(a) Eligibility under this Chapter is limited to persons who complete the application process and who meet the following requirements for clinical eligibility and financial eligibility. In addition, in order to be eligible for the waiver, all persons shall be: - (i) A United States Citizen as determined by the Department of Family Services.
- (ii) A resident of Wyoming as determined by the Department of Family Services.
- (iii) Under 21 years of age.
(b) Clinical eligibility criteria. An applicant is considered clinically eligible if he or she has: - (i) A diagnosis of mental retardation as determined by a psychologist, or
- (ii) A diagnosis of a related condition as determined by a physician and functional limitations verified by a psychologist, and
- (iii) An Inventory for Client and Agency Planning (ICAP) age adjusted services score equal to or less than 70, or
- (iv) An adaptive behavior quotient of 0.50 or below for children birth through age 5, or
- (v) An adaptive behavior quotient of 0.70 or below for individuals age 6 through age 20, and
- (vi) A completed LT-MR-104 that verifies that the participant or applicant meets the ICF/MR level of care.
(c) Financial eligibility. Eligibility for covered services is limited to persons who meet the income and resource criteria set forth in the waiver and in the rules and policies of the Wyoming Medicaid program, as determined by the Department of Family Services.
(d) Application process. - (i) A completed application on a form required by the Division shall be submitted to the Division.
- (A) An application is valid for one year. After that time, if necessary documentation has not been received so that the Division can determine clinical eligibility, the applicant shall be required to re-apply.
- (B) Once an applicant has been determined to be clinically eligible and has been placed on a wait list, he/she does not need to re-apply.
- (ii) Selection of individually-selected service coordinator.
- (A) After an applicant requests services pursuant to this Chapter, the Division shall provide the applicant with a list of individually-selected service coordinators in the area(s) he or she wishes to receive services.
- (B) The applicant, family, or guardian shall select and meet with an individually-selected service coordinator from that list. Once both the applicant and the individually-selected service coordinator have agreed to work together, the individually-selected service coordinator shall notify the Division of that selection on a form designated by the Division.
(e) Determination of clinical eligibility. A person shall not receive covered services unless that person is clinically eligible. The determination of a person's clinical eligibility shall be made as follows: - (i) Psychological evaluation.
- (A) The applicant and the individually-selected service coordinator shall arrange for a psychological evaluation to determine whether the applicant has a diagnosis of mental retardation or a related condition.
- (B) If the applicant has a diagnosis of mental retardation or a related condition, he or she shall be further assessed pursuant to (ii)(B) of this Section to determine clinical eligibility.
- (C) The Division may obtain a second opinion on a psychological evaluation from a contracted expert in order to confirm or deny that an applicant has a related condition.
- (ii) Inventory for Client and Agency Planning.
- (A) An individual who has a diagnosis of mental retardation or related condition as determined by the psychological evaluation shall be assessed to determine his or her functional capacity.
- (B) Assessments shall be performed by a third party, under contract to the Division, who is qualified to perform such assessments using the Inventory for Client and Agency Planning (ICAP).
- (iii) LT-MR-104. The individually-selected service coordinator shall complete the LT-MR-104 that verifies that the participant or applicant meets the ICF/MR level of care.
(f) Notification of determination of clinical eligibility. - (i) The Division shall determine clinical eligibility within 60 calendar days of receipt of the psychological assessment. If additional data or review is needed to determine eligibility, the Division shall notify the applicant in writing that the process will take an additional 30 calendar days.
- (ii) If the applicant does not have a diagnosis of mental retardation or related condition, the applicant does not meet the clinical eligibility requirements.
- (iii) If an applicant does not meet the ICAP service score or adaptive behavior quotient, the applicant does not meet the clinical eligibility requirements.
- (iv) If the applicant does not meet the ICF/MR level of care as determined by the LT-MR-104, the applicant does not meet the clinical eligibility requirements.
- (A) If an applicant is determined not to meet clinical eligibility criteria, the applicant or the applicant's legal guardian shall be notified in writing within 15 business days.
- (B) An applicant determined to not meet clinical eligibility requirements, may appeal the decision pursuant to Chapter 1.
- (v) If an applicant is determined to be clinically eligible, the applicant or applicant's legal representative will be notified in writing that:
- (A) There is a funding opportunity available, or
- (B) There is not a funding opportunity available but the applicant is placed on the Division's waiting list, as specified in Section 13 of this Chapter.
- (vi) Once an individual is notified that there is a funding opportunity available, financial eligibility shall be determined by the Department of Family Services.
(g) Loss of eligibility. - (i) A participant shall be determined to no longer be eligible when the participant:
- (A) Does not meet clinical eligibility when re-tested, or
- (B) Does not meet financial eligibility requirements as determined by the Department of Family Services, or
- (C) Changes residence to another state, or
- (D) Turns 21 years of age.
- (ii) Services to a participant determined to not meet clinical eligibility requirements shall be terminated no more than 45 days after the determination is made.
- (A) If an applicant is determined not to meet clinical eligibility criteria, the applicant or the applicant's legal guardian shall be notified in writing within 15 business days.
- (B) A participant determined to not meet eligibility requirements may appeal the decision pursuant to Chapter 1.
- (iii) A participant may be denied waiver placement and may be required to reapply when the participant:
- (A) Voluntarily does not receive waiver services or case management services, which includes a monthly home visit at the residence of the child, for three consecutive months.
- (B) Is in a nursing home, hospital, or residential treatment facility for six consecutive months.
- (C) Is in an out-of-state placement for six consecutive months.
- (iv) Upon written notification of the denial of waiver placement:
- (A) The participant may submit, in writing, reasons why he/she should still be considered eligible for the services.
- (B) This request shall be reviewed by the Waiver Manager and the Division Administrator.
- (v) If the participant is determined not to be eligible for services due to one of the criteria in (iii) of this section, the participant or the participant's legal guardian shall be notified in writing within 15 business days.
- (A) The participant may appeal the decision pursuant to Chapter 1.
048-42 Wyo. Code R. § 42-6