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(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 (c) Repealed by Laws 1994, ch. 73, § 3.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.
Propose a changeA cost deduction, cost sharing or other similar charge shall not be imposed upon any recipient of medical assistance for inpatient hospital services provided on his behalf pursuant to this chapter.
Propose a change(a) Repealed by Laws 2019, ch. 96, § 3. (b) Repealed by Laws 2019, ch. 96, § 3.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 (d) Repealed by Laws 2019, ch. 96, § 3. (e) Repealed by Laws 2019, ch. 96, § 3.
Propose a change(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.
Propose a change(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.
Propose a changeThe department may enter into a cooperative agreement and may contract with private attorneys to provide legal services and legal representation necessary to assist the department in enforcing its right to reimbursement created under article 2 of this chapter. The department and its contract attorneys shall have an unconditional right to intervene in any action by or on behalf of a recipient or former recipient against any third party who may be legally liable to reimburse any medical assistance provided under the Wyoming Medicaid program. If no action has been brought, the department and its contract attorneys may initiate and prosecute an independent action on behalf of the department against any third party that may be liable to the person to whom the care was furnished. If the department elects not to contract with private attorneys to provide legal services and representation under this section, the attorney general, or an appropriate county attorney, shall provide the legal services and representation.
Propose a change(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.
Propose a change(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.
Propose a change(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.
Propose a changeeligibility criteria; benefits provided; coverage of medications. (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.
Propose a change(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).
Propose a changedepartment; emergency case services; cost based payments; training and certification of specialists. (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.
Propose a change(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.
Propose a change(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.
Propose a changeRepealed by Laws 2019, ch. 189, § 2.
Propose a change(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.
Propose a change(a) If a person who is or becomes an applicant or recipient for medical assistance under this chapter receives an injury under circumstances creating a legal liability in some third party, the applicant or recipient shall not be deprived of any medical assistance for which he is entitled under this chapter. He may also pursue his remedy at law against the third party. If the applicant or recipient recovers from the third party in any manner, including judgment, compromise, settlement or release, the state is entitled to be reimbursed for all payments made, or to be made, on behalf of the applicant or recipient under this chapter. (b) The department shall be served by certified mail, return receipt requested, with a copy of the complaint within seven (7) days of its filing in any suit initiated pursuant to subsection (a) of this section. Any attorney who knowingly fails to serve the complaint on the department shall be reported to the state board of professional responsibility for the Wyoming state bar. The department shall be notified in writing by certified mail return receipt requested of any judgment, compromise, settlement or release entered into by any person who has been an applicant for or recipient of medical assistance under this chapter after the date of injury. If there is a settlement, compromise or release entered into by the parties the attorney general representing the director shall be made a party in all negotiations for settlement, compromise or release. The department, for purposes of facilitating compromise and settlement, may in a proper case authorize acceptance by the state of less than the state's claim for reimbursement under this section for all current and future assistance under this chapter. Any reimbursement right created pursuant to this article shall remain in effect until the state is paid the amount authorized under this section. In addition the person paying the settlement remains liable to the state's reimbursement right unless the state through the attorney general signs the release prior to payment of an agreed settlement. (c) If the injury causes death of the recipient, the rights and remedies in this section inure to, and the obligations are binding upon the personal representative of the deceased recipient for the benefit of his dependents. (d) Repealed By Laws 2002, Ch. 39, § 2. (e) If, after notice is provided in accordance with this section, the department states in writing that it will neither file an independent action nor intervene in an existing action as allowed by W.S. 42-4-114, the department's reimbursement right shall be reduced by not more than thirty-three percent (33%) for attorney's fees together with the amount of its proportionate share of costs. If the department does not provide this written statement, its right to reimbursement shall not be reduced by any share of the recipient's attorney's fees or costs.
