(a) Eligibility shall be determined pursuant to Section 6 of this Chapter before an individualized budget amount is determined.
(b) Determination of the targeted individualized budget amount. - (i) The Division's methodology to determine the amount of Medicaid waiver funds that shall be available to a participant to meet his or her needs shall include the following factors:
- (A) The services the participant has received in the past or that are determined by projected services.
- (B) Participant characteristics, including the participant's needs, as measured on the Inventory for Client and Agency Planning, and
- (C) Economic factors, such as the cost of receiving services in different geographical areas or where the participant resides.
- (ii) Using specific participant factors, the methodology shall correlate a participant's characteristics with the participant's individualized budget amount, so that the participants with higher needs are assigned a higher individualized budget amount, and vice versa.
(c) Redetermination of the individualized budget amount. - (i) The Division or the individual plan of care team may request a new Inventory for Client and Agency Planning or psychological assessment to determine if the characteristics or needs of the participant have changed and if a new individualized budget amount may be assigned.
- (A) The Division may request a new Inventory for Client and Agency Planning or psychological assessment at any time.
- (B) If the individual plan of care team requests a new Inventory for Client and Agency Planning or psychological assessment, the Division shall review the request and decide whether a new Inventory for Client and Agency Planning or psychological assessment will be approved.
- (C) If the new Inventory for Client and Agency Planning or psychological assessment results in a change in the individualized budget amount determination, a change in the individualized budget amount shall be approved or denied in accordance with the procedure described in paragraph (b) of this section.
- (ii) If the individualized budget amount does not meet the characteristics and needs of an individual, the Extraordinary Care Committee may approve a new individualized budget amount as a long-term increase, pursuant to Section 12 of this Chapter. This will be re-evaluated at least every five years.
- (iii) At least once every two years, the Division shall update the targeted individualized budget amount model using the most current Inventory for Client and Agency Planning data, current services, and current funding information.
(d) If funds for covered services become, or are projected to become limited or unavailable, the Division may modify participants' individualized budget amounts as necessary to bring projected expenditures in line with projected funding, recognizing that services shall be altered accordingly.
(e) If funding for covered services is, or is projected to be reduced below the level required to pay for all approved individualized budget amounts, or is eliminated, the Division shall have the discretion to modify participants' individualized budget amounts in order to bring projected expenditures for covered services within the projected available funding.
(f) If the waiver is modified or eliminated, the Division shall have the discretion to modify the individualized budget amounts in order to bring projected expenditures for covered services within projected available funding.
(g) Reinstatement of services. If additional funding becomes available, services that were reduced or eliminated shall be reinstated based on individual needs to the extent of the available funds. There shall be no requirement for the Division to disperse all available funds without a demonstrated need as described in these rules.
048-42 Wyo. Code R. § 42-8