," as enacted by the Wyoming
Legislature and codified at W.S. §§
35-25-101 through
35-25-111.
(b) "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
14
or a change in federal or state law, including an amendment to this Chapter.
"Adverse action" does not include the denial of services because they are not
covered services or other issues about the scope of covered services.
(c) "Alaska Native" shall mean an Eskimo,
Aleut, or other Alaska Native enrolled by the United States Secretary of the
Interior.
(d) "Alien" shall mean a
person residing in Wyoming who is not a citizen of the United States of
America.
(e) "American Indian"
shall mean a person who is an enrolled member of a federally recognized Indian
tribe, band, or group, or a first or second degree descendent of such
person.
(f) "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 ehgibility.
(g) "Application" shall mean the form,
specified by the Department, on which an applicant indicates in writing the
desire to receive benefits.
(h)
"Application date" shall mean the date an application for Kid Care CHIP is
noted as received by the Department.
(i) "Basic level of benefits" shall mean the
level of benefits established by the Health Benefits Plan Committee pursuant to
Chapter 3.
(j) "Benefits" shall
mean the health insurance coverage through Kid Care CHIP.
(k) "Benefit year" shall mean January to
December of each year, so long as the insured remains eligible.
(1) "Change in circumstances" shall mean a
change in an insured's address or health insurance coverage.
(m) "Change report" shall mean a
form, as prescribed by the Department, used to report a change in
circumstances.
(n) "Chapter 4 of
the Medicaid rules" shall mean Chapter 4, Medicaid Administrative Hearings, of
the Rules and Regulations for Medicaid.
(o) "Chapter 16 of the Medicaid rules" shall
mean Chapter 16, Program Integrity, of the Rules and Regulation for
Medicaid.
(p) "Citizen" shall mean
an individual, whether adult or child, who is a citizen of the United States of
America.
(q) "Centers for Medicare
and Medicaid Services (CMS)" shall mean the federal agency which administers
Medicare, Medicaid, and the Children's Health Insurance Program.
(r) "Contested case" as defined in Chapter 1
of the Medicaid rules.
(s) "Cost
sharing or co-payment" shall be a charge to an insured for receiving services
covered under a health insurance plan.
(t) "Cost-effective" shall mean the cost of
providing program benefits does not exceed the average cost of similar programs
in similar states, available state funds, or both.
(u) "Covered services" shall mean those
health services which are covered by a health insurance plan offered pursuant
to Chapter 3. "Covered services" must include the basic level of
benefits.
(v) "Crowd out" shall
mean the replacement or elimination of private health insurance by benefits
offered pursuant to this Chapter.
(w) "Effective date of eligibility" shall
mean: the first day of the month following the application date if the
application date is on or before the twenty-fifth (25th) day of the month; or
the first day of the month after the following month if the application date is
after the twenty-fifth (25th) day of the month.
(x) "Eligible" shall mean a person who is
approved for Kid Care CHIP.
(y)
"Excess payments" shall mean Kid Care CHIP funds received by a participating
insurance company to which the company is not entitled for any reason. "Excess
payments" includes, but is not limited to:
(i) Overpayments;
(ii) Payments made as a result of system
errors;
(iii) Payments for premiums
or services furnished to a non-insured;
(iv) Payments for non-covered services
furnished to an insured; or
(v)
Payments which exceed the contract rate agreed to by the participating
insurance company.
(z)
"Explanation of benefits form (EOB)" shall mean a form sent by the insurance
contractor to the provider and the enrolled child. EOBs provide information,
claim payment, and client responsibility.
(aa) "Federal funds" shall mean the Federal
funds received by the Department pursuant to
42 U.S.C.
§
1397 ee to pay for Kid Care CHIP
costs.
(bb) "Financially
responsible adult" shall mean the person or persons legally responsible to
support one or more low income children. "Financially responsible adult" may
include a caretaker.
(cc)
"Financial records" shall mean all records, in whatever form, used or
maintained by a participating insurance company in the conduct of its business
affairs and which are necessary to substantiate or understand invoices
submitted to the Department.
(dd)
"Guardian" shall mean a child's legally appointed conservator or
guardian.
(ee) "Health insurance
plan" shall mean an individual insurance policy or contract for the purpose of
paying for or reimbursing the cost of hospital and medical care. "Health
insurance plan" includes private insurance plans.
(ff) "HHS" shall mean the United States
Department of Health and Human Services, its agent, designee, or
successor.
(gg) "Household" shall
mean the person or persons who live together in a residence. A "household" may
include one or more families.
(hh)
"Illegal alien" shall mean a foreign national who:
(i) Entered the U.S. without inspection or
with fraudulent documentation; or
(ii) After entering legally as a
nonimmigrant, violated status and remained in the U.S. without
permission.
(ii)
"Ineligible" shall mean not authorized to be an insured under Kid Care
CHIP.
(jj) "Insured" shall mean a
low income child who has been determined eligible for Kid Care CHIP.
(kk) "Invoice" shall mean a request by a
participating insurance company for payment of Kid Care CHIP funds for
insurance premiums.
(ll) "Kid Care
CHIP" shall mean the Children's Health Insurance Program established pursuant
to the Child Health Insurance Program Act, W.S. § 32-25-101 through
35-25-111.
(mm) "Kid Care CHIP funds" shall mean that
combination of Federal funds and State funds which is available to the
Department to make payments to participating insurance companies for insurance
coverage furnished to eligible children.
