Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 13-0007-MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH Sr HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 MOO U°vHISfOR%ifM( Akf&'. if"DKAIPa I i Region VIII November 26, 2013 Teri Green, State Medicaid Agent Wyoming Division of Health Care Financing 401 Hathaway Building Cheyenne, WY 82002 Re: SPA WY- 13- 0007-MM3 Dear Ms. Green: Enclosed is an approved copy of Wyoming' s state plan amendment (SPA) 13- 0007-MM3, which was submitted to CMS on August 28, 2013. SPA 13- 0007-MM3 incorporates the MAGI-based income methodology requirements into Wyoming' s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014. Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of Wyoming' s approved state plan: S 10, pages S10- 1 and S10- 2 In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13- 0007- MM3, which should also be incorporated into a separate section in the front of the state plan. Superseding pages of state plan material, SPA 13- 0007-MM3. CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Cindy Riddle of my staff at ( 303) 844- 7116 or by email at Cindy.Riddle@cros.hhs.gov. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid and Children' s Health Operations CC: Chris Bass Lee Clabots, Deputy Director /s/

State/Territory name: Wyoming Submitted By: Chris Bass Last Revision Date: Nov 25, 2013 Submit Date: Oct 8, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. WY-13-0007 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Public Law 111-148; 42 C.F.R. 435.603 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment Income methodology for MAGI eligibility groups Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Delegated to Teri Green, State Medicaid Agent, Division of Healthcare Financing Signature of State Agency Official Page 1 of 2 WY.0418.R00.00 - Jan 01, 2014 11/26/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

Page 2 of 2 WY.0418.R00.00 - Jan 01, 2014 11/26/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 MAGI-Based Income Methodologies S10 1902(e)(14) 42 CFR 435.603 The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. ■ In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: The pregnant woman is counted just as herself. The pregnant woman is counted as herself, plus one. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: Current monthly household income and family size Projected annual household income and family size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of a reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size. Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d). Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Yes No WY-13-0007-MM3 Wyoming Approval Date: 11/26/13 S10, page 1 Effective Date: 01/01/2014

Page 2 of 2 Medicaid Eligibility The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: ■ Age 19 Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. WY-13-0007-MM3 Wyoming Approval Date: 11/26/13 S10, page 2 Effective Date: 01/01/2014

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: WY- 13- 0008- MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Superseding Pages Notice 4) Approved SPA Pages TN: WY- 13- 0008- MMI Approval Dat 06/ 12- 1/ 2014 Effective Date 01! 01 " 014

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 MOMS r, Region VIII July 18, 2013 Teri Green, State Medicaid Agent Wyoming Division of Health Care Financing 401 Hathaway Building Cheyenne, WY 82002 RE: Wyoming# 13- 0008- MM1 Dear Ms. Green: Yesterday you received our notification letter letting you know that Wyoming' s state plan amendment( SPA) 13- 0008-MM1 was approved on June 12, 2014 with an effective date of January 1, 2014. We are sending a copy ofthe following state plan pages and attachments to be incorporated within a separate section at the end of Wyoming' s approved state plan: S14, S25, S28, S30, S32, S33, S50, S51, S52, S53, S54, S55, S57, S59 In addition are sending a summary of the state plan pages which are superseded by SPA 13- 0008- MM1, which should also be incorporated into a separate section in the front of the state plan. Superseding pages of state plan material, SPA 13- 0008- MM1 CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this amendment, please contact Cindy Riddle at( 303) 844- 7116. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid& Children' s Health Operations CC: Chris Bass Lee Clabots, Deputy Director

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202- 4967 rcMS Region VIII July 16, 2013 Teri Green, State Medicaid Agent Wyoming Division of Health Care Financing 401 Hathaway Building Cheyenne, WY 82002 RE: Wyoming # 13- 0008- MM 1 Dear Ms. Green: Enclosed is the approval notification of Wyoming' s state plan amendment ( SPA) 13- 0008- MM1, which was submitted to CMS on October 8, 2013. SPA 13- 0008- MMI incorporates the MAGI- based mandatory and optional eligibility groups' requirements into Wyoming' s Medicaid state plan in accordance with the Affordable Care Act. This SPA was approved on June 12, 2014 with an effective date of January 1, 2014. We will be sending in a separate email, a copy of the following state plan pages and attachments to be incorporated within a separate section at the end of Wyoming' s approved state plan: S14, S25, S28, S30, S32, S33, S50, S51, S52, S53, S54, S55, S57, S59 In addition we will send a summary of the state plan pages which are superseded by SPA 13- 0008- MM1, which should also be incorporated into a separate section in the front of the state plan. Superseding pages of state plan material, SPA 13- 0008- MMI CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this amendment, please contact Cindy Riddle at ( 303) 844- 7116. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations CC: Chris Bass Lee Clabots, Deputy Director

WY.0419. R00.00 - Jan 01, 2014 Page 1 of 2 Medicaid State Plan Eligibility, Sunri as y Page , , 1' 79 State/Territory name: Wyoming Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the.state abbreviation, YY= tire last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered WY- 13- 0008 Proposed Effective Date 01/ 01/ 2014 mm/ dd/ yyyy) Federal Statute/ Regulation Citation Public Law 111- 148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 3640000. 00 Second Year 2015 8528000.00 Subject of Amendment MAGI-based eligibility groups for implementation on January 1, 2014. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Delegated to Teri Green, State Medicaid Agent, Division of Healthcare Financing. Signature of State Agency Official Submitted By: Chris Bass Last Revision Date: Jun 10, 2014 Submit Date: Oct 8, 2013 TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming Page 1 https:// wms- mmdl. cdsvdc. com/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelector. jsp 06/ 17/ 2014

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13- 0008 Wyoming Pages or sections of pages being superseded by S14, S25, S28, S30, S51, S52, S53, S54, S55, and S57, and related pages or sections of pages being deleted as obsolete State Plan Section Complete Pages Removed Partial Pages Removed Page 11, 2. 1( b)( 3) Section 2 Page 1 Page 2, A. 2. b Attachment 2. 2- A Page 3 Page 2, A. 2. c Page 3a Page 2a, A.3 Page 4 Page 5, A. 10 Page 4a Page 9e Page 12 Page 20, B. 14 Page 13 Page 23a, 13. 20 Page 13a Page 23c, 13. 21 Page 14 Page 23c, 13. 23 Page 14a Page 25, CA Page 21 Page 23 Page 23b Page 23d Spplement 1 to Attachment 2. 2- A Page 1 Page 3b Page 1, A.2.a( i) and( iii) Attachment 2. 6- A Page l ] a Page 6 related to AFDC recipients, Page 19 pregnant women, infants, and Page 19a children Page 19b Page 7 related to AFDC- related Page 21 pregnant women, infants, and children Page 12, C. l. e( 2) Page 18, C. 5. e Page 20, C. 5. k Page 25, C. 1 l. a( 3) TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming Page 1

NOMMOMINUMMONOW Supplement l to Attachment 2. 6- A Pages 1- 4 Supplement 2 to Attachment 2. 6- A Pages 1- 5 Pages 2 Pages 1 a and 3 related to AFDC Supplement 8a to Attachment 2. 6- A Page 5 recipients, pregnant women, infants, and children Supplement 12 to Attachment 2. 6- A Pages 1 and 2 Addendum Supplement 14 to Attachment 2. 6- A Page 1 TN: WY- 1 3- 0008- M M 1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming Page 2

Medicaid Eligibility OMB Control Numher 0938- 1148 OGIB Expiration date: 10/ 31:' O14 AFDC Income Standards 514 Enter the AFDC Standards below. All states must enter: MAGI- equivalent AFDC' Payment Standard in Effect As of'May I, 1988 and AFDC" Payment Standard in Effect As of July 16. 1996 Entry of other standards is optional. MAGI-erluivalent AFDC ,Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic.Increase Option The standard is as follows: ri. Statewide standard C" Standard varies by region C' Standard varies by diving arrangement I I C` Standard varies in some other way mteL!he statewide standard J TN: WY- 1 3- 0008- M M 1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S14, Page 1 Pae,e I oi' 7

4( 00 C:MS Medicaid Eligibility Additional incremental amount I lousehold size Standard($) Yes C Na 219 x Increment amount 2 3, S2 3 400 4 438 5 507 6 575 7 648 8 721 x 789 x 10 863 11 883 x 12 1903 x g-), 13 1 14 943 x 115 964 x 16 984 17 1. 004 The dollar amounts increase automatically each year Yes ( 0 No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase'Option The standard is as follows: o Statewide standard TN: WY- 1- 3_-0001-- M— m1 e-.-JmU-a-q1- 2J1 4 S14. Paae 2 Page 2 of' 7

Medicaid Eligibility C' Standard varies by region i C' Standard varies by living arrangement Standard varies in sonic other xvay Enter the statewide standard Additional incremental amount Household size a- Yes No 1 362 Increment amount S 88 E 2 12 3 590 4 659 5 794 6 871 7 9 1, 214 10 1, 28; 11 1. 424 12 1. 497 1. 633 14 1, 704 15 1. 870 I 16 1. 916 17 2, 054 The dollar amounts increase automatically each year C Yes 6i No MGI-equivaleut A IF-DC P4ymetit Staudard in Effect As of July 16 1996 TNI- I.AN- 13- 0008- A.U.41 Apprnv;;] Datp- 111ne 12 2014 te January 1. 2014_ Wyoming S14, Page 3 Page 3 oi' 7

Medicaid Eligibility Income Standard Entry- Dollar Amount Automatic Increase Option S13a Be standard is as follows: Statewide standard Standard varies by region C Standard varies by living arrangement C Standard varies in some other way Enter the statewide standard Additional incremental amount Household size Standard Yes No 1 529 x Increment amount $ 2 737 x 3 873 x 4 999 x 1, 192 x o 1, 327 x 7 1. 515 x 8 1, 644 x 9 1, 841 x to 1. 972 x I 1 1168 x 12 2. 299 x 13 2, 493 x 14 2, 622 1 2. 845 x 16 3, 145 TN: WY- 13-0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S14, Page 4

fc:MS Medicaid Eligibility The dollar amounts increase automatically each year 7 Yes r* No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry- Dollar Amount Automatic Increase Option Sl3a The standard is as follows: C' Statewide standard C Standard varies by region C' Standard varies by living arrangement r' Standard varies in some other way The dollar amounts increase automatically each year C Yes C No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers( CPI-U) since such date. Income Standard Entry- Dollar Amount - Automatic Increase Option 33 he standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each vear Yes C No MAUI-equivalent AFDC Payment Standard in Effect As, of July 16,, 1996,=increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI- U) since such date Income Standard Entry- Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard TN: WY- 13-00 ate: june 12, ZU14 tive Date. janadly 1, totav- U Wyoming S14, Page 5 11&_, e of 7

0CMS Medicaid Eligibility Standard varies by region Standard varies by living arrangement C Standard varies in some other way The dollar amounts increase automatically each year C' Yes C No TANF payment standard Income' Standard :Entry-: Dollar Amount Automatic Increase Option S13a The standard is as follows: C Statewide standard C"` Standard varies by region C' Standard varies by living arrangement C' Standard varies in some other way l' he dollar amounts increase automatically each year C Yes C No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount Automatic Increase Option S 13a Be standard is as follows: C' Statewide standard C Standard varies by region Standard varies by living arrangement Standard varies in some other way lie dollar amounts increase automatically each year Yes C, No PRA Disclosure Statement............--..--.-................ TN: WY- 13-0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S14, Page 6 Page 6 ol' 7

Medicaid Eligibility According to the Paperwork Reduction Act of 1995. no persons are re(luired to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this inkwmatit:ln collection is 0938 1148, ' The time retluired to complete this information collection is estimated to average 40 hours per response, including the time to review- instructions, search existing data resources, bather the data needed, and complete and review the information collection. If you have comments concer17ing the accuracy of the time estimate( s) or suggestions for improving this form, please write to: CNIS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S14, Page 7 Page 7 of 7

Medicaid Eligibility ON413 Control Number 0938- 1148 OMB Expiration date: 10/ 11/ 2014 Eligibility Groups - Mandatory Coverage S25 Parents and Other Caretaker Relatives 42 CFR 435. 1 10 1902( a)( 1 0)( A)( i)( 1) 193 1( b) and ( d) Parents and Other Caretaker Relatives- Parents and other caretaker relatives of' dependent children vvith household income at or Ink below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: EN] Individuals qualifying under this eligibility group Must meet the following criteria: Are parents or other caretaker relatives( defined at 42 CFR 435. 4), including pregnant women. ot' dependent children defined at 42 CFR 435. 4) under age 18. Spouses of parents and other caretaker relatives are also included. The state elects the following options: his eligibility group includes individuals who are parents or other caretakers of children who are 18 vcars old, E] provided the children are full-time students in a secondary school or the equivalent level ot' vocational or technical training. Options relating to the definition ofcaretaker relative( select any that apply): Options relating to the definition of dependent child( select the one that applies): Have household income at or below the standard established by the state. MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SIO MAGI- Based Income Methodologies, completed by the state. ni] Income standard used for this group Minimum income standard The minimum income standard used for this group is the state' s AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S 14 AFDC Income Standards. The he state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. An attachment is submitted. MaximUrn income standard I he state certifies that it has submitted and received approval for its converted income standard( s) for parents and other caretaker relatives to MAGI- equivalent standards and the determination of the Maximum income standard to be used for parents and other caretaker relatives under this eligibility group. An attachment is submitted. The state' s maximum income standard for this eligibility group is: Tiq VVY Approvat-Date—june 12,--20t4------- EfLeefive Date. Wyoming S25, Pagel llat,,e I of 3

Medicaid Eligibility Fhe state' s effective income level for section 1931 families under the Nledicai( I state plan as of March 23, 2010, converted to a MAGI- equivalent percent ofFPI_or amounts by household size. Fhe state' s effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of 1'.' PL or amounts by household size. The state' s effective income level for any population of parents/caretaker relatives under a Medicaid I I 15 7 demonstration as of March 23. 2010, converted to a MAGI- equivalent percent ofFPI, or amounts by household The state' s effective income level for any population of parents/ caretaker relatives Under a Medicaid I 115 demonstration as of December 31, 2013. converted to a MAGI- equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: C A percentage of the federal poverty level: The state's AFDC' payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards, The state' s AFDC payment standard in effect as of July 16. 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers{ CPI- U) since such date, converted to a MAGI- equivalent standard." fhe standard is described in S14 AFDC Income Standards. The slate' s J ANF payment standard, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. C' Other dollar amount F* j income standard chosen: Indicate the state' s income standard used for this eligibility group: The minimum income standard The maximum income standard The state' s Al,D(,' payment standard in effect as of.luly 16, 1996. increased by no more than the percentage increase in the(' onsurner Price Index for urban consumers((` P14,) since Such date. The standard is described in S14 AFDC Income Standards. Another income standard in- between the minimum and maximum standards allowed There is no resource test for this eligibility group. Presumptive Eligibility The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals Under the Pregnant Women( 42 CU' R 435. 116) and/ or Infants and(' hildren under Age 19( 42 ( TR 435. 118) eligibility groups when determined presumptively eligible. C, Yes co No PRA DiSCIOSLIN Statement TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S25, Page 2 Pate 2 of

Medicaid Eligibility According to the Paperwork Reduction Act of 1995. no persons are required to respond to a cc)IIection of inf«rmation unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1148, The time required to complete this irafornration collection is estimated to average 40 hours per response, including the time W review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comrTrents concerning the accuracy of the time estirnate( s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard. Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN: VVY- 1 3- 0008- M M 1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S25, Page 3 Pate 3 of

Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10! 31! 2014 Eligibility Groups - Mandatory Coverage' S28 Pregnant Women 42 CFR 435, 116 1902( a)( 10)( A)( i)( 111) and ( IV) 1902( a)( I0)( A)( ii)( I),( IV) and 0X) 1931( b) and( d) 1920 Pregnant Women- Women who are pregnant or post-partum, with household income at or below a standard established by the state. The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435. 4. Pregnant women in the last trimester oftheir pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 ofthe Act, if they meet the incorne standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435. 1 10. f;i Yes C No MAGI- based income methodologies are used in calculating household income. Please refer as necessary to SI0 MAGI- Based Income Methodologies, completed by the state. Income standard used fir this group Minimum income standard( Once entered and approved by C NIS.. the minimum income standard cannot be changed.) The state had an income standard higher than 133°',o FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of.luly I. 1989, had authorizing,legislation to do so. Yes cs No The minimum income standard for this eligibility group is 133% FPL. Maximum income standard The state certifies that it has submitted and received approval Im its converted income standard( s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used f> r pregnant women under this eligibility group. An attachment is submitted. The state' s rnaxirnum income standard for this eligibility group is: The state' s highest effective income level far coverage of pregnant women under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( 111)( qualified pregnant women). 1902( a)( I0)( A)( i)( IV)( mandatory poverty level- related pregnant women), 1902( a)( I0)( A)( ii)( IX)( optional poverty level- related pregnant women), 1902( a)( I0) A)( ii)( 1)( pregnant women who meet AFL)('.- financial eligibility criteria) and 1902( a)( 10)( A)( ii)( IV) institutionalized pregnant women) in effect under the Medicaid stage plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S28, Page 1 Pat)e I of 4

Medicaid Eligibility The state's highest effective. income level for coverage of pregnant women under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( tll)( qualified pregnant women), I902( a)( 10)( A)( i)( IV)( mandatory poverty level- related pregnant women), 1902( a)( I0)( A)( ii)( IX)( optional poverty level- related pregnant women), 1902( x)( 10) A)( ii)( 1)( pregnant women who meet AFDC financial eligibility criteria) and 1902( a)( 10)( A)( ii)( IV) institutionalized pregnant women) in effect under the Medicaid state plan as of December 1, 20I 3, converted to a MAGI- equivalent percent of FPL. Fhe state's effective income level for any population of pregnant women under a Medicaid 1 1 15 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid l 115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. 185% FP L, I he amount of the maximum income standard is: 154 ° jo FPI_, Income standard chosen Indicate the state' s income standard used for this eligibility group: C The minimum income standard The maximum income standard C Another income standard in- between the minimum and maximum standards allowed. There is no resource test for this eligibility group. F] Benefits for individuals in this eligibility group consist of the following: ko All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy- related services. 0 Presumptive Eligibility The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Ce Yes C Flo The presumptive period begins on the date the determination is made. s The end date of the presumptive period is the earlier of-, File date the eligibility determination for regular Medicaid is made, if an application for Medicaid is tiled by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. There may be no more than one period of presumptive eligibility per pregnancy. i A written application must be signed by the applicant or representative. Effective Date: January 1 2014 Wyoming S28, Page 2 Pate 2 of 4

Medicaid Eligibility Yes C No C' The state uses a single application t6-ni for Medicaid and presumptive eligibility, approved by CIVIS. The state uses a separate application form for presumptive eligibility, approved by CMS. A cop) of the application form is included. 11.........................---.................. An attachment it submitted. 0 The presumptive eligibility determination is based on the following factors: The woman must be pregnant I iouschold income must not exceed the applicable income standard at 42 CI R 435. 1 16. State residency Citizenship. status as a national, or satisfactory immigration status The state uses qualified entities. as defined in section 1920A of the Act, to determine eligibility presumptively tbr this eligibility group. List of QualifieA Entifies 5171 A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility based on ,in individual' s household income and other requirements, and that meets at least one of the following requirements. Select one or more ofthe following types ofentitics used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state' s approved Medicaid state plan and is eligible to receive payments under the plan Is authorized to determine a child's eligibility to participate in a Ilead Start program under the I lead Start Act Is authorized to determine a child's eligibility to receive child care set-vices for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants and Children ( WIC) Under section 17 of the Child Nutrition Act of 1966 Is authorized to determine a child' s eligibility under the Medicaid state plan or for child health assistance under the Children' s Health Insurance Program( CHIP) Zn Is an elementary or secondary school, as defined in section 14 101 of the Elementary and Secondary Education Act of 1965( 20 U';.S. C. 880 1) E] Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state ot-Tribal child support enforcement agency under title IV- D of the Act Is an organization that provides emeroency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV- A of the Act TN: WY- 1 3- 0008- M M 1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S28, Page 3 Page 3 of 4

cm se M caid Eligibility Is an oroanization that determines eligibility for any assistance or benefits provided under any program of pub I ic or assisted housing that receives Federal funds, including the prograul under section 8 or anN, other section of the United States I lousing Act of 1937( 42 UI. S. C. 1437 or under the Native American I lousing Assistance and Self Determination Act of 1996( 25 L JSC. 4 10 1 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organi7ation. or an Urban Indian Organization I Other entity the agency determines is capable of making preSURIptiVe eligibility determinations: Name of entity Description I rue Care is a nonprofit organization located in Casper, Wyoming whose advocates and nurses are True(' are Women' s Resource experts in hcIpino women facing unplanned Center pregnancies. This organization is a valuable community asset in making referrals to ensure healthy pre- nancies. The state assures that it has communicated the requirements for qUalified entities. at 1920A( b)( 3) ofthe Act, and has provided adequate trainino to the entities and organizations involved. A copy ofthe training, materials has been included. An att-Achinent is subniiitted. PRA Disclosurc Statement According W the Paperwork Reduction Act of 1995, no persons are required to respond to a collection ofinforniation unless it displays a valid OMB control number. The valid OMB control number for this in formation collection is 09338 l| 48. Tlie dmc required wcomplete this information collection is estimated to average 40 hours per response., including the time to review instructions, xcmrh existing data resources, gather the dala needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate( s) or suggestions for improving this form, please write to: CNIS, 7500 SCCtu-itV BOLdevard, Attn: PRA Reports Clearance Officer. Mail Stop C4' 2h' O5, Baltimore, Maryland 2| 244-| V50. TN: WY- 1 3- 0008M M1 Approval Date: June m. 2O14 Effective Date: January 1. ou14 Wyoming S28, Page 4 Po« u4o[ 4

Milli! 4CMS Medicaid Eligibility IB Control Number 0938- 1148 ONIB Expiration date: 10.%31;,", 014 Eligibility Groups - Mandatory Coverage Infants and Children under Age' 19 S30 CFR 43^. 1 18 I 902( a)( I 0)( A)( i)( I I I),( IV),( VI) and( VII) 11902( a)( I 0)( A)( i i)( IV) and( IX) 1193 1( b) and( d) Infants and Children under Age 19- Infants and children under age 19 with [IOUSehOld income at or below standards established by the state based on age grOUP. The state attests that it operates this eligibility group in accordance with the following provisions: Children qualifying under this eligibility group must meet the following criteria: Are underage 19 I lave household income at or below the standard established by the state. MAGI- based income methodologies are used in calculating household income. Please refer as necessary to S I O MAGI- Based Income Methodologies, completed by the state. zn I Income standard used for infants under age one Minimum income standard The state had an income standard higher than 133% FPI. established as of December 19, 1989 for determining eligibility for infants Under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No The minimum income standard for infants under age one is 133",'o FPL. Maximum income standard The state certifies that it has submitted and received approval for its converted income standard( s) for infants R] under age one to MAGI- equivalent standards and the determination of the maxiBIL1111 income standard to be used for ini"ants under aae one. An attachment is submitted. The state' s maximum income standard for this age group is: The state' s hi- hest effective income level for coverage of infants under age one under sections 193 1 ( low- income families), 1902( a)( I 0)( A)( i)( 111)( qualified children), 1902( a)( I 0)( A)( i)( IV)( mandatory poverty level- related 9 infants), 1902( a)( I 0)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( I 0')( A)( ii)( IV) institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL,. TN: WY- 1 3- 0008- M M 1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S30, Page l Pap-c I of