Propose a change(a) When the department provides, pays for or becomes liable for medical care, it shall have a lien for the cost of the medical assistance provided upon any and all causes of action which accrue to the person to whom the care was furnished, or to the person's legal representatives, as a result of the injuries which necessitated the medical care. (b) The department may perfect and enforce its lien by following the procedures set forth in W.S. 29-1-312 and 29-1-313, and its verified lien statement shall be filed with the appropriate clerk in the county of financial responsibility. The verified lien statement shall contain the following: (i) The name and address of the person to whom medical care was furnished; (ii) The date of injury; (iii) The name and address of the vendor or vendors furnishing medical care; (iv) The dates of the service; (v) The amount claimed to be due for the care; (vi) To the best of the department's knowledge, the names and addresses of all persons, firms or corporations claimed to be liable for damages arising from injuries. (c) This section shall not affect the priority of any attorney's lien. The department shall not be subject to any limitations period referred to in title 1 or 29 of the Wyoming statutes to file its verified lien statement. (d) The department shall be given notice of monetary claims against a person, firm or corporation that may be liable to pay part or all of the cost of medical care when the department has paid or become liable for the cost of that care. Notice shall be given as follows: (i) Applicants for medical assistance shall notify the state or local agency of any possible claims when they submit the application. Recipients of medical assistance shall notify the department of any possible claims when those claims arise. A recipient's noncooperation in providing information to the department to assist in pursuing liable third parties shall result in denial or termination of eligibility per federal law; (ii) An enrolled medicaid provider shall notify the department when the person has reason to believe that a third party may be liable for payment of the cost of medical care. If the person providing medical care services fails to notify the department when a third party is liable for payment of the cost of medical care and the department, because of lack of notice from the provider, does not receive reimbursement for the cost of medical care, the department may adjust the value of those claims from future payments to that provider; (iii) An attorney representing an applicant for or a recipient of medical assistance in a claim upon which the department may have a reimbursement right under this chapter shall notify the department of its potential claim for reimbursement before filing a claim, commencing an action, or negotiating a settlement. Any attorney who fails to notify the department of any settlement or fails to ensure the state is reimbursed, to the extent of its reimbursement right, from the proceeds of any settlement or judgment under this section shall be reported to the state board of professional responsibility for the Wyoming state bar. If the attorney knowingly failed to report and insure reimbursement to the state, the department shall have a claim for relief against the attorney for the amount of the reimbursement right under this chapter; (iv) Insurers shall not disburse any settlement payment for a personal injury claim made to a recipient of medical assistance under this act until seven (7) working days after the department has received written notice from the insurer of the proposed settlement or judgment and failed to provide a written objection to the insurer. Failure to provide notice under this paragraph shall commence the tolling of any applicable statute of limitations. (e) Notice given to the local agency is not sufficient to meet the requirements of paragraphs (d)(ii) through (iv) of this section. (f) Repealed By Laws 1999, ch. 125, § 2.
Propose a change(a) No settlement made by and between the applicant or recipient and the tortfeasor or insurer shall discharge the right to reimbursement created pursuant to this article, against any money due or owing by such tortfeasor or insurer to the applicant or recipient or relieve the tortfeasor or insurer from liability by reason of the right to reimbursement unless the settlement also provides for the payment and discharge of the right to reimbursement and the attorney general has signed a written release as provided by W.S. 42-4-201(b). (i) Repealed By Laws 2002, Ch. 39, § 2. (ii) Repealed By Laws 2002, Ch. 39, § 2.
