CHAPTER 47
CHILDREN'S MENTAL HEALTH WAIVER (CMHW)
AND CARE MANAGEMENT ENTITY (CME) RULES
(a) This Chapter applies to Medicaid services provided under the Wyoming Care Management Entity (CME) and the Children's Mental Health Waiver (CMHW) programs.
(b) The Department may issue manuals and bulletins to interpret provisions in this Chapter. Such manuals and bulletins shall be consistent with and reflect the policies contained in this chapter. Provisions contained in manuals and bulletins shall be subordinate to the provisions outlined in this Chapter.
Section 3. General Provisions.
(a) This Chapter has been adopted to establish rules for all-inclusive Care Management Entity (CME) and Children's Mental Health Waiver (CMHW) Programs that improve clinical, functional, and cost outcomes for eligible participants.
(b) Through this Rule, the CME shall be required to collaborate with a network of providers in order to comprehensively serve the intensive care coordination needs of enrollees receiving care under the CME and CMHW Program.
(c) The CME shall provide services for both 1915(b) and 1915(c) waiver eligible populations.
(a) "Diagnostic and Statistical Manual of the American Psychiatric Association (DSM)." The most recent editions of the Diagnostic and Statistical Manual of the American Psychiatric Association. Primary diagnoses are principle disorders requiring immediate attention.
(b) "Care Management Entity (CME)." An organizational entity that has a contract with the Department to serve as the locus of intensive care coordination, accountability, and provider of high fidelity wraparound services for defined populations of youth with serious emotional disturbance and their families
(c) "Child and Adolescent Service Intensity Instrument (CASII)." The CASII is a standardized tool from the American Academy of Child and Adolescent Psychiatrists that provides a determination of the appropriate intensity of services needed by youth, ages six to twenty (6-20) being served within a continuum of care.
(d) "Children's Mental Health Waiver (CMHW)." CMHW is a Department of Health Medicaid program that is managed by the care management entity that aims to help qualifying youth with serious emotional disturbance, reduce their level of service needs, and increase their natural supports in a relatively short amount of time, utilizing High Fidelity Wraparound.
(e) "Early Childhood Service Intensity Instrument (ECSII)." The ECSII is a tool from the American Academy of Child and Adolescent Psychiatrists that provides a determination of the appropriate intensity of service needs for infants, toddlers, and youth from ages four to five (4-5) years who are experiencing social/emotional development delays or challenges.
(f) "Excluded Populations." The Excluded Population includes:
(i) Medicaid beneficiaries who reside in nursing facilities or intermediate care facilities for Individuals with Intellectual Disabilities;
(ii) Medicaid beneficiaries who participate in a Home and Community Based Waiver Services (HCBS), including actively enrolled youth or youth who have met all the clinical criteria for and have been placed on a waitlist for the following waivers:
(A) Children's Developmental Disability Waiver - WY Waiver 0253;
(B) Developmental Disability Supports Waiver - WY Waiver #1060;
(C) Developmental Disability Comprehensive Waiver - WY Waiver #1061; and
(D) Long Term Care Waiver - WY Waiver #0236.
(iii) Medicare beneficiaries who receive services through the State Children's Health Insurance Title XXI program;
(iv) Medicaid beneficiaries for the period of retroactive eligibility;
(v) Any other youth, upon application, whose primary need is determined to be for services that are more habilitative in nature vs. the intensive rehabilitative nature of HFWA services. This need will be determined by a level of co-occurrence indicated as four (4) or five (5) in Dimension III on the CASII or a rating of four (4) or five (5) on the ECSII assessment.
(g) "High Fidelity Wraparound (HFWA)." High Fidelity Wraparound is an evidenced-based intensive care coordination model provided by the Medicaid Care Management Entity.
(h) "Level of Care (LOC)." The Level of Care document is required as part of the clinical eligibility determination process for Care Management Entity enrollment. The Level of Care form is completed by a qualified mental health professional who:
(i) Is licensed to diagnose and treat mental disorders, and has knowledge of the youth's level of care need;
(ii) Can attest that the youth meets one or more psychiatric inpatient criteria listed on the LOC form; and
(iii) Can attest that the youth can be safely served in the community with adequate services and supports in place.
(i) "Serious Emotional Disturbance (SED)." Serious Emotional Disturbance is a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely effects educational performance:
(i) An inability to learn that cannot be explained by intellectual, sensory or health factors;
(ii) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers;
(iii) Inappropriate behavior or feelings under normal circumstances;
(iv) A general pervasive mood of unhappiness or depression; and
(v) A tendency to develop physical symptoms or fears associated with personal school problems.