Medicaid Eligibility The state' s highest effective income level for coverage of infants under age one under sections 1931 ( low- income families)., 1902( a)( 1 0)( A)( i)( 111)( qualified children), 1902( a)( I 0)( A) 6)( IV)( mandatory poverty level- related iril'ants), 1902( a)( I 0)( A)( ii)( IX)( optional poverty level- related infiants) and 1902( a)( I 0)( A)( ii)( IV) institutionalized children)., in effect Under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. C , Fhe state' s effective income level for any population of infants under age one Under a Medicaid 11 I demonstration as of March 23. 2010, converted to a MAGI- equivalent percent of FPL. C, , I'lle state' s effective income level for any Population of infants under age one Under a Medicaid I I I demonstration as of December 31. 2013, converted to a MAGI- equivalent percent of FPL. I FPL Enter the amount of the maximum income standard: 154 °, o FPL Income standard chosen The state' s income standard used for infants under age one is: Ce The maximum income standard If not chosen as the maximum income standard, the state' s highest effective income level for coverage of intants under age one under sections 1931 ( low- income families). 1902( a)( I 0)( A)( i)( 1 11)( qualified children). 1902( x)( 10) C ( 000V)( mandatory poverty level- related infants), 1902( a)( I 0)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( I 0)( A)( ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of March 23. 2010, converted to a MAGI-equivalent percent of FPL. I f higher than the highest effective income level for this age group under the state plan as of March 23). 20 10. and 1 L, i if not chosen as the inaxiinUrn income standard, the state' s highest effective income level for coverage of infants C under age One under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( 111)( qualified children), 1902( a)( 10) A)( i)( IV)( mandatory poverty level- related infants), 1902( a)( I 0)( A)( ii)( IX)( optional poverty level- related infants) and 1902( a)( I 0)( A)( ii)( l V)( institutionalized children), in effect under the Medicaid state plan as of December 31. 2013. converted to a MAGI- equivalent percent of HL. If higher than the ag highest effective income level for this e group under the state plan as of March 23. 2010, and L_ C if not chosen as the maximum income standard, the state' s effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. It' higherthail the highest effective income level for this age group under the state plan as of March 21, 2010, and C if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid I 115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. C, Another incorne standard in- between the minimum and maximum standards allowed, provided it is higher than the effective inconle standard for this age group in the state plan as of March 21, 2010. Income standard for children age one through age five. inclusive Do Minimum income standard TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S30, Page 2 Pace 2 of

CMS Medicaid Eligibility The minimum income standard used for this age group is 1331% FPI..,. Maximum income standard The state certifies that it has submitted and received approval for its converted income standard( s) fbr children age one through five to MAGI- equivalent standards and the determination of the maximum income standard to be used for children age one through five. An attachment is submitted. The state' s maximum income standard for children age one through five is: The state' s highest effective income level for coverage of children age one through five under sections 1931 ( lovv- income families), 1902( a)( 10)( A)( i)( III)( qualified children), 1902( a)( 10)( A)(i)( VI)( mandatory poverty level- related children age one through five), and 1902( x)( I0)( A)( ii)( 1V)( institutionalized children), in effect under the Medicaid stage plan as of March 23, 2010, converted to a. MAGI- equivalent percent of' FPL. The state' s highest effective income level for coverage of children age one through five under sections 1931 ( low- C income families). 1902( a)( 10)( A)( 0( 111)( qualified children). 1902( a)( 10)( A)( i)( VI)( mandatory poverty level- related children age one through five), and I902( a)( I0)( A)( ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of December 31, 201:), converted to a MAGI- equivalent percent of FPL. C The state' s effective income level for any population of children age one through five under a Medicaid 1 115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. The state' s effective income level for any population of children age one through five under a Medicaid 11 15 demonstration as of December 31, 2013. converted to a MA61- equivalent percent of FPL. Enter the amount of the maximum income standard: 154 ;, i, FPI- Income standard chosen The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state' s highest effective income level for coverage of children age one through five under sections 1931 ( low- income families), 1902( a)( 10)( A)( i)( I11)( qualified children), I902( a)( 10)( A)( i)( Vl)( mandatory poverty level- related children age one through five), and 1902( x)( I0)( A)( ii) IV)( institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under- the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state' s highest effective income level for coverage of children C age one through five under sections 1031 ( low- income families), 1902( a)( 10)( A)( i)( I11)( qualified children), 1902( a)( l0)(A)( i)( VI)( mandatory poverty level- related children age one through five), and 1902( a)( I0)( A)( ii) IV)( institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S30, Page 3 Page 3 of 5

Medicaid Eligibility Ifiligher than the highest effective income level for this age group under the state plan as of March 21, 2010, and C if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23. 2010, converted to a MAGI- equivalent percent of FPL. If' higher than the highest effective income level for this age group under the state plan as of' N'larch 23, 2010, and C if not chosen as the maximurn income standard, the state' s effective income level for any population of children age one through five under a Medicaid I 115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent. of FPL. C Another income standard in- between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Do Income standard for children age Six through age eighteen., inclusive Minimum income standard File minimum income standard Used for this age group is 1331,1,) FPL. Maximum incorne standard The state certifies that it has Submitted and received approval for its converted income standard( s) for children age six through eighteen to MAGI- equivalent standards and the determination Of the InaXillIL1111 iuC011lc standard to be used for children age six through age eighteen. An attachment is submitted. The state' s maximum income standard for children age six through eighteen is: Z-1 The state' s highest effective income level for coverage of children age six through eighteen under sections 1931 low- income families), 1902( a)( I 0)( A)( i)( 111)( qualified children), 1902( a)( I 0)( A)( i)( VI 1)( mandatory poverty level- related children age six through eighteen) and I 902( a)( 10)( A)( ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of March 23. 2010, converted to a MAGI-equivalent percent of FPL. The state' s highest effective income level for coverage of children age six through eighteen under sections 1931 C, ( low- income families), 1902( a)( I 0)( A)( i)( 111)( qualified children), 1902( a)( I 0)( A)( i)( VII)( mandatory poverty level- related children age six through eighteen) and 1902( a)( 10)( A)( ii)(] V)( institutionalized children), in effect t" Z l under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent Percent Of FPL- The state' s effective income level for any Population Of children age six through eighteen under a NvIedicaid I I 15 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FVL.. The state' s effective income level for any population of children age six through eighteen under a Medicaid I 115 C demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. e 1333'o FPL Income standard chosen The state' s income standard used for children age six through eighteen is: 1, 2014 TN: WY- 1 3- 0008- M M 1 Approval Date: June 12, 2014 January Wyoming S30, Page 4 Pav-e 4 of

Medicaid E0i ibility The iriaximurn income standard If not chosen as the maximurn income standard, the state' s highest effective income level for coverage of children age six through eighteen under sections 193 1 ( low- income families), I 902( a)( I 0)( A)( i)( 111)( qualified children). poverty level- related children age six through eighteen) and 1 90-1( a)( 1 0)( A) ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of.N-farch 231, 20 10, converted to a M,AGI- equivalent percent of FPI.. I f hinher than the highest effective incorne level k r this age proup under the state plan as of March 2 1, 20 10. and it' not chosen as the maximum income standard. the state' s highest effective income level for coverage of' children C age six through eighteen under sections 193 1 ( low- income fiarnilies), 1902( a)( 10)( A)( i)( 111)( qualifie(I children). 1902( a)( I 0)( A)( i)( VII)( niaiidalory poverty, level- rclated children age six through eighteen) and 1902( a)( I 0)( A) ii)( IV)( institutionalized children), in effect under the Medicaid state plan as of December 3 1, 2013, converted to If higher than the highest effective income level for this age group under the state plan as of March 23, -)() I O and C if not chosen as the maximum income standard, the state' s effective income level for any population of children age six through eighteen undera Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL If' higher than the highest effective income level for this age group under the state plan as ofMarch 21, 20 10, and C ifnot chosen as the maximum income standard, the state' s effective income level for any population orchildren a- e six throuoh ei- liteen under a Medicaid H 15 demonstration as of' Deceniber 3 1, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in- between the inininiurn and maximum standards alIoNNed, provide(] it is higher than the effective inCOlue standard for this age group in the state plan as of March 23, 2010 There is no resource test for this eligibility group. Presumptive Fligibility I he state covers children when determined presumptively eligible by a qualified entity. PRA Disclosure, Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection nfin| b, mmioo unless it display's u valid OMB control number. The valid OMB control number for this information collection is 0938--1148. The time required to complete this ink`onmion collection is estimated m average 4D hours per response. including the time mreview instmuions, search existing data resources, gather the data needed, and complete and review the info-)rmation collection. If you have comments concerning the accuracy of' the tirne estirnate( s) or Suggestions for improving this k-)rm, please write to : CNIS, 7500 Security Boulevard. Attn: PRA Reports C learance Officer, Mail Stop C4' 26' O5. Baltimore. Maryland 2l244'! 0O, Tw: vvY1a* 0ox' wM1 Approval Date: June 1u. uO14 Effective Date: January 1. un14 Wyoming o30. Page s Pxi),c5o[ 5

Ms Medicaid Eligibility xw e, + re wc w ee• s ru. m... e« a, ega ON413 Control Number 0938- 1148 OMB Expiration date: 10/ 31/ 2014 Eligibility Groups- Mandator; Coverage S3 Adult Group 1902( a)( 10)( A)( i)( Vlll) 42 CUR 435, 119 The state covers the Adult Group as described at 42 CUR 435. 119. C Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid ONIB control number. The valid OMB control number for this information collection is 0938- 1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate( s) or suggestions for improving this f6rm. please write to: CMS. 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4 26 05, Baltimore.; Maryland 21244 1850. TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S32, Page 1 Pate 1 of 1

Medicaid Eli =bility O\ 48 Control Number Q938-|\ 48 OMB Expiration date: | O/ 3|/` 0| 4 42 CFR 435. 150 I ormer Foster Care Children - Individuals under the age of' 26, not otherwise mandatorily cligible. who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. The state attests that it operates this eligibility group under the following provisions: Fn Individuals qualifying under this eligibility group must meet the lbllo, ving criteria: Are under a- c 26. Are not otherwise eligible for and enrolled fbr mandatory coverm,e under the state plan. except that eligibility under this group takes precedence over eligibililV under th dult Group. Were in foster care under the responsibility ofthe state or 1 ribe and were enrolled in Medicaid under the state' s state plan or 1115 demonstration when they turned 18 or at the time ofaging out ofthat state' s or Tribe' s foster care The state elects to cover children who were in foster care and on 11viedicaid in atLy, state at the linfle they turned 18 or aged out of the foster care system. The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Worren( 42 CTR 435, 116) and/ or Infants and Children under Age 19( 42 CFR 435. 118) eligibility groups when determined presumptively eligible. According w the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid ONMB control number for this information collection is 0938- 1148, The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search e,\ istin(, data resources, gather the data needed, and complete and review the information C011CCtiOn. If You have comments concerning the accuracy of the tinne estiniale( s) or suggestions fior improving this lbrin, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4- 26' O5. Baltimore, Maryland 2| 344' l85O Tw: vvY1n-0oox' MM1 Approval Date: June 1z. uo14 Effective Date: January 1. zo14 Wyoming S33. Pago1 pooc | o[|

Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10; 31%2014 Eligibility Groups - Options for Coverage S50 Individuals above 133% FPL 1902( a)( 10)( A)( ii)( XX) 1902( hh) 42 CFR 435. 218 Individuals above 133% FPL- The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CER 435. 218. Yes (« No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control rlurnber for this information collection is 0938- 1 148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write tip: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN: WY- 13-0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S50, Page 1 Pace I of 1

Medicaid Eligibility xs. map. xua: surd, n... ti...• hss sn.•, K OMB Control Number 0938- 1148 OMB Expiration date: 10%3112014 Eligibility Groups - Options for Coverage 51 Optional Coverage of Parents and Other Caretaker Relatives 42 CFR 4, 5. 220 1902( a)( 10)( A)( ii)( I) Optional Coverage of Parents and Other Caretaker Relatives- The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435. 220. t Yes No IRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1148. ' 1 he time rcquired to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning;the accuracy of the time estirnate( s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN: WY- 13-0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S51, Page 1 Page 1 of I

Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10/ 11/ 201.4 Eligibility Groups - Options for Coverage S521 Reasonable Classification of Individuals under Age 21 42 CFR 435. 222 1902( a)( I 0)( A)( ii)( 1) 1902( a)( 10)( A)( ii)( IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classihications or individuals Under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFIZ 435. 222 tt Yes C No ovo The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying under this eligibility group must quality under a reasonable classification by meeting the following criteria: Be under age 21, or a lower age, as defined within the reasonable classification. Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification, Do Not be eligible and enrolled for mandatory coverage under the stale plan. Z t" MAGI- based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI- Based Income Methodologies, completed by the state. The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December I 3 1, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher including disregarding all income) than the current mandatory income standards for the individual' s age. Yes C No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher( including disregarding all income) than the current mandatory income standards for the individual' s age. Yes C No Reasonable Classificat ions Covered in the Medicaid State Plan as of March 23. 2010 The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group. An attachment is subni itted. Current Coverage of All Children under a cified ALYe TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S52, Page l Pace I of 5

MIS" Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/ or income standard used in the Medicaid state plan as of March 23., 2010. provided the income standard is higher than the current mandatory income standard for the individual' s age. The age firnit and/ or income standard used must be no higher than any age firnit and/or income standard covered in the%, ,Ie(licaid state plan as of ecember 31, 2013 or tinder a Medicaid 1115 Demonstration as of March 23. 2010 or December 31, 2013. 1 ligher income standards may include the disregard of all income. Yes (—* No Current Covera2e of Reasonable Classifications Covered in the Medicaid State Plan as of' March 23. 2010 Covered........... I--—- The state covers reasonable classifications of children previously covered in the Medicaid state plan as ofAlarch 23. 2010, with income standards higher than the Current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/ or income standard fZ)r this classification covered in the Medicaid state plan as of December 31, 20 13 or tinder a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes ( No Indicate the reasonable classifications of' children that were covered in the state plan in effect as of larch 23. 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than used in the Medicaid state plan as of December 31. 2013 or tinder a Medicaid 1115 Demonstration as of N'larch 23, 2010 or F) ecember 31, 2013. Current Coverasae of Reasonable Classificatioi.i..s....C..o..vere..d. to- the M.ed.i.caicf-S.Iate. Plan as of March.,23,. 20.10 1 1 --................- -........... Reasonable............--- I- -.....................- Reasonable Class ificatioOS of Childrea S11 Individuals for whorn public agencies are assuming full or partial financial responsibility. Individuals placed in foster care homes by public agencies Indicate the age which applies: Under age 21 C Under age 20 C tinder age 19 U nder age 18 F] Individuals placed in foster care homes by private, non- profit agencies Individuals placed in private institutions by public agencies Indicate the age which applies: aW Under age 21 C Under age 20 C' hinder age 19 C Under age 18 F Individuals placed in private institutions by private, non- profit agencies Individuals in adoptions subsidized in Full or part by a public agency Individuals in nursing facilities, if nursing facility services are provided tinder this plan Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided tinder this plan L Effectove Date7 Janua[ y 1. 2014 TN- I.AX- 13- 0009- MIAI 90j 4 Wyoming S52, Page 2 Pate 2 of

Medicaid Eligibility Other reasonable classifications Enter the income standard used for these classifications. ' I lie income standard must be higher than the mandatory standard for the child' s age. It may be no lower than the income standard used in the state plan as of March 23, 2010 and no higher than the highest standard used in the Medicaid state plan as of December 31, 210 13 or under a Z Medicaid I 1 1 5 Demonstration as of March 23, 2010 or December 31, 2013. Click k'e" o nce-, fi io- r-m- a6o-ve is complete to view ti; e income standards forum. Individuals placed in foster care hones, by public agencies Income standard used Minimum income standard The rninirnuin income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI- equivalent. This standard is described in S 14 AFDC Income Standards. Maximum income standard No income test was used( all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013. or under a Medicaid 1115 Demonstration as of March 23. 2010 or December 31, 2013. ce Yes C No No income test was used( all income was disregarded) for this classification under: check all that apply) Me Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. F] A Medicaid 1115 Demonstration as of March 23, 2010. E] A Medicaid 11 15 Demonstration as of December 31, 2013 The state's maximum standard for this classification of children is no income test( all income is disregarded). Income standard chosen Individuals qualify under this classification under the following income standard: 6 This classification does not use an income test( all income is disregarded). C The ininii-nuin standard. Another income standard higher than both the minimum income standard and the effective income C C level for this classification in the state plan as of March 23. 2010. converted to a MAGI equivalent. tndividtllals placed in private instituti6us by public agencies TN: VVY- 13- uuub- mmi Approva! Date. june 12, 20 14 Effeche BatM. jai mai y 1, 2014 iming S52. Panp 3 1 PaLze 3 of'

Medicaid Eligibility Income standard used Minimum income standard The minimum income standard for this classification of children is the AFDC' payment standard in effect as of July 16, 1996, not converted to MAGI- equivalent. This standard is described in S 14 AFDC Income Standards. Maximum income standard No income test was used( all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 201 3, or under a Medicaid 1115 Demonstration as of March 23. 2010 or December 31, 2013. Yes (— No No income test was used( all income was disregarded) for this classification under: check all that apply) The Medicaid state plan as of March 23. 2010. The Medicaid state plan as ot' December 31„ 20 13. E] A Medicaid 1115 Demonstration as of March 213, 2010. D A Medicaid 1115 Demonstration as of December 31, 2013. The state' s maximum standard for this classification ot' children is no income test ( all income is disregarded). Income standard chosen Individuals qualify under this classification under the follo-,ving income standard: Phis classification does not use an income test( all income is disregarded). The minimum standard. Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent, Other Reasonable Classifications PreviousIv Covered The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 201 3, Or under a Medicaid 1115 Demonstration as of I'vlarch 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age D-OUP. C' Yes ( 9' No additional new arse Ljoup-5- or reasonable classifications covered TN: WY- 13- 0008- MM I Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S52, Page 4 Pate 4 of'

0CMS Medicaid Eligibility x¢: " Y. v<,. ubfi. 0 amaw a.e. 549: 4 sk34 If the stage has not elected to covert lie Adult Group( 42 C FR 435. 119), it may elect to cover additional new age groups or reasonable classifications that have riot been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1 1 15 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from. lily 16, 1996, not converted to a MAGI-equivalent standard. Yes is No There is no resource test for this eligibility group. i PRA Disclosure Statement According to the Paperwork Reduction : pct of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09', 8- 1148. ' The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate( s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance. Officer. Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S52, Page 5 Pa,2e 5 o1` 5

Medicaid Eligibility JMB Control Number 0938- 1148 0%, IB Expiration date: 10/ 31/ 2014 Eligibility Croups - Options for Coverage S53 Children with Non W-E Adoption Assistance 42 CFR 435. 227 1902( a)( 10)( A)( i i)( V I I I) Cbildren with Non W- E Adoption Assistance- The state elects to cover children with special needs for whom there is a non IV- E adoption assistance agreement in effect with a stage, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435. 227. rW Yes No The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying under this eligibility group must meet the following criteria: I' he state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; Are under the following age( see the Guidance for restrictions on the selection of an age): W Under age 21 i C Under age 20 C Under age 19 C Under age 18 MAGI- based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- W Based Income Methodologies, completed by the stage. The state covered this eligibility group in the Medicaid state plan as of December 3 I, 201 3, or under a Medicaid 1 115 Demonstration as of March 23. 2010 or December 31, 2013. C: Yes (` No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. 6 Yes (- No Individuals qualify under this eligibility group if they were eligible under the state' s approved state plan prior to the execution of the adoption agreement. The state used an income standard or disregarded all income Ibr this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid I I 15 Demonstration as of March 23, 2010 or December 31, 2013. Yes C No Income standard used for this eligibility group Minimum income standard The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI- equivalent. This standard is described in S 14 AFDC income Standards. Maximum income standard i TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S53, Page 1 Pw-, e 1 of

Disclosure Medicaid Eligibility No incorne test was used( all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23), 2010 or Decernber 3 1, 201 3), or under a Medicaid I I I Demonstration as of rW Yes C No No income test was used( all income was disregarded) fi-)r this eligibility group under check all that apply): I The Medicaid state plan as of March 23, 2010. The Medicaid state plan as ot' December. 33 1. 201 A Medicaid 1115 Demonstration as of March 23, 20 10. A Medicaid 1115 Demonstration as of December 3 1, 20 13. The state' s rriaxiMUM standard for this eli,, ibility group is no income test( all income is disregarded). Income standard chosen Individuals qUalifY under this eligibility group under the followino income standard, NNIiich must be hiolier than the minimum for this child' s age: ZI C The minimum standard. Fhis eligibility group does not use an income test( all income is disregarded). Another income standard higher than both the minimum income standard and the effective income level for this eligibility group in the state plan as of March 23,- 1010, converted to a MAGI- equivalent. Do There is no resource test for this eligibility group. Aocor ingm cPopenvo, RcdouiooAct o[| 995. nopunonomcuquiodmnmpoodNo collection o[ information unless i/ diyy|uy,,-,u valid OMB control numbex. The valid OMB control number for this information collection is O938'| | 48. The time required mcomplete this information collection is estimated movr, ap e40 hours per response, iududioo the time/ o ovicv/ instmcdnos, search cxitio- da( u resources. gatherthe data needed, and complete and review the information collection. |[ yoo have comments concerning the accuracy o[ the time estimazc( s) nr suggestions for improving this| 1orm` please write to: CMS, 75UO8ecu, iry Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4' 26' 05. Baltimore. Maryland 2l244'| X5O, Tm: vvY13-000n' mm1 Approval Date: June 1u. uo1* Effective Date: January 1. un14 Wyoming uoa. Page u Pow,n2of

Medicaid EN0 ibility 0%, 113 Convo\' Numbo0938' 1148 OMB Expiration date: 10V31/ 2014 Disclosure Eligibility Groups - Options for Coverage S54 Optional Tar eted Low Income Children 42 CFR 435. 229 and 435. 4 Optional Ta rgeted Low Income Children- The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435. 4. who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435. 229. PRA According to the Paperwork Reduction Act of 1995, no.) persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number hor this information collection io0938- ll48, The time required mcomplete this infiormation collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. | f you have comments concerning the accuracy o[ the time estimate( s) or suggestions fior improving this ilorm, please write to: CIVIS, 7500 Security Boulevard, Attn: PRA Reports Clearance 0O] ocr, Mail Stop[ 4- 2d' 05. Baltimore. Maryland 2lZ44') D50. TN: vvv 13-0008' Mm1 Approval Date: June 1z. oU14 Effective Date: January 1. uo14 Wyoming S54. Page1 Poue | of!

