(a)  As used in this chapter:

(i)  "Categorically eligible" means any individual in need of medical assistance authorized by the legislature and by Title XIX of the federal Social Security Act to be covered by a state plan for medical assistance and services;

(ii)  "Medical assistance" means partial or full payment of the reasonable charges assessed by any authorized provider of the services and supplies enumerated under W.S. 42-4-103 and consistent with limitations and reimbursement methodologies established by the department, which are provided on behalf of a qualified recipient, excluding those services and supplies provided by any relative of the recipient, unless the relative is a family caregiver providing services through a corporation or a limited liability company, which corporation or limited liability company the relative may own, under a home and community based waiver program, or for cosmetic purposes only;

(iii)  "Qualified" means any categorically eligible individual satisfying eligibility criteria imposed by this chapter, the state plan for medical assistance and services and by rule and regulation of the department;

(iv)  "Relative" means any person as defined by department rule and regulation;

(v)  "Resident" means any individual residing in this state, including any individual temporarily absent from this state;

(vi)  "Institutionalized spouse" means as defined by the Medicare Catastrophic Coverage Act of 1988, P.L. 100-360;

(vii)  "Department" means the state department of health;

(viii)  "Direct patient care personnel" means only:

(A)  Certified nursing assistants;

(B)  Licensed practical nurses;

(C)  Registered nurses.

(ix)  "Skilled nursing home extraordinary care" means skilled nursing home services clearly exceeding standard skilled nursing home services and meeting the criteria established by the department pursuant to W.S. 42-4-104(d);

(x)  "Intermediate care facility for people with intellectual disability" means "intermediate care facility for the mentally retarded" or "ICFMR" or "ICFs/MR" as those terms are used in federal law and in other laws, rules and regulations;

(xi)  "Family caregiver" means a relative of a waiver recipient with a developmental disability or acquired brain injury, who provides waiver services through a corporation or a limited liability company, which corporation or limited liability company the relative may own, to the person with a developmental disability or acquired brain injury and who meets the requirements for a qualified family caregiver as established by rules promulgated by the department. Family caregivers shall be certified by the department in the same manner as nonfamily caregivers. For purposes of providing for reimbursement of services to a family caregiver, the department shall amend the state plan and apply for a waiver from the centers for Medicaid and Medicare services, as necessary;

(xii)  "Intentional" means that a person, with respect to information, intended to act in violation of the law;

(xiii)  "Knowing" or "knowingly" includes intentional or intentionally and means that a person, with respect to information, acts:

(A)  With actual knowledge of the information;

(B)  In deliberate ignorance of the truth or falsity of the information; or

(C)  In reckless disregard of the truth or falsity of the information.

(a)  Services and supplies authorized for medical assistance under this chapter include:

(i)  Inpatient hospital services;

(ii)  Outpatient hospital services;

(iii)  Laboratory and x-ray services;

(iv)  Skilled nursing home services;

(v)  The professional services of a licensed and certified physician, osteopathic physician or chiropractic doctor;

(vi)  Home health services;

(vii)  Family planning services;

(viii)  Services provided by an authorized rural health care clinic;

(ix)  Midwife services provided by a:

(A)  Certified nurse midwife licensed by the board of nursing;

(B)  Midwife licensed by the board of midwifery.

(x)  Early and periodic screening, diagnosis and treatment for individuals who have not attained the age of twenty-one (21) years in accordance with Title XIX of the federal Social Security Act;

(xi)  Premiums, deductibles and coinsurance under federal Medicare Part A, hospital insurance, and Part B, supplemental medical insurance;

(xii)  The professional services of a licensed optometrist;

(xiii)  Prescription drugs and oxygen;

(xiv)  Prosthetic devices which are necessary to replace a missing portion of the body or assist in correcting a dysfunctional portion of the body including training required to implement the use of the device but excluding dental prostheses;

(xv)  Licensed rehabilitation center services and if specifically prescribed by a licensed physician, outpatient services of a privately operated licensed occupational, speech, audiology or physical therapy center and the professional services of a licensed occupational therapist, licensed speech pathologist, licensed audiologist or a licensed physical therapist;

(xvi)  Services provided by an institution for mental illnesses;

(xvii)  Services provided under a federal home and community based waiver;

(xviii)  The professional services of a licensed dentist which may be legally and alternatively performed by a licensed physician or osteopathic physician and except as provided under paragraph (a)(x) of this section, which are not primarily provided for the care, treatment or replacement of teeth or structures directly supporting teeth;

(xix)  Services provided by a freestanding ambulatory surgical center;

