DEPARTMENT OF HEALTH

PRESCRIPTION DRUG ASSISTANCE PROGRAM

CHAPTER 1

  Section 1. Authority. This Chapter is promulgated by the Department pursuant to the Prescription Drug Assistance Act, 2002 Wyoming Senate Bill No. 34, to be codified as W.S. 42-4-118, and the Wyoming Administrative Procedures Act as W.S. 16-3-101 et seq.

  Section 2. Purpose and applicability.

  (a) This Chapter shall apply to and govern all aspects of the Prescription Drug Assistance Program. This Chapter shall become effective for services provided on or after July 1, 2002.

  (b) The Department shall issue Manuals, Bulletins, or both, to interpret the provisions of this Chapter. Such Manuals and Bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in Manuals or Bulletins shall be subordinate to the provisions of this Chapter.

  (c) The incorporation by reference of any external standard is intended to be the incorporation of that standard as it is in effect on the effective date of this chapter.

  Section 3. General Provisions.

  (a) This Chapter is intended to be read in conjunction with the Prescription Drug Assistance Act, 2002 Wyoming Senate Bill No. 34, to be codified as W.S. 42-4- 118, and the Wyoming Medicaid Rules, except as set forth below.

  (b) In accordance with Section 1 of 2002 Wyoming Senate File 34, W.S. 42- 4-118(a), nothing in this Chapter shall be construed as providing an individual with an entitlement to this program.

  Section 4. Definitions. The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indicates that such is the intent, words in the singular number shall include the plural and vice versa. Throughout these rules gender pronouns are used interchangeably except where the context dictates otherwise. The drafters have attempted to utilize each gender pronoun in equal numbers in random distribution. Words in each gender shall include individuals of the other gender.

  (a) "Act." The Prescription Drug Assistance Act, 2002 Wyoming Senate Bill No. 34, to be codified as W.S. 42-4-118.

  (b) "Adverse action." The denial, suspension, or termination of benefits, other than a suspension or termination caused by a suspension of the Program pursuant to Section 12 or a change in State law, including an amendment to this Chapter.

  (c) "Alien." A person residing in, and who is not a citizen of, the United States of America.

  (d) "Applicant." An individual on whose behalf an application for coverage by the Program has been submitted, but there has been no final determination of eligibility.

  (e) "Application." The form, specified by the Department, on which an applicant indicates in writing the desire to receive benefits.

  (f) "Application date." The date an application is received and date stamped by DFS.

  (g) "Approve." To determine an applicant is eligible for program benefits.

  (h) "Assistance unit." The financially responsible persons living together whose income is considered in determining eligibility for program benefits.

  (i) "Benefit month." The calendar month for which program eligibility will be approved.

  (j) "Benefits." Coverage under the program.

  (k) "Benefit year." The twelve month period following the benefit start date, and each twelve month period thereafter so long as an insured remains eligible.

  (l) "Biennium." The period covering two State fiscal years following each regularly scheduled budget session of the Wyoming Legislature.

  (m) "Change in income." An increase of one-third or more in the monthly income of an assistance unit.

  (n) "Change report." A form, as prescribed by the Department, used to report change in income to DFS.

  (o) "Chapter 1 of the DFS rules." Chapter 1 of the DFS rules.

  (p) "Chapter 1 of the Medicaid Rules." Chapter 1, Medicaid Fair Hearings, of the Wyoming Medicaid Rules.

  (q) "Chapter 3 of the Medicaid Rules." Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.

  (r) "Chapter 16 of the Medicaid Rules." Chapter 16, Medicaid and State Funded Program Integrity, of the Wyoming Medicaid Rules.

  (s) "Chapter 39 of the Medicaid Rules." Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid Rules.

  (t) "Claim." A request by a provider for payment of PDAP funds for services provided to a recipient.

  (u) "Contested case." Contested case as defined in Chapter 1, which definition is incorporated by this reference.

  (v) "Copayment." A charge to a recipient for receiving covered services.

  (w) "Countable." A category of income, or resources, which is used to determine program eligibility.

  (x) "Covered service." Services provided to a recipient that may be reimbursed out of program funds as provided in this Chapter.

  (y) "Department." The Wyoming Department of Health, its agent, designee, or successor.

  (z) "Department of Family Services (DFS)." The Wyoming Department of Family Services, its agent, designee, or successor.

  (aa) "Prescription Drug Assistance Program (PDAP)" The Prescription Drug Assistance Program established by the Act.

  (bb) "Prescription Drug Assistance Program (PDAP) allowable payment." The maximum reimbursement for covered services as specified by this Chapter.