Medicaid Eligibility 0\ 413 Control Number 0938- 1148 OMB Expiration date: 10/ 31/2014 Eligibility Groups- Options for Coverage S55 Individuals with Tuberculosis 1902( a)( 10){ A)( ii)( XI 1) 1902( z) Individuals with Tuberculosis- The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis- related services. Yes (- No The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying under this eligibility group 111USt meet the following criteria: Are infected with tuberculosis. F Are not otherwise eligible for mandatory coverage under the Medicaid state plan. Have household income under a standard established by the state. iA(..i]- based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI- Based Income Methodologies, completed by the state. Income standard used for this group Maximum income standard First indicate the maxinium income standard that could be used for this Group and then indicate the income standard the state uses for the group. The state elects to convert the effective income level for coverage of this eligibility group in effect in the Medicaid state plan as of March 23, 2010 and December 31, 2013 to MAGI- equivalent standards. C Yes r* No The state' s rnaXiMUrn income standard for this eligibility group is: The break-even point for earned income under-the SSI program. C The he effective income level for this eligibility group Under the Medicaid state plan in effect as of March 23. 2010. riot converted to a MAGI- equivalent standard. The effective incorne level for this eligibility group under the Medicaid state plan in effect as of December 3l, 2013, not converted to a MAGI-equivalent standard. Income standard chosen The state's income standard used for this eligibility group is: o The maxilTIL1111 income standard. Ifs not chosen as the ina.xilnUrn income standard, the break- even point fbr earned income under the SSI program. C Another income standard less than the maximum standard allowed. Individuals qualifying under this group are eligible only for the following services, provided the service is related to the diagnosis, treatment or management of the individual' s tuberculosis. prescribed drugs, described in 42 C[ R 440, 120 T lAfY June Effec iv n 1 2Q14 N. - 13-0008-AU44-- A.pprnv;; l ate 12-. 201A- Daja_ Wyoming S55, Page l Pate 1 of

Medicaid Eli °b=lity pl Physician services, described in 42 CFR 440. 50 Outpatient hospital and rural health clinic described in 42 CFR 44020 and FederalIV- ClUalil'ied health center services Laboratory and x- ray services( including services to confirm the presence of the infection). described in 42 CFR 440. 30 Clinic services, described in 42 CFR 440. 90 Case management set-vices defined in 42 CFR 440, 169 Services other than room and board designed to encourage completion of regirriens of prescribed drugs by out- patients, including services to observe directly the intake of prescription drugs. Limitations related to tubercu losis- related services may be found in the Benefits section. PRA Disclosure Stateinent According to the Paperwork Reduction Act of 1995, no persons are required to resporid to a collection of information unless it displays a valid ONI8 control number. Thc valid OMB control number for this information collection ix0938-| | 48. The time, cqui, cJ/ ocomp|ur this inlormation collection is estimated to average 40 hours per response, including the time to revie\ N,, instructions, search existing data resources. gather the data. needed, and complete and review the information collection. | f you have comments concerning the accuracy n[ the time estimxte( s) nrsuggestions for improving this fibrin, please° ritoto: [ MS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- U5. Baltimore. Maryland 2| 244'| 85O. Tw: mn' 13' O0O8mmI Approval Date: June 1c. uO1* Effective Date: January 1. eO14 Wyoming S55. Page z p« ec2o[

Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10/ 31/ 2014 Eligibility Groups - Options #or,Coverage S57 42 Foster Care Adolescents WW 42 CFR 435. 226 1902( a)( 10)( A)( ii)( XVI I) Independent Foster Care Adolescents- I' ht state elects to cover individuals under an age specified by the state, less than age j 21, who were in state- sponsored foster care on their 18th birthday and who meet the income standard established by the state and I in accordance with the provisions described at 42 CFR 435. 226. Yes i` No j The state attests that it operates this eligibility group in accordance with the following provisions: Individuals qualifying tinder this eligibility group must meet the following criteria: Are under the following age Under age 21 i C Under age 20 C under age 19 Were in foster care under the responsibility of a state on their 18th birthday. Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. Have household income at or below a standard established by the state. MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI- Based Income Methodologies, completed by the state. The state covered this eligibility group under its Medicaid state plan as of December 31. 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. Ce Yes C No 1 he state also covered this eligibility group in the Medicaid stage plan as of March 23, 2010. C Yes ( No The state covers children under this eligibility group, as follows( selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid I 1 15 demonstration as of March 23, 21010 or December 31, 2013): f: All children under the arse selected C A reasonable classification of children under the age selected: F Income standard used for this eligibility group klinimum income standard The minimam income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S57, Page 1 Page 1 of-I

Medicaid Eli ipility No income test was used( all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 3 L,20 13., or under a Medicaid I I 15 Demonstration as of March 23. 20 10 or December 11, 2013 Yes C No No income test was used( all income was disregarded) for this eligibility group under check all that apply): The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 3 1, 2013. E] A Medicaid I I 15 demonstration as of March 23, 20 10, The state' s niaxiniurn standard for this eligibility group is no income test( all income is disregarded). Income standard chosen Individuals qualify under this eligibility group under the following income standard: J his eligibility group does not use an incorne test( al I income is disregarded). IF! There is no resource test. for this eligibility group. PRA DiSCIOSUrc Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection iy0938-| | 4X. The time required tocomplete this information collection is estimated to average 40 hours per response. including the time to review instructions. search existing data resources, gather the data needed, and complete and review the information collection. | f you have comments concerning the accuracy of the time estimate( s) or suggestions for improving this form. please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop[ 4' 26- 0i Baltimore, Maryland 2| 244' l858. TN: vvv 13-0008- mM1 Approval Date: June 1u. uO14 Effective Date: January 1, 2014 Wyoming s57. Page c Poxc2of2

Medicaid Eligibility OMB Control Number 0938- 1148 0i013 Expiration date: 10%31/ 2014 Eligibility Groups- Options for Coverage S59 Individuals Eligible for Family Planning Services 1902( a)( 10)( A)( i i)( XXI) 42 CFR 435. 214 Individuals Eligible for Family Planning Services- The state elects to cover individuals who are not pregnant. and have household income at or helow a standard established by the state. whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435. 214. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0N413 control number. The valid ONIB control number for this information collection is 0918- 1148. " I'he time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions. search existing data resources. gather the data needed, and complete and review the information collection. Ifyou have comments concerning the accuracy of the time estimate( s) or suggestions for improving this form, please write to: CMS, 7500 Secrn•ity Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4- 26-05, Baltimore, Maryland 21244- 1850. TN: WY- 13- 0008- MM1 Approval Date: June 12, 2014 Effective Date: January 1, 2014 Wyoming S59, Page 1 Page I of I

Table of Contents State/Territory Name: Wyoming State Plan Amendment ( SPA) #: WY-13- 0009- MM This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) Summary Form 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan TN: WY- 13- 0009- MM Approval Date: 12/ 31/ 13 Effective Date: 10/ 01/ 2013

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 Region VIII January 14, 2014 Teri Green, State Medicaid Agent Wyoming Division of Health Care Financing 401 Hathaway Building Cheyenne, WY 82002 RE: Wyoming 13- 0009- MM Dear Ms. Green: Enclosed is an approved copy of Wyoming' s state plan amendment ( SPA) 13- 0009-MM, which was submitted to the Centers for Medicare & Medicaid Services ( CMS) on October 8, 2013. SPA 13- 0009- MM incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into Wyoming' s state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013. The approval of SPA 13- 0009- MM includes full approval of your state' s alternative single streamlined application used to apply for multiple human service programs. Until May 31, 2014, the state is using an interim online alternative single streamlined online application. By June 1, 2014 the state will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval. Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the end of South Dakota' s approved state plan: S94, pages S94- 1 and S94- 2 Attachment 3 - Statement of Use with Respect to the Alternative Single, Streamlined Online Application In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13- 0009-MM, which should also be incorporated into a separate section in the front of the state plan. Superseding pages of state plan material, SPA 13- 0009- MM.

Wyoming 13- 0009-MM, Page 2 CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Cindy Riddle at 303- 844- 7116, or by e- mail at Cynthia.Riddle@cros.hhs.gov. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid& Children' s Health Operations CC: Chris Bass Lee Clabots, Deputy Director 2

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300( 5W) CMS San Francisco, CA 94103-6706 C:EN FFR5 FOR, NIFDICARt& MUDICAID SERVICUS DIVISION OF MEDICAID& CHILDREN' S HEALTH OPERATIONS January 14, 2014 Teri Green, State Medicaid Agent Wyoming Division of Health Care Financing 401 Hathaway Building Cheyenne, WY 82002 Dear Ms. Green: This letter is being sent as a companion to Centers for Medicare & Medicaid Services ( CMS) approval of state plan amendment ( SPA) 13- 0009-MM, which was submitted to CMS on October 8, 2013. Our review of this submission included a review of both the paper and online alternative single streamlined applications developed by the state. Until March 30, 2014, the state is using an interim alternative single streamlined on-line application. The interim on-line application must be revised to reflect the following changes: Date by which changes Necessary changes: will be completed: Wyoming will add language to indicate that both family members living together, as well as people sharing a tax return, should be April 1, 2014 included on the application. Wyoming will remove a question about applicants being deceased. April 1, 2014 Wyoming will not request documentation from the application filer unless attestations cannot be verified using electronic data April 1, 2014 sources. The following questions will not appear, by not later than April 1, 2014, for applicants that have not indicated potential eligibility on a non-MAGI basis: Questions regarding strudent status; Questions regarding child support income; April 1, 2014 Questions regarding resources; Questions regarding disregards not applicable under MAGI The following questions will not appear for household members who are not seeking any benefits: Questions regarding citizenship; April 1, 2014 Questions regarding residency; Questions regarding immigration status

Page 2 of 2, Teri Green Applicants will have the opportunity to identify themselves as American Indian and Alaska Natives for purposes of cost-sharing protections, and identify American Indian and Alaska Native April 1, 2014 income not countable for Medicaid and CHIP income determinations. Please submit the revised alternative single streamlined on-line application to CMS for review no later than March 1, 2014 to ensure approval by April 1, 2014. We continue to be available to provide technical assistance. For technical assistance with your application, please contact Dena Greenblum at 410- 786- 8684 or Dena.Greenblum@cros.hhs.gov. If you have any questions or require any further assistance, please contact Cynthia Riddle of my staff at either 303- 844- 7116 or by email at Cynthia.Riddle@cros.hhs.gov. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division of Medicaid& Children' s Health Operations CC: Chris Bass Lee Clabots, Deputy Director

WY.0417. R00. 00 - Oct 01, 2013 Page 1 of 2 k] C,. 6;: i ( 2 ikKt iig 1 35th '; siounwrlary 1 s 3 s. State/Territory name: Wyoming Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered WY- 13- 0009 Proposed Effective Date 10/ 01/ 2013 mm/ dd/ yyyy) Federal Statute/ Regulation Citation Public Law 111- 148; 42 C. F. R. 435. 907 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment This Amendment establishes Wyoming Medicaid eligibility processes and application procedures. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Delegated to Teri Green, State Medicaid Agent, Division of Healthcare Financing. Signature of State Agency Official Submitted By: Chris Bass Last Revision Date: Dec 18, 2013 Submit Date: Oct 8, 2013 TN: WY- 13-0009- MM Approval Date: 12/ 31/ 13 Effective Date: 10/ 01/ 13 Wyoming Summary( 179) http:// 157. 199. 113. 99/ MMDL/ faces/ protected/ mac/c0I/ print/ PrintSelector.jsp 01/ 07/ 2014

r MS Medicaid Eligibility OMB Control l°Jurnber 0938- 1148 OMB Expiration date: I0/ 31, 22014 General Eligibility Requirements S94 Eligil)T y ProccsS -- .._. 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance aPf6rdability progrars, developed by the Secretary in accordance with section 1413( b)( I)( A) of the Affordable Cate Act An alternative single. streamlined application developed by the state in accordance with section 1413( h)( I)( B) ofthe Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. 1 An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only far insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted ross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility au such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to deterrine eligibility on a basis other than the applicable MAGI standard which minimizes the burden oil applicants, submitted to the. Secretary. L... An attachment is submitted The agency' s procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 C:FR 435. 1200( 1). by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes f: No Effective IIaTe_ iU7017i3_._.......__..._._..............__ TN: WY- 13- 0009- MM Approval Date: 12/ 31/ 13 Wyoming S94, page 1 l' aw'e I of

MS Mecticaid Eligibility The aoency has procedures to take application,,, assist applicants and perl6rm initial processino ofapplications l6rthe eligibility the title I V- N program, groups listed below at locations other than those used 4or tile reccipt and processing of applications toi inclUding Federal ly- clualified health centers and disproportionate share hospitals. Parents aid Other Caretaker Relatives Pregnant Women Inf'ants arid Children under Age 19 Redetermination Processing Redeterminations of elipibility for individuals whose financial eliuibilitv is base(] on the applicable modified adiusted gross income standard are pei'tormed as follows, consistent with 42 Cli 435' 916: once every I 2Z months Do Without re(lUiring information from the individual ifable to do so based oil reliable information contained in the individual' s account or other more Current information available to the agency If tile agency cannot determine eliggibility solely 011 the basis of the information available to it, or other),vise need,, additional z:1 - It a pre- populated renewal fi) rrn containing the Dn inf6irmation to complete the redetermination, it pro ides tile individu, I wit Redeterminations of eligibility for individuals whose financial efigibilitv is not based oil the applicable modified ad usted gross income standard are perlormed, consistent with 42 CFR 43,. 916( check all that apply): Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of,12 CT'R 435, Subpart M relative to coordination of eligibility and enrollment betv eell Medicaid.(' 11111. ENCIliniges and other insurance affordability programs. The single state agency has entered into agreements ing insurance affordability programs. vith tile Exchanoe and with other agencies administet AccnrdioL, m the Pupc, wor KeducdooAuof\ 99j, nnpcnmnswrmqvimdm, e ondmumJ cb000[ iok`nmuhnnun\ md displays x ndidO Duou n| numkn~ Thcvn| dDh1Duvmm| oomhurDxr hisiof m u| i0000Uouk`niaO9] 8'| l48. Thrbmcrequired mcomp| ae this information collection is estimated m' average 40 hours per response, including the time mreview iusuoc. ioou search existing data resources, gather the data needed, and complete and review the information collection. if YOU have comments concerning( lie accuracy of mvin this| 6mn. please wh/cu: CMS, 75OO Security Boulevard. Aun: PRA KeponuC|mmncu the time cshmo( u) nrsAinns f 00ficu & 4oi| Stop C4Z6-O5. Baltimore, Maryland 2| 344-| 8j0. snommeou nm1no TN: vvv1 0oou xm Approval Date: 1um1no Wyoming ne* page

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION Paper Application 0 Online Application TRANSMITTAL NUMBER: STATE: WY 13- 0009 Wyoming Through May 31, 2014, the state is using an interim online alternative single streamlined application. As of June 1, 2014, the state will use a revised online alternative single streamlined application. The revised application will address the issues outlined in the CMS companion letter, which was issued with the approval of this state plan amendment, concerning the state' s application. The revised application will be incorporated by reference into the state plan. TN: WY- 13-0009- MM Approval Date: 12/ 31/ 13 Effective Date: 10/01/ 13 Wyoming

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: WY- 13- 0010-MM5 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form 3) Superseding Pages Notice 4) Approved SPA Pages 1 TN: WY- 13- 0010- MM5 Approval Dat 1 1/ 18/ 3.013 Effective Date 110} 1!` 2 t} 1 1

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 110L AM 1600 Broadway, Suite 700 Denver, CO 80202-4967 ro" Region VIII November 20, 2013 Teri Green, State Medicaid Agent Wyoming Division of Health Care Financing 401 Hathaway Building Cheyenne, WY 82002 RE: WY- 13- 0010-MM5 Dear Ms. Green: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number ( TN) 13- 0010- MM5. With this SPA, in accordance with the Affordable Care Act, the State affirms residency regulations and addresses interstate agreements and temporary absence protocol. Please be informed that this State Plan Amendment is approved effective January 1, 2014. We are enclosing the summary page (CMS- 179) and the amended plan page( s). If you have any questions concerning this amendment, please contact Cindy Riddle at( 303) 844- 7116. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations CC: Chris Bass Lee Clabots, Deputy Director

WY.0420.R00.00 - Jan 01, 2014 Page l of 2 Medicaid tate Plan Eligibility: ions m' Pa- ( CNIS FIN') State/Territory name: Wyoming Transmittal Number: Please enter the Transmittal Number( TN) in the format ST- YY- 0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= a four digit number with leading zeros. The dashes must also be entered. WY- 13- 0010 Proposed Effective Date 01/ 01/ 2014 mm; dd/ yyyy) Federal Statute/Regulation Citation Public Law 111- 148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment The State affirms residency requirements of the Medicaid program. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Delegated to Teri Green, State Medicaid Agent, Division of Healthcare Financing Signature of State Agency Official Submitted By: Maraizu Onyenaka Last Revision Date: Nov 18, 2013 Submit Date: Oct 8, 2013 htto:H157. 199. 113. 99/ MMDL/faces/ protected/ mac/ c01/ print/PrintSelector.j sp 11/ 20/ 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13- 0010 Wyoming PAGE NUMBER OF THE PLAN SECTION OR PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT(/fApplicable): S88 Non- Financial Eligibility- State Residency Section 2, Page 13, Item 2. 3, TN 87- 5 Attachment 2. 6- A: Page 3, Item 4, TN 13- 0011

4cms Medicaid Eligibility ON113 Control Number 0938- 1148 OXIB Expiration date: 10/31;_' 01- I Non-Financial Eligibility S88 State Residency 42 CTR 435. 403 State Residency The state provides Medicaid to otherwise eligible residents of the state. including residents NNho are absent from the state under certain conditions. Individuals are considered to be residents of the state under the following conditions: Non- institutionalized individuals age 21 and over, or under age 21, capable of indicating intent and who are emancipated or married, if the individual is living in the state and: Intends to reside in the state, including without a fixed address, oi- Entered the state with a Job commitment or seeking employrnew. whether or not Currently employed. C, I I I iidividuals age 21 and over, not living in an institution, who are not capable of indicating intent, are residents of the state in Vl) icll they live. Fwj Nun- institutionalized individuals under 21 not described above and non JV- E beneficiary children: Residing in the state, with or without a fixed address. or F* The state of residency of the parent or caretaker, in accordance with 42( TR 435. 403( h)( I), with whom the individual resides. Individuals living in institutions, as defined in 42 CIA 435, 10 10, including foster care homes, who became incapable of indicating intent before age 21 and individuals Under age 21 who are not emancipated or married: Reaardless of which state the individual resides, if the parent or guardian applying for Medicaid on the individual' s behalf resides in the state, or Reaardless of which state the individual resides, if the parent or guardian resides in the state at the time of the individual', placement, or If the individual applying for; Medicaid on the individual' s behalf resides in the state and the parental rights of the c rm-] institutionalized individual's parent( s) were terminated and no guardian has been appointed and the individual is institutionalized in the state. Individuals living in institutions who becanic incapable of indicating intent at or after age 21, if physically present in the state, unless another state made the placement. Individuals who have been placed in an out- of-state institution, including foster care homes, by an agency of the state. any other institutionalized individual age 21 or over when living in the state with the intent to reside there. and not placed in the institution I) v another state. IV- F eligible children living in the state, or TN: WY- 13- 0010- MM5 Approval Date: 11/ 18/ 13 Effective Date: 1/ 1/ 14 Wyoming S88, page l Page i of

Medicaid Eligibility LFI] Othcr\kise meet the requirements of 42 ( TR 435. 403. TN: WY- 13- 0010- MM5 Approval Date: 11118/ 13 Effective Date: 1/ 1/ 14 Wyoming S88, page 2 Pate 2 of 3

Medicaid..%- 0 0 0 ° 0 1& 0N8 00 NN 00N Eligibility Meet the criteria specified in an interstate aareement. The, tate has a policy related to individuals in the state only to attend school. j Other" ise meet the criteriaof resident, but who may be temporarily absent from the state. The state has a definition of temporary absence, including treatment of individuals who attend school in another state. Provide a description ofthe definition: N,' hen the client leaves Wyoming for an indefinite period of time and intends to return to Wyoming"\ hen the purpose of the absence has been accomplished. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, 110 Pei-soiis( ire required to respond to a collection ofinforniation unless it displays a valid OMB control number. I-lie valid OMB control number for this information collection is 0938 1148. The time required to complete this information collection is estimated tnovcm c40 hours poresponse. including the time u review instructions. search existing data osounes. x|horthe dumneeded, and oomp| e and review the information collection. |[ you have comments concerning fkcxoumcy of the time csLinnmu( a) orsuggestions for improving this| hnn. please write to: CN8` 7500 Security Bou| ovoW`& un: PK.A Reports Clearance Officer, Mail Stop C4- 26' O5, Baltimore, Nur?|ond2| I44-| 85O. TN: vvv13-0010- Mm5 Approval Date: 11118n3 Effective Date: 1nn4 Wyoming S88, page

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 13-0011 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 ENV d RS FOR% 1t:I3WARF.& sbW( B Region VIII November 6, 2013 Teri Green, State Medicaid Agent Wyoming Division of Health Care Financing 401 Hathaway Building Cheyenne, WY 82002 RE: Wyoming# 13- 0011 Dear Ms. Green: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number ( TN) 13- 0011. With this SPA, the State affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility in accordance to the Affordable Care Act. Please be informed that this State Plan Amendment is approved effective January 1, 2014. We are enclosing the Summary Page ( CMS- 179) and the amended plan page( s). If you have any questions concerning this amendment, please contact Cindy Riddle at( 303) 844- 7116. Sincerely, Mary Marchioni Acting Associate Regional Administrator Division for Medicaid& Children' s Health Operations CC: Chris Bass Lee Clabots, Deputy Director /s/

State/Territory name: Wyoming Submitted By: Chris Bass Last Revision Date: Oct 17, 2013 Submit Date: Oct 8, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. WY-13-0011 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Public Law 111-148 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 150000.00 Second Year 2015 $ 150000.00 Subject of Amendment The State affirms citizenship and immigration status requirements of the Medicaid program. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Delegated to Teri Green, State Medicaid Agent, Division of Healthcare Financing Signature of State Agency Official Page 1 of 2 WY.0421.R00.00 - Jan 01, 2014 11/20/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

Page 2 of 2 WY.0421.R00.00 - Jan 01, 2014 11/20/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

WY-13-0011

STATE:

Wyoming

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S89 Non-Financial Eligibility- Citizenship and Non-Citizen Eligibility

PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Attachment 2.6-A: Page 2, Item 3, Subparagraphs (a) and (b), TN 91-14 Attachment 2.6-A: Page 3, Item 3, Subparagraphs (d) and (e), TN 91-14

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Non-Financial Eligibility Citizenship and Non-Citizen Eligibility S89 1902(a)(46)(B) 8 U.S.C. 1611, 1612, 1613, and 1641 1903(v)(2),(3) and (4) 42 CFR 435.4 42 CFR 435.406 42 CFR 435.956 Citizenship and Non-Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non-citizens consistent with requirements of 42 CFR 435.406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. ✔ The state provides Medicaid eligibility to otherwise eligible individuals: ■ Who are citizens or nationals of the United States; and

■ Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); and ■ Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), 1902(ee) of the SSA and 42 CFR 435.406, and 956.