(xx)  Services provided by a certified mental health center or community substance abuse treatment center; mental health services provided to qualified recipients by a licensed physician or under the direction of a physician if an individual treatment plan is established in writing, approved and periodically reviewed by a licensed physician; services provided by a licensed mental health professional. Authorized services shall include services provided by a person holding a provisional license as a mental health professional if the services were provided under the supervision of a licensed mental health professional. The department of health shall by rule and regulation or within the state plan for medical assistance and services, define those services qualifying as mental health services under this paragraph and, pursuant to W.S. 9-2-102, establish standards for certification under this paragraph. As used in this paragraph "licensed mental health professional" means a licensed professional counselor, a licensed marriage and family therapist, a licensed addictions therapist or a licensed clinical social worker;

(xxi)  Services provided by intermediate care facilities;

(xxii)  Services provided by an intermediate care facility as defined under 42 U.S.C. 1396d(d);

(xxiii)  Services provided by freestanding end stage renal dialysis clinics or centers;

(xxiv)  Services provided by advanced practitioners of nursing;

(xxv)  Hospice care as defined in W.S. 35-2-901(a)(xii) and authorized under 42 U.S.C. 1396a(a)(10)(A)(ii)(VII) including hospice care in a hospice facility for an eligible individual and room and board for individuals receiving the care in a hospice facility. Reimbursement rates for hospice care shall be set annually to match Medicare hospice reimbursement rates. The room and board reimbursement rate for hospice facilities shall not exceed fifty percent (50%) of the statewide average of the Medicaid nursing home room and board rate. For the purposes of this paragraph, "eligible individual" means a person who is eligible for hospice care as defined in the state Medicaid plan in effect on July 1, 2012;

(xxvi)  Tuberculosis ambulatory care authorized under 42 U.S.C. 1396a(a)(10)(A)(ii)(XII);

(xxvii)  Targeted case management services, which shall be services which will assist targeted individuals eligible under the state plan in gaining access to needed medical, social, educational and other services;

(xxviii)  Skilled nursing home extraordinary care in accordance with W.S. 42-4-104(d);

(xxix)  Bone marrow, kidney and liver transplant services;

(xxx)  Programs and services provided under the school health program;

(xxxi)  Services of a licensed dietitian;

(xxxii)  Air ambulance transport services, consistent with W.S. 42-4-123;

(xxxiii)  Clubhouse rehabilitation services in accordance with W.S. 42-4-124;

(xxxiv)  The professional services of a school psychologist;

(xxxv)  The professional services of a school social worker;

(xxxvi)  School based services delivered pursuant to an individualized education program, including services:

(A)  Provided by an otherwise enrolled Medicaid provider type;

(B)  Provided by a licensed professional in a school setting; or

(C)  Otherwise covered under this chapter to support delivery of special education programs and services.

(xxxvii)  The professional services of a licensed pharmacist;

(xxxviii)  Podiatry services provided by a podiatrist licensed by the board of registration in podiatry, if referred to a podiatrist by a physician, physician assistant or an advanced practice registered nurse.

(b)  In addition to other payments authorized under this chapter, the department may provide payments to skilled nursing homes which are providing services covered under this chapter if:

(i)  The nursing home demonstrates that one hundred percent (100%) of the additional amount received will be expended upon direct patient care personnel salaries and benefits; and

(ii)  The nursing home agrees to provide sufficient data to the department substantiating compliance with paragraph (i) of this subsection.

(c)  For purposes of implementing Medicaid reform pursuant to 2013 Wyoming Session Laws, Chapter 117, the department may apply for any applicable waivers or permissions to allow exceptions to federal conflict free case management definitions for frontier and rural areas, which to the extent consistent with federal law, shall implement a system using a neutral third party to ensure no conflicts exist. Consistent with federal law, the department may phase in the independent case management system. In negotiating a waiver pursuant to this subsection, the department shall, to the extent practicable and approved by the center for Medicare and Medicaid services:

(i)  Allow an individual or agency to provide case management and direct services to discrete clients if the services are provided under conflict free circumstances;

(ii)  When implementing updated case manager educational standards, provide for a three (3) year transition period and allow credit for prior case manager experience.

(a)  The department of health shall:

(i)  Administer this chapter;

(ii)  Develop a state plan for medical assistance and services provided to qualified recipients under this chapter and otherwise providing for the effective administration of this chapter;

(iii)  Maintain records on the administration of this chapter, report to the federal government as required by federal law and regulation and within limitations imposed under W.S. 42-4-112, may provide for the availability of information on the administration of this chapter to interested persons;

(iv)  Adopt, amend and rescind rules and regulations on the administration of this chapter following notice and public hearing in accordance with the Wyoming Administrative Procedure Act.

