RevisionHCFAPM945APRIL1994StateTerritory19MBWYOMINGSECTION3SERVICESGENERALPROVISIONS31AmountDurationandScopeofServicesaMedicaidisprovidedinaccordancewiththerequirementsof42CFRPart440SubpartBandsections1902a1902e1905a1905p19151920and1925oftheActcitation42CFRPart440SubpartB1902a1902e1905a1905p19151920and1925oftheAct1categoricallyneedyServicesforthecategoricallyneedyaredescribedbelowandinATTACHMENT31ATheseservicesincludei1902a10Aand1905aoftheActiiEachitemorservicelistedinsection1905a1through5and21oftheActisprovidedasdefinedin42CFRPart440SubpartAorforEPSDTservicessection1905rand42CFRPart441SubpartBNursemidwifeserviceslistedinsection1905a17oftheActareprovidedtotheextentthatnursemidwivesareauthorizedtopracticeunderStatelaworregulationandwithoutregardtowhethertheservicesarefurnishedintheareaofmanagementofthecareofmothersandbabiesthroughoutthematernitycycleNursemidwivesarepermittedtoenterintoindependentprovideragreementswiththeMedicaidagencywithoutregardtowhetherthenursemidwifeisunderthesupervisionoforassociatedwithaphysicianorotherhealthcareproviderNotapplicableNursemidwivesarenotauthorizedtopracticeinthisstateTNNo00005SLlpersedesTNNoqlL3ApprovalDateEffectiveDate40110

19aRevisionHCFAPM914AUGUST1991BPDOMBNo0938CitationStateTerritory3lalAmountDurationandSCODeofServicesCategoricallYNeedYContinuedWYOMING1902a10clauseVIIofthematterfollowingoftheActFiiiPregnancyrelatedincludingfamilyplanningservicesandpostpartumservicesfora60dayperiodbeginningonthedaypregnancyendsandanyremainingdaysinthemonthinwhichthe60thdayfallsareprovidedtowomenwhowhilepregnantwereeligibleforappliedforandreceivedmedicalassistanceonthedaythepregnancyendsLXivServicesformedicalconditionsthatmaycomplicatethepregnancyotherthanpregnancyrelatedorpostpartumservicesareprovidedtopregnantwomenvServicesrelatedtopregnancyincludingprenataldeliverypostpartumandfamilyplanningservicesandtootherconditionsthatmaycomplicatepregnancyarethesameservicesprovidedtopovertyleyelpregnantwomeneligibleundertheprovisionofsections1902alOAiIVand1902alOAiiIXoftheAct1902e5oftheActTNNoq3supereQeAPprOVlTNNolo1190DateqdEffectiveDateHCFAID7982E

19bRevisionHCFAPM927MBOctober1992CitationStateTerritoryWVMTN31a1AmountDurationandScopeofServicesCategoricallYNeedyContinued71902e7oftheAct1902e9oftheAct1902a52and1925oftheAct1905a23and1929TNNoSuperseTNNoHomehealthservicesareprovidedtoindividualsentitledtonursingfacilityservicesasindicatedinitem31bofthisplanviiInpatientservicesthatarebeingfurnishedtoinfantsandchildrendescribedinsection190211Bthrough0orsection1905n2oftheActonthedatetheinfantorchildattainsthemaximumageforcoverageundertheapprovedStateplanwillcontinueuntiltheendofthestayforwhichtheinpatientservicesarefurnishedviviiiRespiratorycareservicesareprovidedtoventilatordependentindividualsasindicatedinitem31hofthisplanixServicesareprovidedtofamilieseligibleundersection1925oftheActasindicatedinitem35ofthisplanHomeandCommunityCareforFunctionallyDisabledElderlyIndividualsasdefineddescribedandlimitedinSupplement2toAttachment31AandAppendicesAGtoSupplement2toAttachment31AxATTACHMENT31AidentifiesthemedicalandremedialservicesprovidedtothecategoricallyneedyspecifiesalllimitationsontheamountdurationandscopeofthoseservicesandliststheadditionalcoveragethatisinexcessofestablishedservicelimitsforpregnancyrelatedservicesandservicesforconditionsthatmaycomplicatethepregnancyApprovalOate3I93EffectiveOate

