(a) Eligibility under this Chapter is limited to persons who complete the application process and who meet the following requirements for clinical and financial eligibility. In order to be eligible for the Wyoming Medicaid Supports Waiver or Wyoming Medicaid Comprehensive Waiver, an individual shall meet all of the following criteria: - (i) All citizenship, residency, and financial eligibility requirements established in Chapter 18 of the Department of Health's Medicaid Rules;
- (ii) ICF/ID level of care, as measured by the LT-104; and
- (iii) One of the following clinical eligibility diagnoses:
- (A) A diagnosis of an intellectual disability, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), which is incorporated by reference. The diagnosis shall:
- (I) Be determined by a Medicaid enrolled clinical psychologist who is independent from the provider of waiver services and currently licensed in Wyoming,
- (II) Be verified in a written and signed psychological evaluation,
- (III) Reflect adaptive behavior scores as determined through standard measurement of adaptive behavior using a validated test of adaptive functioning such as the most current forms of the Vineland Adaptive Behavior Scales or Adaptive Behavior Assessment System, and
- (IV) For a child applicant who is old enough to take an Intelligence Quotient test, shall meet a qualifying clinical diagnosis like an adult. A child too young to complete an Intelligence Quotient test may meet the criteria of a developmental disability as described in subsection (B) through medical records of a related condition using a standardized test of development, such as the Bayley Scales of Infant and Toddler Development or other similar instrument.
- (B) A developmental disability or a related condition determined by a physician or independent psychologist currently licensed in Wyoming with verification in medical records or a written psychological evaluation which includes assessment scores. The evaluation or records shall identify a severe, chronic disability, which:
- (I) Manifested before the person turned age twenty-two;
- (II) Reflects the need for a combination and sequence of special services which are lifelong or of extended duration;
- (III) Is attributable to a mental or physical impairment, other than mental illness;
- (IV) Is likely to continue indefinitely;
- (V) Results in substantial functional limitations in three (3) or more of the following major life activity areas: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency; and
- (VI) For those with a diagnosis of Autism Spectrum Disorder, a current autism evaluation and severity rating shall be completed.
- (C) An Acquired Brain Injury (ABI), as defined by Chapter 1 of the Wyoming Medicaid Rules and meets the following criteria:
- (I) Is between the ages of twenty-one (21) and sixty-four (64), and
- (II) Meets at least one of the following evaluations to confirm the diagnosis:
- (1.) A score of 42 or more on the Mayo Portland Adaptability Inventory (MPAI),
- (2.) A score of 40 or less on the most current version of the California Verbal Learning Test Trials 1-5 T, or
- (3.) A score of 4 or more on the Supervision Rating Scale.
- (iv) If clinical eligibility is met, qualify on the Inventory for Client and Agency Planning (ICAP) assessment, as administered by the Division's designee, with one of the following:
- (A) If age twenty-one (21) or older,
- (I) A service score of 70 or less; or
- (II) At least three (3) significant functional limitations listed in the following sections of the ICAP: Personal Living domain, Social/Communication domain, Community Living domain, a diagnosis of an intellectual disability, or is non-ambulatory without assistance.
- (B) If age two (2) through twenty (20) with an ICAP service score between 30 and 70, respectively depending on age.
- (C) If age twenty (20) or below, the age adjusted ICAP service score shall be higher than the ICAP service score for his or her actual age and meet eligibility based on their Adaptive Behavior Quotient (ABQ):
- (I) For ages zero (0) through five (5), an adaptive behavior quotient of .50 or below; and
- (II) For individuals age six (6) through twenty (20), an adaptive behavior quotient of .70 or below.
(b) Diagnoses and assessments used to meet initial clinical eligibility shall be accurate and shall be completed within the past five (5) years. Any assessment or reassessment for eligibility is subject to review by the Division before acceptance, and may require additional evidence or verification.
(c) Case managers shall complete all eligibility paperwork within thirty (30) calendar days of being selected. Submitted paperwork shall be reviewed by the Division within thirty (30) calendar days of receipt.
(d) To be eligible for participation in the Comprehensive Waiver, an individual shall: - (i) Meet the clinical eligibility specified in this section and have a qualifying ICAP assessment;
- (ii) Have assessed service needs in excess of the established cost limit on the Supports Waiver; and
- (iii) Meet one of the following:
- (A) The emergency criteria as approved by the Extraordinary Care Committee (ECC); or
- (B) The criteria for reserved capacity as specified in Section 11(f) or (g) of this Chapter.
(e) Reassessments. - (i) A participant shall be reassessed for clinical eligibility at least annually or more frequently should a change in circumstances occur which requires a participant to receive a higher level of services or support to ensure the participant's health, safety, and welfare.
- (A) A subsequent psychological evaluation shall be prior authorized and be necessary due to the participant's change in condition or as determined by the Division.
- (B) Psychological reassessments shall be conducted by an entity without a conflict of interest to the providers chosen by the participant or legally authorized representative.
- (ii) The ICAP assessment shall be completed every five (5) years, or more frequently at the option of the Division, to provide continued verification that the participant meets waiver clinical eligibility.
- (iii) The Division may require other assessments to determine budget amounts or service authorization.
(f) Loss of eligibility. - (i) A participant shall be determined to have lost eligibility when the participant:
- (A) Does not meet clinical eligibility when re-assessed;
- (B) Does not meet financial eligibility; or
- (C) Changes residence to another state.
- (ii) The Division may terminate a participant's eligibility when the participant:
- (A) Voluntarily does not receive any waiver services for three (3) consecutive months;
- (B) Is in a nursing home, hospital, residential treatment facility, in-patient hospice, institution, or ICF/ID for thirty (30) or more calendar days;
- (C) 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
- (D) Chooses another waiver outside of the Comprehensive or Supports waiver.
- (iii) If the participant is determined not to be eligible for services due to one of the criteria in subsection (ii) of this Section, the participant or the participant's legally authorized representative shall be notified in writing within fifteen (15) calendar days.
- (iv) Notice of Ineligibility or Loss of Eligibility
- (A) The Division shall notify an applicant or participant, or legally authorized representative, in writing, of the determination of clinical ineligibility or termination of clinical eligibility within fifteen (15) calendar days of the determination or termination.
- (I) Upon written notification of ineligibility in the case of an applicant, or the loss of clinical eligibility in the case of a participant, 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 or loss of eligibility, 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 this written 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 a hearing within thirty (30) calendar days following the adverse reconsideration decision.
- (III) Requests for an administrative 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.
- (B) Upon notification from Wyoming Medicaid, the Division shall notify the applicant, participant, or legally authorized representative, in writing, of termination of financial eligibility within fifteen (15) calendar days.
- (v) An applicant who is determined ineligible, or a participant whose eligibility is terminated under this Section, may reapply at any time.
048-46 Wyo. Code R. § 46-5