Propose a changeapplicant or recipient; utilization of personal health insurance; insurance coverage of recipients. (a) The department shall be subrogated to any right of recovery or indemnification arising from an accident or occurrence resulting in expenditures by the department, which an applicant or recipient of medical assistance or any legally liable party has against an insurer, health insurer, self-insured plan, group health plan, service benefit plan, managed care organization, pharmacy benefit manager or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for health care items or services, including but not limited to hospitalization, pharmaceutical services, physician services, nursing services and other medical services, not to exceed the amount expended by the department for the care and treatment of the applicant or recipient. An applicant or recipient or legally liable party, by the act of applying for, or recipient receiving medical assistance, shall be deemed to have made a subrogation assignment and an assignment of claim for benefits to the department. The department shall inform an applicant of the assignments at the time of application. In addition, any entitlements from a contractual agreement with an applicant or recipient or legally liable party, a state or federal program or a claim or action against any responsible third party for medical services, not to exceed the amount expended by the department, shall be so assigned. The entitlements shall be directly reimbursable to the department by third party payors. The department may assign its right to subrogation or its entitlement to benefits to a designee or a health care provider participating in the medicaid program and providing services to an applicant or recipient, in order to assist the provider in obtaining payment for the services. A provider that has received an assignment from the department shall notify the insurer of the assignment upon rendering of services to the applicant or recipient. Failure to so notify the insurer shall render the provider ineligible for payment from the department. Once the insurer has been billed or notified the provider may not request payment through the medicaid program until a payment, denial or other explanation of benefits, not including mistakes in billing, is received from the insurer. The provider shall notify the department of any request by the applicant or recipient or his legally liable party or representative for billing information. (b) When a recipient of medical assistance has access to personal health insurance through his employer, payment or part payment of the premium for the insurance may be made by the department when deemed appropriate by the director of the department. (c) No individual accident policy, group accident policy, health policy, accident and health policy, medical expense policy or medical service plan contract, delivered, issued for delivery or renewed in this state on or after July 1, 1995, and no self-insured plan, managed care policy or plan, pharmacy benefit management plan or policy or other policy or plan issued by any other party that is, by statute, contract or agreement legally responsible for payment of a claim for items or services, delivered, issued for delivery or renewed in this state on or after July 1, 2007, shall contain any provision denying or limiting insurance benefits because services are rendered to an insured who is eligible for or who received medical assistance under this chapter. This section shall supersede any statutory provision to the contrary. No such policy, plan or contract, when enrolling an individual, shall take into account the individual's eligibility for medical assistance under this chapter. This subsection applies to all such policies, plans and contracts issued by any person including, but not limited to: (i) An insurer; (ii) A group health plan as defined in section 607(1) of the Employee Retirement Income Security Act of 1974; (iii) A managed care organization, pharmacy benefit manager or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service; (iv) An entity offering a service benefit plan; (v) A self-insured plan. (d) Medicaid shall not pay for any services provided under this chapter if the individual eligible for medical assistance has coverage for the services under an accident or health insurance policy or other source. (e) In addition to the separate requirements set forth in W.S. 42-4-205, all health insurers, including all self-insured plans, group health plans as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service, shall agree, as a condition of doing business in the state of Wyoming, to: (i) Provide, with respect to the individuals who are eligible for or are provided medical assistance by the department of health, information to determine the period during which the individual or the individuals' spouses or dependents may be or may have been covered by a health insurer and the nature of the coverage provided, including the name and address of the insurer and identifying number of the plan, in a manner prescribed by the secretary; (ii) Accept the state's right of recovery and the assignment to the state of any right of an individual or other entity to payment from another party for an item or service for which payment has been made under the state plan; (iii) Respond within sixty (60) days to any inquiry by the state regarding a claim for payment for any health care item or service that is submitted not later than three (3) years after the date of the provision of such health care item or service; and (iv) Agree not to deny a claim submitted by the state solely on the basis of the date of submission of the claim, the type or format of the claim form, a failure to obtain required prior authorization or a failure to present proper documentation at the point of sale that is the basis of the claim, if: (A) The claim is submitted by the state within the three (3) year period beginning on the date on which the item or service was furnished; and (B) Any action by the state to enforce its rights with respect to the claim is commenced within six (6) years of the state's submission of the claim.
