Section 1-7 - Determining Established Charges (a) The legally responsible party shall complete the following procedures in determining the established charge: - (i) Complete a financial questionnaire, identifying all income and assets, and any assets disposed of by the legally responsible person in the past three (3) years or in accordance with Wyoming Medicaid Procedure. The Questionnaire shall be:
- (A) Signed by the legally responsible person or his/her legal guardian or conservator under oath and subject to penalty of false swearing as set forth in W.S. 6-5-303;
- (B) Submitted within forty-five (45) days of the resident's admission. If the financial questionnaire is not submitted within forty-five (45) days, the agency shall set the established charge as the actual cost until financial information becomes available.
- (ii) Provide any documents required by the institution for verifying any information stated on the financial questionnaire on an annual basis;
- (iii) Update the financial questionnaire on an annual basis;
- (iv) Notify the institution of any change in circumstances which affect a legally responsible persons income and assets. The notice shall be submitted to the institution within sixty (60) days of the changed financial status. If a legally responsible person fails to notify the institution within sixty (60) days, the agency may set the established charge as the actual cost;
- (v) The legally responsible person may be exempt from the requirements if the legally responsible person pays the actual costs for services and treatment set by the agency throughout the resident's admission to a state institution;
- (vi) If payment becomes overdue or the legally responsible person's financial status changes, the legally responsible person shall comply with the financial disclosure requirement;
(b) The institution shall complete the following procedures in determining the established charge: - (i) Review the information stated in the financial questionnaire;
- (ii) Verify any stated information by requesting copies of documents as necessary which shall be incorporated into the residents record;
- (iii) Allow any applicable deductions for payments actually made by the legally responsible person including but not limited to:
- (A) Federal and state withholding taxes;
- (B) Social security taxes and/or other required retirement deductions;
- (C) Union or employee association dues;
- (D) Court ordered alimony and child support payments.
- (iv) Allow minimum living allowances for:
- (A) The resident's personal support per the schedule established by the state institution;
- (B) The resident's spouse, parent and other legal dependent's supported in the home per the schedule established by the state institution.
- (v) Allow any applicable exemptions based upon the resident's needs and the institution's services. Exemptions may not exceed five times the Medicaid resource limit.
- (vi) Determine the legally responsible person's ability to pay charges based on available income, assets, deductions and exemptions;
- (vii) Obtain an assignment of benefits from the legally responsible person who has the insurance coverage;
- (viii) Established charges shall be actual costs in the following situations:
- (A) If a legally responsible person submits claims directly to the third party payor in lieu of assigning benefits to the institution; or
- (B) If the party payor is obligated by law or contract to pay full actual costs for services provided to a resident admitted to an institution;
- (C) If the legally responsible person fails to submit a financial questionnaire.
- (ix) Revise the established charge upon the annual promulgation of actual costs or if a change occurs in the resident's financial status;
- (x) Review the established charge and ability to pay on an annual basis;
- (xi) Refer any payor's protest of the established charge to the agency in accordance with W.S. W.S. W.S. 25-11-103(b);
- (xii) Submit established charges to the administrator or his designee for approval.