State of Wyoming Section 3

Page 19 C

Citation 31a1Amount Duration and Scope of Services Categorically NeedyContinued

1905a26and 1934X Program of All Inclusive Care for the Elderly PACE services as

described and limited in Supplement 3 to Attachment 31A

ATTACHMENT 31A identifies the medical and remedial services provided tothe categorically needy Note Other programs to be offered to CategoricallyNeedy beneficiaries would specify all limitations on the amount duration andscope of those services As PACE provides services to the frail elderly populationwithout such limitation this is not applicable for this program In addition otherprograms to be offered to Categorically Needy beneficiaries would also list theadditional coverage that is in excess of established service limits for pregnancyrelated services for conditions that may complicate the pregnancy As PACE isfor the frail elderly population this also is not applicable for this program

TN No 11 003 Approval Date Effective Date 10012011

SupersedesTN NO New

20RevisionHCFAPM91August1991stateTerritoryBPDOMBNo0938WYOMINGcitation31AmountDurationandScopeofServicescontinued42CFRPart440SubpartBa2Medicallyneedy1ThisStateplancoversthemedicallyneedyTheservicesdescribedbelowandinATTACHMENT31bareprovidedServicesforthemedicallyneedyinclude42CFR4402201902a10CivoftheActiIfservicesinaninstitutionformentaldiseases42CFR440140and440160oranintermediatecarefacilityforthementallyretardedorbothareprovidedtoanymedicallyneedygrouptheneachmedicallyneedygroupisprovidedeithertheserviceslistedinsection1905a1through5and17oftheActorsevenoftheserviceslistedinsection1905a1through20servicesareprovidedasdefinedin42CFR440SubpartAandinsections190219051915oftheActThePartand1Notapplicablewithrespecttonursemidwifeservicesundersection1902a17NursemidwivesarenotauthorizedtopracticeinthisState1902e5oftheActiiPrenatalcareanddeliveryservicesforpregnantwomenTNNofsedesApprovalDateIIq33qEffectiveDatedHCFA107982E

120aRevisionHCFAPM91August1991stateTerritoryBPDOMBNo0938WYOMINGCitation31a2AmountDurationandScooeofServicesMedicallvNeedvContinuediiiPregnancyrelatedincludingfamilyplanningservicesandpostpartumservicesfora60dayperiodbeginningonthedaythepregnancyendsandanyremainingdaysinthemonthinwhichthe60thdayfallsareprovidedtowomenwhowhilepregnantwereeligibleforappliedforandreceivedmedicalassistanceonthedaythepregnancyends1ivServicesforanyothermedicalconditionthatmaycomplicatethepregnancyotherthanpregnancyrelatedandpostpartumservicesareprovidedtopregnantwomenfofiXcvAmbulatoryservicesasdefinedinATTACHMENT31forrecipientsunderage18andrecipientsentitledtoinstitutionalservices1NotapplicablewithrespecttorecipientsentitledtoinstitutionalservicestheplandoesnotcoverthoseservicesforthemedicallyneedyviHomehealthservicestorecipientsentitledtonursingfacilityservicesasindicatedinitem31bofthisplan42CFR440140440150440160SubpartB442441SubpartC1902a20and21oftheAct1viiServicesinaninstitutionformentaldiseasesforindividualsoverage651viiiServicesinanintermediatecarefacilityforthementallyretarded1ixInpatientpsychiatricservicesforindividualsunderage21TNNo900FsedesApprovalDate1qlEffectiveDateqHCFAID7982E