(j) "Serious Mental Illness (SMI)." Serious Mental Illness is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.
Section 5. Eligibility.
(a) Enrollment for CME 1915(b) services is mandatory for the following populations:
(i) Youth qualifying under Section 1931 of the Social Security Act and related populations, to include poverty-level related groups and optional groups of older youth;
(ii) Blind/Disabled youth and related populations, to include beneficiaries, generally under age 18, who are eligible for Medicaid due to blindness or disability;
(iii) Youth in Foster Care in the State of Wyoming, or youth receiving adoption assistance under Title IV-E, or are otherwise in out-of-home placement.
(iv) Targeting Criteria for the populations includes:
(A) Medicaid youth ages four to twenty (4-20) at risk of out-of-home placement (defined and identified as youth with two hundred (200) days or more of behavioral health services within one State fiscal year);
(B) Medicaid youth ages four to twenty (4-20) who currently meet Psychiatric Residential Treatment Facility (PRTF) level of care as outlined in Chapter 40, Psychiatric Residential Treatment Facilities;
(C) Medicaid youth ages four to twenty (4-20) who currently meet acute psychiatric stabilization hospital level of care as determined by a licensed clinician; had an acute hospital stay for mental or behavioral conditions in the last three hundred sixty-five (365) days; or are currently placed in an acute hospital stay for mental or behavioral health conditions;
(D) Youth enrolled in the Children's Mental Health Waiver (Section 1915(c) WY Waiver #0451); or
(E) Medicaid youth ages four to twenty (4-20) referred to the pre-paid ambulatory health plan (PAHP) and who meet defined eligibility, including clinical eligibility and SED criteria.
(v) Medical Eligibility Criteria is a condition for enrollment in the CME after initial targeting criteria is met. The Medical Eligibility Criteria includes:
(A) Youth ages six to twenty (6-20) who have a minimum CASII composite score of twenty (20), and youth ages four (4) and five (5) who have an ECSII score of eighteen (18) to thirty (30) or the appropriate social and emotional assessment information provided to illustrate level of service needs; and
(I) CASIIs administered for the purpose of establishing medical eligibility shall not be administered by the CME but instead be administered by a neutral third party to ensure conflict free case management.
(B) Youth who have a DSM Axis 1 or International Classification of Disease (ICD) diagnosis that meets the State's diagnostic criteria.
(b) Enrollment for CME 1915(c) services is mandatory for the following populations:
(i) Targeting Criteria for the populations includes:
(A) Medicaid youth ages four to twenty-one (4-21) at risk of out-of-home placement (defined and identified as youth with two hundred (200) days or more of behavioral health services within one State fiscal year);
(B) Medicaid youth ages four to twenty-one (4-21) who currently meet PRTF level of care as outlined in Chapter 40, Psychiatric Residential Treatment Facilities or are placed in a PRTF;
(C) Medicaid youth ages four to twenty-one (4-21) who currently meet acute psychiatric stabilization hospital level of care as determined by a licensed clinician; had an acute hospital stay for mental or behavioral conditions in the last three hundred sixty-five (365) days; or are currently placed in an acute hospital stay for mental or behavioral health conditions; or
(D) Medicaid youth ages four to twenty-one (4-21) referred to the PAHP and who meet defined eligibility, including clinical eligibility and SED/SMI criteria.
(ii) Medical Eligibility Criteria is a condition for enrollment in the CME after initial targeting criteria is met. The Medical Eligibility Criteria includes:
(A) Youth ages six to twenty-one (6-21) who have a minimum CASII composite score of twenty (20), and youth ages four (4) and five (5) who have an ECSII score of eighteen (18) to thirty (30) or the appropriate social and emotional assessment information provided to illustrate level of service needs; and
(I) CASIIs administered for the purpose of establishing medical eligibility shall not be administered by the CME but instead be administered by a neutral third party to ensure conflict free case management.
(B) Youth who have a DSM Axis 1 or primary ICD diagnosis that meets the State's diagnostic targeting criteria as specified above.
(c) Those listed as "Excluded Populations" in Section 4(f) of this Rule are not eligible for the CME or CMHW Program.
(d) A person is not considered financially eligible when the Department expects the costs of HCBS furnished to the individual would exceed the per member, per month (PMPM) amount specified by the Department in the 1915 (c) waiver's cost neutrality equation.
(a) The Department shall automatically enroll eligible youth into the CME.