■ The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. Yes No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. Yes No The date benefits are furnished is: The date of application containing the declaration of citizenship or immigration status. The date the reasonable opportunity notice is sent. Other date, as described: TN: WY-13-0011-MM Wyoming Approval Date: 11/6/13 S89, page 1 Effective Date: 1/1/14

Page 2 of 3 Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non-Citizens whose eligibility is not prohibited by section 403 of PRWORA (8 U.S.C. §1613). Yes No Indicate which requirements apply: The state requires Lawful Permanent Residents to have 40 qualifying work quarters under Title II of the Social Security Act. Yes No The state limits eligibility to 7 years for certain non-citizens. Yes No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903(v)(4) of the Act. Yes No Pregnant women Individuals under age 21: An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. ■ An individual is considered to be lawfully present in the United States if he or she: ■ 1. Is a qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c); 2. Is a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U.S.C. 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U.S.C. 1160 or 1255a, respectively; ■ Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; ■ Granted employment authorization under 8 CFR 274a.12(c); ■ Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended; ■ Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ■ Granted Deferred Action status; ■ Granted an administrative stay of removal under 8 CFR 241; ■ Beneficiary of approved visa petition who has a pending application for adjustment of status; ■ 5. Is an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.1231, or under the Convention Against Torture who - TN: WY-13-0011-MM Wyoming Approval Date: 11/6/13 S89, page 2 Effective Date: 1/1/14

Page 3 of 3 Medicaid Eligibility Has been granted employment authorization; or ■ Is under the age of 14 and has had an application pending for at least 180 days; ■ 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)); 10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903(v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/or present an SSN: ✔ Qualified non-citizens subject to the 5 year waiting period described in 8 U.S.C. 1613; ■ Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903(v)(4) and implemented at 435.406(b). ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: WY-13-0011-MM Wyoming Approval Date: 11/6/13 S89, page 3 Effective Date: 1/1/14

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) W; W'Y- 13- 0012-MM4 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Superseding"Pages Notice 4) Approved SPA Pages TN: WY- 13- 0012- MM4 ApprovalDat 06/ 16/ 2014 Effective Date 01/ 01/ 2014

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services IdErp- l" WM 1600 Broadway, Suite 700 Denver, CO 80202-4967 two Region VIII July 16, 2014 Teri Green, State Medicaid Agent Wyoming Division of Health Care Financing 401 Hathaway Building Cheyenne, WY 82002 RE: Wyoming# 13- 0012- MM Dear Ms. Green: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number WY- 13- 0012- MM. This SPA implements the Affordable Care Act' s provision for addressing the single state agencies delegation of appeals and determinations. Please be informed that this State Plan Amendment was approved on June 16, 2014 with an effective date of January 1, 2014. We are enclosing the summary sheet ( CMS- 179) and the amended plan page( s). If you have any questions concerning this amendment, please contact Cindy Riddle at ( 303) 844- 7116. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid& Children' s Health Operations CC: Chris Bass Lee Clabots, Deputy Director

Medicaid Slate Plan Efii €Dili" : SattriBaary 11af;e ( CMS 179) State/Territory name: Wyoming Transmittal Number: Please enter the TranstnittalhNumber( TN) in thefornmt ST- YY-0000 wliere ST the strne'abbreviation, YY= the last hvo digits of 0_ ofadr,digit number with leading zeros.. The dashes.must also he entered, the subs»sumr t ear, and 0000— _ WY- 13- 0012 Proposed Effective Date. 01/ 0112014 fnm/ dd/ vvPY) Federal Statute/ Regulation Citation 42 CF.R. 431. 10 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment The State affirms that the Department ofHealth is the SingleState: Medicaid Agency. Governor' s Office Review Governor' s office repocted' oo comment Comments of Cove rnor's, office,received Describe: i W No reply received within 45 days;of submittal Other, as specified Describe: Delegated to Teti Green, State Medicaid Agent, Division of Healthcare Financing. Signature of State Ageney.Official Submitted, By: Chris Bass Last.Revision Date: Jun 16, 2014 Submit Date: Oct 8, 2013 TN: WY- 13- 0012- MM Approval Date: 6/ 16/ 14 Effective, Date: 1/ 1/ 14 Wyoming

SUPERSEDING PAGES, OF STATE,PLAN MATERIAL TRANSMITTAL NUMBER: STATE: 13- o012- MM4 Wyoming PAGE NUMBER OF THE PLAN SECTION OR COMPLETE PAGES PARTIAL PAGES ATTACHMENT: SUPERSEDED: SUPERSEDED: A] — A3 Page I Section 1. 4( page 9)( State Medical Care Advisory Section LI ( pages 2- 6) Comnlitteeonly. Tribal consultation will remain in the Section 1. 2( page Z) state plan.) Section 1. 3 ( page 8) Attachment, l_ I- A'( Attorney General certification) Attachment 1. 2- A Organizational cliart); Attach,incm,L2- B-( Description of the functions ofthe single state agency) Attachment. 1. 2- C(Description of professional medical and supporting staff) Attachment 1. 2- D Al- A2 Notwithstanding any other provisions of the Medicaid State Plan. the agencies designated` in Al and A2 will determine eligibility for coverage to the extent specified in l and A2. TN:- VVY- 13- 0012- MM Approval Date: 6/ 16/ 14 Effective Date: 1/ 1/ 14 Wyoming

Medica 'd Administration OMB Control Number 04381148 OMB Eapirationclate: 10131/ 2014 42CFR43L10 Desigmation and Authority State Mine: Wyoming As a condition lox receipt of[ Federal funds, under title XIX of the Social Security Act. the single state agency named. below submits the following state plan for the medical assistance progrpfi, and herehyaecces to administer the' program in accordance is ith the provisions o this state plan, the requirements of tides XI. and XIX of the Act. and all applicable f ede} al' regulations and other official issuances of the Depmorent. Name of snn*_le state tgency: Departmentof.Health Type of Agency: Title I V- A' Agency Co'. Health P' Human Resources Other P-vpe of Agency The above named agency is the single state aL ncs desi« iiated to administer.or supervise the administration of the Medicaid program i tinder title XIX of-the Social Security Act.( All iefevenecs, in this plan to " the Medicaid agency" Mean the agency named as the single state agcncy.) The state statutory citation for the legal. anthoiity under which the single state agency administers. the state plan is: W. S- 42-4- tot-- 41- 4- I17 The single StaI0 allencv SUPCr\ iscs the,acfiriinisnati(, 11 ofiho slate plan by local political. subdivisions. Yes' (_ 9 No Phe ceruhcation signed by the state Attorney General identifying the single state abeney and citing the legal authority under which it administers of aupervisca administration of the piogiam has been provided. Ao artacFhtnent is I a: t c Y O R, ' t Al AN. The state plan may be administered solely by the simle state agency, or some portions may be administered by other agencies- 7 he single state agency administers the entire state plan under title XIX ( i. c_ no other agency or otganiration administers any portion of iQ. Yes {" No 6iTL- M Approval, Date: 4 ffective Date:-1717TV Wyoming Al- 3, Page 1 page I of 5

Medicaid Administration j1h, entity or entities that have responsibility for deterillillations ofeligibility for film liesz adulls, and for individuals under 21 are: The Medicaid rieency Sinale state a,, Ci) cv under T theIV-A( in the 50 states or the District of Colintibim;Of Under Title I or XVI ( AABU) in Guam, El Puerto Rico, or the Viigdn ?stands An Exchange that is a -, owmalent al-cricy estah I ished under,sections 131 N b)( I) or' l 3-11( c)(]) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the agled., blind- and disabled ire; The Medicaid aucncy Sin(de state agency under Title N- A ( iwthc 50 states or the District of Columbia): 01 Ullc[6 ' I itic I or XVI ( AABD) in Guarn. Puerto Rico, or-ti e Virgin Islands E] Air Lxchan,gc thal is a government agency established under sections' 13 I l( b)( I) or 1311( c)( 1) of the Affordable Cate Act Fhe Federal agency administering the SSI pro.grain Indicate which a.,,enev determines cligibility1bi any groups whose eligibility is not determined by the Federal agency: Medicaid a.geno, E] Title IV- Aagency U An FNchan',,e The entity or entities that have responsibility, for conducting fail beatings ofilh respect to denials ofeligibility based on the applicable nocilled ad.jusied Igross income standard ire: Medicaid agency An Exchange that is a government agency established under sections 131 I( b)( I) or I 321( c)( I) of the Affordable Care Act An Exchange appeals entity, including arvenlity established undersection 1411( 1) of,the Affordable Care Act Name cifentitv: [ Olflcccit %I,,, k,etplacc Eligibility Appeals schange or FNCIIIaLe appeals entity or other state agency. bar only with respect-io conclusions oflaw- including inteiprettations of state or federal policies. t:Yes No 1W MIN W u Admin iii PIP, 1 0, . 1 1 1- 11111*- QM 94t", @ON 42 CFR 431.. 10 42 CFR 43 1. 11 Organization arid Administration Provide a description of the organization and functions of the•Medicaid agcnc.y. The \ Vyonning Department of Health is the, Single State: Medicaid Agency. The Deparinnent is divided into the Vuhlic Health Division, Aging-Lik ision. Behasioral Health Division, the Director' s office, ice, and tine9k ision ofHeididicane Financing. The Public Health Division submits Nesurnpik,e Flil6bility for pregnant women applications( the I' Llies built into the eligibility systent make TN WY- 13- 0012- MM Approval Date: 6/ 16114 Effective Date 1/ 1/ 14 Morning A1- 3, Page 2 I' due 2 of 5

Modrea,° Administration d Ad nstr at ®n e • PE determinations) rminationsi and also completes - t 01 assessments which are. man ator} for ceitain Medicaid programs. Tie Aging- Division manages several progi tins for the elderly, sonic of which arcfunded' by rMedidaitl dollars.' I'fie Behavioral Health Division assesses clinical ehgrbility for Wyomingts Developntental:1Disabilities. Acquired. Brain-Injury and Children' s Mental Health waiver programs. The-Director' s Office is responsiblOoroversightofall activities of the, Department of I- Iealth including the management of the Medicaid budget, with [he assistance ofFiscal Service staff. i he;Division of.I-lealthcme Financing( DI-ICP) provides oversight and accountability for the managemerivand operatiowoftlie Medicaid and C1 1111 The Medicaid Progrmn encompasses.Medicaid Waiver, Provider Policy and Reimbuisenlent. Program Integrity: the ti1edicaid Medical Officer, the Medicaid' Dental Officer, Systems and ! Hligrbility and kid Care CHIP MI Of these sectionssarcunder the oversight of the State Medicaid. Agent/Senior Administrator toc.thc Divisiori of I-leafthcare Financing- the Medicaid Dental Officer, reports to the Public Health Division administrator but is a"vail"able to V(edieaid and CHIP stafffor'dental- relateil!geiestions. The; Medicaid Waiver section oversees the Assisted I n mg Facility and tire I lome add Community Based waivers,and coordinates with the Behavioral Health Division on waivers- manae& by: that Division. ' file PRNylde'[' of icy Reiinbibsement section works with Medicaid providers-rewarding payment rates. claiins; training and pharniacy, nsucs.. P-rogram Inte'erity ensures Medicaid payments are billed and paid appropriately, The Medicaid Medical Officer provides clinical adviceand oversight for-Medicaid programs, the Medicaid Dental Officer provides dental clinicahadvice and.ovcisight for Medicaid programs, the Systems and Lligibifity administrates I oversees eligibility for Medicaid and' CHIP programs, including-the Customer Service Center,,and also oversees the Eligibility system and its coordination with the MMIS.' I; he-Kid Care CHIP director,manages CI III, eligibility, policy and the CHIP contract with the insurance vendor. Lligibilily determinations are inade:byDHCF staff with file Use of Wyoming's Medicaid eligibility system if inconsistencies need to be resolved or.•additional information is: necessmy to make a determination. DHCF statTwill manually irucrvei e. All adminrstratve' hearings are conducted by the. Wvonting Office of.Administradve Herrings( OAH), Appellants may also receive an mfornial' hem ine at the single staic agency; if'theychose. prior to an administrative hearing being conducted. OAH is a separate slate agency from the State Medicaid' Agency that isindependentof the policy functions of the Medicaid Prograin. IN ICF staff refers appeals to 0AF1 and provides supporting evidence for the decision that is being appealed. CAI I issues a recommended decision-which is then passed to the Director ofthe Wyoniiifg,Department of Health for a final decision.. An Administrative Law iudgelat OAH issues a recommended decision after the administrative hearing. State Medicaid Agency staff provides input oil ca, e; details andiprogcgin policy prior to and during the hem in&. " throughout This process, the Sate Medicaid Agency retains overslghi iifthelState Plan and monitors the appeals piocess., includinc, the quality and accuracy of the decision- rendered by OAH. The Director of tra Deptutmeril of Health rcvigws, 1 he, 0Al-1 decisions for both conclusions of law and findings of fact and then issues wfrial decision cii the administrative hearing..' I he, Diiectoi considers all documentation and evidence submitted in order:to issue: tire final>decision. The applicant/ benet-wiaty has the opportunity to request a de novo review ac the Department( if Health/ Medicaid agency. The applicant/ berieticiary lisp. has the`.opportunity to appeal the final decision resulting from the administrative hearing through District Court. Upload an organizational chart' of-the' Mcdicaidagency. t- F i i rri. " Ili . " t x , g«. t ,•.at t rk} i 1tD ,,, q : rr,r pr n attachment is submrttect' sin f , s r witfit Provide a desci iptio n- ofthe structuie of.the`state'SlCNecut ive branch which i ncl odes how the hued icai d`agency fits in with other, health; human service and public assistance agencies. In addition to the Division of Ifealthcare Fira icing,.the vbvomiing Department o f f ealth also administers State I1ealthenre Facilities, public health programs, behavioral health programs, and v tai,statistics for the State of Wyoming. I he Wyoming Department of Family Services administers the State' s SNAP HEAP. Child Caw, and I ANF( irograhns As the state agencies that admimsterthe majority ofWyomm ` s=public. assistance proc,rams, the Department of I:Ieeilth and, Depaftment of Family Services coordinate;efforts and have rcgnlai scheduled. meetings.on the topic of service delivery. All Medicaid administrative hearings are conducted by. the' Office of Administrative I fear ings( OAbI)- 6 iait , i3F& m' srf; • " T ;." 4' i' rIPpB?" `" uTr=,{kv4irrf% r`Zt2rfNr`". a, a.r6ir si".{ m 4- rim Fnttes that determine a ipibihty then then the Medrevd is etmp tfentities are)des itbe r ndzr Desr naG nand Authatriv} `{ ii t tillrL+ " hi'?3a;i•.,l'u L.' u', a N°. sr kH113...", 3fm2..cusm: r,W' Y' !.- x- xi'";'L-a?.>s+. a"'sa fiif.: , 4,:; i a..,. k,fli: `.: ia.;t ':, ,"' i 47 t;. wvNE't u m`sRz::movc'j Fvpeof entity that deternii'nes elreihility: Single slate a enev under f rile I V- A ( m the 50 states or_the District of C olmnbia) m under Title I or XVI ( AABD) in Guam. Pucito Rico or the Virgin Islands J TN: WV- 73- 0012- MM Approval Date: 6/ 16/ 14 Effective Dater 1/ 1/ 14 Wyoming AI- 3, Page 3 Page 3 of

Medicaid Administration C(t„ An Exchange that is a goverinnerin agency established under sections. 131 1( 6)( I I or 1321(c)( 1) of the Affordable Care Act C+'I' he, Federal agency administering tire SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. The Fedet ill)- Facilitated Marketplace( FGlg will be dcenimining eligibility. foi Medicaid for groups of individuals whose income eligibility is determined based on MA( hincome methodology°and who apply through the FFM. The FFNI will not be assigning an individual who isdetermined eh<,dble for Medicaid whose income eligibility. is determined usiniz,MAGI methodology to aspecitic eligibility group; determining cost-sharing( if applicable), or assigning a benefit-package— functions that will be performed by the single State agency. Remorse=. Type of entity that determines eligibility: Single state agency under Title IV-/ V{ in the 30 states or the District of Columbia) under" Pule I or XVI (AA BD) in Guam, i Puerto Rico. or the Virgin Islands: C An Exchange that is a government agency established under sections 1 ( bj(.I) or F; 21( c)( I) of the Affordable Care Act C: 1 he Federal agency administering the SSl: program Provide a description of the staff designated by the entity-and the functions they perform in carrying out their responsibility. pursuant to a 1614 agreement; the Social Security Administration determines. Medicaid.eliggibdity lot Supplemental Security Income recipients. w Add,. ? y Fnrtre illiat conduct ffirs l eai vsoil eit} an,th'e Meted card ii ' ( p{fare clesc the i un'de l>eSiSaaTonand Aliithortvj:. l , ' tiKpwIN aPa. Ky}y r?tia) I' a".w°s'"GI.',L F?i .__ ". g'_,' u; t +' gl jry "` °. ti` g .. NPk{ 5 , 3s" ': lVi`Ur.w:.n* 'i` "'... u''r>''`i a..!^., I Retiiove= Pvpe of entity that conducts fair hearinS: An F:xchan,ge that is a government agency' established unifier sections 131 I( b)( Iq or 132I( c)( I) of the Afford able Care Act An Exchange appeals entity. includingan entity established under section 141, 1( 1) of the Affordable Care Act Provide, a description ofthe staff desigmited by the entity and the functionsdi6, perform in carrying out their responsibility. ONIEA will conduct Medicaid fair hearings for individuals whose Medicaid eligibility has been determined and found ineligible for Medicaid by the Federady- facdrtate d I'darketplace( FFNI). These will be individuals-whose income eligibility is determined based on MAGI incomenlethodofogy and who applied for health coverage through the F'FM. AdiLj Supervision of state plan administration sby' local political subdivisions( if described under Designation and Authority) Is the' supervisipn of the administration done through, a state- wide agency which uses local political subdivisions? Q Yes ( 4 No The IN pes of the local subdivisions that adnlinistei the state plan under the superyision,of the Medicaid" agency are: 1 C"Counties C'. Parishes TN WY- 13- 0012- MM A royal Date: 6/ 16/ 14 Effective Date: 1/ 1/ 14 Wyoming A1- 3, Page 4 Pace 4 of

Medicaid Administration C 0tner Are all of the local subdivisions indicated above used to administer-the-state plan? C- Yes ( 7 No go StAtE'x IdnFllj ril «. i , 11. jI11 t t ij C` t rp_, rP*$ tiUa a k..l? 1, PRA' iMP'. A : Acturancc r 42 CPR 431. 10 42 CFR 431. 12 42 CPR 431. 50 Assurances All requirements plan is 42 operation n 9 slitewl, de basil;. in accordance with all the iequirementsbf 42 CF.R 431. 50. Him is a Medical (, are Advisory Comgiittee to the agency director on health and medical.services established in accordance with meeting all the requirement's of CPR 431: 12: The Medicaid agenev does not delegate,: to otherthan its own' officials, the authority to supervise the plan or to develop or issue policies, rules. and regulations onTrogrant,matteis. Assurance for states that Have delegated authority to deterniine eligibility: 1 here is t written a* reenlent between the Medicaid agency and the Exchange or any other stale of- local agency that has been delegated authority to delemnine ehaibility: for Medicald eligibility in compliance with 42 CFR 4" 1. 10td1. Assurances for states that have delegatedauthority`to conduct"fair hearings: here is a written agreement between the Medicaid igency and the Fxchange of Exchange appeals citify that has been deleeated lZi authority to conduct Medreiid fair hearings in coopli'ahce with 42 CFR 4" 1. 10( d); When authority is delegated to the Exchange or gii Exchange appeals entity, individuals who have requested a fair hearing are given 1 the option to have then fair hear mg conducted instead by the Yledicvd aoericy: Assurance for States that have delegated authority to determine eligibility-andior to conduct fairltearings: The Medlcard a e_iic} does not delegate authority to drake eligibility determinations or to:conduct Pair hearings to entities other than government aeericies which maintain personnel slaudirds on a merit basis, PRA Disclosure Statement According to the papeneork Reduction Act of 1995- do persons are required to respond to a collection of intormation unless it displays a valid OMB control rondier. Fhe valid OMB-control-number for this information' collection r is 0938- 1148. The.time required to complete this information collection is estimatI average 40 hours pet response, including the time to review instructions.. search existing data resources, gather the data needed, and complete and review the information collection If you have comments concerning the accuracy of the time eshmate( s), oi sugv,e tioi s forimproving; this" form, please write to: CMS,. 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore. rNlaryland 21244- 1$ 50. TN: VVV- 13- 0012- MM Approval Date: 6116/ 14 Effective Date: 1/ 1114 Wyoming Ai- 3, Page 5 Pace S of 5

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: WY- 14=008 This file contains the following documents in the order listed 1) Approval Letter 2) CMS 179 3) Approved SPA Pages A, TN WY- 14-008 Approval Date 4/ 23/ 14 Effective Date 2/ 1/ 14

DEPARTMENT OF HEALTH& HUMAN' SERVICES Centers for Medicare& Medicaid6e_rvices 1600 Broadway Suite 700 cms Denver CO 80202-4967 Region VIII April 23 2014 Teri Green, State Medicaid Agent, Wyoming Division of Health Care Financing 401 Hathaway Building Cheyenne, WY 82002 RE Wyoming 414-008 Dear Ms. Green. We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number( TN) 14- 008 This SPA concerns Targeted.Case Management for Children with Serious Emotional Disturbance Please be informed that this State Plan Amendment is approved effective February 1, 2014 We are enclosing the CMS- 179"and.the amended',plan page( s) Please note that the SPA WY- 14- 007 corresponds to thisL SPA and is,pending approval This SPA identifies the rate methodology,for the coverage definitions.of'the Target Case Management services m WY- 14=008 Since,the,coverage definitions have not,yet.been approved, changes to SPA WY- 14- 007 could require changes to the State Plan sections that are covered by this SPA. If you have any questions concerning this arnendinent; please contact Cindy Riddle at ( 303) 844- 7116 Sincerely, s/ Richard C Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations CC Chris Bass Lee.Clabois, Deputy Director i