(b)  In carrying out subsection (a) of this section, the department may:

(i)  Advise, consult and cooperate with any state agency or political subdivision, any other state, the federal government, private industry and other interested persons;

(ii)  Negotiate and enter into contract with other public and private agencies and persons as necessary to administer this chapter;

(iii)  Directly or by contract and through one (1) or more fiscal intermediaries, provide payments to providers of services and supplies for medical assistance authorized by this chapter in the manner and amount provided by this chapter;

(iv)  Receive funds from any source for purposes of carrying out this chapter;

(v)  Establish reasonable limits on services and supplies authorized under W.S. 42-4-103;

(vi)  Conduct pilot projects pursuant to W.S. 42-4-107(c);

(vii)  Provide for part or all of the services and supplies authorized under W.S. 42-4-103 for some or all categorically eligible individuals through health care insurance or through contracts with networks of health care providers;

(viii)  Purchase stop gap insurance;

(ix)  Enter into intergovernmental transfer arrangements with qualifying facilities and providers, including but not limited to hospitals, nursing homes, hospital owned and operated professional service providers and ground ambulance service providers, in which all federal funding received as a result of the intergovernmental transfer arrangements shall be distributed to participating facilities and providers in accordance with the terms of an approved state plan amendment or other agreement with the centers for Medicare and Medicaid services. Notwithstanding, if consistent with the state plan amendment or agreement, the department may use funds derived from such intergovernmental transfers to pay administrative expenses incurred by the department or its agent in performing the activities authorized under this subsection, provided that these expenses shall not exceed a total of three percent (3%) of the aggregate intergovernmental transfer funds collected in the fiscal year;

(x)  Provide for the withholding of medical assistance payments from nursing care facilities in accordance with W.S. 42-8-107(b)(i).

(c)  Subject to limitations imposed under this subsection, the department shall, at least once every five (5) years but not more than once in any three (3) year period, establish a new base period to be used in calculating all skilled nursing homes' medical assistance per diem base rate reimbursable under this chapter, using the most recent cost report information provided to the department. For purposes of medical assistance reimbursable under this chapter, the department shall reimburse each eligible provider of skilled nursing home services the greater of the following amounts:

(i)  Medical assistance computed on the per diem base rate under the new base period established pursuant to this subsection; or

(ii)  For the state fiscal year beginning July 1, 2003 and ending June 30, 2004, medical assistance computed on the per diem base rate existing prior to the establishment of the new base period under this subsection.

(d)  The department shall establish by rule the conditions and requirements for skilled nursing home extraordinary care. The requirements shall include, but are not limited to the following:

(i)  The care shall be previously authorized by the department for each individual and subject to continual audit by the department;

(ii)  The cost for the care shall clearly exceed the standard skilled nursing home per diem rate;

(iii)  The cost shall be excluded from the nursing home's cost report to the department; and

(iv)  No extraordinary care payment shall be made for equipment owned by the nursing home in providing the care.

(e)  The chief administrator of the Medicaid program created pursuant to this chapter shall be the state Medicaid agent within the department of health, who shall be appointed by the governor, shall serve at the pleasure of the governor and may be removed by the governor as provided by W.S. 9-1-202. The state Medicaid agent shall oversee and coordinate all programs which provide Medicaid services or determine Medicaid eligibility pursuant to W.S. 42-4-106 and chapter 2 of this title.

(a)  Any Wyoming resident may apply for medical assistance under this chapter by filing an application by telephone, by mail, in person at the eligibility customer service center in Cheyenne, on the eligibility internet site or at a department of family services field office located in the county in which the individual resides. A determination of eligibility for medical assistance shall be based upon the application. Medical assistance shall be provided on behalf of a qualified applicant with reasonable promptness.

(b)  Upon signing an application for medical assistance under this chapter, an applicant assigns to the department any right to medical support or payment for medical expenses from any other person on his behalf or on behalf of any relative for whom application is made. The assignment is effective upon a determination of eligibility. Application for medical assistance shall contain an explanation of the assignment provided under this subsection.

(c)  In determining the eligibility of an institutionalized spouse for medical assistance under this chapter, the resources of the noninstitutionalized spouse shall not be considered available to the institutionalized spouse to the extent the amount of his resources does not exceed the maximum authorized by the Medicare Catastrophic Coverage Act of 1988, P.L. 100-360. For purposes of determining the amount of an institutionalized spouse's monthly income to be applied towards payment of institutional care costs, the maximum amount of allowance authorized by the Medicare Catastrophic Coverage Act of 1988, P.L. 100-360 shall be deducted from his monthly income.

(d)  In any assistance program under this chapter for which income is the criterion or one (1) of the criteria for assistance payments, compensation received for a veteran's service connected disability shall not be counted in determining income if that compensation on an annual basis is not more than the poverty level for the applicant as determined by the federal office of management and budget.