Propose a change(a) With respect to cases for which there is an assignment in effect pursuant to W.S. 42-4-204: (i) The department, upon receipt of the health coverage information, shall notify the obligor's insuring entity that the department shall be notified thirty (30) days prior to discontinuance of coverage; (ii) Entities providing health insurance as defined in title 26 and health maintenance organizations and prepaid health clinics as defined in W.S. 26-34-102 shall upon request by the department, provide a list of insureds residing in the state and any records and information as necessary to accomplish the purpose of this section, unless the requirement results in an unreasonable burden; (iii) The department and the insurance commissioner appointed pursuant to W.S. 26-2-102 shall enter into a cooperative agreement for requesting and obtaining information necessary to effect the purpose and objectives of this section; (iv) The department shall only request information from the entity providing health insurance necessary to determine whether health insurance, as defined pursuant to title 26 or those health services provided pursuant to W.S. 26-34-102, are discontinued; (v) The department, in consultation with the department of insurance, shall promulgate rules for the development and administration of the cooperative agreement. The rules shall include the following: (A) A method for identifying those entities subject to furnishing information under the cooperative agreement; (B) A method for furnishing requested information; and (C) Procedures for requesting exemption from the cooperative agreement based on an unreasonable burden to the reporting entity. (vi) If the department notifies the insurer that it has made payments to the provider, payment of benefits or notices of denial issued by the insurer shall be made directly to the department. (b) Upon the department receiving notice from the obligor's insuring entity that the coverage is discontinued due to cancellation for any reasons, the department shall retain that information for use in enforcing any court order requiring the obligor to provide health insurance to the individuals stated in the court order.
Propose a change(a) If an individual receives any medical assistance pursuant to this chapter, upon the individual's death, if single, or upon the death of the survivor of a married couple, either of whom received medical assistance, the total amount paid for medical assistance rendered for the individual or the spouse shall be filed by the department of health as a claim against the estate of the individual or the estate of the surviving spouse in the court having jurisdiction to probate the estate. A claim shall be filed if medical assistance was rendered for either person under one (1) of the following circumstances: (i) The person was fifty-five (55) years of age or older when he received medical assistance; or (ii) The person was an inpatient in a nursing facility, intermediate care facility for people with intellectual disability or other medical institution when he received medical assistance. (b) The claim shall be considered an expense of the last illness of the decedent. Any statute of limitations which attempts to limit the department of health to recover for medical assistance provided pursuant to this chapter shall not apply to any claim made under this section for reimbursement for the medical assistance. (c) The claim shall include only the total amount of medical assistance rendered after the individual attains fifty-five (55) years of age or during a period of institutionalization as described in paragraph (a)(ii) of this section, and shall not include interest. A claim for medical assistance rendered for the predeceased spouse, against the estate of a surviving spouse who did not receive medical assistance, is limited to the value of the assets of the estate that were marital property or jointly owned property at any time during the marriage. (d) If a decedent who was single, or who was the surviving spouse of a married couple, is survived by a child who has not attained twenty-one (21) years of age or is blind or permanently and totally disabled as defined by 42 U.S.C. § 1382c, no claim shall be filed against the estate. (e) Repealed By Laws 2002, Ch. 39, § 2. (f) The department of health shall establish procedures, in accordance with standards specified by the secretary of health and human services, under which the department of health shall waive the application of this section if application would work an undue hardship on the basis of criteria established by the secretary. (g) As used in this section: (i) "Asset" means as defined under W.S. 42-2-401(a)(i); (ii) "Estate" shall include all real and personal property and other assets included within the individual's estate, as defined for purposes of this state's probate law, and includes any other real and personal property and other assets in which the individual had any legal title or interest at the time of death to the extent of that interest, including such assets conveyed to a survivor, heir or assign of the deceased individual through joint tenancy, tenancy in common, survivorship, life estate, living trust or other arrangement.