  (cc) "Prescription Drug Assistance Program (PDAP) funds." That State general funds appropriated by the Wyoming State Legislature and available to the Department to make payments to providers for furnishing covered services to recipients.

  (dd) "Effective date of eligibility." A recipient will be covered for services as of the first day of the month in which the recipient submitted an application.

  (ee) "Eligible." An applicant who is approved.

  (ff) "Excess payments." "Excess payments" as defined in Chapter 39, which definition is incorporated by this reference. Except that the phrase "Medicaid Funds" in Chapter 39 is replaced with "Program funds." (gg) "Federal poverty level." The poverty line as specified in the federal poverty guidelines as published and updated annually in the Federal Register pursuant to Section 673(2) of OBRA.

  (hh) "Financial records." All records, in whatever form, used or maintained by provider which are necessary to substantiate or understand a claim submitted to the Department.

    (ii) "Formulary." "Formulary" as defined in Chapter 10, which definition is incorporated by this reference.

  (jj) "Income." Earned income, unearned income, or in-kind payments received from any source, excluding money classified as a resource or exempt income:

    (i) Earned income includes:

      (A) Any payment received by an employee or agent in cash or in-kind as wages, salary, tips, commissions, or pursuant to a contract.

      (B) Net profits received from activities in which the individual is engaged. "Net profits" means the total sum before deductions for personal or employment expenses and excludes the meal allowance used by the Federal Insurance Contribution Act (FICA).

    (ii) Exempt income. Money set aside or free from program policy limits and not counted against program income limits. The following income is exempt:

      (A) Income which is required to be excluded under a federal statute;

      (B) Unearned income paid in-kind to a household member, such as payments made to a third party for food, shelter, clothing, or other needs;

      (C) Educational income, such as grants, scholarships, fellowships, education loans, and work-study income paid to a person who is enrolled in an educational program;

      (D) Needs-based veteran's benefits;

      (E) Reimbursement for expenses incurred by the individual; and

      (F) Child care assistance paid under Title XX of the Social Security Act.

    (iii) In-kind income. Goods or services received in lieu of cash. In-kind income is countable when the individual has a legal right to liquidate such goods or services to cash.

    (iv) Unearned income. Income received which is neither earned by providing goods or services nor defined as a resource.

  (kk) "Income disregard." Income which is not included in countable income.

  Income disregards shall be determined as follows:

    (i) Each working member of a household shall receive a $200.00 per month disregard, except that a married couple shall be entitled to a $400.00 per month disregard;

    (ii) All earned income of a full-time high school student under age eighteen (18) who is living with a caretaker relative;

    (iii) Twenty-five percent of the assistance unit's gross self-employment income or a deduction of actual business expenses; and

    (iv) Fifty ($50.00) dollars of child support per assistance unit.

  (ll) "Inmate of a public institution." "Inmate of a public institution" as defined in 42 C.F.R. 435.1009, which definition is incorporated by this reference.

  (mm) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act or the Wyoming Medical Assistance and Services Act of 1967, as amended. "Medicaid" includes any successor or replacement program enacted by Congress or the Wyoming Legislature.

  (nn) "Medically necessary." Medically necessary as defined by Chapter 3, which definition is incorporated by this reference.

  (oo) "Medical records." All records, in whatever form, in the possession of or subject to the control of a provider which describe a recipient's diagnosis, treatment or condition.

  (pp) "Medical supplies." Disposable, semi-disposable or expendable medical supplies.

  (qq) "Medicare approved Discount Card." A card that provides a discount on prescription drugs specifically for Medicare recipients that is approved by the Centers for Medicare and Medicaid Services.

  (rr) "Month." A calendar month.

  (ss) "Notice of action." A written notice mailed to a recipient which informs the recipient of intended action affecting eligibility for benefits. The notice shall include the action to be taken, the effective date of the action, and the legal authority for the action. Notice shall be timely if mailed, by first-class United States mail, ten days before the effective date of the intended action.

  (tt) "OBRA." The Omnibus Budget Reconciliation Act of 1981, Pub. L. No.

  (uu) "Overpayments." Program funds received by a provider as the result of fraud or abuse, as those terms are defined in Chapter 16 of the Medicaid Rules, which definitions are incorporated by this reference.

  (vv) "Periodic review." A review of a recipient's eligibility. A periodic review shall be conducted every twelve months after the effective date of eligibility. A periodic review is timely if it is conducted within one-month before or one month after the effective date of eligibility.

  (ww) "Physician." A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners.

  (xx) "Prescription." "Prescription" as defined by Chapter 10, which definition is incorporated by this reference.