(a)  This chapter and the state plan for medical assistance and services developed under W.S. 42-4-104(a)(ii) shall be uniformly applied within all political subdivisions of the state.

(b)  The provision of medical assistance to any applicant or qualified recipient shall not be denied or delayed and the administration of this chapter shall not otherwise discriminate against any applicant or recipient on the basis of race, creed, color, national origin, sex or mental or physical handicap.

(c)  Notwithstanding any other provision of this act, the department, in providing services and supplies authorized by this act, may conduct pilot projects pertaining to some or all categorically eligible individuals.

(a)  Renumbered as 42-4-207(a) by Laws 1994, ch. 73, 2.

(b)  Renumbered as 42-4-207(b) by Laws 1994, ch. 73, 2.

(c)  Repealed by Laws 1994, ch. 73, 3.

(d)  Renumbered as 42-4-207(f) by Laws 1994, ch. 73, 2.

(a)  Repealed by Laws 2019, ch. 96, 3.

(b)  Repealed by Laws 2019, ch. 96, 3.

(c)  No person shall knowingly make a false statement or misrepresentation or knowingly fail to disclose a material fact in obtaining medical assistance under this chapter. A person violating this subsection is guilty of a misdemeanor punishable by imprisonment for not more than six (6) months, a fine of not more than seven hundred fifty dollars ($750.00), or both.

(d)  Repealed by Laws 2019, ch. 96, 3.

(e)  Repealed by Laws 2019, ch. 96, 3.

(a)  Any application, information and record obtained, compiled and maintained for an applicant or qualified recipient of medical assistance under this chapter is confidential and shall not be disclosed or used for any purpose other than the administration of this chapter.

(b)  A violation of subsection (a) of this section is a misdemeanor.

(c)  Notwithstanding subsection (a) of this section and any other provision of law to the contrary, and for purposes of ensuring any medical assistance under this act does not duplicate any benefit payment made by another state agency, insurer, group health plan, third party administrator, health maintenance organization or similar entity, the department may upon request of the state agency, insurer or similar entity, disclose information limited to a recipient's name, social security number, amount of payment, charge for services, date of services and services rendered relating to medical assistance payments made under this act. A state agency, insurer, group health plan, health maintenance organization or similar entity shall, upon request of the department, disclose the same limited information to the department. Information received under this subsection shall be used only for the purpose authorized by this subsection and shall otherwise be confidential and the state agency, insurer, group health plan, health maintenance organization or other recipient entity shall be subject to the confidentiality restrictions imposed by law upon information received to the extent required of the department. Any violation of this subsection is a misdemeanor punishable by imprisonment for not more than six (6) months, a fine of not more than seven hundred fifty dollars ($750.00), or both.

(d)  Prior to receipt of any payment under this act, the department shall require an applicant for or recipient of assistance under this act to sign a waiver authorizing the release of information limited to assistance payment information to state agencies, insurers, group health plans, third party administrators, health maintenance organizations or similar entities for purposes specified by subsection (c) of this section.

(a)  The department shall not consider as assets available to an applicant seeking medical assistance the corpus of a Medicaid qualifying trust:

(i)  That is irrevocable;

(ii)  In which the trustee and trustor retain no discretion with respect to distributions to the applicant;

(iii)  In which the income from the trust shall be transferred to the applicant at least annually;

(iv)  In which the trust corpus shall not exceed five thousand dollars ($5,000.00); and

(v)  In which the trust corpus is specifically and irrevocably designated, assigned, or pledged for payment of the applicant's burial expenses.

(b)  If any of the trust corpus remains after payment of burial expenses, that remainder shall be transferred to the department to be used in the medical assistance program.

(a)  The department may amend the state plan for medical assistance and services developed under W.S. 42-4-104(a)(ii) to allow individuals with countable income not to exceed three hundred percent (300%) of the supplemental security income level to receive services authorized under W.S. 42-4-103(a), provided that:

(i)  Repealed by Laws 2002, Ch. 31, 2.

(ii)  Repealed By Laws 2002, Ch. 31, 2.

(iii)  The individual is eligible to buy into the Wyoming Medical Assistance and Services Act under the federal Ticket to Work and Work Incentive Improvement Act of 1999 and subsequent similar federal enactments and the federal government is not restricted from paying its proportionate share of the individual's eligible medical expenses;

(iv)  Provided that the individual's earnings do not exceed the level specified in section 201(a)(3) of the Federal Ticket to Work and Work Incentive Improvement Act of 1999; and

(v)  The individual pays to the department a premium of seven and one-half percent (7.5%) of his total gross earnings from work and seven and one-half percent (7.5%) of his unearned income in excess of six hundred dollars ($600.00) per year, provided that:

(A)  The total paid in premiums under this section does not exceed the yearly premium as calculated pursuant to W.S. 42-4-116; and

(B)  The individual is not liable for more than the full premium calculated pursuant to W.S. 42-4-116.