20bRevisionHCFAPM93SMBMay1993stateCitation31a2190239ofxActWYOMINGAmountDurationandscopeofServicesMedicallvNeedYcontinued1905a23and1929oftheActxiRespiratoryprovidedindividualsthisplanHomeandCommunitycareforFunctionallyDisabledElderlyIndividualsasdefineddescribedandlimitedinsupplement2toAttachment31AandAppendicesAGtoSupplement2toAttachment31Acareservicesaretoventilatordependentasindicatedinitem31hofATTACHMENT31BidentifiestheservicesprovidedtoeachcoveredgroupofthemedicallyneedyspecifiesalllimitationsontheamountdurationandscopeofthoseitemsandspecifiestheambulatoryservicesprovidedunderthisplanandanylimitationsonthemItalsoliststheadditionalcoveragethatisinexcessofestablishedservicelimitsforpregnancyrelatedservicesandservicesforconditionsthatmaycomplicatethepregnancyTN95003SupersedesTN9213ApprovalDateJqJEffectiveDate010195

State ofWyoming Section 3

Page 20 C

Citation 31a2Amount Duration and Scope of Services Medically Needy Continued1905a26and 1934

Program ofAll Inclusive Care for the Elderly PACE services as described andlimited in Supplement 3 to Attachment 31 A

ATTACHMENT 31 B identifies services provided to each covered group of themedically needy Note Other programs to be offered to Medically Needybeneficiaries would specify all limitations on the amount duration and scope ofthose services As PACE provides services to the frail elderly population withoutsuch limitation this is not applicable for this program In addition otherprograms to be offered to Medically Needy beneficiaries would also list theadditional coverage that is in excess of established service limits for pregnancyrelated services for conditions that may complicate the pregnancy As PACE isfor the frail elderly population this also is not applicable for this program

TN No 11 003 Approval DateSEP 0 6 2M

Effective Date 10012011

SupersedesTN NO New

21RevisionHCFAPM981CMSOAPRIL1998StateWYOMINGCitation31AmountDurationandScopeofServicescontinueda3OtherRequiredSpecialGroupsQualifiedMedicareBeneficiaries1902a1OEiandclauseVIllofthematterfollowingFand1905p3oftheActMedicarecostsharingforqualifiedMedicarebeneficiariesdescribedinsection1905poftheActisprovidedonlyasindicatedinitem32ofthisplan1902a10Eiiand1905softheActa4iOtherRequiredSpecialGroupsQualifiedDisabledandWorkinIndividualsMedicarePartApremiumsforqualifieddisabledandworkingindividualsdescribedinsection1902a10EiioftheActareprovidedasindicatedinitem32ofthisplan1902a10Eiiiand1905p3AiioftheActiiOtherRequiredSpecialGroupsSpecifiedLowIncomeMedicareBeneficiariesMedicarePartBpremiumsforspecifiedlowincomeMedicarebeneficiariesdescribedinsection1902a10EiiioftheActareprovidedasindicatedinitem32ofthisplan1902a10Eiv11905p3Aiiand1933oftheActiiiOtherRequiredSpecialGroupsQualifyinIndividuals1MedicarePartBpremiumsforqualifyingindividualsdescribedin1902a10EivIandsubjectto1933oftheActareprovidedasindicatedinitem32ofthisplanTNNo9805SupersedesTNNo9802ApprovalDatefqIJfqEffectiveDatef11I

21ContinuedRevisionCMSOSTATEWyomingCitation1925oftheActa5OtherRequiredSpecialGroupsFamiliesReceivinqExtendedMedicaidBenefitsExtendedMedicaidbenefitsforfamiliesdescribedinsection1925oftheActareprovidedasindicatedinitem35ofthisplanTNNo03001SupersedesTNNo9805ApprovalDate03fII03EffectiveDate01012003