Propose a change(a) The department may through appropriate action recover any incorrect payment of medical assistance under this chapter on behalf of a recipient and may adjust any subsequent payment by an amount equal to the incorrect payment. Any recovery shall be prorated to the federal government in proportion to the amount it contributed for medical assistance rendered. (b) In addition to subsection (a) of this section and subject to a court order for recovery, the department may file a lien upon all real and personal property of the recipient for the incorrect payment of medical assistance on his behalf. (c) The department may file a pre-death lien upon real property of an individual for medical assistance correctly paid under this chapter to an individual: (i) Who is an inpatient in a nursing facility, intermediate care facility for people with intellectual disability, or other medical institution; and (ii) With respect to whom the department determines, after notice and opportunity for a hearing, cannot reasonably be expected to be discharged from the medical institution and to return home. (d) No lien may be imposed under subsection (c) of this section on an individual's home if any of the following persons are lawfully residing in the home: (i) The spouse of the individual; (ii) The individual's child who is under age twenty-one (21), or is blind or disabled as defined in 42 U.S.C. 1382c; or (iii) A sibling of the individual, who has an equity interest in the home and who was residing in the home for a period of at least one (1) year immediately before the date of the individual's admission to the medical institution. (e) No lien imposed under subsection (c) of this section shall be subject to recovery if any of the following persons are lawfully residing in the home on a continuous basis since the date of the individual's admission to the facility or institution: (i) A sibling of the individual who was residing in the individual's home for a period of at least one (1) year immediately before the date of the individual's admission to the facility or institution; (ii) A child of the individual who was residing in the individual's home for a period of at least two (2) years immediately before the date of the individual's admission to the facility or institution, and who establishes by a preponderance of the evidence that he provided care to the individual which permitted the individual to reside at home rather than in a facility or institution. (f) Any lien imposed with respect to an individual pursuant to subsection (c) of this section shall dissolve upon that individual's discharge from the medical institution and return home. (g) Nothing in this section shall require an applicant for medical assistance under this chapter to enter into agreement for a lien upon his real and personal property for the payment of medical assistance on his behalf. (h) Upon sale of the property on which a lien has been imposed pursuant to subsection (c) or (j) of this section, the department shall seek recovery of the amount stated in its lien. Transfers of real or personal property on or after the look-back dates defined in 42 U.S.C. § 1396p by recipients of medical assistance under this chapter, or their spouses, without adequate consideration are voidable and may be set aside by an action in district court. (j) The department may file a lien against the property of any estate, as defined in W.S. 42-4-206(g), of a deceased recipient for the amount of medical assistance provided while the recipient was fifty-five (55) years of age or older or while the recipient was an inpatient in a nursing facility, intermediate care facility for people with intellectual disability or other medical institution. The department shall perfect this lien by filing a notice in the county in which the real property exists. The department may file an amended lien prior to the entry of the final order closing the estate. (k) The department may file a lien upon real property pursuant to W.S. 2-18-103(g) upon the death of the grantor. The department may file such lien regardless of whether the grantee applied for a certificate of clearance pursuant to W.S. 2-18-103(n) or filed an affidavit to establish the death of the grantor pursuant to W.S. 34-11-101.
Propose a change(a) The department, to the extent necessary to reimburse its costs, shall be entitled to recover from any parent who: (i) Is required by court or administrative order to provide coverage of the cost of health services to a child eligible for medical assistance under this act; and (ii) Has received payment from a third party for the costs of such services but has not used the payments to reimburse either the other parent or guardian of the child or the provider of the services. (b) The department shall be entitled to enforce any judgment entered pursuant to this section by garnishment or any other available statutory remedy. (c) Claims for current and past due child support shall take priority over claims made under this section.
Propose a changeThis act shall be known and may be cited as the "Wyoming Medicaid False Claims Act."
Propose a change(a) As used in this act: (i) "Claim" means any request or demand under the Medicaid program, whether under a contract or otherwise, for money, property or services that: (A) Is presented to an officer, employee or agent of the state or a political subdivision of the state; or (B) Is made to a contractor, grantee or other recipient, if the money or property is to be spent or used on the state's behalf or to advance a state program or interest, and if the state provides or has provided any portion of the money or property requested or demanded. (ii) "Material statement" means a statement that affects the payment or receipt of money or property; (iii) "This act" means W.S. 42-4-301 through 42-4-306.