DEPARTMENT Or HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO 0938: 0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1 TRANSMITTAL NUMBER. 2 STATE STATE PLANVATERIAL WYOMING 14- 008 FOR. HEALTH CARE FINANCING,ADMINISTRATION 3 PROGRAM IDENTIFICATION TITLE XIX OF THE SOCIAL SECURITY-ACT ( MEDICAID) TO- REGIONAL.ADMINISTRATOR 4 PROPOSED EFFECTIVE-DATE HEALTHCARE FINANCING ADMINISTRATION February] 2014 DEPARTMENT OF HEALTH AND HUMAN' SERVICES 5 ' TYPE OF PLAN MATERIAL'( Check"One) NEW STATE PLAN. AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 1. 0 IF THIS. IS AN AMEN_DMENT (Se agate Transmittalfor each ainendment) 6 FEDERAL STATUTE/ REGULATION CITATION 7 FEDERAL.BUDGET' IMPACT 42 CFR 441 18, 42 CFR 440 169 0 8 PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9 P-.AGE'NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT( lfApplicable) Attachment 4 19B Item 19 Page 4a 10 SUBJECT OF AMENDMENT Wyoming is seeking to update the targeted case manageinent state plan to include eligible:services,provided to children with a serious emotional disturbance( as defined in Federal Register volume 58, no 96, published.May,20 1' 993' pgs. 29422 through 2942) who are betweerrthe ages of four( 4) and,twenty one( 2 1) and who are being-served by the Care Management Entity( CME) or by the Children s Mental Health Waiver I I GOVERNOR' S REVIEW (Check One) GOVERNOR S OFFICE,REPORTED NO COMMENT Z,OTHER, AS SPECIFIED- Delegated to Teri COMMENTS OF GOVERNOR' S OFFICE ENCLOSED Green, State-Medicaid Agent, Division of NO REPLY RECEIVED WITHIN 45 DAYS' OF•SUBMITTAL Healthcare Financing 11 SIGNATURE OF STATE AGENCY OFFICIAL 1, 6 RETURN TO- s/ TERI GREEN" STATE MEDICAID.AGENT 13- TYPED NAME TERI GREEN DIVISION OF HEALTHCARE FINANCING 6101 YELLOWSTONE, ROAD SUITE 210 14 TITLE STATE MEDICAID AGENT CHEYENNE, WY 82001 15 DATE SUBMITTED- 02/ 26/ 14 CC_' CHRIS BASS.; MANAGEMENT ASSISTANT SAME ADDRESS) FOR' kW1ONAGOFFIC;E.;USE.ONLY,„ . 1. 7 DATE RECEIVED l8 DATE APPROVED- 4/23/ 14 2/ 26714 _ 19 EFFECTIVE DATE OF APPROVED MATERIAL. 20 SIGNATURE',OF REGIONAL OFFICIAL. :. 2/ 1% 14. s% R 4 DMCH . 2'1.` TYPED_ NAME 22: TITLE Richard:C: Allen A_ , l Q . REMARKS w _... k Z r`t a, T FORM HCFA=179( 07- 92)

Attachment.4.19. B Item 19, Page_ 4a STATE PLAN UNDER TITLE XIX' OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE OF WYOMING METHODS. AND.STANDARDS' FOR,EXTABLISHING PAYMENT RATES OTHER TYPES OF SERVICES Payment for Targeted Caso,Management (TCM) services provided to children and youth ages four (4) through twenty- one ( 21), who meet the defnrtton of.having a serious emotional disturbance (per Federal Register,-volume 5.8, no 96; published May' 20, 1993, pgs 29422 through 29425) will be' reimbursed on afee-for-service basis per unit of'service For the purpose of this rule, a unit of service is a-period of 15 minutes. The Department will pay the Power ofthe following for TOM services,for this target population. o The provider' s actual submitted,charge' for the services, or The Department' s fee schedule Except as otherwise noted ma,the plan, state-developed 'fee schedule. rates are the same for both public and private providers of TC,M services Rates do not include the cost of room and board and include only Medicaid allowable costs. Y The agency' s fee schedule,rates for targeted case management services for children and youth ages four (4) through twenty-one ( 2 1) who meet the definition ofhaving a serious emotional disturbance( per Federal Register; volume 58 no 96, published May 20, 1993, pgs. 29422 through.2942 were,last updated on January 1 20`14 The most recent agency fee schedule rates are,effective for services:provided.on or:after February 1, 2014; the effective date of the approved State Plan Amendment. All rates are published at http.// wyequalitycare acs- inc com/fee—whedule.html. w TN, NO M14-008. Approval Date 4/23/14 Supersedes' TN NO ' New Effective Date 2/ 1/ 14

Table of Contents State/Territory Name: WY State Plan Amendment (SPA) #: 20-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 April 7, 2020 Ms. Teri Green State Medicaid Agent Office of Health Care Financing 6101 Yellowstone Road Suite 210 Cheyenne, WY 82002 Re: Wyoming State Plan Amendment (SPA) 20-0003 Dear State Medicaid Agent, Ms. Green: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 20-0003. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions.

The State of Wyoming requested a waiver of public notice requirements applicable to the state plan amendment (SPA) submission process. Public notice for SPAs is required under 42 C.F.R §447.205 for changes in statewide methods and standards for setting Medicaid paymentrates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 forchanges to ABPs. These requirements help to ensure that the affected public has reasonableopportunity to comment on these SPAs. CMS recognizes that during this public healthemergency, Wyoming must act expeditiously to protect and serve the general public. Therefore,under section 1135(b) (5) of the Act, CMS is approving the state’s request to waive these noticerequirements applicable to this SPA. The State of Wyoming also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Under section 1135(b)(5) of the Act, CMS is also approving the State of Wyoming’s request for flexibility to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA. These approvals under section 1135 only apply with respect to SPAs that provide or increase beneficiary access to items and services related to COVID-19 (such as cost sharing waivers, payment rate increases, or amendments to ABPs to add services or providers) and that would not restrict or limit payment or services or otherwise burden beneficiaries and providers, and that are temporary, with a specified sunset date that is not later than the last day of the declared COVID- 19 emergency (or any extension thereof). Even though CMS is approving this waiver, we encourage the state to make all relevant information available to the public so they are aware of the changes. We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Wyoming Medicaid SPA Transmittal Number 20-0003 is approved effective April 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages. Please contact Ford Blunt at (214) 767-6381or by email at Ford.blunt@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Wyoming and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.04.07 17:14:21 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0193 FORM HCFA-179 (07-92) TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: HEALTH CARE FINANCING ADMINISTRATION 1. TRANSMITTAL NUMBER: WY-20-0003 2. STATE WYOMING 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR HEALTH CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 4. PROPOSED EFFECTIVE DATE 04/01/2020 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR 447.55 7. FEDERAL BUDGET IMPACT: a. FFY 2020 $20,000 b. FFY 2021 $0.00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Section 7 Page 89 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): 10. SUBJECT OF AMENDMENT: Medicaid Disaster Recovery – Wyoming Medicaid would like to suspend premiums for the Employed Individuals with Disabilities program during the COVID-19 National Emergency. 11. GOVERNOR’S REVIEW (Check One): GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: Delegated to Teri Green, State Medicaid Agent, Division of Healthcare Financing COMMENTS OF GOVERNOR’S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: TERI GREEN STATE MEDICAID AGENT OFFICE OF HEALTH CARE FINANCING 6101 YELLOWSTONE ROAD, SUITE 210 CHEYENNE, WY 82002 CC: JOLENE FLORES, EXECUTIVE ASSISTANT (SAME ADDRESS) 13. TYPED NAME: TERI GREEN 14. TITLE: STATE MEDICAID AGENT 15. DATE SUBMITTED: FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED – ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: 0DUFK 0DUFK $SULO $SULO $QQH0DULH&RVWHOOR 'HSXW\'LUHFWRU &HQWHUIRU0HGLFDLGDQG&+,36HUYLFHV Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.04.07 17:15:41 -04'00' REDACTED

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 __X__ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X__ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X__ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). ϮϬͲϬϬϬϯ ϬϰͲϬϳͲϮϬ ϬϰͲϬϭͲϮϬ EŽŶĞͲEĞǁWĂŐĞ Zηϭ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ c. _X___ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in WY Medicaid state plan, as described below: Conduct Tribal consultation after submission of the SPA. Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies: Less restrictive resource methodologies: ϮϬͲϬϬϬϯ ϬϰͲϬϳͲϮϬ ϬϰͲϬϭͲϮϬ EŽŶĞͲEĞǁWĂŐĞ Zηϭ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in ϮϬͲϬϬϬϯ ϬϰͲϬϳͲϮϬ ϬϰͲϬϭͲϮϬ EŽŶĞͲEĞǁWĂŐĞ Zηϭ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. _____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g). 2. __X__ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. __X___ The following eligibility groups or categorical populations: ϮϬͲϬϬϬϯ ϬϰͲϬϳͲϮϬ ϬϰͲϬϭͲϮϬ EŽŶĞͲEĞǁWĂŐĞ Zηϭ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Suspend premiums for the Employed Individuals with Disabilities program. 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. _____ The agency makes the following adjustments to benefits currently covered in the state plan: 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe. ϮϬͲϬϬϬϯ ϬϰͲϬϳͲϮϬ ϬϰͲϬϭͲϮϬ EŽŶĞͲEĞǁWĂŐĞ Zηϭ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Please describe. Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology: a. _____ Published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ ϮϬͲϬϬϬϯ ϬϰͲϬϳͲϮϬ ϬϰͲϬϭͲϮϬ EŽŶĞͲEĞǁWĂŐĞ Zηϭ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ b. _____ Other: Describe methodology here. Increases to state plan payment methodologies: 2. _____ The agency increases payment rates for the following services: Please list all that apply. a. _____ Payment increases are targeted based on the following criteria: Please describe criteria. b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: Please describe. ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. ϮϬͲϬϬϬϯ ϬϰͲϬϳͲϮϬ ϬϰͲϬϭͲϮϬ EŽŶĞͲEĞǁWĂŐĞ Zηϭ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for telehealth; Describe telehealth payment variation. d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _____ Other payment changes: Please describe. Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: ϮϬͲϬϬϬϯ ϬϰͲϬϳͲϮϬ ϬϰͲϬϭͲϮϬ EŽŶĞͲEĞǁWĂŐĞ Zηϭ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. ϮϬͲϬϬϬϯ ϬϰͲϬϳͲϮϬ ϬϰͲϬϭͲϮϬ EŽŶĞͲEĞǁWĂŐĞ Zηϭ

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 20-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS 179 Form/Summary Form (with 179-like data) 4) Approved SPA Pages

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Division of Program Operations

601 E. 12th St

Room 355

Kansas City , MO 64106

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

Center for Medicaid & CHIP Services

November 23, 2022

Jan Stall

Interim - State Medicaid Agent

Wyoming Department of Health - Division of Healthcare Financing 112 West 25th Street

4 West

Cheyenne, WY 82002

Re: Approval of State Plan Amendment WY-20-0007 Dear Jan Stall,

On September 15, 2020, the Centers for Medicare and Medicaid Services (CMS) received Wyoming State Plan Amendment (SPA) WY-20-0007 to approve the state's online single streamlined application.

We approve Wyoming State Plan Amendment (SPA) WY-20-0007 with an effective date(s) of October 01, 2020. CMS is approving this amendment along with an attached companion letter.

Name Date Created

WY 20-0007 Companion Letter 11/22/2022 12:23 PM EST A

If you have any questions regarding this amendment, please contact Ford Blunt at ford.blunt@cms.hhs.gov

Sincerely, Nicole McKnight

Acting Director, Division of Program Operations

Center for Medicaid & CHIP Services

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Rv

CENTERS FOR MEDICARE & MEDICAID SERVICES

Medicaid and CHIP Operations Group (CENTER FOR MEDICAID & CHIP SERVICES

November 21, 2022

Ms. Jan Stall

Interim State Medicaid Agent Division of Healthcare Financing 122 West 25" Street, 4 West Cheyenne, WY 82002

Dear Ms. Stall:

This letter is sent as a companion to the Centers for Medicare and Medicaid Services (CMS) approval of state plan amendment (SPA) WY — 20-0007, which was submitted to CMS on September 15, 2020. This approval will be effective as of October 1, 2020. Approval of SPA WY 20-0007 includes approval of the alternative single, streamlined online application.

Until June 2023 and pending implementation of the changes described below, Wyoming will use an interim alternative single, streamlined online application. The state will revise the online

application as described below.

Necessary Change

Date by which the changes will be completed:

Wyoming will update the section requesting the type of eligible immigration status so that applicants will respond with an open text field. (This will follow the question asking the applicant to attest to having eligible immigration status.) The name of the status will remain an optional field.

June 30, 2023

Wyoming will update the optional drop-down list of document types presented to individuals with eligible immigration status. The list will match guidance provided to the state, and will not include document types not used in the verification of immigration status.

June 30, 2023

Wyoming will update the household composition instructions to reflect accurate and comprehensive MAGI rules.

June 30, 2023

Wyoming will add a question to the application asking all household members if they are an American Indian or Alaska Native. This question will be its own question, separate from questions of race and ethnicity.

June 30, 2023

Wyoming will update the application so that unearned income types that are not counted under MAGI are not asked of MAGI applicants.

June 30, 2023

Page 2

Please submit the revised changes to CMS for review no later than June 2023. We continue to be available to provide technical assistance. Should you have any questions about this letter, please contact Kirstin Michel at Kirstin.michel@cms.hhs.gov.

Sincerely, Digitally signed by James G. Scott -S OF Shock Date: 2022.11.21 14:05:23 -06'00' James G. Scott, Director Division of Program Operations

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CMS-10434 OMB 0938-1188

Submission - Summary

MEDICAID | Medicaid State Plan | Eligibility | WY2020MS00020 | WY-20-0007

Package Header

Package ID WY2020MS00020 SPAID WY-20-0007 Submission Type Official Initial Submission Date 9/15/2020 Approval Date 11/23/2022 Effective Date N/A

Superseded SPAID N/A

State Information

State/Territory Name: Wyoming Medicaid Agency Name: Wyoming Department of Health

Submission Component

State Plan Amendment Medicaid

CHIP

Submission - Summary

MEDICAID | Medicaid State Plan | Eligibility | WY2020MS00020 | WY-20-0007

Package Header Package ID Submission Type Approval Date Superseded SPA ID

WY2020MS00020 Official 11/23/2022

N/A

SPA ID and Effective Date

SPAID

Reviewable Unit

Application

Wy-20-0007

Proposed Effective Date

10/1/2020

SPAID WY-20-0007 Initial Submission Date 9/15/2020

Effective Date N/A

Superseded SPA ID

wy-19-0024

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | WY2020MS00020 | WY-20-0007 Package Header

Package ID WY2020MS00020 SPAID WY-20-0007 Submission Type Official Initial Submission Date 9/15/2020 Approval Date 11/23/2022 Effective Date N/A

Superseded SPAID N/A

Executive Summary

Summary Description Including The goal of this SPA is to make updates to the current online application used by Wyoming Medicaid. The updates include: Goals and Objectives adding Remote Identity Proofing, updates to the application to more closely align with the hard copy streamlined applications, allow clients to view notices by logging into their account, and making the online application more user friendly.

Federal Budget Impact and Statute/Regulation Citation

Federal Budget Impact

Federal Fiscal Year Amount First 2021 $0 Second 2022 $0

Federal Statute / Regulation Citation These changes will not have any impact not he current budget. Changes are based on CFR 435.907.

Supporting documentation of budget impact is uploaded (optional).

Name Date Created

No items available

Submission - Summary

MEDICAID | Medicaid State Plan | Eligibility | WY2020MS00020 | WY-20-0007

Package Header Package ID Submission Type Approval Date Superseded SPA ID

WY2020MS00020 Official 11/23/2022

N/A

Governor's Office Review

No comment

Comments received

No response within 45 days Other

SPAID WY-20-0007 Initial Submission Date 9/15/2020

Effective Date N/A

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

This view was generated on 12/12/2022 5:51 PM EST

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Medicaid State Plan Eligibility General Eligibility Requirements

Application

MEDICAID | Medicaid State Plan | Eligibility | WY2020MS00020 | WY-20-0007 CMS-10434 OMB 0938-1188

Package Header

Package ID WY2020MS00020, SPAID WY-20-0007 Submission Type Official Initial Submission Date 9/15/2020 Approval Date 11/23/2022 Effective Date 10/1/2020

Superseded SPAID WY-19-0024

User-Entered

A. MAGI Paper Application

The state uses the following paper application(s) for individuals applying for coverage based on the applicable modified adjusted gross income (MAGI) standard.

1. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act

2. One or more alternative single, streamlined applications developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary

Name Application for Health Coverage & Help Paying Costs

The paper application(s) has been uploaded.

Document Name + Date Created 1

Application for Health Coverage & Help Paying Costs 7/30/2020 4:11 PM EDT A

3. One or more alternative applications used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single streamlined application used only for insurance affordability programs to individuals seeking assistance only through such programs

4. Other alternative applications, provided that the agency makes readily available the single streamlined application used only for insurance affordability programs to individuals seeking assistance only through such programs.

Application MEDICAID | Medicaid State Plan | Eligibility | WY2020MS00020 | WY-20-0007 Package Header Package ID WY2020MS00020 Submission Type Official Approval Date 11/23/2022 Superseded SPAID WY-19-0024

User-Entered

B. MAGI Online Application

SPAID WY-20-0007

Initial Submission Date

Effective Date

9/15/2020 10/1/2020

The state uses the following online application(s) for individuals applying for coverage based on the applicable MAGI standard.

1. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the

Affordable Care Act

2. One or more alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and

approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary

Name

Additional Screen Shots 10-20-2020

Screenshots or other documentation of the online application(s) has been uploaded.

Document Name

WY Additional Screen Shots 10-20-2020

Name

Online application screen shots

t

Date Created

10/20/2020 2:49 PM EDT

Screenshots or other documentation of the online application(s) has been uploaded.

Document Name

CWP WES Wise

WY_CWP_Modernization_Screenshots_Part1_v1.0

WY_CWP_Modernization_Screenshots_Part2_v1.0

WY_CWP_Modernization_Screenshots_Part10_v1.0

WY_CWP_Modernization_Screenshots_Part9_v1.0

Name

Application Screen shots with all drop down menus

1

Date Created

9/4/2020 12:33 PM EDT

9/4/2020 12:33 PM EDT

9/4/2020 12:33 PM EDT

9/4/2020 12:33 PM EDT

9/4/2020 12:33 PM EDT

Screenshots or other documentation of the online application(s) has been uploaded.

Document Name

WY_CWP_Modernization_Screenshots_Part3.1_v1.0

WY_CWP_Modernization_Screenshots_Part3.2_v1.0

WY_CWP_Modernization_Menu_Screenshots_Part9_v1.0

WY_CWP_Modernization_Menu_Screenshots_Part8_v1.0

WY_CWP_Modernization_Menu_Screenshots_Part7_v1.0

t

Date Created

10/28/2020 4:06 PM EDT

10/28/2020 4:06 PM EDT

10/28/2020 3:20 PM EDT

10/28/2020 3:20 PM EDT

10/28/2020 3:20 PM EDT

1-S5of11

Name Screenshots September 2022 Set 2

Screenshots or other documentation of the online application(s) has been uploaded.

Document Name 4 Date Created

Other Information Screen 8/31/2022 10:43 AM EDT

Household Income 1 8/31/2022 10:42 AM EDT

Address Screen 8/31/2022 10:37 AM EDT

Pregnancy Details Screen 8/31/2022 10:36 AM EDT

Other Information Screen 2 8/31/2022 10:35 AM EDT Name

Screenshots September 2022 Set 1

Screenshots or other documentation of the online application(s) has been uploaded.

Document Name + Date Created

Child Support Screen 8/31/2022 10:40 AM EDT NonCitizen Details Screen 8/31/2022 10:39 AM EDT Household Income 2 8/31/2022 10:39 AM EDT Member Information Screen 8/31/2022 10:38 AM EDT Immigration Status Document Type 8/31/2022 10:31 AM EDT

1-50f10

1-5o0f12

1-Sof11

Pe ee ee ee

3. One or more alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily

available the single application used only for insurance affordability programs to individuals seeking assistance only through such programs

4. Other alternative applications, provided that the agency makes readily available the single streamlined application used only for insurance affordability

programs to individuals seeking assistance only through such programs

Application MEDICAID | Medicaid State Plan | Eligibility | WY2020MS00020 | WY-20-0007 Package Header

Package ID WY2020MS00020, SPAID WY-20-0007 Submission Type Official Initial Submission Date 9/15/2020 Approval Date 11/23/2022 Effective Date 10/1/2020

Superseded SPAID WY-19-0024

User-Entered

C. Basis Other than MAGI - Paper Application

The state uses the following paper application(s) for individuals applying for coverage on a basis other than the applicable MAGI standard:

1. The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary

The supplemental form(s) used to collect additional information has been uploaded.

