048-35 Wyo. Code R. § 35-10

Current through April 27, 2019

Section 35-10 - Medicaid Third Party Liability Recovery

(a) The Department may not agree to a settlement which involves the compromise or release of any portion of the federal medical assistance percentage, except as allowed by federal law.

(b) Amount of the Department's recovery. The Department may recover from any settlement or judgment involving a third party payer the full amount of Medicaid funds paid or to be paid on behalf of the client because of the injury, illness, or disability for which such payments were made.

• (i) If the Department does not file an independent action or intervene in an existing action, the Department shall calculate its reduced lien by deducting:
  • (A) Thirty-three percent (33%) for attorney's fees; and
  • (B) A proportionate share of the reasonable attorney's costs incurred in obtaining the client's recovery.
    • (I) The Department's proportionate share of the reasonable costs incurred in making the client's recovery shall be determined by:
      • (1.) Dividing the amount of the Department's recovery (the amount of Medicaid benefits reimbursed minus attorney's fees as provided in this Section) by the amount of the client's gross recovery; and
      • (2.) Multiplying the determined fraction by the reasonable costs incurred in making the recovery.
    • (II) For purposes of this section, "the reasonable attorney's costs incurred in making the client's recovery" shall be court costs, costs of litigation, travel costs, expert witness fees, deposition expenses, and any other costs necessarily incurred in making the recovery. Reasonable costs shall be in the sole discretion of the Department and shall not include any items for which the client is not also responsible.

• (ii) The Department may consider the cost-effectiveness of reducing its claim for reimbursement after evaluating all relevant factors, including:
  • (A) Available insurance coverage or other factors relating to the assets or solvency of the liable third party;
  • (B) Factual and legal issues pertaining to liability;
  • (C) Legal issues or restrictions on the Department's recovery, including problems of proof affecting the ability to obtain settlement or judgment and;
  • (D) Estimated fees and costs associated with the Department pursuing its claim.

(c) Structured settlements. A client's recovery shall not be placed in a structured settlement until the Department has been reimbursed and issued a release of its reimbursement right. If a client prematurely enters into a structured settlement under which the initial payment to the client is insufficient to reimburse the Department, the client shall pay the Department all funds received in each installment until the Department is paid in full. All structured settlements shall fully comply with the requirements pertaining to annuities under the Department's rules.

(d) Future Medicaid payments. Except as otherwise agreed, the settlement of a client's claim does not preclude the Department from seeking Medicaid benefit recovery for Medicaid payments made after the date of such settlement.

(e) The Department shall have the right to recover directly from a third party payer to the extent of Medicaid funds paid or to be paid on behalf of a client when the existence and extent of liability of such third party payer is established. In situations where a Medicaid client was not represented by legal counsel, an attorney representing an insurance company shall not disburse any insurance proceeds to the Medicaid client prior to submitting a statement of available proceeds (declaration sheet), payment to the Department, and approval by the Department.

(f) The Department shall have the right to recover from any attorney who knowingly fails to notify the Department of any settlement of judgment or fails to ensure the Department is reimbursed to the extent of its reimbursement right.

(g) The Department shall have the right to recover directly from a provider which has received Medicaid funds paid on behalf of a client to the extent the provider has received payments from a third party payer for the same services.

(h) The Department shall have the right to recover from any attorney who knowingly fails to notify the Department of any settlement or judgment or fails to ensure the Department is reimbursed to the extent of its reimbursement right.

048-35 Wyo. Code R. § 35-10

Amended, Eff. 2/19/2019.