21aRevisionHCFAPM981CMSOAPRll1998StateWYOMINGCitationSec245AhoftheImmigrationandNationalityActa6LimitedCoverageforCertainAliensiAliensgrantedlawfultemporaryresidentstatusundersection245AoftheImmigrationandNationalityActwhomeetthefinancialandcategoricaleligibilityrequirementsundertheapprovedStateMedicaidplanareprovidedtheservicescoveredundertheplaniftheyAAreagedblindordisabledindividualsasdefinedinsection1614a1oftheActBArechildrenunder18yearsofageorCAreCubanorHaitianentrantsasdefinedinsection501e1and2AofPL96422ineffectonApril11983iiExceptforemergencyservicesandpregnancyrelatedservicesasdefinedin42CPR44753baliensgrantedlawfultemporaryresidentstatusundersection245AoftheImmigrationandNationalityActwhoarenotidentifiedinitems31a6iAthroughCaboveandwhomeetthefinancialandcategoricaleligibilityrequirementsundertheapprovedStateplanareprovidedservicesundertheplannoearlierthanfiveyearsfromthedatethealienisgrantedlawfultemporaryresidentstatusTNNo9805SupersedesTNNo9113ApprovalDatedIJ1EffectiveDate111ft

21bRevisionHCFAPM914August1991StateTerritoryBPDOMSNo0938Citation3la6AmountDurationandScooeofServicesLimitedOoveraoeforCertainAlienscontinued1902aand1903voftheActi11AlienswhoarenotlawfullyadmittedforpermanentresidenceorotherwisepermanentlyresidingintheUnitedStatesundercoloroflawwhomeettheeligibilityconditionsunderthisplanexceptfortherequirementforreceiptofAFDCSSIoraStatesupplementarypaymentareprovidedMedicaidonlyforcareandeervicesnecessaryforthetreatmentofanemergencymedicalconditionincludingemergencylaboranddeliveryasdefinedinsection1903v3oftheAct1905a9oftheActa7HomelessIndividualsClinicservicesfurnishedtoeligibleindividualswhodonotresideinapermanentdwellingordonothaveafixedhomeormailingaddressareprovidedwithoutrestrictionsregardingthesiteatwhichtheservicesarefurnished1902a47and1902oftheActXa8PresumDtivelyElioiblepreonantWomen42CFR4415550FR436541902a431905a4Band1905roftheActAmbulatoryprenatalcareforpregnantwomenisprovidedduringapresumptiveeligibilityperiodifthecareisfurnishedbyaproviderthatiseligibleforpaymentundertheStateplana9EPSDTServicesTheMedicaidagencymeetstherequirementsofsections1902a431905a4Band1905roftheActwithrespecttoearlyandperiodicscreeningdiagnosticandtreatmentEPSDTservicesTNNo911iSupersedesTNNo9202ApprovalDate121oSi14EffectiveDate11192

22RevisionHCFAPM91August1991StateTerritoryBPDOMBNo0938WYOMINGcitation31a9AmountDurationandScopeofServicesEPSDTServicescontinued42CFR44160LTheMedicaidagencyhasincontinuingcareprovidersmethodsemployedtoassurewiththeiragreementseffectagreementswithDescribedbelowarethetheproviderscompliance42CFR440240a10ComparabilitvofServicesand4402501902aand1902a10I1902a521903v1915gand1925b4oftheActExceptforthoseitemsorservicesforwhichsections1902a1902a101903v1915and1925oftheAct42CFR440250andsection245AoftheImmigrationandNationalityActpermitexceptionsiServicesmadeavailabletothecategoricallyneedyareequalinamountdurationandscopeforeachcategoricallyneedypersoniiTheamountdurationandscopeofservicesmadeavailabletothecategoricallyneedyareequaltoorgreaterthanthosemadeavailabletothemedicallyneedyiiiServicesmadeavailabletothemedicallyneedyareequalinamountdurationandscopeforeachpersoninamedicallyneedycoveragegroupLivAdditionalcoverageforpregnancyrelatedservicesandservicesforconditionsthatmaycomplicatethepregnancyareequalforcategoricallyandmedicallyneedyTNNo92FsedesApprovalDateqj3bqEffectiveDateLJqIHCFAID7982E