(b) A youth and his or her family may choose to disenroll at any time pursuant to Section 7 of this Chapter.
(a) The Department will review and approve all requests by the CME to disenroll youth based on the medical necessity of the HFWA service plan. An individual may be disenrolled from the CME if:
(i) The youth is no longer Medicaid eligible;
(ii) The youth moves out of the State;
(iii) The youth ages out of the program;
(iv) The youth is incarcerated;
(v) The youth is no longer financially eligible;
(vi) The youth is no longer clinically eligible;
(vii) The youth is determined eligible for any excluded program/population pursuant to Section 4;
(viii) The youth is in out-of-home placement longer than one hundred eighty (180) days;
(ix) The youth needs related services (for example a cesarean section and tubal ligation) to be performed at the same time; not all related services are available within the network; and the youth's Primary Care Provider (PCP) or another provider determines that receiving the services separately would subject the youth to unnecessary risk; or
(x) Other reasons, including but not limited to, poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the youth's specific health care needs.
(b) A participant may voluntarily disenroll from the CME without cause at any time.
(a) A participant shall be determined no longer eligible for CME program services when:
(i) The youth is no longer Medicaid eligible;
(ii) The youth moves out of the State;
(iii) The youth ages out of the program;
(iv) The youth is incarcerated;
(v) The youth is no longer financially eligible;
(vi) The youth is no longer clinically eligible;
(vii) The youth is determined eligible for any excluded program/population pursuant to Section 4 of this Chapter;
(viii) The youth is an out-of-home placement longer than one hundred eighty (180) days;
(ix) The CME provider's agreement with CMS and the Department is not renewed or is terminated; or
(x) The CME provider is unable to offer health care services due to the loss of contracts with outside providers.
(b) An enrollee may appeal their loss of eligibility pursuant to the grievance process outlined in Section 22 of this Rule.
(a) Any youth enrolled with the CME who meets the eligibility criteria as outlined in Section 5 of this Chapter is eligible for HFWA and respite services. Each enrollee maintains full access to all Medicaid state plan services. Special health care needs shall be identified and treated through primary and specialty care providers in Medicaid fee for service.
(b) Appropriately trained, credentialed, and Medicaid-enrolled providers may contract with the CME as part of the CME's provider network for the provision of HFWA and respite services.
(i) HFWA and respite is available to all enrolled youth statewide.
(c) Respite service shall accommodate the needs of the youth and his or her family. Prior to the authorization of respite services, the youth's plan of care shall document how respite would support HFWA service goals.
(d) Service settings are either based in the provider's residence, the youth's residence, or in community locations that are not institutional. Respite providers who choose to use their home shall have their home approved for respite prior to providing services.
(e) Respite shall only be provided for one youth at a time unless the CME reviews and approves additional youth.
(f) Respite services shall be restricted to a maximum of four hundred sixteen (416) hours per calendar year for each enrolled and qualified youth.
(g) To determine clinical eligibility, youth accessing the CME through the CMHW Program shall complete an application containing all pertinent demographic and identifying information, including the LOC determination as recommended by a qualified licensed mental health professional, and the CASII/ESCII assessment completed by a qualified third party evaluator.
(i) The CASII, ESCII and LOC evaluation shall be completed upon initial application and annually thereafter prior to the plan of care development and approval. Ongoing eligibility determinations shall be made using the same criteria as the initial assessment.
(ii) If the youth meets the clinical criteria, information is uploaded into Electronic Medicaid Waiver System (EMWS) and the applicant is notified. The applicant shall then complete the financial eligibility application.
(A) Youth that are financially able are notified of either their assignment to the wait list or notification of a funding opportunity.
(I) Youth are scored and ranked on the wait list using the following criteria to determine applicants with the highest level of care scores:
(1.) Eligibility qualification acuity (CASII/ESCII score);
(2.) Threat for custody relinquishment - being denied care because of custody status;
(3.) Child in Need of Supervision (CHINS) petition is being recommended or considered;
(4.) DFS is involved;
(5.) Threat to home/school situation - expulsion or placement from school or homelessness; or
(6.) Youth who are part of a household where other members are already receiving wraparound services.
(iii) Youth may be denied if wraparound services are already being provided to immediate family.
(h) Reapplication is an option at any time, and the CME and the State reserve the right to deny reapplication if the youth's previous CME enrollment ended due to non-participation, refusal of essential plan services, or goals of their plan have been met and there has not been a subsequent change or transition in the applicant's assessed needs.