Propose a change(a) Except as provided in subsection (c) of this section, any person who commits any of the following acts in relation to the Wyoming Medicaid program shall be liable to the state for three (3) times the amount of damages which the state sustains because of the act of that person. A person who commits any of the following acts shall also be liable to the state for the costs of a civil action brought to recover any penalties or damages provided in this subsection, and shall be liable to the state for a civil penalty of not less than one thousand dollars ($1,000.00) and not more than ten thousand dollars ($10,000.00) for each violation: (i) Knowingly presents or causes to be presented a false or fraudulent claim for payment or approval; (ii) Knowingly makes, uses or causes to be made or used, a false record or statement material to a false or fraudulent claim; (iii) Is a beneficiary of an inadvertent submission of a false claim to any employee, officer or agent of the state or a political subdivision of the state, or to any contractor, grantee or other recipient of state funds or funds of any political subdivision of the state, who subsequently discovers the falsity of the claim and fails to disclose the false claim and make satisfactory arrangements for repayment to the state or affected political subdivision within ninety (90) days after discovery of the false claim; (iv) Conspires to commit a violation of paragraph (i), (ii) or (iii) of this subsection. (b) Notwithstanding subsection (a) of this section, the court may assess not more than two (2) times the amount of damages which the state sustains because of the act in violation of subsection (a) of this section, and no civil penalty, if the court finds all of the following: (i) The person committing the violation furnished officials of the state who are responsible for investigating false claims violations with all information known to that person about the violation within forty-five (45) days after the information is requested; and (ii) The person has substantially cooperated with any investigation by the state. (c) The provisions of subsections (a) and (b) of this section shall not apply to a recipient as defined by W.S. 42-1-101(a)(v). Any recipient who knowingly: (i) Presents or causes to be presented a false or fraudulent claim shall be liable to the state for the amount of damages which the state sustains because of the claim and shall be liable for a civil penalty of not more than one thousand dollars ($1,000.00); (ii) Violates paragraph (i) of this subsection a second or subsequent time shall be liable to the state for three (3) times the amount of damages which the state sustains because of the claim and shall be liable for a civil penalty of not more than one thousand dollars ($1,000.00).
Propose a changeprosecuting authority; remedies for retaliation; venue; no private right of action. (a) The Medicaid fraud control unit created by W.S. 42-4-403 or a district attorney may investigate alleged violations of W.S. 42-4-303(a) and (c). If the Medicaid fraud control unit or district attorney finds that a person has violated or is violating W.S. 42-4-303(a) or (c), the unit or district attorney may bring a civil action under this section against that person. (b) Any employee, contractor or agent of a person being investigated for a violation of W.S. 42-4-303(a) shall be entitled to recover all economic damages suffered if that employee, contractor or agent is discharged, demoted, suspended, threatened, harassed or in any other manner retaliated against in the terms and conditions of employment because of lawful acts taken in good faith by the employee or others in an action reported, filed or investigated under this act. An action by an employee, contractor or agent under this subsection shall not be brought more than three (3) years after the date when the retaliation occurred. A person may bring an action in the appropriate district court for the relief provided in this subsection. This subsection shall not otherwise be construed to create a private cause of action for violations of this act and is limited to the remedies expressly created by this subsection related to employment retaliation. (c) Except as provided in subsection (b) of this section, any action under this act may be brought in the district court of any county in which the defendant, or any of them, resides. If the defendant is not a resident of the state of Wyoming, the action shall be brought in the first judicial district court in Laramie County. (d) Except as provided in subsection (b) of this section, nothing in this act shall be construed to create a private cause of action. (e) The remedies provided in this act are separate from and additional to any remedies available under the State Government Fraud Reduction Act.
Propose a change(a) A civil action under W.S. 42-4-304(a) shall not be brought more than six (6) years after the date on which the violation was committed or more than three (3) years after the date when facts material to the right of action are known or reasonably should have been known by the official of the state charged with responsibility to act in the circumstances, whichever occurs last, provided that in no event shall a civil action be brought more than seven (7) years after the date on which the violation is committed. (b) In any action brought under W.S. 42-4-304(a), the state shall be required to prove all essential elements of the cause of action, including damages, by clear and convincing evidence. (c) Notwithstanding any other provision of law, a guilty verdict rendered in a criminal proceeding charging false statements or fraud is admissible in any civil action which involves the same transaction as in the criminal proceeding and which is brought under W.S. 42-4-304.
Propose a change(a) The provisions of this act are not exclusive, and the remedies provided for in this act shall be in addition to any other remedies provided for in any other law or available under common law. (b) Liability pursuant to this act is joint and several for any violation done by two (2) or more persons.