Name Date Created

Application for Health Coverage

& Help Paying Costs 7/30/2020 4:13 PM EDT B

2. One or more applications designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary 3. One or more applications used to apply for multiple human service programs

4. Other alternative applications

Application

MEDICAID | Medicaid State Plan | Eligibility | WY2020MS00020 | WY-20-0007

Package Header Package ID Submission Type Approval Date Superseded SPA ID

D. Other than MAGI - Online Application

WY2020MS00020 Official 11/23/2022 WY-19-0024

User-Entered

SPAID WY-20-0007

Initial Submission Date 9/15/2020

Effective Date

10/1/2020

The state uses the following online application(s) for individuals applying for coverage who may be eligible on a basis other than the applicable MAGI standard:

1. The single, streamlined application developed by the Secretary or one of the alternate online forms developed by the state and approved by the Secretary,

and supplemental online forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary

Screenshots or other documentation of the online form(s) used to the collect additional information have been uploaded

Name

WY_CWP_Modernization_Screen shots_Part4_v1.0

WY_CWP_Modernization_Screen shots_Part7_v1.0

WY_CWP_Modernization_Screen shots_Part6_v1.0

WY_CWP_Modernization_Screen shots_Part5_v1.0

WY_CWP_Modernization_Screen shots_Part8_v1.0

WY_CWP_Modernization_Screen shots_Part3_v1.0

WY_CWP_Modernization_Screen shots_Part9_v1.0

WY_CWP_Modernization_Screen shots_Part10_v1.0

WY_CWP_Modernization_Screen shots_Part2_v1.0

WY_CWP_Modernization_Screen shots_Part1_v1.0

CWP WES Wise

WY Additional Screen Shots 10- 20-2020

WY_CWP_Modernization_Menu_ Screenshots_Part9_v1.0

WY_CWP_Modernization_Menu_ Screenshots_Part8_v1.0

WY_CWP_Modernization_Menu_ Screenshots_Part7_v1.0

WY_CWP_Modernization_Menu_ Screenshots_Part6_v1.0

WY_CWP_Modernization_Menu_ Screenshots_Part1_v1.0

Date Created

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

9/4/2020 12:39 PM EDT

10/20/2020 2:51 PM EDT

10/28/2020 3:25 PM EDT

10/28/2020 3:25 PM EDT

10/28/2020 3:25 PM EDT

10/28/2020 3:25 PM EDT

10/28/2020 3:25 PM EDT

Name

WY_CWP_Modernization_Menu_

Screenshots_Part2_v1.0

WY_CWP_Modernization_Menu_

Screenshots_Part4_v1.0

WY_CWP_Modernization_Menu_

Screenshots_Part5_v1.0

WY_CWP_Modernization_Screen

shots_Part3.2_v1.0

WY_CWP_Modernization_Screen

shots_Part3.1_v1.0

Disability Question

Resource Stepper

Unearned Income Types

Date Created

10/28/2020 3:25 PM EDT

10/28/2020 3:25 PM EDT

10/28/2020 3:25 PM EDT

10/28/2020 4:07 PM EDT

10/28/2020 4:07 PM EDT

8/31/2022 10:46 AM EDT

8/31/2022 10:46 AM EDT

8/31/2022 10:46 AM EDT

1-25 of 25

2. One or more application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on

applicants, submitted to the Secretary 3. One or more application used to apply for multiple human service programs

4. Other alternative applications

Application

MEDICAID | Medicaid State Plan | Eligibility | WY2020MS00020 | WY-20-0007

Package Header Package ID Submission Type Approval Date Superseded SPA ID

WY2020MS00020 Official 11/23/2022 WyY-19-0024

User-Entered

E. Additional Information (optional)

SPAID WY-20-0007 Initial Submission Date 9/15/2020 Effective Date 10/1/2020

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:

PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

This view was generated on 12/12/2022 5:55 PM EST

Table of Contents State/Territory Name: WY State Plan Amendment (SPA) #: 20-0008 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All WY - Submission Package - WY2020MS0003O - (WY-20-0008) - Eligibility CMS-10434 OMB 0938-1188 Package Information Package ID WY2020MS0003O Program Name N/A SPA ID WY-20-0008 Version Number 5 Submitted By Heather Gallo Package Disposition Priority Code P2 Submission Type OŰcial State WY Region Denver, CO Package Status Approved Submission Date 10/13/2020 Approval Date 5/13/2021 2:39 PM EDT Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter RAI Transaction Logs News Related Actions

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group - Division of Program Operations 601 East 12th Street Suite 355 Kansas City , MO 64106-2898 Center for Medicaid & CHIP Services May 13, 2021 Teri Green Director Wyoming Department of Health Wyoming Department of Health 6101 Yellowstone Road Suite 210 Cheyenne, WY 82009 Re: Approval of State Plan Amendment WY-20-0008 Dear Teri Green, On October 13, 2020, the Centers for Medicare and Medicaid Services (CMS) received Wyoming State Plan Amendment (SPA) WY-20-0008 to add the Optional Targeted Low Income Children eligibility group to the Medicaid state plan. This SPA is part of the state's transition of its separate Children's Health Insurance Program (CHIP) to a Medicaid expansion program. We approve Wyoming State Plan Amendment (SPA) WY-20-0008 with an eſective date(s) of October 01, 2020. Please see the companion letter attached with this approval. If you have any questions regarding this amendment, please contact Ford Blunt at ford.blunt@cms.hhs.gov Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID N/A SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date N/A State Information State/Territory Name: Wyoming Medicaid Agency Name: Wyoming Department of Health Submission Component State Plan Amendment Medicaid CHIP

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 East 12th Street, Suite 355 Kansas City, Missouri 64106-2898 Medicaid and CHIP Operations Group May 12, 2021

Ms. Teri Green State Medicaid Director Wyoming Department of Health 6101 Yellowstone Road, Suite 210 Cheyenne, WY 82009

RE: Wyoming MACPro State Plan Amendment (SPA) Transmittal Number WY-20-0008

Dear Ms. Green:

We are issuing this letter as a companion to the approval of Wyoming State Plan Amendment (SPA) WY-20-0008, which adds the Optional Targeted Low Income Children eligibility group to the Medicaid state plan. This SPA is part of the state’s transition of its separate Children’s Health Insurance Program (CHIP) to a Medicaid expansion program. The effective date of the approved SPA is October 1, 2020. During the course of our review of SPA 20-0008, we found an issue stemming from the difference in the requirement between CHIP and Medicaid relating to lawful permanent residents (LPR) and 40 quarters of qualifying work history. This letter memorializes an agreement to resolve the 40 qualifying work quarters policy issue.

States are required to provide full Medicaid coverage to individuals who are LPRs, have 40 qualifying work quarters, and are otherwise eligible for Medicaid. (See 8 USC 1612(b)(2)(B).) States have the option to extend Medicaid eligibility to other LPRs, but states must cover in Medicaid LPRs with 40 qualifying work quarters, who are otherwise eligible under the state plan. (When a state limits coverage only to LPRs with 40 qualifying work quarters, an LPR without the 40 qualifying work quarters in such states would only be eligible for Medicaid coverage of the treatment of an emergency medical condition.) Wyoming has elected in its Medicaid state plan to require LPRs to have 40 qualifying work quarters. (See Wyoming’s S89 “Non-Financial Eligibility Citizenship and Non-Citizen Eligibility” MMDL template in SPA WY-13-0011.) By contrast, there is no requirement for LPRs to have 40 qualifying work quarters in CHIP eligibility determinations.

Prior to October 1, 2020, Wyoming required LPR children to have – or for their parents to have – 40 quarters of qualifying work history to be eligible for full Medicaid coverage. Because states may not require 40 qualifying work quarters for eligibility in a separate CHIP, Wyoming was enrolling in its CHIP program children under age 19 who were denied Medicaid due to the lack of 40 qualifying work quarters (as well as those within the CHIP income range).

Page 2 – Teri Green, Director

On October 1, 2020, Wyoming transitioned its separate CHIP population to a Medicaid expansion group, the Optional Targeted Low Income Children group. The state informed CMS that it included in its transition a small number of LPR children who had previously attained eligibility for CHIP and who did not meet the 40 qualifying work quarters requirement in Wyoming’s Medicaid state plan.

On the basis of the maintenance of effort requirement described in section 2105(d)(3) of the Social Security Act, CMS informed the state that it must continue enrolling children with income from 0 to 119 percent of the federal poverty level without 40 qualifying work quarters into Medicaid or CHIP. We provided several options for the state to continue coverage for these individuals. The state informed CMS that it would elect to eliminate the requirement of 40 qualifying work quarters for LPRs in Medicaid effective April 1, 2021.

Additionally, CMS determined that once the separate CHIP enrollees were enrolled in Medicaid, the state may continue to claim the increased federal medical assistance percentage authorized under section 6008(a) of the Families First Coronavirus Response Act (FFCRA), if the state does not terminate the Medicaid eligibility of these children during the COVID-19 public health emergency, in accordance with the continuous enrollment requirement described in section 6008(b)(3) of the FFCRA.

Therefore, this letter documents that Wyoming agrees it will submit an additional Medicaid SPA as soon as practicable, but no later than June 30, 2021, to remove the 40 qualifying work quarters requirement for LPRs in its Medicaid state plan. This SPA will be submitted through the MACPro system to include the “Citizenship and Non-Citizen Eligibility” reviewable unit, and the state has agreed the SPA will have a proposed effective date no later than April 1, 2021. Elimination of the 40 qualifying work quarters policy will permit the state to enroll otherwise eligible LPRs in full Medicaid coverage without regard to the individual’s qualifying work history.

CMS welcomes the opportunity to work with you and your staff to resolve these issues. Should you or your staff have any questions regarding this letter, please contact Ford Blunt at Ford.Blunt@cms.hhs.gov.

James G. Scott, Director Division of Program Operations Sincerely, Digitally signed by James G. Scott -S Date: 2021.05.12 13:21:45 -05'00'

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID N/A SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date N/A SPA ID and Eſective Date SPA ID WY-20-0008 Reviewable Unit Proposed Eſective Date Superseded SPA ID Optional Eligibility Groups 10/1/2020 WY-20-0001 Optional Targeted Low Income Children 10/1/2020 WY-13-008-MM1 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID N/A SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date N/A Executive Summary Summary Description Including Goals and Objectives Children previously enrolled in the State's stand-alone Children's Health Insurance Program (CHIP) will now be enrolled as Medicaid Expansion children as Optional Targeted Low Income Children. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2021 $0 Second 2022 $0 Federal Statute / Regulation Citation 42 CFR 435.229 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID N/A SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date N/A Governor's OŰce Review No comment Comments received No response within 45 days Other

Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID WY-20-0001 System-Derived SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date 10/1/2020 A. Options for Coverage The state provides Medicaid to speciţed optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classiţcations of Individuals under Age 21 CONVERTED Children with Non-IV-E Adoption Assistance CONVERTED Independent Foster Care Adolescents CONVERTED Optional Targeted Low Income Children APPROVED Individuals above 133% FPL under Age 65 NEW Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis CONVERTED Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization NEW Yes No

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules NEW Optional State Supplement Beneţciaries NEW Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability NEW Age and Disability- Related Poverty Level NEW Work Incentives NEW Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID WY-20-0001 System-Derived SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date 10/1/2020 B. Medically Needy Options for Coverage The state provides Medicaid to speciţed groups of individuals who are medically needy. Yes No

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID WY-20-0001 System-Derived SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date 10/1/2020 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A

Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Optional Targeted Low Income Children MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Uninsured children who meet the deţnition of optional targeted low income children at 42 C.F.R. §435.4, who have household income at or below a standard established by the state. Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID WY-13-008-MM1 User-Entered SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date 10/1/2020 The state covers the optional targeted low income children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 19, or a lower age, as speciţed in C. 2. Are uninsured and otherwise meet the deţnition of optional targeted low-income child at 42 CFR 435.4 and section 1905(u)(2)(B) of the Act. 3. Have household income at or below the standard established by the state, if the state has an income standard. 4. Are not otherwise eligible for and enrolled in mandatory coverage under the state plan. B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Individuals Covered 1. The state covers all children under a speciţed age under this eligibility group. The age of children covered under this eligibility group is: D. Income Standard Used The income standard for this eligibility group is: FPL 200.00% Yes No a. Under age 19 b. Under age 18 c. Under other age

Optional Targeted Low Income Children MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID WY-13-008-MM1 User-Entered SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date 10/1/2020 E. Basis for Income Standard 1. Minimum income standard The minimum income standard for this eligibility group is a standard greater than the lowest income standard currently used for children of this age under the mandatory Infants and Children under Age 19 eligibility group. 2. Maximum income standard b. The state's maximum income standard for this eligibility group is: c. The amount of the maximum income standard is: FPL 200.00% a. The state certiţes that it has submitted and received approval for its converted income standard(s) for this eligibility group to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classiţcation of children under this eligibility group. i. The state's eſective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. ii. The state's eſective income level for this group of children under the CHIP state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. iii. The state's eſective income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. iv. The state's eſective income level for this group of children under the CHIP state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. v. The state's eſective income level for this group of children under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. vi. The state's eſective income level for this group of children under a CHIP-1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. vii. The state's eſective income level for this group of children under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. viii. The state's eſective income level for this group of children under a CHIP 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. ix. 200% FPL x. A percentage of the FPL which may exceed the Medicaid Applicable Income Level, deţned in section 2110(b)(4), but by no more than 50 percentage points.

Optional Targeted Low Income Children MEDICAID | Medicaid State Plan | Eligibility | WY2020MS0003O | WY-20-0008 Package Header Package ID WY2020MS0003O Submission Type OŰcial Approval Date 5/13/2021 Superseded SPA ID WY-13-008-MM1 User-Entered SPA ID WY-20-0008 Initial Submission Date 10/13/2020 Eſective Date 10/1/2020 F. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format deţned by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reŤects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in eſorts to boost program integrity eſorts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OŰcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/26/2021 9:14 AM EDT

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Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 21-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages



  

 

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Table of Contents State/Territory Name: :\RPLQJ State Plan Amendment (SPA) #: 22-000 This file contains the following documents in the order listed:  Approval Letter  CMS 179 Form/Summary Form  Approved SPA PageV

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

June 24, 2022

Jan Stall Interim State Medicaid Agent Division of Health Care Financing Herschler Building 122 West 25th Street, 4 West Cheyenne, WY 82002

Re: Wyoming State Plan Amendment (SPA) 22-0002

Dear Interim State Medicaid Agent, Ms. Stall:

We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) 22-0002. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID- 19 outbreak (or any renewals thereof).

On March 13, 2020, the President of the United States issued a proclamation that the COVID- 19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID- 19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions.

Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency.

These waivers or modifications of the requirements related to SPA submission timelines apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending Alternative Benefits Plans (ABPs) to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes.

We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that Wyoming Medicaid SPA Transmittal Number 22-0002 is approved effective October 1, 2021. This SPA is in addition to the Disaster Relief SPAs approved on April 7, 2020, and March 4, 2022 and does not supersede anything approved in that SPA.

Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

Please contact Ford Blunt at (214) 767-6381 or by email at Ford.Blunt@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of Wyoming and the health care community.

Sincerely,

Alissa Mooney DeBoy

On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services

Enclosures Alissa M. Deboy -S Digitally signed by Alissa M. Deboy -S Date: 2022.06 24 08 03:45 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVALOF |) MEER estas STATE PLAN MATERIAL _-WY 22 — 0002 Wyoming

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES October 1, 2021 DEPARTMENT OF HEALTH AND HUMAN SERVICES

5. TYPE OF PLAN MATERIAL (Check One)

(0 NEW STATE PLAN (0 AMENDMENT TO BE CONSIDERED AS NEW PLAN [AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT a. FFY 2021 $ 0.00

42 CFR 435.4, 42 CFR 435.110 & Title XIX of the SSA b. FFY 2022 $ 0.00

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Section 7.4 Medicaid Disaster Relief for the COVID-19 National OR ATTACHMENT (If Applicable) Emergency, DR #3 pages 1-9. These pages are in addition to the previously approved pages for this

10, SUBJECT OF AMENDMENT

To request from 10/1/2021 to 3/31/2022 to temporarily eliminate the “deprivation” requirement relating to dependent children living with individuals who seek err aleieoes. of being parents and other caretaker relatives. The policy change will be incorporated in the eligibility section of the state plan effective A

11. GOVERNOR'S REVIEW (Check One)

DB) GOVERNOR'S OFFICE REPORTED NO COMMENT BW OTHER, AS SPECIFIED: Delegated to Jan Stal, ntrim State ( COMMENTS OF GOVERNOR'S OFFICE ENCLOSED —_ eens [1 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 72. SIGNATURE OF STATE AGENCY OFFICIAL 76. RETURN TO — ata J INTERIM STATE MEDICAID AGENT 13. TYPED NAME JAN STALL DIVISION OF HEALTHCARE FINANCING

122 WEST 25th STREET, 4 WEST CHEYENNE, WY 82002

14. TITLE INTERIM STATE MEDICAID AGENT CC: HEATHER GALLO, EXECUTIVE ASSISTANT (SAME ADDRESS)

15, DATE SUBMITTED May 24, 2022

FOR REGIONAL OFFICE USE ONLY 18. DATE APPROVED

17. DATE RECEIVED

April 20, 2022 June 24, 2022 PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SIGNATURE OF REGIONRESBAWMIAL 2) ctned PY Alssa October 1, 2021 Deboy -S peer 21. TYPED NAME 22. TITLE Alissa Mooney DeBoy On Behalf of Anne Marie Costello, Deputy Director, CMCS

23. REMARKS This is a revised CMS-179. The original 179 was submitted on April 20, 2022.

FORM CMS-179 (07/92) Instructions on Back

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: Describe shorter period here. This amendment will be effective only from 10/01/2021 to 03/31/2022 for a temporary elimination of the “deprivation” requirement relating to dependent children living with individuals who seek Medicaid on the basis of being parents and other caretaker relatives. The policy change will be incorporated in the eligibility section of the state plan effective 04/01/2022. NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 __X__ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X__ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by December 31, 2021, to obtain a SPA effective date during the last calendar quarter of 2021, pursuant to 42 CFR 430.20. b. ____ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), ϮϮͲϬϬϬϮ EŽŶĞͲ EĞǁ WĂŐĞƐ ϭϬͬϬϭͬϮϭ dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ tLJŽŵŝŶŐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ ϰͬϬϳͬϮϭ ĂŶĚ ϬϯͬϬϰͬϮϮ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^WƐ͘ ϲͬϮϰͬϮϮ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). c. ____ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in WY Medicaid state plan, as described below: Section A – Eligibility 1. _____ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. Include name of the optional eligibility group and applicable income and resource standard. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies: dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ tLJŽŵŝŶŐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ ϰͬϬϳͬϮϭ ĂŶĚ ϬϯͬϬϰͬϮϮ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^WƐ͘ ϮϮͲϬϬϬϮ EŽŶĞ Ͳ EĞǁ WĂŐĞƐ ϭϬͬϬϭͬϮϭ ϲͬϮϰͬϮϮ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Less restrictive resource methodologies: 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. Please describe the applicable eligibility groups/populations and any changes to reasonable limitations, performance standards or other factors. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Please describe any limitations related to the populations included or the number of allowable PE periods. dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ tLJŽŵŝŶŐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ ϰͬϬϳͬϮϭ ĂŶĚ ϬϯͬϬϰͬϮϮ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^WƐ͘ ϮϮͲϬϬϬϮ EŽŶĞ Ͳ EĞǁ WĂŐĞƐ ϭϬͬϬϭͬϮϭ ϲͬϮϰͬϮϮ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. Please describe the designated entities or additional populations and any limitations related to the specified populations or number of allowable PE periods. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. _____ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: Please describe whether the state suspends all cost sharing or suspends only specified deductibles, copayments, coinsurance, or other cost sharing charges for specified items and services or for specified eligibility groups consistent with 42 CFR 447.52(d) or for specified income levels consistent with 42 CFR 447.52(g). 2. ____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations: dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ tLJŽŵŝŶŐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ ϰͬϬϳͬϮϭ ĂŶĚ ϬϯͬϬϰͬϮϮ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^WƐ͘ ϮϮͲϬϬϬϮ EŽŶĞ Ͳ EĞǁ WĂŐĞƐ ϭϬͬϬϭͬϮϭ ϲͬϮϰͬϮϮ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Please specify the standard(s) and/or criteria that the state will use to determine undue hardship. Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. _____ The agency makes the following adjustments to benefits currently covered in the state plan: 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). a. _____ The agency assures that these newly added and/or adjusted benefits will be made available to individuals receiving services under ABPs. b. _____ Individuals receiving services under ABPs will not receive these newly added and/or adjusted benefits, or will only receive the following subset: Please describe. dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ tLJŽŵŝŶŐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ ϰͬϬϳͬϮϭ ĂŶĚ ϬϯͬϬϰͬϮϮ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^WƐ͘ ϮϮͲϬϬϬϮ EŽŶĞ Ͳ EĞǁ WĂŐĞƐ ϭϬͬϬϭͬϮϭ ϲͬϮϰͬϮϮ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Please describe. Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. Please describe the change in days or quantities that are allowed for the emergency period and for which drugs. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. Please describe the manner in which professional dispensing fees are adjusted. 9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology: a. _____ Published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ tLJŽŵŝŶŐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ ϰͬϬϳͬϮϭ ĂŶĚ ϬϯͬϬϰͬϮϮ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^WƐ͘ ϮϮͲϬϬϬϮ EŽŶĞ Ͳ EĞǁ WĂŐĞƐ ϭϬͬϬϭͬϮϭ ϲͬϮϰͬϮϮ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ b. _____ Other: Describe methodology here. Increases to state plan payment methodologies: 2. _____ The agency increases payment rates for the following services: Please list all that apply. a. _____ Payment increases are targeted based on the following criteria: Please describe criteria. b. Payments are increased through: i. _____ A supplemental payment or add-on within applicable upper payment limits: Please describe. ii. _____ An increase to rates as described below. Rates are increased: _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Please describe. dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ tLJŽŵŝŶŐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ ϰͬϬϳͬϮϭ ĂŶĚ ϬϯͬϬϰͬϮϮ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^WƐ͘ ϮϮͲϬϬϬϮ EŽŶĞ Ͳ EĞǁ WĂŐĞƐ ϭϬͬϬϭͬϮϭ ϲͬϮϰͬϮϮ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: a. _____ Are not otherwise paid under the Medicaid state plan; b. _____ Differ from payments for the same services when provided face to face; c. _____ Differ from current state plan provisions governing reimbursement for telehealth; Describe telehealth payment variation. d. _____ Include payment for ancillary costs associated with the delivery of covered services via telehealth, (if applicable), as follows: i. _____ Ancillary cost associated with the originating site for telehealth is incorporated into fee-for-service rates. ii. _____ Ancillary cost associated with the originating site for telehealth is separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. Other: 4. _____ Other payment changes: Please describe. Section F – Post-Eligibility Treatment of Income 1. _____ The state elects to modify the basic personal needs allowance for institutionalized individuals. The basic personal needs allowance is equal to one of the following amounts: a. _____ The individual’s total income b. _____ 300 percent of the SSI federal benefit rate c. _____ Other reasonable amount: _________________ 2. _____ The state elects a new variance to the basic personal needs allowance. (Note: Election of this option is not dependent on a state electing the option described the option in F.1. above.) The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ tLJŽŵŝŶŐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ ϰͬϬϳͬϮϭ ĂŶĚ ϬϯͬϬϰͬϮϮ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^WƐ͘ ϮϮͲϬϬϬϮ EŽŶĞ Ͳ EĞǁ WĂŐĞƐ ϭϬͬϬϭͬϮϭ ϲͬϮϰͬϮϮ

State/Territory: ____WY_______ TN: ________________ Approval Date: __________ Supersedes TN: ________________ Effective Date: __________ Please describe the group or groups of individuals with greater needs and the amount(s) protected for each group or groups. Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information Effective 10/01/2021, Wyoming is changing the policy for the Parents and Other Caretaker Relatives eligibility group under 42 CFR 435.110 to remove the eligibility requirement, described in the definition of “dependent child” at 42 CFR 435.4, that a dependent child must be deprived of parental support or care. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. dŚŝƐ ^W ŝƐ ŝŶ ĂĚĚŝƚŝŽŶ ƚŽ ƚŚĞ tLJŽŵŝŶŐ ŝƐĂƐƚĞƌ ZĞůŝĞĨ ^WƐ ĂƉƉƌŽǀĞĚ ŽŶ ϰͬϬϳͬϮϭ ĂŶĚ ϬϯͬϬϰͬϮϮ ĂŶĚ ĚŽĞƐ ŶŽƚ ƐƵƉĞƌƐĞĚĞ ĂŶLJƚŚŝŶŐ ĂƉƉƌŽǀĞĚ ŝŶ ƚŚŽƐĞ ^WƐ͘ ϮϮͲϬϬϬϮ EŽŶĞͲEĞǁ WĂŐĞƐ ϭϬͬϬϭͬϮϭ ϲͬϮϰͬϮϮ

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 22-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

Records / Submission Packages - View All

WY - Submission Package - WY2022MS00010 - (WY-22-0004) - Eligibility

Summary Reviewable Units Versions Analyst Notes

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group

601 E. 12th St.

Room 355

Kansas City , MO 64106

Center for Medicaid & CHIP Services July 15, 2022

Jan Stall

Interim Director Wyoming Department of Health Wyoming Department of Health

112 West 25th Street

4 West

Cheyenne, WY 82002

Re: Approval of State Plan Amendment WY-22-0004

Dear Jan Stall ,

Approval Letter Transaction Logs News Related Actions v

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES

On May 10, 2022, the Centers for Medicare and Medicaid Services (CMS) received Wyoming State Plan Amendment (SPA) WY-22-0004 which proposed to eliminate the "deprivation" requirement relating to dependent children living with individuals who seek Medicaid on the basis of being parents and other caretaker relatives. This policy change was previously approved in Section 7.4 of the state plan, under WY Disaster Relief (DR) SPA 22-0002.