(i) Enrollment in the program for the purposes of accessing institutional care or receiving financial assistance to cover medical services or co-pays and deductibles related to insurance coverage is not a valid reason for enrollment in HFWA.
(i) Program participants may select any willing and qualified provider to furnish waiver services included in the service plan as long as they are not financially affiliated with the assessor who is performing the ECSII or CASII evaluation for that participant's enrollment process.
(a) An individualized plan of care (POC) shall be developed with the Family Care Coordinator (FCC), family, youth, and family team (CFT) within thirty (30) days of selection of an FCC.
(b) A crisis plan shall be included as part of the POC to assist in stabilizing the youth and family during a crisis.
(c) The POC shall be updated at least every ninety (90) days. More frequent updates may be necessary depending on the needs of the youth and his or her family.
(d) Each youth's PCP shall be documented in the POC.
(a) Services delivered by the CME shall be appropriate in type, frequency, and duration.
(b) Services shall include HFWA services only, and be subject to the following requirements:
(i) A ratio of no more than one (1) FCC for a total of ten (10) persons (1:10) being served by that FCC regardless of the referral source;
(ii) A ratio of no more than one (1) Family Support Partner (FSP) for a total of ten (10) persons (1:10) being served by that FSP regardless of the referral source;
(iii) A ratio of no more than one (1) Youth Support Partner (YSP) for a total of twenty-five (25) persons (1:25) being served by that YSP regardless of the referral source;
(iv) Adequate capacity for FSPs and YSPs. Every family shall initially be provided a FSP and YSP until the family decides they do not need either an FSP or YSP; and
(v) Natural supports consisting of a family member, friend, or community member selected by the participant or family, or both, to participate on the CFT. Any form of supports to the family or youth by an unpaid family member, friend, or community members.
(a) The Department shall perform, at minimum, quarterly monitoring of the CME 1915(b) waiver program's impact, access, and quality to ensure access to adequate services where medically necessary.
(i) The Department shall establish standards of quality for CME adherence, including, but not limited to, plan assurances on network adequacy.
(ii) The Department shall deem the CME in compliance with standards as long as the accrediting agency maintains standards as required by the Department.
(b) The Department shall perform, at minimum, annual monitoring of the CMHW 1915(c) waiver to collect information regarding waiver participants and cost effectiveness in accordance with CMS data collection plan.
(c) The Department and the Federal Health and Human Services Agency, or their designee, have the authority to perform monitoring activities as determined appropriate in accordance with the Act. The Department and the Federal Health and Human Services Agency, or their designees, shall perform remediation when necessary and to the level necessary.
Section 14. Conflict of Interest. Conflicts of interest that may result in provider practices that have an appearance of impropriety are prohibited. The Department and the CME shall issue policy regarding conflict of interest in the form of manuals and bulletins to provide guidance to providers on how to avoid practices that result in a potential conflict of interest.
Section 16. Documentation Standards. All documentation shall be conducted pursuant to Chapter 3, Provider Participation.
Section 17. Background Check Requirements.
(a) All service providers shall successfully complete a central registry check, a Federal Bureau of investigation (FBI)/Division of Criminal Investigation (DCI) background screening, and an Office of the Inspector General (OIG) background screening.
(i) A successful background check shall verify the person has not been convicted of an Offense Against the Person including:
(A) Homicide (W.S. § 6-2-101 et seq.);
(B) Kidnapping (W.S. § 6-2-201 et seq.);
(C) Sexual assault (W.S. § 6-2-301 et seq.);
(D) Robbery and blackmail (W.S. § 6-2-401 et seq.);
(E) Assault and battery (W.S. § 6-2-501 et seq.); or
(F) Similar laws of any other state or the United States relating to these crimes.
(ii) A successful background check shall verify the person has not been convicted of an Offense Against Morals, Decency and Family including:
(A) Bigamy (W.S. § 6-4-401);
(B) Incest (W.S. § 6-4-402);
(C) Abandoning or endangering children (W.S. § 6-4-403);
(D) Violation of order of protection (W.S. § 6-4-404);
(E) Endangering children; controlled substances (W.S. § 6-4-405); or
(F) Similar laws of any other state or the United States relating to these crimes.
(iii) All providers and employees of providers providing services to participants pursuant to this Chapter shall complete a Wyoming Department of Family Services (DFS) Central Registry Screening (W.S. § 7-19-201). The screening shall verify that the person does not appear on the Wyoming Department of Family Services Central Registry.
(b) The CME shall verify through a provider attestation that the provider successfully completed the required background checks.