(b)  If the federal government does not allow a state plan amendment containing the expense limitations provided in paragraphs (a)(i) and (ii) of this section or provisions with similar fiscal effects, the state plan amendment authorized by this section shall not be implemented without specific legislative authorization.

(c)  With respect to the premium received pursuant to subsection (a) of this section, the department shall deduct and forward to the federal government any amount owed under federal regulations. Any overpaid premium shall be refunded to the individual and the balance shall be deposited in the general fund. The sum of all amounts deposited under this section shall be reported in the biennial budget submissions to the joint appropriations interim committee as premium earned to offset the expenses of the program.

(d)  Repealed by Laws 2015, ch. 54, 2.

(e)  Repealed by Laws 2002, Ch. 31, 2.

(f)  Repealed By Laws 2002, Ch. 31, 2.

(a)  The calculation of premium for services under W.S. 42-4-115 shall be as follows:

(i)  Determine the total expenses of the Medicaid program for the most recent state fiscal year and the total number of clients in the Medicaid program served in that period;

(ii)  Deduct from the totals in paragraph (i) of this subsection the clients over the age of sixty-five (65) years and the expenses associated with those clients;

(iii)  Divide the resulting expenses calculated pursuant to paragraph (ii) of this subsection by the clients remaining after the deduction pursuant to paragraph (ii) of this subsection. The result is the basic annual premium;

(iv)  Add to the basic premium a risk factor of fifty percent (50%) of the basic premium to recover additional costs incurred by the population eligible to be served pursuant to W.S. 42-4-115; and

(v)  The premium shall be the sum of the basic annual premium calculated pursuant to paragraph (iii) of this subsection and the risk factor calculated pursuant to paragraph (iv) of this subsection.

(a)  Effective July 1, 2001, the department shall expand coverage for services authorized under W.S. 42-4-103(a)(xxiii) for qualified individuals in need of end stage renal dialysis to the extent funding is available.

(b)  The department shall by rule and regulation establish reasonable limits on services and supplies authorized under this section, including establishing eligibility criteria for receipt of services. In establishing eligibility criteria, the department shall consider financial ability of the individual or his family to contribute to the services, severity of the illness, the critical need for the services and the ability of the program to meet the needs of the individual.

(a)  There is created a prescription drug assistance program to assist residents of the state. The program shall be a state funded program to provide prescription drug assistance, in addition to the services provided under the Wyoming Medical Assistance and Services Act. Effective July 1, 2002, the prescription drug assistance program shall replace the minimum medical program. Eligibility for assistance under the program created by this section shall not constitute an entitlement and services shall be provided under this section only to the extent funds are available.

(b)  Residents of the state may apply for the prescription drug assistance program in the manner provided in W.S. 42-4-106. Upon a determination of eligibility, the applicant remains eligible for assistance under the prescription drug assistance program as provided in this section. If a recipient ceases to be a resident of the state, his eligibility under the program shall terminate. The department shall by rule and regulation establish income eligibility guidelines no later than July 1 of each year based on the federal poverty levels in effect on January 1 of that calendar year. Persons with family income of one hundred percent (100%) of the federal poverty level or less shall be eligible under this section. The rules shall take into consideration family size up to four (4) individuals. Eligibility for families consisting of more than four (4) individuals shall be determined on the basis of the income of a family of four (4) individuals. Persons eligible for prescription drug assistance under other state or federal programs, except the state high risk health insurance pool, shall be ineligible for assistance under the prescription drug assistance program.

(c)  Except as provided by this subsection, an eligibility determination made under subsection (b) of this section shall be valid for one (1) year. A recipient whose monthly income changes by more than one-third (1/3), shall report the change in income to the department. The recipient is entitled to a redetermination if his income has declined and may, at the option of the department, be subject to a redetermination if his income has increased.

(d)  A recipient shall be required to pay a copayment per prescription of ten dollars ($10.00) for generic drugs and twenty-five dollars ($25.00) for brand name drugs.

(e)  The department shall project costs of the program created by this section at least quarterly and compare those projected costs against the funds appropriated for the program. If the funds available to the program are insufficient to meet the projected costs of the program, the department shall take action to prevent the program from incurring costs beyond available funds, including taking any of the following actions:

(i)  Imposing a moratorium on new enrollments in the program;

(ii)  Reducing the gross family income eligibility level specified in subsection (b) of this section;

(iii)  Imposing higher prescription drug copayments not to exceed twenty-five dollars ($25.00) per prescription;

(iv)  Eliminating specified drugs from eligibility under the program;

(v)  Carrying claims for payment into the next biennium if the amount of claims are less than one twenty-fourth (1/24) of the appropriation that has been enacted for the next biennium.