We approve Wyoming State Plan Amendment (SPA) WY-22-0004 with an effective date(s) of April 01, 2022.

We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulation at 42 CFR 435.110.

If you have any questions regarding this amendment, please contact Ford Blunt at ford.blunt@cms.hhs.gov.

Sincerely, Nicole McKnight

Acting Director - Division of Program Operations

Center for Medicaid & CHIP Services

Records / Submission Packages - View All WY - Submission Package - WY2022MS0001O - (WY-22-0004) - Eligibility Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 0MB 0938-1188 Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I WY2022MS0001O I WY-22-0004 Package Header Package ID WY2022MS00010 Submission Type Official Approval Date 7/15/2022 Superseded SPA ID N/A State Information State/Territory Name: Wyoming Submission Component 0 State Plan Amendment SPA ID WY-22-0004 Initial Submission Date 5/10/2022 Effective Date N/ A Medicaid Agency Name: Wyoming Department of Health 0Medicaid QCHIP

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I WY2022MS0001O I WY-22-0004 Package Header Package ID WY2022MS0001O Submission Type Official Approval Date 7/15/2022 Superseded SPA ID N/A SPA ID and Effective Date SPA ID WY-22-0004 Reviewable Unit Mandatory Eligibility Groups Parents and Other Caretaker Relatives Proposed Effective Date 4/1/2022 4/1/2022 SPA ID WY-22-0004 Initial Submission Date 5/10/2022 Effective Date N/ A Superseded SPA ID WY-20-0001 WY-13-0008

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I WY2022MS0001O I WY-22-0004 Package Header Package ID WY2022MS0001O Submission Type Official Approval Date 7/15/2022 Superseded SPA ID N/A Executive Summary SPA ID WY-22-0004 Initial Submission Date 5/10/2022 Effective Date N/ A Summary Description Including This SPA eliminates the Deprivation requirement relating to dependent children living with individuals who seek Medicaid Goals and Objectives in Wyoming on the basis of being parents or other caretaker relatives, effective April 1, 2022. This policy change was previously approved in section 7.4 of the State Plan, under SPA WY-22-0002. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact First Second Federal Fiscal Year 2022 2023 Federal Statute / Regulation Citation 42 CFR 435.4 42 CFR 435.110 Amount $0 $0 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID I Medicaid State Plan I Eligibility I WY2022MS0001O I WY-22-0004 Package Header Package ID WY2022MS0001O Submission Type Official Approval Date 7/15/2022 Superseded SPA ID N/A Governor's Office Review 0Nocomment 0 Comments received 0 No response within 45 days Qother SPA ID WY-22-0004 Initial Submission Date 5/10/2022 Effective Date N/ A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Records / Submission Packages - View All

WY - Submission Package - WY2022MS00010 - (WY-22-0004) - Eligibility

Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Related Action:

v

CMS-10434 OMB 0938-1188

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | WY2022MS00010 | WY-22-0004 Package Header Package ID WY2022MS00010. SPAID WY-22-0004 Submission Type Official Initial Submission Date 5/10/2022 Approval Date 7/15/2022 Effective Date 4/1/2022

Superseded SPAID W/Y-20-0001

System-Derived Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults

Include RU In Package Included in Another e Submission Package

O CONVERTED

APPROVED.

Eligibility Group Name Covered In State Plan Source Type @

Infants and Children under Age 19

Parents and Other Caretaker Relatives

Pregnant Women CONVERTED

Deemed Newborns NEW

Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care

NEW

Former Foster Care

Children New

[P| [P| [P| [P| [P| [P|

Transitional Medical

‘ NEW Assistance

Extended Medicaid due

to Spousal Support [P|

Collections

NEW

O00 0 000

Aged, Blind and Disabled

Include RU In Package Included in Another e Submission Package

O NEW O NEW

O NEW

Eligibility Group Name Covered In State Plan Source Type @

SSI Beneficiaries

Closed Eligibility Groups

Individuals Deemed To Be Receiving SSI

fe] fe el

Eligibility Group Name

Working Individuals under 1619(b)

Qualified Medicare Beneficiaries

Qualified Disabled and Working Individuals

Specified Low Income Medicare Beneficiaries

Qualifying Individuals

ee & & &

Covered In State Plan

Include RU In Package 2)

Included in Another Submission Package

O

O00 0

Source Type @

NEW

APPROVED

NEW

APPROVED.

APPROVED.

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children's Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children's Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Records / Submission Packages - View All

WY - Submission Package - WY2022MS00010 - (WY-22-0004) - Eligibility

Summary Reviewable Units Versions Analyst Notes Approval Letter Transaction Logs News Related Action:

v CMS-10434 OMB 0938-1188 Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives MEDICAID | Medicaid State Plan | Eligibility | WY2022MS00010 | WY-22-0004 Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. Package Header Package ID WY2022MS00010 SPAID WY-22-0004 Submission Type Official Initial Submission Date 5/10/2022 Approval Date 7/15/2022 Effective Date 4/1/2022

Superseded SPAID WY-13-0008 System-Derived The state covers the mandatory parents and other caretaker relatives group in accordance with the following provisions:

A. Characteristics

Individuals qualifying under this eligibility group must meet the following criteria:

1. Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included.

The state elects the following options:

a. This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training.

b. Options relating to the definition of caretaker relative: c. Options relating to the definition of dependent child:

i. The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent.

ii, The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies):

2. Have household income at or below the standard established by the state.

Parents and Other Caretaker Relatives MEDICAID | Medicaid State Plan | Eligibility | WY2022MS00010 | WY-22-0004

Package Header Package ID Submission Type Approval Date Superseded SPA ID

WY2022MS00010 SPAID WY-22-0004 Official Initial Submission Date 5/10/2022 7/15/2022 Effective Date 4/1/2022 WY-13-0008

System-Derived

B. Financial Methodologies

MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the

state.

C. Income Standard Used

1. The income standard for this group is based on a percentage of the federal poverty level.

Yes

No

2. The state uses the following income standard for this group:

e. The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards.

Parents and Other Caretaker Relatives MEDICAID | Medicaid State Plan | Eligibility | WY2022MS00010 | WY-22-0004

Package Header Package ID Submission Type Approval Date Superseded SPA ID

WY2022MS00010 SPAID WY-22-0004 Official Initial Submission Date 5/10/2022 7/15/2022 Effective Date 4/1/2022 WY-13-0008

System-Derived

D. Basis for Income Standard

1. Minimum Income Standard

a. The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in AFDC Income Standards.

b. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard.

N

Maximum income standard

a. The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI- equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility

group.

fom

. The state's maximum income standard for this eligibility group is:

i. The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

ii. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

iii. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size.

iv. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size.

c. The amount of the maximum income standard is:

i. A percentage of the federal poverty level:

ii. The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards.

iii. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards.

iv. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards.

v. Other dollar amount

Parents and Other Caretaker Relatives MEDICAID | Medicaid State Plan | Eligibility | WY2022MS00010 | WY-22-0004 Package Header

Package ID WY2022MS00010. SPAID WY-22-0004 Submission Type Official Initial Submission Date 5/10/2022 Approval Date 7/15/2022 Effective Date 4/1/2022

Superseded SPAID WY-13-0008

System-Derived

E. Additional Information (optional)

The policy to eliminate the Deprivation requirement was previously approved.

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state's program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

This view was generated on 7/15/2022 5:12 PM EDT

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 23-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages



  

 

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Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 23-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Page

Records / Submission Packages - View All WY - Submission Package - WY2023MS0003O - (WY-23-0005) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St. Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services September 14, 2023 Lee Grossman Director Wyoming Department of Health Wyoming Department of Health 112 West 25th Street 4 West Cheyenne, WY 82002 Re: Approval of State Plan Amendment WY-23-0005 Dear Lee Grossman, On June 21, 2023, the Centers for Medicare & Medicaid Services (CMS) received Wyoming State Plan Amendment (SPA) WY-23-0005, in which the state proposed to elect the option described in section 1902(e)(16) of the Social Security Act to provide 12 months of postpartum coverage to Medicaid-eligible pregnant individuals. We approve Wyoming State Plan Amendment (SPA) WY-23-0005 with an effective date(s) of July 01, 2023. If you have any questions regarding this amendment, please contact Ford Blunt at ford.blunt@cms.hhs.gov Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services CMS Cf US JOR MEDICARE &MEDICAJO SIIMCES

Records / Submission Packages - View All WY - Submission Package - WY2023MS0003O - (WY-23-0005) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | WY2023MS0003O | WY-23-0005 CMS-10434 OMB 0938-1188 Package Header Package ID WY2023MS0003O Submission Type Official Approval Date 09/14/2023 Superseded SPA ID N/A SPA ID WY-23-0005 Initial Submission Date 6/21/2023 Effective Date N/A State Information State/Territory Name: Wyoming Medicaid Agency Name: Wyoming Department of Health Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | WY2023MS0003O | WY-23-0005 Package Header Package ID WY2023MS0003O Submission Type Official Approval Date 09/14/2023 Superseded SPA ID N/A SPA ID WY-23-0005 Initial Submission Date 6/21/2023 Effective Date N/A SPA ID and Effective Date SPA ID WY-23-0005 Reviewable Unit Proposed Effective Date Superseded SPA ID Continuous Eligibility for Pregnant Women and Extended Postpartum Coverage 7/1/2023 New Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | WY2023MS0003O | WY-23-0005 Package Header Package ID WY2023MS0003O Submission Type Official Approval Date 09/14/2023 Superseded SPA ID N/A SPA ID WY-23-0005 Initial Submission Date 6/21/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives Seeking to implement the 12-month postpartum care extension offered by the American Rescue Plan Action that was also approved by Wyoming Legislature General Session 2023 for Session Law CH0152. Wyoming has implemented IT system changes in system of records (Wyoming Eligibility System-WES) that will allow the system to recognize pregnancy programs and allow redetermination dates to allow for the 12 month extended postpartum coverage. Wyoming has also provided training and resources for our Customer Service Staff to follow policy, rules, and regulations in regards to authorizing this extended coverage for this coverage group. Wyoming policy has been updated to reflect the 12 month extended postpartum coverage. Wyoming Chapter 18 Rules have also been updated to reflect the 12 month extended postpartum coverage and are currently in review for final publishing. Department of Family Services and Child Support have also been trained and updated on the 12 month postpartum coverage changes. We have also met and trained outside agencies such as WIC and Enroll Wyoming. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2023 $0 Second 2024 $3870000 Federal Statute / Regulation Citation Section 9812 and 9822 of the American Rescue Plan Act of 2021 Section 1902(e)(16) of the Social Security Act 42 CFR 435.116 W.S. 42-4-122(b)(iii) Supporting documentation of budget impact is uploaded (optional). Name Date Created Notice 6/14/2023 11:43 AM EDT I

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | WY2023MS0003O | WY-23-0005 Package Header Package ID WY2023MS0003O Submission Type Official Approval Date 09/14/2023 Superseded SPA ID N/A SPA ID WY-23-0005 Initial Submission Date 6/21/2023 Effective Date N/A Governor's Office Review Describe The Governor does not review state plan amendments prior to submission. PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 9/14/2023 10:26 AM EDT No comment Comments received No response within 45 days Other 0 0 0 0

Records / Submission Packages - View All WY - Submission Package - WY2023MS0003O - (WY-23-0005) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Pregnant Women and Extended Postpartum Coverage MEDICAID | Medicaid State Plan | Eligibility | WY2023MS0003O | WY-23-0005 CMS-10434 OMB 0938-1188 Package Header Package ID WY2023MS0003O Submission Type Official Approval Date 09/14/2023 Superseded SPA ID New User-Entered SPA ID WY-23-0005 Initial Submission Date 6/21/2023 Effective Date 7/1/2023 The state provides continuous eligibility for pregnant individuals and extended postpartum coverage in accordance with the following provisions: A. Mandatory Continuous Eligibility for Pregnant Women The state provides continuous eligibility to pregnant individuals who were eligible and enrolled under the state plan, without regard to any changes in income that otherwise would result in ineligibility, through the last day of the month in which a 60-day postpartum period (beginning on the last day of the pregnancy) ends. This extension does not apply to pregnant individuals eligible only during a period of presumptive eligibility. B. Optional 12-Month Postpartum Continuous Eligibility for Pregnant Women The state provides continuous eligibility to pregnant individuals who were eligible and enrolled under the state plan while pregnant (including during a period of retroactive eligibility) through the last day of the month in which a 12-month postpartum period (beginning on the last day of the pregnancy) ends. The 12-month postpartum continuous eligibility option applies for the period beginning on the effective date of this reviewable unit and is available through March 31, 2027 (or other date as specified by law). 1. This extension does not apply to pregnant individuals eligible only during a period of presumptive eligibility. 2. Full benefits are provided for a pregnant or postpartum individual under this option. This includes all items and services covered under the state plan (or waiver) that are not less in amount, duration, or scope than, or are determined by the Secretary to be substantially equivalent to, the medical assistance available for an individual described in subsection 1902 (a)(10)(A)(i) of the Act. 3. Continuous eligibility is provided to pregnant individuals eligible and enrolled under the state plan through the end of the 12-month postpartum period who would otherwise lose eligibility because of a change in circumstances, unless: a. The individual requests voluntary termination of eligibility; b. The individual ceases to be a resident of the state; c. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse or perjury attributed to the individual; or d. The individual dies. C. Additional Information (optional) The authority for the election of this option to provide 12 months postpartum continuous eligibility under section 1902(e)(16) of the Social Security Act is available through March 31, 2027 (as described in Section B. above), in accordance with Wyoming Legislature General Session 2023, session Law Ch. 152. PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Yes No This view was generated on 9/14/2023 10:27 AM EDT 0 0

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 23-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Se1vices 601 E. 12th St., Room 355 Kansas City, Missomi 64106 Medicaid and CHIP Operations Group July 21, 2023 Mr. Lee Grossman State Medicaid Agent Division of Healthcare Financing Herschler Building 122 West 25th Street, 4 West Cheyenne, WY 82002 Re: Wyoming State Plan Amendment (SPA) 23-0007 Dear Mr. Grossman: CENTERS FOR MEDICARE & MEOICAIO SERVICES CENTER FOR MEDICi\lD & CHIP SERVICES The Centers for Medicare & Medicaid Se1vices (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 23-0007. This amendment proposes to update the requirements for Third Party Liability - Payment of Claims for Third Paiiy Liability- Identifying Liable Resources. We conducted our review of your submittal according to statuto1y requirements in Title XIX of the Social Security Act and implementing regulations of the Bipaiiisan Budget Act of 2018, Section 53102. This letter is to inform you that Wyoming Medicaid SPA 23-0007 was approved on July 21, 2023, with an effective date of April 1, 2023. If you have any questions, please contact Ford Blunt at 214-767-6381or via email at Ford.Blunt@cms.hhs.gov. cc: Lee Grossman Sheila Mclnemey Sincerely, Digitally signed by James G. Scott-S Date: 2023.07.21 11 :37:29 -05'00' James G. Scott, Director Division of Program Operations

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 1. TRANS MITT Al NUMBER 23-0007 2. STATE WY FORM APPROVED 0MB No. 0938-0193 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES 04/01/2023 DEPARTMENT OF HEAL TH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check0ne)0NEW STATE PLAN □AMENDMENT TO BE CONSIDERED AS NEW PLAN 'Jjl AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate transmittal for each amendment a FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT Updating Attachments 4.22-A and 4.228 as a result of the a. FFY_ 2023. _____ $ o _____ _ Bipartisan Budget Act of 2018. Section 53102, Third Party liability b. FFY_2024 _ ____ $ _o _____ _ and u atin the State Plan 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT Attachment 4.22-A, Pages 1-3 Attachment 4.22-8, Pages 1-3 Page 69a 10. SUBJECT OF AMENDMENT 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Attachment 4.22-A, Pages 1-3 (TN 17-0007) Attachment 4.22-8, Pages 1-3 (TN 00-008) Page 69a, Page (TN 00-005) Updates to the Requirements for Third Party Liability - Payment of Claims and for Third Party Liability - Identifying Liable Resources 11. GOVERNOR'S REVIEW (Check One) □ GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SlyNATUR STATE AGENCY OFFICIAL ~ 13. TYPED NAME: LEE GROSSMAN IZJ OTHER, AS SPECIFIED - Delegated to Lee Grossman, State Medicaid Agent, Division of Healthcare Financing 16. RETURN TO: LEE GROSSMAN OFFICE OF HEAL TH CARE FINANCING I 22 WEST z5rli STREET, 4 WEST I ST ATE MEDICAID AGENT ------------------------1,CHEYENNE, WY 82002 14. TITLE: STATE MEDICAID AGENT CC: SHEILA MCINERNEY, TPL & ESTA 1E RECOVERY SPECIALIST I (SAME ADDRESS) 15. DATE SUBMITTED April 26, 2023 17. DATE RECEIVED April 26, 2023 FOR REGIONAL OFFICE USE ONLY 18. DATE APPROVED July 21, 2023 PLAN APPROVED -ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL 20. SI NAL OFFICIAL April 1, 2023 21. TYPED NAME James G. Scott 22. TITLE Digitally signed by James G. Scott-5 Date: 2023.07.21 11 :37:59 -05'00' Drector, Division of Program Operations

State/Territory: __Wyoming

TN: 23-0007 Supersedes TN: 17-0001 Approval Date: ϬϳͬϮϭͬϮϬϮϯ Effective Date: 04/01/2023 Requirements for Third Party Liability - Identifying Liable Resources – ATTACHMENT 4.22-A Page -1 1. Frequency of data exchanges (42 CFR 433.138(f)): A. SSA Wage, State Wage Information Collection Agencies (SWICA), and Title IV-A: Not utilizing these data sources currently. The Agency has an alternate source of information that furnishes information as timely, complete and useful as these files in determining the legal liability of third parties pursuant to 42 CFR 433.138(d)(2). B. Commercial health insurance carriers: Monthly C. Workers compensation: Monthly D. Motor Vehicle: Monthly E. Diagnosis and Trauma Codes: Monthly 2. Timeliness of follow-up (42 CFR 433.138(g)(1)(i) and (g)(2(i)): A. SWICA & SSA Wage – 433.138(g)(1)(ii) and IV-A data exchange – 433.168(g)(1(ii) The Agency is not utilizing these data sources currently. The Agency has an alternate source of information that furnishes information as timely, complete and useful as these files in determining the legal liability of third parties pursuant to 42 CFR 433.138(d)(2). However, the Agency will begin to perform data matching with SWICA by July 01, 2023. All new clients over the age of 14 will be sent to the Wyoming Department of Workforce Services (DWS) to verify state wage data. If a change in income is disclosed prior to the annual renewal of eligibility, a record will be sent to DWS to confirm income information. For any new and ongoing clients, eligibility records are sent from the Agency to its claims vendor who creates a commercial insurance lead for verification of health insurance coverage by the TPL vendor. During the application for and upon annual renewal of Wyoming Medicaid benefits, applicants and clients are asked to provide third party coverage information. This data is transmitted daily from the eligibility system to the claims processing system creating a “TPL Leads” file (Leads File). The Leads File is included in the eligibility extract from the claims processing vendor and transmitted to the TPL vendor. The TPL vendor conducts data matching for all clients included in the eligibility file with private health insurance companies described below. Any confirmed TPL coverage is transmitted from the TPL vendor to the claims processing vendor on a daily basis and loaded into the client’s TPL File. Since the process is conducted daily, it occurs more frequently than the quarterly SWICA and SSA Wage data match. When new health insurance information is verified, it is transmitted daily from the TPL vendor to the claims processing vendor for cost avoidance of claims. This data matching process is not just targeting individuals with income that may have private health insurance, it is

State/Territory: __Wyoming

TN: 23-0007 Supersedes TN: 17-0001 Approval Date: ϬϳͬϮϭͬϮϬϮϯ Effective Date: 04/01/2023 targeting any applicant or client with disclosed private health insurance and any newly eligible clients. Requirements for Third Party Liability - Identifying Liable Resources – ATTACHMENT 4.22-A Page - 2 B. Commercial Health Insurance Carriers – 433.138(g)(2) Health insurers in Wyoming are required by state statute to disclose private health care eligibility for all individuals eligible for and provided medical assistance by the agency, and for the individuals’ spouses or dependents. The TPL vendor receives eligibility data for 96% of the Wyoming lives covered by health insurance carriers. At the time of application for and renewal of Medicaid benefits, applicants are requested to disclose health insurance coverage information. Eligibility workers have 45 days to incorporate eligibility data into the eligibility database and determine financial eligibility. On a daily basis, an eligibility file is transmitted from the eligibility vendor through SFTP and by the system integrator to the claims processing vendor with suspected health insurance coverage information. The claims vendor uses this information to create a Leads File. This leads data is included in an eligibility extract and transmitted daily to the TPL vendor. Through an algorithm and data matching logic, the TPL vendor matches Medicaid eligibility data to eligibility information from private health insurance companies. Any confirmed health insurance coverage is transmitted daily from the TPL vendor to the claims vendor who updates the TPL eligibility file in the claims processing system. Cost avoidance is immediate through electronic edits in the claims processing system. On a weekly cadence, a paid claims file is transmitted to the TPL vendor, who screens and determines which claims are the responsibility of another health insurance company. Post payment recovery is initiated within 60 days of receipt of the extract. The TPL vendor maintains the TPL recovery records on its database. C. Workers Compensation – 433.138(g)(2) No cost avoidance occurs with workers compensation data. On a monthly basis through the system integrator and by Secure File Transfer Protocol (SFTP), a vendor receives two files from Wyoming’s Department of Workforce Services, Workers’ Compensation Division. The workers claim record file contains active workers compensation payments issued since the last reporting period. The vendor uses this file to perform data matching against the paid claims file to identify overlapping payments made by the Agency and the Department of Workforce Services. The second file is the workers compensation case file. It contains new workers compensation cases in the state of Wyoming since the last reporting period. The vendor uses demographic data from this file to perform a match against the Agency’s

State/Territory: __Wyoming

TN: 23-0007 Supersedes TN: 17-0001 Approval Date: ϬϳͬϮϭͬϮϬϮϯ Effective Date: 04/01/2023 eligibility file. Within 60 days, the vendor begins the post-payment recovery process and tracks all actions in the TPL tracking database. Requirements for Third Party Liability - Identifying Liable Resources – ATTACHMENT 4.22-A Page – 3 D. Follow through on motor vehicle data match – 42 CFR 433.138(g)(3)): The agency executed a Memorandum of Understanding (MOU) with the Department of Transportation, Highway Safety program. Pursuant to this MOU, the agency, or their designee, is authorized to access the state of Wyoming motor vehicle crash data. The TPL vendor runs a predefined ad hoc report on a monthly basis displaying all individuals injured in motor vehicle accidents. The TPL vendor performs a data match between Medicaid’s eligibility file and the report of the injured parties utilizing the injured party’s first name, last name, date of birth, and date of loss. For any confirmed matches, the TPL vendor pulls claims data, determines if Medicaid has paid accident related claims totaling $250.00 or more, pulls accident reports to determine who the responsible parties are. Within 45 days, the vendor will verify discrepant information and notify liable third parties of Medicaid’s reimbursement right, requests reimbursement, and tracks all actions in the TPL tracking database. E. Trauma diagnosis codes (433.138(g)(4))): The Agency contracts with a vendor to identify and pursue paid claims that are indicative of trauma, injury, poisoning or other external causes for the purposes of ascertaining the legal liability of third parties. Through the use of algorithms, the vendor determines whether the client should be sent a trauma code mailer based upon cost effectiveness criteria. The vendor begins the post-payment recovery process within five days of determining a claim meets the trauma code criteria. The vendor maintains the TPL case data on their database.