(c) The CME shall require proof of current Wyoming Medicaid provider enrollment before submitting claims to Medicaid on behalf of the provider.
(a) Any willing and qualified agency or individual can enter into a contract with the CME for the provision of HFWA and respite services.
(b) All HFWA provider requirements are detailed in the Medicaid state plan, Targeted Case Management for Youth with SED/SMI.
(c) All HFWA providers shall comply with Department requirements for obtaining initial credentialing as a HFWA provider and shall recertify their credentials annually.
(d) To be a FCC, the individual shall:
(i) Have a Bachelor's degree in a human service area (or related field), or two years of work or personal experience in providing direct services or linking of services for youth experiencing SED/SMI;
(ii) Be at least twenty-one (21) years of age;
(iii) Complete all Department and CME-required training components;
(iv) Possess a valid driver's license, automobile insurance coverage that complies with the Wyoming Department of Insurance's required liability coverage limits, and car;
(v) Maintain current CPR and First Aid Certification;
(vi) Complete the HFWA credentialing processes as specified by Medicaid;
(vii) Be enrolled as a Wyoming Medicaid provider;
(viii) Be under contract (or have an employment agreement) with the CME; and
(ix) Successfully pass all background screenings as required by Medicaid.
(e) To be a FSP, the individual shall:
(i) Have a high school diploma or GED equivalent;
(ii) Be a parent or caregiver of a youth with behavioral health needs or have two years of experience working closely with youth with serious emotional/behavioral challenges and their families;
(iii) Have a minimum two years of experience in the behavioral health field;
(iv) Complete the credentialing requirements specified by Medicaid;
(v) Be enrolled as a Wyoming Medicaid provider;
(vi) Be under contract (or have an employment agreement) with the CME;
(vii) Be at least twenty-one (21) years of age;
(viii) Successfully pass all background screenings as required by Medicaid; and
(ix) Complete all Medicaid-required training components.
(f) To be a YSP, the individual shall:
(i) Have a high school diploma or GED equivalent;
(ii) Be a youth with behavioral health needs or have experience overcoming various systems and obstacles related to mental and behavioral health;
(iii) Successfully pass all background screenings as required by Medicaid;
(iv) Complete the credentialing requirements specified by Medicaid;
(v) Be enrolled as a Wyoming Medicaid provider;
(vi) Be under contract (or have another employment agreement) with the CME;
(vii) Be eighteen (18) to twenty-six (26) years of age; and
(viii) Complete all Medicaid-required training components.
(g) Respite. Any provider of respite care is required to attain and maintain a certification for this service from the CME and shall:
(i) Successfully pass a criminal history background check per Section 17 of this rule;
(ii) Maintain a current CPR and First Aid Certification;
(iii) Be at least twenty-one (21) years of age;
(iv) Have two (2) years of work/personal experience with youth; and
(A) Preference is given to individuals who have worked with a youth with serious emotional disturbance;
(v) Maintain auto insurance as required by state law if transporting enrolled youth.
(h) The CME shall ensure all provider qualifications are met upon initial contracting and annually thereafter.
(i) A respite provider determined to be out of compliance with Department requirements at any point in the year will receive notification from the CME regarding the nature of the non-compliance and a specified timeframe for resolution.
Section 19. Marketing.
(a) All marketing materials produced by the CME shall be approved by the Department before disseminating.
(b) The CME may participate in indirect marketing as follows:
(i) The CME may attend health fairs, sponsor community forums, obtain radio spots, print media, and provide general outreach so long as the entity does not target its material directly to Medicaid beneficiaries.
(c) The CME may participate in direct marketing as follows:
(i) HFWA Youth and Family Handbooks issued to those automatically referred to the CME. Handbooks shall outline all Federal information requirements and include any additional HFWA educational material that may be helpful to families when being assessed for enrollment.
(d) The CME shall not provide gifts or incentives to Medicaid beneficiaries.
Section 20. Transition Process.
(a) Transition of youth who exceed the maximum age limitation shall occur before the end of the month of their twenty-first (21st) birthday:
(i) Any and all pertinent POC shall initiate development of a plan to address transition goals before transition is expected to occur.
(A) Transition plans shall include, but not be limited to, detailed, measurable objectives to be followed by the team in support of the youth and family during the transition.
(b) If a youth loses Medicaid eligibility, the youth is no longer eligible for state plan services. The Department will reserve five (5) waiver funding opportunities per year for Medicaid state plan youth enrolled in the HFWA program who lose Medicaid eligibility to assist with the transition off or completion of their HFWA POC. This transition shall occur concurrently to the youth's loss of Medicaid to prevent a lapse in care.