23RevisionECFAAT8038BPPMay221980StateWyomingCitaticn42emPart440SubpartB42erR44115AT7890AT8034310acnehealtservicesareprovidedinaccordancgwiththerequiremmtsof42CFR441151acmehealthservicesareprovidedtoallcategoricallyneedyincUviduals21yearsofageorCNer2Banehealtservicesareprovidedtoallcategoricallyneedyirdividqlunder21yearsofagegDYesNotapplicableTheStateplanacest1jtprovideforskillednursingfacilityservicesforsuchWividuals3HallehealthservicesareprovidedtothemedicallyneedyDDYestoallYestoindiviilJage21oroverSNFservicesareprovidedYestoindividualsunderage21SNFservicesareprovidedDNc1SNFservicesarerotprovided@NotlicablethemedicallyneedyarenotincludedunderthisplanaIN7912SupesedesINApprovalDate11780EffectiveDate1017Qi

24RevisionHCFAPM938December1993BPDOMSNo0938stateTerritoryWYOMINGCitation31AmountDurationandScooeofServicescontinued42CFR43153clAssuranceofTransoortationprovisionismadeforassuringnecessarytransportationofrecipientstoandfromprovidersMethodsusedtoassuresuchtransportationaredescribedinATTACHMENT31D42CFR48310c2PaymentforNursinqFacilityServicesTheStateincludesinnursingfacilityservicesatleasttheitemsandservicesspecifiedin42CFR48310c8iTNNO93019SupersedesTNNO9113ApprovalDateS9ffectiveDate119

etlisicnECFA8038BPPay221980StateWYomina25Citaticn42CFR440260Jl7S9031dMethcdsardSandardstoAssureQualitvofServicesThestandardsestablishedandthemeth03susedtoassurehighqualitycarearedescribedinATrACEMENT31771rsedesAppcovalDate3217EffectileDate1177tiA

RevisionJIiAF268CFAAT8038BPPMay221980StateWyominqCitaticn42em44120Xri89031eFaroilyPlninqServicesTherequireI1entsof42em44120aremetregardingfreedomframcoercicnorpressureofmindandooscielceandfreeanofchoiceofmethcdtolellSedforfamilyplanningIN771SupersedesINiApprovalDate32177EffectiveDate1177

RevisionHCFAPM875BERCApril1987STATEWYOMINGCitation42CFR44130AT789031f11903i1oftheActPL99272Section9507227OMBNo09380193OptometricServicesOptometricservicesotherthanthoseprovidedunder435531and436531arenotnowbutwerepreviouslyprovidedunderthisplanServicesofthetypeanoptometristislegallyauthorizedtoperformarespecificallyincludedinthetermphysiciansservicesunderthisplanandarereimbursedwhetherfurnishedbyaphysicianoranoptometristYesNoTheconditionsprescribedinthefirstsentenceapplybutthetermphysiciansservicesdoesnotspecificallyincludeservicesofthetypeanoptometristislegallyauthorizedtoperformXNotapplicableTheconditionsinthefirstsentencedonotapplyOrganTransplantProceduresOrgantransplantproceduresareprovidedNoXYesSimilarlysituatedindividualsaretreatedalikeandanyrestrictiononthefacilitiesthatmayorpractitionerswhomayprovidethoseproceduresisconsistentwiththeaccessibilityofhighqualitycaretoindividualseligiblefortheproceduresunderthisplanStandardsforthecoverageoforgantransplantproceduresaredescribedatAttachment3IE0010TNNO04006SupersedesTNNO96005ApprovalDateEffectiveDateOctober12004

28OKBNo09380193RevisionHCFAPM874BERCKARCH1987StateTerritorywyomingCitation42CFR431110bAT789031gParticipationbyIndianHealthServiceFacilities1902e9oftheActPL99509Section9408IndianHealthServicefacilitiesareacceptedasprovidersinaccordancewith42CFR431110bonthesamebasisasotherqualifiedprovidershRespiratoryCareServicesforVentilatorDependentIndividualsRespiratorycareservicesasdefinedinsection1902e9CoftheActareprovidedundertheplantoindividualswho1Aremedicallydependentonaventilatorforlifesupportatleastsixhoursperday2HavebeensodependentasinpatientsduringasinglestayoracontinuousstayinoneormorehospitalsSNFsorICFsforthelesserofL30consecutivedaysZdaysthemaximumnumberofinpatientdaysallowedundertheStateplan3ExceptforhomerespiratorycarewouldrequirerespiratorycareonaninpatientbasisinahospitalSNForICFforwhichMedicaidpaymentswouldbemade4Haveadequatesoeialsupportservieestobeearedforathomeand5WishtobeearedforathomeIYesTherequirementsofsection1902e9oftheAetaremetXINotapplieableTheseservicesarenotineludedintheplanLApprovalDateq7BffeetiveDate77TNNo87CSupersedesTNNo7g3HCFA101008P00IIPW

