Section 1. Authority. These rules are promulgated pursuant to W.S. 25-11-108.
Section 2. Purpose. These rules have been adopted to implement W.S. 25-11-101 through 25-11- 108 to:
(a) Establish uniform procedures for collection of charges from residents in Department of Health Institutions: Veterans' Home of Wyoming, Wyoming Pioneer Home, Wyoming Retirement Center, Wyoming State Hospital, and Wyoming State Training School;
(b) Establish charges based upon an ability to pay;
(c) Determine persons legally responsible for payment of established charges;
(d) Establish limitations on liability for established charges;
(e) Establish penalties for giving false or misleading information in determining an ability to pay.
Section 3. Definitions. The definitions provided for in W.S. 25-11-101 as they currently appear or as amended, are incorporated herein by reference. Other applicable definitions are as follows:
(a) "Actual cost" means the cost of providing treatment or services for resident in a state institution including minimum costs, as set by the department having the direct authority and control of the institution, or maintaining of a resident;
(b) "Agency" means the Department of Health which is administratively responsible for the respective institutions;
(c) "Average resident occupancy" means the average resident census for all days during the fiscal year;
(d) "Debt" means any form of legal indebtedness, liability or obligation to pay money by express agreement against the resident's assets such as mortgages, liens, loans, purchase contracts or security interests;
(e) "Deduction" means deductions as per the Department of Family Services Combined Manual unless Department of Health policy dictates otherwise;
(f) "Established charge" means that part of the actual cost for which the resident, and/or resident's estate and legally responsible persons are liable;
(g) "Exemptions" means exemptions as per the Department of Family Services Combined Manual unless Department of Health policy dictates otherwise;
(h) "Income" means all cash, profits, wages or gains available to a person from any source as defined by the Department of Family Services Combined Manual, unless the Department of Health's policy dictates otherwise;
(i) "Indebtedness" means a sum of money due and owing for services rendered at a state health care institution;
(j) "Medicaid" means a program authorized by Title XIX of the Social Security Act, and the Wyoming Medical Assistance and Services Act in W.S. 42-4-101 through 42-4-112;
(k) "Resident" means a patient or resident voluntarily admitted or involuntarily committed to a state health care institution;
(l) "Resources" means assets as per Department of Family Services Combined Manual, unless the Department of Health's policy dictates otherwise;
(m) "Services and treatment" means any help, use or benefit to a resident as a result of the work performed by the staff at a state health care institution, including but not limited to diagnosis, evaluation, medication, therapy or prescribed care, observation, supervision, discharge planning, rehabilitation, reformation, and custodial or domiciliary care. Services and treatment shall not include education provided to any person which is required by state or federal law;
(n) "Schedule of Charges" means sliding scale based upon the ability to pay;
(o) "State Institution" means any state health care institution listed in Title 25 of the Wyoming Statutes that are under the direct authority and control of the Department of Health;
(p) "Third party payor" means an entity which is under contract with the resident or legally responsible person to pay costs for medical, nursing home or other specified services and treatment;
(q) "Verification" means acquiring information or documents that prove a statement to be true.
Section 4. Agency Responsibilities for Collection.
(a) The Agency shall be responsible for:
(i) Promulgating on or before October 1 of each year a schedule of charges based on actual costs for services and treatment at each state health care institution;
(ii) Establishing a schedule of charges for each state health care institution or related group of state health care institutions;
(iii) Establishing criteria for determining an ability to pay established charges, including assessing income and resources and making allowances for that resident and its dependents;
(iv) Deciding which cases will be referred to a collection agency pursuant to W.S. 25-11- 106(c) or to the attorney general's office for further proceedings against the resident's estate pursuant to W.S. 25-11-105(b) and W.S. 9-1-415 (b);
(v) Establishing written policies and procedures for implementing these rules.
Section 5. State Health Care Institution Responsibilities for Collection.
(a) The state health care institutions shall be responsible for:
(i) Establishing a schedule of charges and actual costs for services and treatment given to resident;
(ii) Providing necessary information to third party payors for submission of claims;
(iii) Notifying legally responsible persons of established charges, liability for payment and agency action in the event payment is not made;
(iv) Establishing written policies and procedures necessary for the state health care institution to implement these rules.