(c) The Department shall reserve five (5) CMHW program funding opportunities to triage financially and clinically qualified youth with a CASII composite score of 25 or higher or an ESCII composite score of 23 or higher. Immediate service initiation shall occur to prevent or divert the youth from being admitted to an inpatient psychiatric facility for individuals under age 21 as provided in 42 CFR § 440.160.
(d) CME and CMHW participants who are placed out of their community in an out-of-home placement that results from hospitalization, detention, other types of institutionalization, or who have relocated out of their home community for any other reason, shall be disenrolled no later than one hundred twenty (120) days from the initial date of their absence from the community.
(i) Upon written request from the provider, exceptions to the one hundred twenty (120) day absence rule may be allowed when it is anticipated the youth will return to their community within one hundred eighty (180) days of the initial date of their absence, and the CME network provider has gained prior approval from the CME via the youth's current POC to extend wraparound services during this time frame to assist in transition back to the community.
Section 21. Non-English Languages.
(a) Potential enrollee and enrollee materials shall be translated into the prevalent non-English languages, which is defined as any language spoken by approximately four percent (4%) or more of the potential enrollee/enrollee population.
(b) The Department shall maintain an active contract with a translation service. If an enrollee or provider needs translation services, he or she shall contact the CME to set an appointment with the translation service, and the cost shall be billed to the Department.
(c) All marketing and education materials shall be available in prevalent non-English languages. For language needs, other than prevalent non-English languages, the Department shall allow the enrollee or provider to use the translation service at the expense of the Department.
Section 22. Grievance and Complaints.
(a) The CME shall have a system in place for enrollees or providers acting on behalf of enrollees to access a grievance process, an appeal process, and access to the Department's fair hearing system. The CME's grievance procedure shall meet the following requirements:
(i) Notice of the CME's grievance procedure shall be sent to enrollees once the Department informs the CME of the youth's eligibility as a program enrollee;
(ii) The CME's grievance and one-level appeal process must adhere to the timeframes specified in 42 C.F.R. §438.400 and §438.424.
(iii) An enrollee has sixty (60) calendar days from the date on the adverse action notice to file an oral or written request
(iv) The CME shall acknowledge in writing, via certified mail, the receipt of a written or oral grievance or complaint within five (5) working days of receipt;
(v) The CME shall prepare and present a proposed resolution to the complaint within forty-five (45) calendar days from the date the CME receives the grievance. If the CME's proposed resolution is not accepted by the enrollee or entity acting on behalf of the enrollee they may file a request for continuation of benefits within ten (10) calendar days of receipt of the proposed resolution or the intended effective date of the adverse action notification, whichever is later. The CME has thirty (30) calendar days to review and respond to the appeal.
(vi) An enrollee may request a State fair hearing after receiving notice under 42 C.F.R. §438.408 that the adverse benefit determination is upheld by the CME.
(vii) If the CME fails to adhere to the notice and timing requirements in §438.408, the enrollee is deemed to have exhausted the CME's appeals process. The enrollee may initiate a State fair hearing.
Section 23. Audits. Audits shall be subject to the provisions of Chapter 16.
Section 24. Payment of Claims.
(a) The CME is paid using per member, per month (PMPM) administrative services rate for HFWA service administration.
(b) The PMPM paid to the CME for administrative services is contractually negotiated.
(c) The CME network providers are paid on a fee for service basis for the HFWA and waiver services specified in the contract.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of various provisions
Section 28. Incorporation by Reference.
(a) For any code, standard, rule, or regulation incorporated by reference in these rules:
(i) The Department has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules;
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of this section; and
(iii) The incorporated code, standard, rule, or regulation is maintained at the Department and is available for public inspection and copying at cost at the same location.
(b) Each rule or regulation incorporated by reference in these rules is further identified as follows:
(i) Referenced in Sections 9, 18, and 20 of this Chapter is the Wyoming Medicaid state plan, which is incorporated as of the effective date of this Chapter and can be found at https://health.wyo.gov/healthcarefin/medicaid/spa/.
(ii) Referenced in Section 20 of this Chapter is 42 C.F.R. § 440.160, which is incorporated as of the effective date of this Chapter and can be found at http://www.ecfr.gov.
(iii) Referenced in Section 22 of this Chapter are 42 C.F.R. § 438.400, § 438.408 and § 438.424, which are incorporated as of the effective date of the Chapter and can be found at http://www.ecfr.gov.