(nm) "Kid Care CHIP State Plan" shall mean
the state plan prepared by the Department pursuant to
42 U.S.C.
§
1397 aa(b) and submitted to
HHS.
(oo) "Medicaid" shall mean
medical assistance and services provided pursuant to Title XIX of the Social
Security Act or the Wyoming Medical Assistance and Services Act.
(pp) "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:
(i)
Consistent with the diagnoses and treatment of the insured's
condition;
(ii) In accordance with
the standards of good medical practice among the provider's peer
group;
(iii) Required to meet the
medical needs of the insured and undertaken for reasons other than the
convenience of the insured and the provider; and
(iv) Performed in the most cost effective and
appropriate setting required by the insured's condition.
(qq) "Medical records" shall mean all
records, in whatever form, in the possession of or subject to the control of a
participating insurance company which describes the insured's diagnosis,
treatment, or condition.
(rr)
"Mid-level practitioner" shall mean a physician's assistant, a certified nurse
practitioner, a certified nurse midwife, or any other licensed health care
professional authorized to diagnose and treat patients.
(ss) "Month" shall mean a calendar
month.
(tt) "Notice of action"
shall mean a written notice mailed to an insured which informs the insured 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 (10) days before the effective date of the intended
action.
(uu) "Orthodontia medical
necessity" shall mean medically necessary orthodontic services or cranial
facial orthopedic deformities with an evaluation report from an
orthodontist.
(vv) "Out of pocket
maximum" shall mean the most money in cost sharing that a household will have
to pay in. a given benefit year. This amount is capped at five percent (5%) of
the household's gross annual income. Once the out of pocket maximum has been
met, the family will not pay any more cost sharing until the next benefit year
begins.
(ww) " Overpayments" shall
mean Kid Care CHIP funds received by a participating insurance company as the
result of fraud or abuse, as those terms are defined in Chapter 16 of the
Medicaid rules.
(xx) "Participating
insurance company" shall mean an insurance company which has contracted with
the Department to provide health benefits to eligible children.
(yy) "Periodic review" shall mean a review of
an insured's eligibility. A "periodic review" shall be conducted every twelve
(12) months after the effective date of eligibility.
(zz) "Plan A" shall mean the Kid Care CHIP
plan that includes Native American children, Alaskan Native children, and those
children whose family income is one hundred percent (100%) or lower of the
federal poverty level and who do not qualify for Medicaid because of a failure
to meet the 40 quarter rule.
(aaa)
"Plan B" shall mean the Kid Care CHIP plan that includes children from one
hundred one percent (101%) to one hundred fifty percent (150%) of the federal
poverty level.
(bbb) "Plan C" shall
mean the Kid Care CHIP plan that includes children from one hundred fifty-one
percent (151%) to two hundred percent (200%) of the federal poverty
level.
(ccc) "Practitioner" shall
mean a physician, nurse practitioner, dentist, optometrist, or any other health
care professional acting within the scope of practice.
(ddd) "Pre-existing condition" shall mean an
illness, injury, or health condition which exists as of the application
date.
(eee) "Premium" shall mean
the payment necessary to pay for a health insurance plan provided to an
eligible child.
(fff) "Program"
shall mean Kid Care CHIP.
(ggg)
"Provider" shall mean an individual or entity that has an agreement with a
participating insurance company to furnish services to an insured.
(hhh) "Qualified alien" shall mean a lawfully
admitted alien who qualifies if the individual:
(i) Is admitted to the United States as a
refugee under Section 207 of the Immigration and Naturalization Act
(INA);
(ii) Has been granted asylum
under Section 208 of the INA;
(iii)
Is eligible for deportation, but the deportation is being withheld under
Sections 241(b)(3) or 243(h) of the INA;
(iv) Is a lawfully admitted, permanent
resident under the INA, and who has lived in the United States for five (5) or
more consecutive years;
(v) Is
lawfully residing within the State; and
(A)
Is a veteran of the United States military service and received an honorable
discharge (except such a discharge for alienage);
(B) Is on active duty with the United States
military service, other than active duty for training; or
(C) Is the spouse or dependent child of a
veteran or active member of the United States military.
(vi) Is a member of another group for which
citizenship is met pursuant to the Balanced Budget Act of 1997.
(iii) "Residence" shall mean the
place the insured uses as a primary dwelling place and intends to continue to
use indefinitely for that purpose.
(jjj) "Resident" shall mean a person who
lives in the State of Wyoming and has the initention of residing in the
State.
(kkk) "Resource" shall mean
real or personal property in which an individual has a legal or equitable
interest.
(Ill) "Services" shall
mean health or medical services, medical supplies, or medical
equipment.
(mmm) "State fiscal
year" shall mean July first (1st) through June thirtieth (30th) of the
following calendar year.
(nnn)
"State fiinds" shall mean the state funds appropriated by the Wyoming
Legislature for Kid Care CHIP. "State funds" may include grant funds received
by the Department from a non-governmental source, if such funds are granted to
constitute a portion of the State's expenditures for this program.
(ooo) "Termination" shall mean to remove an
insured from the program or close the insured's file.
(ppp) "Twelve (12) months of eligibility"
shall mean the period of time in which a child is eligible for Kid Care CHIP,
unless the child moves out of state, enters an institution, turns nineteen
(19), fails quality control, becomes eligible for Medicaid, and/or requests
that the policy be closed.
(qqq)
"Weil-baby or well-child services" shall mean the regular or preventive
diagnostic and treatment services necessary to ensure the health of babies and
children.
Notes
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