(a)  The department may apply for a demonstration waiver under section 1115 of the federal Social Security Act to allow individuals with income or assets in excess of limits generally established in the state plan to receive services under a pharmacy plus program provided that:

(i)  The individual is a beneficiary under the federal Medicare program who has not been determined to be eligible for full Medicaid benefits under the state plan;

(ii)  The total family income of the individual does not exceed one hundred seventy-five percent (175%) of the federal poverty level in effect on April 1 of that calendar year;

(iii)  The total family net assets of the individual do not exceed three hundred fifty thousand dollars ($350,000.00); and

(iv)  An individual determined eligible to receive services under this section shall not be eligible for other services under W.S. 42-4-103, unless the individual otherwise qualifies for the services. Eligibility for assistance under the program created by this section shall not constitute an entitlement and services shall be provided under this section only to the extent funds are available.

(b)  The department is directed to negotiate the terms and conditions of the waiver with the United States secretary of health and human services as necessary to implement this section.

(c)  Upon approval of the final terms and conditions by the United States secretary of health and human services and the legislature of the waiver applied for under this section, the department shall implement the pharmacy plus program to assist eligible individuals with payment and management of prescription drug costs. In implementing the pharmacy plus program, the department may use private sector benefit management approaches, including pharmacy benefit managers, preferred drug lists, prior authorization, pharmacist consultation, provider education, disease state management and variable enrollee cost sharing in the form of annual or monthly premium assessments, per prescription copayment requirements, coinsurance, deductibles and coverage limits. The department shall establish through rules and regulations variable enrollee cost sharing provisions under this subsection on a graduated basis, taking into consideration the differing income levels of enrollees and the funding available to the program.

(d)  If the federal Medicare program is amended to provide pharmaceutical benefits for recipients under that program, the pharmacy plus program authorized under this section shall terminate upon implementation of the federal Medicare pharmaceutical benefits program.

(e)  The department shall project costs of the program created by this section at least quarterly and compare those projected costs against the funds appropriated for the program. If the funds available to the program are insufficient to meet the projected costs of the program, the department shall take action to prevent the program from incurring costs beyond available funds, including taking any of the actions specified in W.S. 42-4-118(e).

(a)  The department is authorized to enter into contracts with providers of services under a federal home and community based waiver and to enforce the provisions of this section.

(b)  The department shall adopt and enforce reasonable rules and regulations for the certification of home and community based waiver services, and shall include minimum certification standards for each category of service provider.

(c)  Before entering into a contract with a provider of services under this section, the department shall ascertain that the provider is in compliance with applicable regulations regarding health care providers adopted pursuant to W.S. 35-2-908, with all applicable professional licensing statutes and regulations and with regulations adopted pursuant to subsection (b) of this section.

(d)  In addition to other remedies, in the event of a chronic failure to provide services or services that fail to meet the applicable standard of care for the profession involved or a continuing condition creating serious detriment to the health, safety or welfare of recipients of home and community based waiver services, the department may impose a civil penalty upon the provider. For each day of continuing violation, the civil penalty shall not exceed one thousand dollars ($1,000.00) or one percent (1%) of the amount paid to the provider during the previous twelve (12) months, whichever is greater, and any administrative penalty assessed under this section shall be paid over to the state treasurer who shall remit the monies to the county treasurer to the credit of the public school fund of the county in which the violation occurred, except as otherwise provided by federal law for Medicaid certified nursing facilities.

(e)  The department shall have the same authority to place conditions upon a provider, to impose a monitor or to revoke a certification issued under this section in the manner described in W.S. 35-2-905.

(f)  The department, not later than April 1, 2008, shall promulgate rules under which an emergency case shall be determined to exist with respect to eligibility for federal home and community based waiver services for persons with developmental disabilities or adult brain injury under this act.

(g)  The department shall establish by rule and regulation a cost based reimbursement system to pay providers of services and supplies under home and community based waiver programs for persons with developmental disabilities or acquired brain injury. The payment system shall:

(i)  Use information provided to the department, including but not limited to:

(A)  Provider cost data;

(B)  Provider claims data;

(C)  Participant needs assessment data;

(D)  Other relevant regional and national data.