  (yy) "Program," The Prescription Drug Assistance Program.

  (zz) "Provider." A provider as defined by Chapter 3, which definition is incorporated by this reference.

  (aaa) "Recipient." An individual who has been determined and is currently eligible for the program.

  (bbb) "Residence." The place a recipient uses as his or her primary dwelling place and intends to continue to use indefinitely for that purpose.

  (ccc) "Resident." A person who lives in the State of Wyoming and has the intention of establishing a permanent residence in the State.

  (ddd) "Resource." Real or personal property in which an individual has a legal or equitable interest.

    (i) Exempt resources. A category of resources not subject to program policy or limits and is not counted. The following resources are exempt:

      (A) Any resource for which:

        (I) A legal barrier exists; or

        (II) A restriction exists, such as:

          (1.)  The resource is jointly owned and the co- owner (if the co-owner must legally consent to sale) cannot be located;

          (2.)  The resource is jointly owned and the co- owner (if the co-owner must legally consent to sale) has provided a statement of refusal to sell; or

          (3.)  Legal documents include a barrier to sale or inability to convert to cash.

      (B) Term insurance policies;

      (C) The family home or life estate in family home when lived in by the client, client's spouse or dependent relatives;

      (D) The household furnishings belonging to the assistance unit;

      (E) Trade-in value less than fifteen thousand dollars ($15,000) for one vehicle. Value of each additional vehicle is a countable resource; and

      (F) Real property when the client is making a bona fide effort to sell the property.

      (G) Vehicles and other resources used for self-employment purposes.

      (H) Resources which the assistance unit is making a bona fide effort to sell when:

        (I) The bona fide effort to sell was initiated at least fifteen (15) days prior to application; and

        (II) The bona fide effort to sell has not lasted more than ninety (90) days.

  (eee) "Services." Health or medical services, medical supplies, or medical equipment.

  (fff) "State fiscal year." July 1st through June 30th of the following calendar year.

  (ggg) "State general funds." The dollar amount of the state funds appropriated by the Wyoming Legislature for the program and available for the Department to reimburse providers for furnishing covered services to recipients.

  (hhh) "Termination." To remove a recipient from the program.

  (iii) "Utilization controls." The standards and procedures established pursuant to Chapter 16 of the Medicaid rules, which are incorporated by this reference to deter and detect fraud or abuse by beneficiaries or providers.

  (jjj) "Usual and customary charge." A provider's charge to the general public for the same or a similar service.

  Section 5. Eligibility.

  (a) Introduction. This section is intended to provide uniform procedures for determining eligibility for the PDAP.

  (b) Application process. DFS shall follow the process described below when an individual makes a request for the PDAP program:

    (i) An application form shall be provided;

    (ii) A separate application shall be required for each assistance unit, and the applicant shall be notified, in writing, of the result;

    (iii) The application shall be accepted when complete, and date stamped;

    (iv) Applicants shall be informed of the eligibility criteria and their rights and responsibilities for and services available under the program;

      (A) An application shall be approved if the applicant is found to be eligible; or

      (B) An application shall be denied if the applicant: (1) is found to be ineligible; (2) does not provide all required information; (3) has withdrawn the application; (4) is an inmate of a public institution; or (5) is not a resident of Wyoming.

    (v) Documentation of the action taken and the reasons for the action shall be placed in the applicant's case file.

    (vi) DFS shall provide written notice, delivered by first-class United States mail, to the applicant of the determination.

    (vii) A completed application shall be acted upon within forty-five (45) calendar days from the date it is received;

  (c) Rights of applicants. Applicants have the following rights:

    (i) To apply without delay at the DFS office of choice;

    (ii) To be accompanied or assisted by the person of choice in requesting or completing an application;

    (iii) To request assistance from DFS in completing an application;

    (iv) To apply for PDAP in the DFS office of choice, either in person or by mail, to leave the application at that DFS office, to have eligibility determined and maintained in that DFS office;

    (v) The application and all personally identifiable information shall be kept confidential and shall not be disclosed except as necessary to determine or verify eligibility or in accordance with the rules of the Department.

    (vi) To be treated with respect and nondiscrimination in accordance with applicable federal and state laws.

    (vii) Persons requesting program assistance shall be informed:

      (A) Orally or in writing of the program eligibility factors and required verifications;

      (B) In writing of the effective date of eligibility; and

      (C) In writing of their rights and responsibilities.

    (viii) The denial of an application for benefits is an adverse action and an applicant is entitled to reconsideration and an administrative hearing pursuant to W.S. 16-3-102 and W.S. 9-2-104(a)(vii).