Section 6. Notice Requirements.
(a) When a resident is voluntarily admitted or involuntarily committed to a state health care institution, the institution shall advise the legally responsible person in writing prior to admission, at the time of admission or within fifteen (15) days after admission of the following:
(i) The obligation to pay pursuant to W.S. 25-11-101(a) (iii), 25-11-102(c) and 25-11-103;
(ii) The schedule of charges for services and treatment established by the agency pursuant to W.S. 25-11-102(a) or the established daily rate;
(iii) Liability for payment and any applicable limitations as provided in W.S. 25-11-105;
(iv) The right to request agency review of the established charge as provided in W.S. 25-11- 103(b) or appeal the agency decision pursuant to the Wyoming Administrative Procedure Act in W.S. 16-3- 107; and the right of the agency to amend the established charges based upon change of financial information;
(v) Penalties for falsifying or misrepresenting any financial information as provided in W.S. 6-5-303.
(b) Upon the court vesting the legal custody of a child in the agency and ordering the legally responsible person to pay charges pursuant to W.S. 14-6-236, the institution shall comply with the notice requirements;
(c) Whenever the initial established charge is revised after a resident has been admitted, the institution shall notify the legally responsible person within a minimum of thirty (30) days prior to the effective date of the revision. The notice shall also include the basis for the revision and the effective date.
Section 7. Determining Established Charges.
(a) The legally responsible party shall complete the following procedures in determining the established charge:
(i) Complete a financial questionnaire, identifying all income and assets, and any assets disposed of by the legally responsible person in the past three (3) years or in accordance with Wyoming Medicaid Procedure. The Questionnaire shall be:
(A) Signed by the legally responsible person or his/her legal guardian or conservator under oath and subject to penalty of false swearing as set forth in W.S. 6-5-303;
(B) Submitted within forty-five (45) days of the resident's admission. If the financial questionnaire is not submitted within forty-five (45) days, the agency shall set the established charge as the actual cost until financial information becomes available.
(ii) Provide any documents required by the institution for verifying any information stated on the financial questionnaire on an annual basis;
(iii) Update the financial questionnaire on an annual basis;
(iv) Notify the institution of any change in circumstances which affect a legally responsible person's income and assets. The notice shall be submitted to the institution within sixty (60) days of the changed financial status. If a legally responsible person fails to notify the institution within sixty (60) days, the agency may set the established charge as the actual cost;
(v) The legally responsible person may be exempt from the requirements if the legally responsible person pays the actual costs for services and treatment set by the agency throughout the resident's admission to a state institution;
(vi) If payment becomes overdue or the legally responsible person's financial status changes, the legally responsible person shall comply with the financial disclosure requirement;
(b) The institution shall complete the following procedures in determining the established charge:
(i) Review the information stated in the financial questionnaire;
(ii) Verify any stated information by requesting copies of documents as necessary which shall be incorporated into the resident's record;
(iii) Allow any applicable deductions for payments actually made by the legally responsible person including but not limited to:
(A) Federal and state withholding taxes;
(B) Social security taxes and/or other required retirement deductions;
(C) Union or employee association dues;
(D) Court ordered alimony and child support payments.
(iv) Allow minimum living allowances for:
(A) The resident's personal support per the schedule established by the state institution;
(B) The resident's spouse, parent and other legal dependent's supported in the home per the schedule established by the state institution.
(v) Allow any applicable exemptions based upon the resident's needs and the institution's services. Exemptions may not exceed five times the Medicaid resource limit.
(vi) Determine the legally responsible person's ability to pay charges based on available income, assets, deductions and exemptions;
(vii) Obtain an assignment of benefits from the legally responsible person who has the insurance coverage;
(viii) Established charges shall be actual costs in the following situations:
(A) If a legally responsible person submits claims directly to the third party payor in lieu of assigning benefits to the institution; or
(B) If the party payor is obligated by law or contract to pay full actual costs for services provided to a resident admitted to an institution;
(C) If the legally responsible person fails to submit a financial questionnaire.