29RevisionHCFAPM935May1993MBStateWYOMINGCitation32CoordinationofMedicaidwithMedicareandOtherInsuranceaPremiums1MedicarePartAandPartB1902a10Eiand1905p1oftheActiOualifiedMedicareBeneficiary1QMlUTheMedicaidagencypaysMedicarePartApremiumsifapplicableandPartBpremiumsforindividualsintheQMBgroupdefinedinItemA25ofATTACHMENT22AthroughthegrouppremiumpaymentarrangementunlesstheagencyhasaBuyinagreementforsuchpaymentasindicatedbelowBuyinagreementforPartAPartBTheMedicaidagencypayspremiumsforwhichthebeneficiarywouldbeliableforenrollmentinanHMOparticipatinginMedicareTN95003SupersedesTN93008ApprovalDateoCr19EffectiveDate010195

RevisionHCFAM973CMSODecber1997Citation1902a10Eiiand1905softheAct1902a1OEiiiand1905p3AiioftheAct1902a10EivI1905p3Aiiand1933oftheActTNNo03001SupersedesTNNo9802ApprovalDate29aiiQualifiedDisabledandWorkinqIndividualODWITheMedicaidagencypaysMedicarepartApremiumsunderagrouppremiumpaymentarrangementsubjecttoanycontributionrequiredasdescribedinATTACHMENT418EforindividualsintheQDWIgroupdefinedinitemA26ofATTACHMENT22AofthisplaniiiSpecifiedLowIncomeMedicareBeneficiarySLMBTheMedicaidagencypaysMedicarePartBpremiumsundertheStatebuyinprocessforindividualsintheSLMBgroupdefinedinitemA27ofATTACHMENT22AofthisplanivQualifvinqIndividual1QI1TheMedicaidagencypaysMedicarePartBpremiumsundertheStatebuyinprocessforindividualsdescribedin1902a10Eivlandsubjectto1933oftheActytL311D3EffectiveDate01012003

RevisionHCFAPM973CMSODecember1997StateWYOMING29bCitation1843band1905aoftheActand42CFR4316251902a30and1905aoftheActviOtherMedicaidRecipientsTheMedicaidagencypaysMedicarePartBpremiumstomakeMedicarePartBcoverageavailabletothefollowingindividualsLAllindividualswhoareareceivingbenefitsundertitlesIIVAXXIVorXVIAABDorSSIbreceivingStatesupplementsundertitleXVIorcwithingagrouplistedat42CFR431625d2IndividualsreceivingtitleIIorRailroadRetirementbenefitsMedicallyneedyindividualsFFPisnotavailableforthisgroup2OtherHealthInsuranceXTheMedicaidagencypaysinsurancepremiumsformedicaloranyothertypeofremedialcaretomaintainathirdpartyresourceforMedicaidcoveredservicesprovidedtoeligibleindividualsexceptindividuals65yearsofageorolderanddisabledindividualsentitledtoMedicarePartAbutnotenrolledinMedicarePartBEffectiveDateTNNo9802SupersedesTNNo93011ApprovalDatefjJJ3q119I