(ii)  Establish a new base period to be used in calculating reimbursement rates to providers for fiscal year 2012 and at least once every four (4) years thereafter but not more than once in any two (2) year period. When a new base period is established, the department shall submit a biennial or supplemental budget request to adjust provider reimbursement rates based on the most current base period;

(iii)  Be developed following consultation with Wyoming developmental disability and acquired brain injury waiver program service providers, developmental disability waiver program clients and their families and an expert in cost based waiver program payment systems, which the department is authorized to retain by contract following competitive bidding;

(iv)  Be implemented for services and supplies provided under individual budget amounts established on and after July 1, 2008;

(v)  Be contingent upon approval by the center for Medicare and Medicaid services of the United States department of health and human services;

(vi)  Require service and supply providers to provide actual cost of service and supply data to the department and to submit to reasonable audits of the submitted data, if requested by the department.

(h)  The department shall apply to the center for Medicare and Medicaid services of the United States department of health and human services for authorization to reimburse at an enhanced rate direct care providers who have training and certification as behavioral specialists in the care of persons dually diagnosed with a developmental disability and a mental illness.

(j)  The department, through the developmental disabilities division and the mental health and substance abuse services division, shall collaborate with the University of Wyoming institute for disabilities and the community college commission in developing a training program for behavioral specialists in the care of persons dually diagnosed with a developmental disability and a mental illness. The program shall provide for timely testing and certification and shall include a required curriculum and standards for certification and evaluation of dual diagnosis behavioral specialists where certificants will qualify for reimbursement under the requirements of subsection (h) of this section.

(k)  Department budget requests for the cost based reimbursement system established pursuant to subsection (g) of this section shall be calculated to reflect all service units required in plans of care for recipients as of the preceding June 30.

(m)  The department shall ensure that state agencies working with service providers receiving funds pursuant to this section shall have established employment first policies, including competitive employment in an integrated setting, consistent with the requirements of W.S. 9-2-3207.

(n)  For purposes of this section, "military service member" means any person serving in the uniformed services as defined in W.S. 8-1-102(a)(xxii). Military service members shall have the following benefits if they meet the qualifications listed:

(i)  Active duty military service members who have been assigned to serve in Wyoming may submit an application for waiver services under this paragraph upon receiving military orders to serve in Wyoming, provided that no qualifying dependent shall receive services until the dependent is residing in Wyoming;

(ii)  Active duty military service members retiring or separating from active duty military service may submit an application for waiver services under this paragraph upon receiving retirement or separation orders, provided that:

(A)  The military member certifies on a form provided by the department that he intends to reside in Wyoming within eighteen (18) months after retiring or separating from military service;

(B)  The military service member claimed Wyoming as his primary state of residency for not less than two (2) years prior to his military service as proved by documentation required by the department;

(C)  The military service member claimed Wyoming residency on his leave and earnings statements while serving in the military; and

(D)  No covered services shall be received pursuant to this paragraph unless and until the qualifying dependent and the military service member are residing in Wyoming within eighteen (18) months after the military service member retires or separates from active military service.

(iii)  Military service members who qualified for and received or were previously placed on the waiting list to receive dependent waiver services under the home and community based Medicaid waivers authorized by this section, and who left the state for military reasons, shall upon their return to the state for continued military service or upon military separation or retirement be placed in a status identical to where they would be if they had not left the state provided that:

(A)  The military service member claimed Wyoming residency on his leave and earnings statements while serving in the military; and

(B)  For retiring or separating military service members, in no case shall covered services be received pursuant to this paragraph unless and until the military service member and the qualifying dependent are residing in Wyoming within eighteen (18) months after the military service member retires or separates from active military service.

(o)  Applicants who are qualifying military service members under subsection (n) of this section may also be considered for funding made available to any other applicant under this section and shall receive services from whatever source of funding for which they first qualify. In consultation with the Wyoming military department, the department of health shall promulgate rules and regulations regarding applications and qualifications for waiver services authorized by subsection (n) of this section.

(a)  The department, as an optional services program of the Medicaid program, may develop and implement a program of all-inclusive care for the elderly (PACE) in accordance with section 4802 of the Balanced Budget Act of 1997, P.L. 105-33, as amended, and 42 C.F.R. part 460.

(b)  The department may contract with approved PACE organizations to provide, in the manner and to the extent authorized by federal law, comprehensive, community based acute and long term care services for older Medicaid eligible participants who are at least fifty-five (55) years old, living in a PACE service area, certified by the department as eligible for long term care facility placement and who elect to participate in the PACE program. Services provided through a PACE organization shall include all necessary medical and related care required by the PACE participant, including but not limited to physician and other health care provider visits, regular check ups, prescription drugs, rehabilitation services, home and personal care services, medically necessary transportation, hospitalization and skilled nursing facility services.