(ix) Revise the established charge upon the annual promulgation of actual costs or if a change occurs in the resident's financial status;
(x) Review the established charge and ability to pay on an annual basis;
(xi) Refer any payor's protest of the established charge to the agency in accordance with W.S. 25-11-103(b);
(xii) Submit established charges to the administrator or his designee for approval.
Section 8. Confidentiality of records.
(a) A legally responsible person's financial questionnaire and other personally identifiable information are confidential and will not be disclosed except as necessary to determine an ability to pay the established charge, to verify any disclosed financial information, or for use by the state agency in a contested case or other legal proceeding which involves the resident or his legally responsible person;
(b) A legally responsible person shall have signed an authorized consent form prior to a state institution disclosing financial or other personally identifiable information, except as provided in Section 8 (a) of these rules and regulations.
Section 9. Recording and Collecting Charges.
(a) An account shall be established for each resident which records the established charge, payments received, and the unpaid balance of established charges;
(b) Monthly billings shall be sent to the legally responsible person the month following either receipt of the completed financial questionnaire or forty-five (45) days after the resident's admission to a state institution. The monthly billings shall include, at a minimum, the daily established charge and the total monthly balance due. (For specific billing procedures), please refer to relevant policy for applicable state institutions;
(c) If full payment is not received within thirty (30) days after mailing the monthly billing, the state institution shall send a notice to the legally responsible person that the payment is overdue. The notice may also provide that the account may be referred to the agency for collection if payment is not received within ninety (90) days after the end of the month in which the charges accrue;
(d) If full payment is not received within ninety (90) days after the end of the month in which the charges accrue, the account is in arrears, and the state institution may refer the account to the agency for collection. If a third party payor payment is pending, the state institution may refer only the difference between the third party payor payment and the unpaid established charge;
(e) If partial payment is received, the state institution may carry forward the indebtedness according to the state accounting system. Any indebtedness shall be referred to the agency for collection pursuant to W. S. 25-11-106 if full payment is not received within the ninety (90) days after the end of the month in which the charges accrue. The agency retains the right to seek full reimbursement of any unpaid established charges from the resident or other legally responsible persons, or from the resident's estate upon his death by filing claim;
(f) Any collection efforts by the agency shall comply with W. S. 9-1-415. If any unpaid established charges are collected, the agency shall complete the following procedures:
(i) Credit the resident's account for the amount collected;
(ii) Prorate the amount collected if the established charges have accrued at more than one state institution.
(g) Finance or handling charges may apply.
Section 10. Discharge for Nonpayment for Services Rendered.
A resident of a facility may be involuntarily discharged for nonpayment of established charges for services rendered by the facility. The facility shall provide a resident, his guardian or legally responsible person, whichever individual is appropriate, with at least thirty (30) days written notice of the facility's intent to begin steps necessary to involuntarily discharge the resident for failure to pay established charges for services rendered by the facility.
Section 11. Penalties for False Information.
(a) If a legally responsible person knowingly makes a false acknowledgment, declaration or statement in disclosing any information regarding the resident's income and assets on the financial questionnaire, the agency may file a petition with the state attorney general to initiate court proceedings pursuant to W. S. 6-5-303;
(b) Upon verifying a false acknowledgment, declaration or statement on the resident's financial questionnaire, the agency may take any of the following actions:
(i) Reevaluate the legally responsible person's financial status and ability to pay;
(ii) Make any necessary adjustments in the established charges, including setting the established charges as the actual cost;
(iii) Seek reimbursement from the resident, his/her estate and other legally responsible persons for any unpaid established charges to the state institution had the false statement not occurred.
(iv) Discharge the resident.
Section 12. Schedule of Charges.
(a) Criteria for determining ability to pay established charges shall include the following:
(i) Income;
(ii) Exemptions;
(iii) Resources;
(iv) Deductions;
(v) For an adult resident who has a family to support or for a juvenile resident who is supported by a family refer to Department of Family Services Combined Manual; Medicaid / Medicare certified agencies shall have these agencies established charges per state medicaid / medicare manuals / regulations for their program participants.
Section 13. Discharge of Uncollectible Debts.
(a) Institutional determination of uncollectible debts will be submitted to the Agency Director;
(b) Pursuant to W. S. 9-1-415, all uncollectible debts must be certified by the State Auditor's Office on the attached SA-25 Forms.