  (d) Responsibilities of applicants.

    (i) An applicant must complete an application in the form and in the manner specified in writing by the Department. The application must be:

      (A) Completed;

      (B) Dated; and

      (C) Signed under penalty of perjury by the applicant.

    (ii) An applicant must cooperate fully in the process of determining eligibility, including the following:

      (A) Provide any and all necessary information required by the application; and

      (B) Promptly provide a notice of change to reflect change in income, a change of address, or a change in health insurance coverage.

    (iii) An applicant who is eligible for the Medicare approved prescription drug discount card, if cost effective, must:

      (A) Upon application, provide the cardholder information; and

      (B) Use the subsidy provided by the card.

  (e) Verifications. The following information shall be documented, and such documentation shall be maintained in the individual's case file:

    (i) Wyoming residence; and

    (ii) The reasons for the denial of eligibility.

  (f) Residents. Eligibility is limited to residents of Wyoming.

  (g) Eligible persons. Eligibility shall be limited to persons whose income is less than or equal to the Federal poverty level.

  (h) Income. Eligibility shall be determined using the countable income of the assistance unit in which the applicant lives.

    (i) Except as specified in paragraph (ii), eligibility shall be determined based on the applicant's family's countable income during the most recently completed calendar month.

    (ii) Income from self-employment shall be based on the monthly average of the assistance unit's annual countable income for the previous twelve month period.

    (i) Resources. Eligibility shall be limited to those with countable resources less than Two Thousand Five Hundred Dollars ($2,500).

  (j) Eligibility redetermination. DFS shall conduct twelve month periodic reviews to determine continuing eligibility. Such reviews shall be done on forms and in accordance with procedures developed and specified in Manuals or Bulletins by the Division.

  (k) Duration of eligibility. After being determined eligible, a recipient shall remain eligible for twelve months following the effective date of eligibility, or until the recipient becomes eligible for Medicaid or the recipient enters a public institution, whichever comes first, unless there is a change in income which renders the recipient ineligible.

  (l) Copayments. Each recipient will be responsible for making co-payments pursuant to this subsection.

    (i) Generic prescription drugs: $10.00 per prescription; and

    (ii) Brand name prescription drugs: $25.00 per prescription.

    (iii) Copayments may be adjusted pursuant to W.S. 42-4-118.

  Section 6. Provider Participation.

  (a) Payments only to providers. No individual or entity that furnishes covered services to a recipient shall receive PDAP funds unless the individual or entity is a provider.

  (b) Eligible providers. An individual or entity that furnishes covered services to a recipient must meet the provider participation requirements of Chapter 3, Provider Participation of the Wyoming Medicaid Rules which are incorporated by this reference.

  (c) Compliance with Chapter 3. An individual or entity which wishes to receive PDAP funds for covered services furnished to a recipient must meet the provider participation requirements of Chapter 3 Provider Participation of the Wyoming Medicaid Rules, which are incorporated by this reference.

  Section 7. Provider Records. A provider must comply with the record keeping requirements of Chapter 3, Provider Participation of the Wyoming Medicaid Rules, which are incorporated by this reference.

  Section 8. Verification of Recipient Data.

  (a) PDAP identification notices. DFS issues PDAP identification notices to recipients. Such notices are valid only for the month and year shown of the notice.

  (b) Failure to notify provider of eligibility. If a provider furnishes services to an individual who fails to notify the provider that he or she is a recipient, the provider may submit a claim to the Department or seek reimbursement or payment from the recipient. A provider that seeks PDAP reimbursement must accept such payments as payment in full, except that the provider may assess and seek to collect a copayment as provided in Section 5.

  Section 9. Covered Services.

  (a) PDAP will reimburse for the services provided in subsection (b) if the services are:

    (i) Medically necessary; and

    (ii) Prescribed by a health care provider licensed to prescribe and acting within the scope of his or her licensure.

    (iii) Services contained in the formulary.

  (b) Service limitations. PDAP shall not reimburse:

    (i) More than a 31 day supply of medication per prescription;

    (ii) Medical supplies, except diabetic supplies.

    (iii) Dispensing limitations. The dispensing limitations of Chapter 10, Pharmaceutical Services of the Wyoming Medicaid Rules, are incorporated by this reference.

    (iv) Additional service limitations. In no event shall the program reimburse for otherwise covered services:

      (A) In excess of the service limitations established pursuant to the Wyoming Medicaid Rules; or

      (B) In excess of the PDAP budget as established by the Wyoming Legislature.