RevisionHCFAPMMBstateTerritoryCitation1902a301902n1905aand1916oftheActSections1902a10Eiand1905p3oftheAct1901a101902a30and1905aoftheAct42CFR4316251902a101902a301905aand1905poftheActTNNoSupersedesApprovalDateTNNo4Jo29cWYOMINGbDeductiblesCoinsurance1MedicarePartAandBSUDPlement1toATTACHMENT419BdescribesthemethodsandstandardsforestablishingpaymentratesforservicescoveredunderMedicareandorthemethodologyforpaymentofMedicaredeductibleandcoinsuranceamountstotheextentavailableforeachofthefollowinggroupsiQualifiedMedicareBeneficiariesCOMBSTheMedicaidagencypaysMedicarePartAandPartBdeductibleandcoinsuranceamountsforQMBssubjecttoanynominalMedicaidcopaymentforallservicesavailableunderMedicareilOtherMedicaidRecipientsTheMedicaidagencypaysforMedicaidservicesalsocoveredunderMedicareandfurnishedtorecipientsentitledtoMedicaresubjecttoanynominalMedicaidcopaymentForservicesfurnishedtoindividualswhoaredescribedinsection32a1ivpaymentismadeasfollows1LFortheentirerangeofservicesavailableunderMedicarePartBOnlyfortheamountdurationandscopeofservicesotherwiseavailableunderthisplaniiiDualElioibleQMBplusTheMedicaidagencypaysMedicarePartAandPartBdeductibleandcoinsuranceamountsforallservicesavailableunderMedicareandpaysforallMedicaidservicesfurnishedtoindividualseligiblebothasQMBsandcategoricallyormedicallyneedysubjecttoanynominalMedicaidcopaymentEffectiveDate3HCFAID7982E

29dRevisionHCFAPM91cOctober1991MBlOMBNoStateTerritoryCitationConditionorRequirement1906oftheActcPremiumsOeductiblesCoinsuranceandOtherCosSharinqObliqationsTheMedicaidagencypaysallpremiumsdeductiblescoinsuranceandothercostsharingobligationsforitemsandservicescoveredundertheStateplansubjecttoanynominalMedicaidcopaymentforeligibleindividualsinemployerbasedcosteffectivegrouphealthplans1902a10FoftheActWhencoverageforeligiblefamilymembersisnotpossibleunlessineligiblefamilymembersenrolltheMedicaidagencypayspremiumsforenrollmentofotherfamilymemberswhencosteffectiveInadditiontheeligibleindividualisentitledtoservicescoveredbytheStateplanwhicharenotincludedinthegrouphealthplanGuidelinesfordeterminingcosteffectivenessaredescribedinsection422hdTheMedicaidagencypayspremiumsforindividualsdescribedinitem19ofAttachment22ATNNoqOOsupercedesIApprovalDateTNNoJUtr119sEffectiveDateHCFAIO7983EX

30RelisicnEFAT8038BPPMay221980StateIiycrninaCitaticn42cR44110142CER431620canddr792933MedicaidferIrividualsAce65orOveriniticrnDiseasesMedicaidisprovicedforLdiviCuals65yearsofaceoroldwoo3Iecatie1tsinirst1ttticnsformentaldiseasesi7YesTherequiraYle1tsof42ctPart441SuC9artCand42CPR431620car0aremetJNotlCbleJdiC3idisrctorovidedtoagedirdivid1I4insinsnmCerthisplanr1AIN84cSupersedesN77AprovalDate6g4IIEffectiveDate6F4rr

31RevisioneO38BPPMay221980StateCibticn42CFR441252N7899Wyoming34SoecialReauirementsAcPlicabletoSterilizationProceduresAllrequirementsof42ernPart441SubpartFaremetIN794SupersedesmilAarovalDate72579EffectiveDate71179A