Propose a changeThis act may be cited as the "Wyoming Medicaid Fraud Control Act".
Propose a change(a) As used in this act: (i) "Claim" means as defined in W.S. 42-4-302(a)(i); (ii) "Provider" means a person who furnishes services or supplies for which payment is claimed under Medicaid; (iii) "Record" means information in physical or electronic form relating to: (A) The treatment or care of any patient; (B) A service or supply provided to a Medicaid recipient; (C) Rates paid for a service or supply; (D) Any other information required to be kept by rule of the Medicaid program. (iv) "Unit" means the Medicaid fraud control unit created by this act to investigate and prosecute fraud, waste, abuse, bribery, kickback and related cases under Medicaid; (v) "This act" means W.S. 42-4-401 through 42-4-412.
Propose a change(a) The Medicaid fraud control unit is recognized and continued in existence within the office of the attorney general. The unit shall conduct a statewide program for investigating and prosecuting violations of all applicable state laws pertaining to fraud in the administration of the Medicaid program and the provision of services or supplies, or the activities of providers of services or supplies, under the state Medicaid plan. The unit may also conduct criminal investigations and prosecutions relating to patient abuse, neglect, exploitation and other violations of law, if the violation is primarily connected to Medicaid. (b) The office of the attorney general shall employ attorneys, auditors, agents and other personnel which are necessary to carry out the duties specified in this act in an effective and efficient manner. Agents employed under this subsection shall have the qualifications and powers of an agent under W.S. 9-1-611(b)(i). (c) The unit may file criminal charges without consultation with another person or entity outside the office of the attorney general. Before the filing of criminal charges under this act, the unit may consult with the district attorney of the judicial district in which the prosecution would take place. If the district attorney, after consultation, concurs with the decision to file criminal charges, the unit may refer the case to the district attorney. A district attorney may request that the unit assign an attorney to assist with prosecution under this act.
Propose a change(a) Notwithstanding any other provision of law, the unit shall have full access to all records held by a provider or by another person or entity acting on the provider's behalf, if the unit determines that such information is material to its duties under this act. A provider, or another person or entity acting on the provider's behalf, shall promptly comply with a request from the unit for access to records. (b) The unit shall avoid disclosure of personally identifiable information concerning any patient received in the course of an investigation, except as authorized by this section. The unit may transmit personally identifiable information to authorized persons, consistent with federal law, including governmental entities responsible for oversight of the health care system, benefit programs or the regulation of health care facilities or health care providers. The unit may also disclose information under this section as otherwise permitted or required by law. (c) No provider or other person or entity holding records required to be made available to the unit under this section may refuse to provide access on the basis that release would violate any right of privacy, privilege against disclosure or use or any other grounds for nondisclosure. (d) Nothing in this section shall be interpreted to limit the authority of the unit to use other legal processes to conduct investigations and prosecutions authorized by this act or other provisions of law.
Propose a changeThe department of health, department of family services, health care licensing boards, state agencies and the agents, contractors and subcontractors of these entities shall refer to the unit all cases where reasonable cause likely exists that fraud, waste, abuse, bribery or kickbacks relating to Medicaid has occurred, is occurring or will occur, as well as suspected cases of patient abuse, neglect or exploitation under Medicaid.
Propose a change(a) In relation to the delivery of or payment for services or supplies under Medicaid, a person shall not knowingly, in whole or in part: (i) Make or cause to be made a false or fraudulent claim; (ii) Deliberately conceal a material fact; (iii) Make or cause to be made a false statement or misrepresentation which will be used by another person; (iv) Execute a scheme or artifice to commit fraud. (b) A person who violates subsection (a) of this section is guilty of: (i) A misdemeanor punishable by imprisonment of not more than six (6) months, a fine of not more than seven hundred fifty dollars ($750.00), or both, if the amount of the claims for services or supplies under Medicaid is less than one thousand dollars ($1,000.00); or (ii) A felony punishable by imprisonment for not more than ten (10) years, a fine of not more than ten thousand dollars ($10,000.00), or both, if the amount of the claims for services or supplies under Medicaid is one thousand dollars ($1,000.00) or more. (c) The department of health shall ensure that the following documents contain a statement, under penalty of perjury and signed by the responsible provider, that all matters stated therein are true and accurate: (i) An application to become a Medicaid provider; (ii) All reports stating income or expenses upon which rates of payment by the department of health may be based; and (iii) Each invoice for payment of a service or supply provided to a person eligible for Medicaid. (d) A person commits perjury if the person signs or submits, or causes to be signed or submitted a statement under subsection (c) of this section, knowing that the application, report or invoice contains information that is false, in whole or in part. Perjury under this subsection shall be punished as specified in W.S. 6-5-301(b).