(c)  The objective of the PACE program is to provide prepaid, capitated, quality comprehensive health care services that are designed to:

(i)  Enhance the quality of life and autonomy for frail, older adults;

(ii)  Maximize dignity of, and respect for, older adults;

(iii)  Enable frail, older adults to live in the community as long as medically and socially feasible;

(iv)  Preserve and support the older adult's family unit.

(d)  The department shall adopt rules as necessary to implement this section. In adopting rules, the department shall:

(i)  Provide application procedures for organizations seeking to become a PACE program provider;

(ii)  Establish the capitation rate for Medicaid participants electing to participate in the PACE program instead of receiving Medicaid services on a fee for service basis. The capitation rate shall be no less than ninety percent (90%) of the fee for service equivalent cost, including the department's cost of administration, that the department estimates would be payable for all services covered under the PACE organization contract if all of those services were to be provided on a fee for service basis;

(iii)  Provide application procedures, including acknowledgment of informed consent, for Medicaid participants electing to participate in the PACE program in lieu of receiving fee for service Medicaid benefits.

(e)  PACE provider organizations shall be public or private organizations providing or having the capacity to provide, as determined by the department, comprehensive health care services on a risk based capitated basis to PACE patients.

(f)  To demonstrate capacity as required by subsection (e) of this section, the department shall consider evidence such as an organization's insurance, reinsurance, cash reserves, letters of credit, guarantees of companies affiliated with the organization or a combination of those arrangements.

(g)  PACE organizations shall assume responsibility for all costs generated by PACE program participants, and shall create and maintain a risk reserve fund that will cover any cost overages for any participant. A PACE organization is responsible for the full financial risk that the cost of services required by a program participant might exceed the Medicaid capitated fee for that participant.

(h)  The department shall develop and implement a coordinated plan to promote the PACE program among prospective Medicaid long term care patients in the service areas of approved PACE organizations.

(j)  As soon as practicable after July 1, 2010, the department shall submit to the federal centers for Medicare and Medicaid services an amendment to the state Medicaid plan authorizing the state to implement the program of all-inclusive care for the elderly pursuant to this section. The department shall not enter into a contract with any PACE provider organization until all necessary state plan amendments or waivers are approved. An additional amendment to the state Medicaid plan shall not be required each time the department enters into a contract with a new PACE provider organization.

(k)  Nothing in this section shall be construed to require a PACE organization to hold a certificate of authority as an insurer or a health maintenance organization under title 26 of the Wyoming statutes.

(m)  Repealed by Laws 2015, ch. 59, 2.

(n)  No PACE organization shall withhold any necessary medical or nonmedical services to any PACE participant in order to increase the organization's profit from the Medicaid capitated payment.

(o)  PACE participants may disenroll from the PACE program at any time. A PACE organization shall promptly report the identity of all disenrolled participants to the department.

(a)  Except as otherwise provided in subsection (b) of this section, as a condition of eligibility, or continuing eligibility, for medical assistance under this chapter, a person who receives medical assistance shall cooperate in good faith with the department to:

(i)  Establish the paternity of a child, including any proceeding to adjudicate parentage that is held pursuant to W.S. 14-2-801 through 14-2-823;

(ii)  Obtain a child support obligation payment or other payments or property to which the state may have a claim, including recovery of birth costs paid by medical assistance pursuant to W.S. 14-2-1001 through 14-2-1008.

(b)  The following persons are not required to cooperate with the department pursuant to subsection (a) of this section:

(i)  A person who is pregnant, or who has been pregnant within the preceding sixty (60) days;

(ii)  A person who has good cause to not cooperate with the department, as determined by rule promulgated pursuant to W.S. 14-2-1008;

(iii)  A woman who has been pregnant within the preceding twelve (12) months. This paragraph is repealed effective March 31, 2027.

(a)  The director of the department shall include reimbursement for clubhouse rehabilitation services within the Medicaid program.

(b)  Within the limits of available funding, the department may enter into contracts with certified clubhouse providers for clubhouse rehabilitation services.

(c)  On or before September 1, 2019 the department shall report to the joint labor, health and social services interim committee on information, findings and recommendations related to clubhouse rehabilitation services including information to facilitate implementation of Medicaid contracts to be entered into pursuant to this section.

(d)  As used in this section, "clubhouse" means a community-based psychosocial rehabilitation program that:

(i)  Has members of the program, with staff assistance, engaged in operating all aspects of the clubhouse, including food service, clerical, reception, janitorial and other member services such as employment training, housing assistance and educational support; and

(ii)  Is designed to alleviate a member's emotional or behavior problems with the goal of transitioning the member to a less restrictive level of care, reintegrating the member into the community and increasing social connectedness beyond a clinical or employment setting.