  (c) Dissemination of formulary. The Wyoming Department of Health Pharmacy Unit shall disseminate the formulary, along with any updates, to providers through Manuals or Bulletins.

  Section 10. PDAP allowable payment.

  (a) In General. The PDAP allowable payment for covered services shall be the lower of the providers usual and customary charges or the payment specified in this Section.

  (b) Pharmaceutical services.

    (i) The PDAP allowable payment for pharmaceutical services shall be determined pursuant to the Medicaid allowable payment provisions of Chapter 10, Pharmaceutical Services of the Wyoming Medicaid Rules, which are incorporated by this reference, except that there shall be no exemptions from copayment, and the term "PDAP" shall be substituted for the term "Medicaid" in that rule.

    (ii) Copayment. PDAP services shall be subject to a copayment pursuant to Section 5.

  Section 11. Submission and payment of claims. Payment of claims shall be pursuant to the payment of claims provisions of Chapter 3, Provider Participation of the Wyoming Medicaid Rules, which are incorporated by this reference, except that the term "PDAP" shall be substituted for the term "Medicaid" in that rule.

  Section 12. Contingent on funding.

  (a) Payment contingent on funding. Payment to providers is contingent on the availability of PDAP funds. The Department shall not be obligated to make payments in the absence of such funds.

  (b) Projection of costs. The Department shall project costs of the program at least quarterly and compare those projected costs against PDAP funds. If the funds available to the program are insufficient to meet the projected costs of the program, the Department shall take action to prevent the program from incurring costs beyond available funds, including taking any of the following actions:

    (i) Imposing a moratorium on enrolling new recipients in the program;

    (ii) Reducing the income eligibility level specified in section 4 below the federal poverty level;

    (iii) Imposing higher prescription drug copayments not to exceed twenty-five dollars ($25.00) per prescription;

    (iv) Eliminating specified drugs from the formulary;

    (v) Carrying claims into the next biennium if the amount of claims is less than one twentyfourth (1/24) of the appropriation that has been enacted for the next biennium.

  (c) Automatic termination of PDAP. PDAP shall be automatically discontinued, and reimbursement for services shall be suspended, when and if PDAP funds become exhausted. Claims for services which have not been paid at the time PDAP is discontinued shall be suspended until such time as additional funds are appropriated. If additional, appropriated PDAP funds become available, claims which were suspended shall not be retroactively paid unless otherwise specified by the statute or appropriation which provides for additional PDAP funds.

  (d) Automatic Reinstatement of PDAP. PDAP shall be automatically reinstated, and reimbursement for services shall be reinstated, when and if the Legislature appropriates additional funds. Claims which were suspended shall not be retroactively paid unless otherwise specified by the statute or appropriation which provides for additional PDAP funds.

  (e) Notice of program reduction or termination. The Department shall provide thirty days written notice, if possible, to participating providers and recipients of any program reductions or termination of the program.

  (f) No appeal. A program reduction, termination, suspension, or the denial of eligibility because of a moratorium, shall not be adverse actions and shall not be subject to reconsideration pursuant to this Chapter or an administrative hearing pursuant to Chapter 1, Administrative Hearing of the Wyoming Medicaid Rules.

  Section 13. Audits

  (a) Financial audits. The Department may audit a provider's financial records at any time to determine the accuracy and appropriateness of claims submitted to the Department.

  (b) The Department may recover excess payments pursuant to Chapter 39, Recovery of Excess Payments of the Wyoming Medicaid Rules, which is incorporated by this reference.

  (c) The Department may recover overpayments pursuant to Chapter 16, Medicaid and State Funded Program Integrity of the Wyoming Medicaid Rules, which is incorporated by this reference.

  Section 14. Reconsideration. A provider may request that the Department reconsider a decision to recover excess payments or overpayments. The request for reconsideration, the reconsideration, and any administrative hearing shall be pursuant to the reconsideration provisions of Chapter 3, Provider Participation of the Wyoming Medicaid Rules, which are incorporated by this reference.

  Section 15. Disposition of recovered funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16, Medicaid and State Funded Program Integrity of the Wyoming Medicaid Rules, which provisions are incorporated by this reference.

  Section 16. Interpretation of Chapter.

  (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 its various provisions.

  Section 17. Superseding effect. When promulgated, this Chapter supersedes all prior rules or policy statements issued by the Department, including provider manuals and provider bulletins, which are inconsistent with this Chapter.

  Section 18. Severability. If any provision of these rules or the application thereof to any person, program, service, or circumstance is held invalid, the invalidity shall not affect other provisions or applications of these rules. To the extent that these rules can be given effect without the invalid provision; the provision of these rules are severable.