31asionHCFAPM911991BPOOMBNo0938stateWYOMINGCitation1902a52and1925oftheAct35FamiliesReceivinaExtendedMedicaidBenefitsaServicesprovidedtofamiliesduringthefirst6monthperiodofextendedMedicaidbenefitsunderSection1925oftheActareequalinamountdurationandscopetoservicesprovidedtocategoricallyneedyAFOCrecipientsasdescribedinATTACHMENT31AormaybegreaterifprovidedthroughacaretakerrelativeemployershealthinsuranceplanbServicesprovidedtofamiliesduringthesecond6monthperiodofextendedMedicaidbenefitsundersection1925oftheActare11EqualinamountdurationandscopetoservicesprovidedtocategoricallyneedyAFOCrecipientsasdescribedinATTACHMENT31AormaybegreaterifprovidedthroughacaretakerrelativeemployershealthinsuranceplanLXIEqualinamountdurationandscopetoservicesprovidedtocategoricallyneedyAFOCrecipientsormaybegreaterifprovidedthroughacaretakerrelativeemployershealthinsuranceplanminusanyoneormoreofthefollowingacuteservicesLXINursingfacilityservicesotherthanservicesinaninstitutionformentaldiseasesforindividuals21yearsofageorolder11Medicalorremedialcareprovidedbylicensedpractitioners11HomehealthservicesTNNoSupersedeApprovalDateTNNoF9cJ5fEffectiveDatel1IHCFAIO7982E

sionHCFAPM911991citationApprovalDatestate3531bBPDOMBNo0938WOMINGFamiliesReceivinaExtendedMedicaidBenefitsContinued11Privatedutynursingservices11Physicaltherapyandrelatedservices11OtherdiagnosticscreeningpreventiveandrehabilitationservicesLXIInpatienthospitalservicesandnursingfacilityservicesforindividuals65yearsofageoroverinaninstitutionformentaldiseasesLXIIntermediatecarefacilityservicesforthementallyretardedLXIInpatientpsychiatricservicesforindividualsunderage2111Hospiceservices11Respiratorycareservices11AnyothermedicalcareandanyothertypeofremedialcarerecognizedunderstatelawandspecifiedbytheSecretaryEffectiveDated9HCFA107982E

31cRevisionHCFAPM911991BPDOMBNo0938stateWYOMINGCitation35FamiliesReceivinaExtendedMedicaidBenefitsContinuedcLITheagencypaysthefamilyspremiumsenrollmentfeesdeductiblescoinsuranceandsimilarcostsforhealthplansofferedbythecaretakersemployeraspaymentsformedicalassistanceLILI1st6monthsLI2nd6monthsTheagencyrequirescaretakerstoenrollinemployershealthplansasaconditionofeligibilityLI1st6mosLI2nd6mosdLI1TheMedicaidagencyprovidesassistancetofamiliesduringthesecond6monthperiodofextendedMedicaidbenefitsthroughthefollowingalternativemethodsLIEnrollmentinthefamilyoptionofanemployershealthplanLIEnrollmentinthefamilyoptionofastateemployeehealthplanLIEnrollmentinthestatehealthplanfortheuninsuredLIEnrollmentinaneligiblehealthmaintenanceorganizationHMOwithaprepaidenrollmentoflessthan50percentMedicaidrecipientsexceptrecipientsofextendedMedicaidTNNo3sllPersedesApprovalDateNo2EffectiveDateIHCFAIO7982E

31dRevisionHCFAPM91BPD1991OMBNo0938StateWYOMINGCitation35FamiliesReceivingExtendedMedicaidBenetitscontinuedSupplement2toATTACHMENT31Aspecifiesanddescribesthealternativehealthcareplanesofferedincludingrequirementsforassuringthatrecipientshaveaccesstoservicesofadequatequality2TheagencyiPaysallpremiumsandenrollmentfeesimposedonthefamilyforsuchplanesiiPaysalldeductiblesandcoinsuranceimposedonthefamilyforsuchplanes36UnemployedParentForpurposesofdeterminingwhetherachildisdeprivedonthebasisofunemploymentofaparenttheagencyUsesthestandardformeasuringunemploymentwhichwasintheAFDCStatePlanineffectonJuly161996XUsesthefollowingmoreliberalstandardtomeasureunemploymentTheprincipalwageearnerisconsideredunemployedifthefamilysincomeisbelowtheprogramsincomelimitforthefamilysizeTNNo9904SupersedesTNNo9113ApprovalDate099EffectiveDateJulyL1999