Propose a changereferral fees and illegal copayments; criminal penalty; exception. (a) A person shall not knowingly, in whole or in part: (i) Act on behalf of a provider to purchase or lease a service or supply for which payment may be made, in whole or in part, under Medicaid and then solicit or accept anything of additional value in connection with the purchase or lease; (ii) Sell or lease to a provider a service or supply for which payment may be made, in whole or in part, under Medicaid, and offer, transfer or pay anything of additional value in connection with the sale or lease; (iii) Refer an individual to a provider for the provision of a service or supply for which payment may be made, in whole or in part, under Medicaid, and solicit or accept anything of value in connection with the referral; (iv) Act on behalf of a provider to charge, solicit, accept or receive anything of value in addition to the amount payable for a service or supply under Medicaid. (b) A violation of subsection (a) of this section is a felony punishable by imprisonment of not more than five (5) years, a fine of not more than ten thousand dollars ($10,000.00), or both. (c) A person does not commit a violation of paragraph (a)(i) or (ii) of this section in cases where the additional value transferred is a refund or discount made in the ordinary course of business and is reflected by the records of the person within a reasonable period of time after the transfer of value.
Propose a change(a) A person, after submitting a claim or receiving a payment for a service or supply under Medicaid, shall not knowingly fail to maintain records required under Medicaid, including records that fully disclose the nature of the services or supplies provided to a recipient. (b) A person who violates subsection (a) of this section is guilty of: (i) A misdemeanor punishable by imprisonment for not more than thirty (30) days, a fine of not more than seven hundred fifty dollars ($750.00), or both, if: (A) The claims for which records were not maintained are less than twenty-five percent (25%) of the Medicaid claims submitted by the provider in any consecutive three (3) month period; and (B) The amount of the claims for which records were not maintained is five thousand dollars ($5,000.00) or more. (ii) A misdemeanor punishable by imprisonment for not more than six (6) months, a fine of not more than one thousand dollars ($1,000.00), or both, if: (A) The claims for which records were not maintained are twenty-five percent (25%) or more of the Medicaid claims submitted by the provider in any consecutive three (3) month period; and (B) The amount of the claims for which records were not maintained is five thousand dollars ($5,000.00) or more. (iii) A felony punishable by imprisonment for not more than five (5) years, a fine of not more than ten thousand dollars ($10,000.00), or both, if: (A) The person intended to defraud Medicaid and the claims for which records were not maintained are twenty-five percent (25%) or more of the Medicaid claims submitted by the provider in any consecutive three (3) month period; and (B) The amount of the claims for which records were not maintained is five thousand dollars ($5,000.00) or more.
Propose a changeThe amount of claims relating to violations of this act through a common scheme, or based on the same transaction or occurrence, may be aggregated to determine the level of penalty under this act, whether or not the claims were made as part of the same claim under Medicaid.
Propose a change(a) The department of health or the department of family services may suspend or exclude a provider from providing services and supplies under Medicaid if: (i) The department determines that the provider has committed an offense under this act or the Wyoming Medicaid False Claims Act, whether or not a criminal prosecution is brought under this act or any civil action is brought under the Wyoming Medicaid False Claims Act; or (ii) A provider fails to provide the unit with access to records pursuant to W.S. 42-4-404(a). (b) Any term of suspension or exclusion under this section, which may be permanent, shall be determined by the department of health or the department of family services. (c) The department of health and the department of family services may adopt rules necessary to implement this section.
Propose a change