State/Territory: _Wyoming_______ TN: 23-0007 Supersedes TN: 00-008 ƉƉƌŽǀĂů ĂƚĞ͗ ϬϳͬϮϭͬϮϬϮϯ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ϬϰͬϬϭͬϮϬϮϯ Requirements for Third Party Liability – Payment of Claims – ATTACHMENT 4.22-B Page 1 The Agency’s TPL program is designed to function primarily as a cost avoidance system. This method was chosen as the most efficient and cost effective option. Claims for medical services, unless excluded by federal law, are cost avoided when a third party liability exists within Agency’s claims payment system. In certain circumstances, a vendor pursues post payment recovery of claims when confirmed third party coverage is loaded into the member’s TPL file after the claims are paid as described in this attachment. 1. Monitoring provider compliance (42 CFR 433.139(b)(ii)(C): The State Plan as referenced herein requires providers to bill third parties. When the probable liability of a third party is established, the Agency notifies the provider that the claim was cost avoided due to the existence of TPL. Cost avoided services/claims are identified with Claim Adjustment Reason and Remark Codes, Remittance Advice Remark Codes, and claim error codes transmitted to the provider with non-payment on the provider’s remittance advice. Providers are able to access third party coverage information through an online secure web portal. The Agency further certifies that our claims processing system enforces cost avoidance for prenatal services, including labor, delivery, and postpartum care services. The only exceptions to the cost avoidance requirements are as follows: A. Under the exemption authority found in 42 CFR 433.139(b) and 42 CFR 433.147(c), children that have been placed in the Wyoming Department of Family Services’ custody (DFS) or related entities are excluded from TPL cooperation. (i) The Agency will use standard “pay and chase” when processing claims unless it is confirmed that the child’s life will be put in jeopardy (e.g. medical support order). B. Under the exemption authority found in 42 CFR 433.139(b)(3)(i), the Agency makes payments without regard to potential third party liability for preventative pediatric services, including early and periodic screening, diagnosis and treatment services (EPSDT), unless the state has made a determination related to cost effectiveness and access to care that warrants cost-avoidance for up to 90 days. (i) Wyoming will use standard “pay and chase” when processing claims for preventative pediatric services. C. Under the exemption authority found in 42 C.F.R. 433.139(b)(3)(ii), the state has flexibility to make payments without regard to potential TPL for up to 100 days for claims related to child support enforcement beneficiaries, In regard to child support services, the Agency chooses to make payment within 30 days as it is cost-effective and necessary for access to care.

State/Territory: _Wyoming_______ TN: 23-0007 Supersedes TN: 00-008 ƉƉƌŽǀĂů ĂƚĞ͗ ϬϳͬϮϭͬϮϬϮϯ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ϬϰͬϬϭͬϮϬϮϯ Requirements for Third Party Liability – Payment of Claims – ATTACHMENT 4.22-B Page 2 (i) Wyoming will use standard “pay and chase” when processing claims for child support enforcement beneficiaries. Providers are monitored for compliance with insurance billing requirements through a post payment recovery process by a vendor. The vendor is responsible for identifying claims with potential third party liability where Medicaid has paid primary. The vendor will either directly bill the primary insurance or will perform disallowance by requesting the provider seek payment from the primary insurance and Wyoming’s payment will be recouped. If a provider has billed a third party and has not received payment, the provider will be required to submit a form as proof that they attempted to bill the third party two times within a 90-day period and have not received payment. The provider must have waited 90 days from the date of service and not received payment from the third party before the Agency will pay. 2. Guidelines Used to Determine When to Seek Reimbursement from a Liable Third Party (42 CFR 433.139(f)(2)): A. Health Insurance For medical claims that were paid by Wyoming prior to the TPL policy being entered into the claims system, recovery is pursued by a vendor from the provider for amounts greater than $10.00 within eleven months from the date of service. The timeframe is only one year from the date of the service if the provider would need to bill Medicare. For medical claims that were paid by Wyoming prior to the TPL policy being entered into the member’s eligibility file in the claims processing system, recovery is pursued by a vendor from the liable third party payer for amounts greater than $0.01 within a timeframe of twelve months to three years of the claim from date of service. B. Casualty Threshold The Agency does not have a threshold amount for casualty insurance claims; however, priority is given to identifying third party liability for those members who have had at least $250.00 in trauma related claims during the month. Those individuals with less than $250.00 in claims are worked as time permits. C. Casualty Recovery For casualty recoveries, the agency complies with 42 U.S.C. Section 1396(a)(25)(B) and uses the following factors and guidelines in determining whether to pursue recovery of benefit, after deduction of the agency’s proportionate share of attorney’s fees and costs, from a liable party.

State/Territory: _Wyoming_______ TN: 23-000ϳ Supersedes TN: 00-008 ƉƉƌŽǀĂů ĂƚĞ͗ ϬϳͬϮϭͬϮϬϮϯ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ϬϰͬϬϭͬϮϬϮϯ Requirements for Third Party Liability – Payment of Claims – ATTACHMENT 4.22-B Page 3 (i) Ascertain the amount of the Medicaid reimbursement right and the amount of the gross settlement. (ii) Determine whether the Medicaid right to reimbursement plus attorney’s fees and costs will exhaust or exceed the settlement funds. (iii) If the answer to 2 (ii) is Yes; and if the agency: (a) Is informed the client will not pursue the claim; or (b) Cannot handle the case, once it is tendered to the agency by the client or the client’s attorney to pursue on behalf of the client; or (c) Made reasonable effort to ascertain the client’s intention regarding the claim, but could not obtain a response; then the agency shall follow procedures stated in (iv). (iv) The agency shall consider the cost-effectiveness principle in determining the estimated net recovery amount to be pursued, based on the likelihood of collections. Net recovery amount is defined as that amount of recovered dollars to apply to Medicaid costs. In determining the estimated recovery amount, the following factors will be considered: (a) Settlement as may be affected by insurance coverage or other factors relating to the liable party; (b) Factual and legal issues of liability as may exist between the client and liable party; (c) Problems of proof faced in obtaining the award or settlement; and (d) The estimated attorney’s fees and costs required for the agency to pursue the claim. After considering the above factors, the agency may pursue a lesser recovery amount to the extent that the agency determines it to be cost-effective to do so.

69a Revision: HCFA-PM-94-1 (MB) FEBRUARY 1994 State/Territory: __________________WYOMING________________________________ TN: 23-0007 Supercedes TN: 00-005 ƉƉƌŽǀĂů ĂƚĞ͗ ϬϳͬϮϭͬϮϬϮϯ

ĨĨĞĐƚŝǀĞ ĂƚĞ͗ ϬϰͬϬϭͬϮϬϮϯ Citation 42 CFR 433.139 (b)(3)(ii)(A) __X__ (c) Providers are required to bill liable third parties when services covered under the plan are furnished to an individual on whose behalf child support enforcement is being carried out by the State IV-D agency. (d) ATTACHMENT 4.22-B specifies the following: 42 CFR 433.139(b)(3)(ii)(C) (1) The method used in determining a provider’s compliance with the third §433.139(b)(3)(ii)(C). 42 CFR 433.139(f)(2) (2) The threshold amount or other guideline used in determining whether to seek recovery of reimbursement from a liable third party, or the process by which the agency determines that seeking recovery or reimbursement would not be cost effective. 42 CFR 433.139(f)(3) (3) The dollar amount or time period the State uses to accumulate billings from a particular liable third party in making the decision to seek recovery of reimbursement. 42 CFR 447.20 (e) The Medicaid agency ensures that the provider furnishing a service for which a third party is liable follows the restrictions specified in 42 CFR 447.20.

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 24-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Se1vices 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group December 9, 2024 Lee Grossman State Medicaid Agent Division of Healthcare Financing Herschler Building 122 West 25th Street, 4 West Cheyenne, WY 82002 Re: Wyoming State Plan Amendment (SP A) 24-0004 Dear State Medicaid Agent Grossman: CENTERS FOR MEDICARE & MEOICAIO SERVICES CENTER FOR MEDICi\lD & CHIP SERVICES The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) WY 24-0004. This amendment temporarily suspends beneficia1y cost sharing for pha1macy claims with dates of service from Febrnaiy 22, 2024 to June 30, 2024. The te1ms of this State Plan Amendment sunset at midnight on June 30, 2024. We conducted our review of your submittal according to statuto1y requirements in Title XIX of the Social Security Act and implementing regulations. This letter info1ms you that Wyoming's Medicaid SPA TN WY 24-0004 was approved on December 9, 2024, with an effective date of Febrnaiy 22, 2024. Enclosed are copies of Fo1m CMS-179 and approved SPA pages to be inco1porated into the Wyoming State Plan. If you have any questions, please contact Ford Blunt at (214) 767-6381 or via email at Ford.Blunt@cms.hhs.gov. Enclosures cc: Jennifer Comick Jesse Springer Sincerelv, Digitally signed by James G. Scott-5 Date: 2024.12.09 14:32:08 -06'00' James G. Scott, Director Division of Program Operations

WY.7423.R00.00 - Feb 22, 2024 Medicaid Premiums and Cost Sharing: Summary Page (CMS 179) State/Tenitory name: Wyoming Transmittal Number: Enter tlte Transmittal Number (TN), including dashes, in the format SS-YY-NNNN or SS-YY-NNNN-xxxx (with xxxx being optional to specific SP A types), wltere SS = 2-cltaracter state abbreviation, YY = last 2 digits of submission year, NNNN = 4-digit number witlt leading zeros, and xxxx = OPTIONAL, 1- to 4-cltaracter a/pita/numeric suffix. I WY-24-0004 Proposed Effective Date I 02/22/2024 1 (mm/dd/yyyy) Federal Statute/Regulation Citation I Sections 1916 and 1916A of SSA and 42 CFR 447.50-.57 Federal Budget Impact. Federal Fiscal Yea1· Amount First Year $112500.00 Second Year ~ Subject. of Amendment Requests waiving the advance public notice and advance Tribal consultation requirements and requirements to submit responses to Medicaid funding questions as pemtitted in the CIB dated March 15, 2024. In response to the CHC cyber-attacl:, this SPA will temporarily remove beneficiary pharmacy cost sharing requirements for claims with DOS from 2/22/14-6/30/24. Gove1·nor's Office Review 0 Governo1·'s office reported no comment 0 Comments of Governo1·'s office received Describe: 0 No reply received within 45 days of submittal 0 Other, as specified Describe: LEE.GI.OSSM..\N SfAI'E MEDJCAID A.GENT DIVISIO!'i Of HE.ALTBCAll FnlA.."K:tNG BE1SCHI.D. BtlILDING 1nW1tc:.T .... ,sncc:.nnT 4.WF~~ Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Denzel Clifton Nov 6, 2024 Nov 1, 2024 https://wms-mmdl.cms.gov/MMDUfaces/protected/mpc/fOl/print/PrintSelector.jsp[l l/25/2024 9:50:47 AM]

Medicaid Premiums and Cost Sharing State Name:I ~W_ y_o_rm_·_n_g ________________ ~ 0MB Control Number: 09381148 Transmittal Number: WY - 24 - 0004 Cost Sharing Requirements Gt 1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55) The state charges cost sharing (deductibles, co-insmance or co-payments) to individuals covered under Medicaid. [ZI The state assmes that it administers cost sharing in accordance with sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50 through 447.57. General Provisions [ZI The cost sharing amounts established by the state for services are always less than the amount the agency pays for the service. ~ No provider may deny services to an eligible individual on account of the individual's inability to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)(l). ~ The process used by the state to infonn providers whether cost sharing for a specific item or service may be imposed on a beneficia1y and whether the provider may require the beneficiaiy to pay the cost sharing charge, as a condition for receiving the item or service, is (check all that apply): i:gJ The state includes an indicator in the Medicaid Management Info1mation System (MMIS) D The state includes an indicator in the Eligibility and Enrollment System [gJ The state includes an indicator in the Eligibility Verification System D The state includes an indicator on the Medicaid card, which the beneficiary presents to the provider D Other process Iii Contracts with managed care organizations (MCOs) provide that any cost-shaimg chai·ges the MCO imposes on Medicaid enrollees are in accordance with the cost sharing specified in the state plan and the requirements set forth in 42 CFR 447.50 through 447.57. Cost Sharing fo1· Non-Emergency Services Provided in a Hospital Emergency Depa11ment The state imposes cost sharing for non-emergency services provided in a hospital emergency department. ~ [ZI The state ensmes that before providing non-emergency services and imposing cost shaimg for such services, that the hospitals providing care: liJ Conduct an appropriate medical screening under 42 CFR 489.24, subpait G to dete1mine that the individual does not need emergency services; ~ Info1m the individual of the amount of his or her cost sharing obligation for non-emergency services provided in the emergency department; ~ Provide the individual with the name and location of an available and accessible alternative non-emergency services provider; TN No. WY 24-0004 Supersedes - New Page Approval Date: 12-09-24 Effective Date 02-22-24 Page 1 of2

Medicaid Premiums and Cost Sharing ~ Detennine that the altemative provider can provide services to the individual in a timely manner with the imposition of a lesser cost sharing amount or no cost sharing if the individual is othe1wise exempt from cost sharing; and ~ Provide a refe1rnl to coordinate scheduling for treatment by the altemative provider. IZJ The state assures that it has a process in place to identify hospital emergency depa1tment services as non-emergency for purposes of imposing cost sharing. This process does not limit a hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Act; or modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical services by any managed care organization. The process for identifying emergency depaitment services as non-emergency for pwposes of imposing cost sharing is: Wyoming uses the emergency indicator on the UB 08 claim form, and does not apply any cost shai·ing if this box is checked on emergency depaitment claims. This results in a ve1y small proportion of claims being assigned any cost shai·ing. Cost Sharing fo1· Drngs The state charges cost shai·ing for drugs. Beneficiary and Public Notice Requirements IZJ Consistent with 42 CFR 447.57, the state makes available a public schedule describing cwrent cost sharing requirements in a manner that ensures that affected applicants, beneficiai-ies and providers are likely to have access to the notice. Prior to submitting a SP A which establishes or substantially modifies existing cost sha1-ing amounts or policies, the state provides the public with advance notice of the SP A, specifying the amount of cost sharing and who is subject to the chai·ges, and provides reasonable opportwtity for stakeholder comment. Documentation demonstrating that the notice requirements have been met are submitted with the SP A. The state also provides opportunity for additional public notice if cost sharing is substantially modified during the SP A approval process. Othe1· Relevant Info1·mation PRA Disclosure Statement According to the Pape1work Reduction Act of 1995, no persons ai·e required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 09381148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instrnctions, seai·ch existing data resources, gather the data needed, and complete and review the information collection. If you have comments conceming the accuracy of the time estimate(s) or suggestions for improving this form, please w1-ite to: CMS, 7500 Secw-ity Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C42605, Baltimore, Maryland 212441850. TN No. WY-24-0004 Supersedes - New Page Approval Date:12-09-24 Effective Date 02-22-24 V.20160722 Page 2 of2

Page 1 of 2 Medicaid Premiums and Cost Sharing State Name: Wyoming OMB Control Number: 09381148 Transmittal Number: WY - 24 - 0004 Cost Sharing Amounts - Categorically Needy Individuals G2a 1916 1916A 42 CFR 447.52 through 54 The state charges cost sharing to all categorically needy (Mandatory Coverage and Options for Coverage) individuals. Yes Services or Items with the Same Cost Sharing Amount for All Incomes Add Service or Item Amount Dollars or Percentage Unit Explanation Remove Add Office Visits 2.45 $ Visit Procedure code range 99201 – 99215 Office Visits only when place of service is 11. Remove Add Home Visits 2.45 $ Visit Procedure code range 99341 -99350 Remove Add Eye Exams 2.45 $ Visit Procedure code range 92002, 92004, 92014 Remove Add Rural Health Center per visit 3.65 $ Visit T1015 and 0521 Revenue Code Remove Add Federally Qualified Health Center per visit 3.65 $ Visit T1015 and 0521 Revenue Code Remove Add Outpatient hospital visits (non –emergency) 3.65 $ Visit 0450-0459 and 0510-0519 Revenue Codes. Only apply cost sharing to claims without the emergency indicator on the UB08 claim form. Remove Add Pharmacy (Generic) 0.65 $ Prescription $0.65 for each generic prescription. For prescriptions dispensed during the 2024 Change Healthcare Network Interruption, member pharmacy cost sharing requirements are suspended through full system restoration. The effective date for this SPA is February 22, 2024, and the sunset date is June 30, 2024. Remove Add Pharmacy (Brand) 3.65 $ Prescription $3.65 for each brand prescription. For prescriptions dispensed during the 2024 Change Healthcare Network Interruption, member pharmacy cost sharing requirements are suspended through full system restoration. The effective date for this SPA is February 22, 2024, and the sunset date is June 30, 2024. Remove Services or Items with Cost Sharing Amounts that Vary by Income Service or Item: Not applicable. Remove Service or Item Indicate the income ranges by which the cost sharing amount for this service or item varies. TN No. WY-24-0004 Supersedes  1HZ 3DJH Approval Date:  Effective Date: 02-22-24 - D D I I I I D D □ CJ I I I

Page 2 of 2 Medicaid Premiums and Cost Sharing Add Incomes Greater than Incomes Less than or Equal to Amount Dollars or Percentage Unit Explanation Remove Add Remove Add Service or Item Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-preferred drugs (entered above), answer the following question: The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. No Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-emergency services provided in the hospital emergency department (entered above), answer the following question: The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise exempt individuals. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C42605, Baltimore, Maryland 212441850. V.20181119 71 1R :<  6XSHUVHGHV  1HZ 3DJH $SSURYDO 'DWH   (IIHFWLYH 'DWH  I I I I 11 1l1 11 I I I I - □ - □

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 24-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

601 E. 12th St., Room 355

Kansas City, Missouri 64106

Medicaid and CHIP Operations Group

CMS

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

November 27, 2024

Lee Grossman

State Medicaid Agent

Division of Healthcare Financing Herschler Building

122 West 25" Street, 4 West Cheyenne, WY 82002

Re: Wyoming State Plan Amendment (SPA) 24-0006

Dear State Medicaid Agent Grossman:

The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) WY 24-0006. This amendment complies with the Consolidated Appropriations Act of 2022 and makes changes to the state plan so that health insurance companies cannot deny reclamation claims for the Agency not obtaining prior authorization for the item or service through the health insurance company and requiring health insurance companies to process

reclamation claims within 60 days of receipt of such claims.

We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations. This letter informs you that Wyoming’s Medicaid SPA TN WY 24-0006 was approved on November 27, 2024, with an effective date of October 1, 2024.

Enclosed are copies of Form CMS-179 and approved SPA pages to be incorporated into the Wyoming State

Plan.

If you have any questions, please contact Ford Blunt at (214) 767-6381 or via email at

Ford.Blunt@cms.hhs.gov.

Sincerely,

Digitally signed by James G. Scott -S Date: 2024.11.27 11:11:25 -06'00"

James G. Scott, Director

Division of Program Operations

Enclosures

cc: Jennifer Conrick Karen Small

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

FORMAPPROVED OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

1. TRANSMITTAL NUMBER 2. STATE 2.4 —-0 006 | W 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL

SECURITY ACT @) xix QO xxl

TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE 07/01/2024 10/01/2024

5. FEDERAL STATUTE/REGULATION CITATION

6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars)

a FFY__ 2024 $_0 1902(a)(25)(I) ep 7 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT ((f Applicable)

Pages 2 and 3

ATTACHMENT 4.22-B2.A.

9. SUBJECT OF AMENDMENT

Pursuant to the Consolidated Appropriations Act of 2022, make changes to the state plan so health insurance companies cannot deny reclamation claims for the Agency not obtaining prior authorization for the item or service through the health insurance company and requiring health insurance companies to process reclamation claims within 60 days of receipt of such claims.

10, GOVERNOR'S REVIEW (Check One)

GOVERNOR'S OFFICE REPORTED NO COMMENT COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

© OTHER, AS SPECIFIED:

11. E OF STATE AGENCY OFFICIAL

GNA’

“72. TYPED NAME Lee Grossman, MPA 13. TITLE

Senior Administrator/State Medicaid Agent

14. DATE SUBMITTED 10/22/2024

15. RETURN TO

FOR CMS

USE ONLY

16. DATE RECEIVED 10/28/2024

17. DATE APPROVED November 27, 2024

PLAN APPROVED - ONE COPY ATTACHED

18. EFFECTIVE DATE OF APPROVED MATERIAL

19. SIGMA THD Oe “PPROVING OFFAL hed by James G. Scott -S

10/0 1/2024 Date: 2024.11.27 11:11:53 -06'00' 20. TYPED NAME OF APPROVING OFFICIAL 21. TITLE OF APPROVING OFFICIAL

James G. Scott Director, Divsion of Program Operations 22. REMARKS

Pen and Ink change to Box 4 to effective date of 10/

1/24 as per e-mail from state dated 11/21/24.

FORM CMS-179 (09/24)

Instructions on Back

State/Territory: Wyoming Requirements for Third Party Liability – Payment of Claims – ATTACHMENT 4.22-B Page 2 TN: 24-0006 Supersedes TN: 23-0007 Approval Date:  Effective Date: 10/01/2024 (i) Wyoming will use standard “pay and chase” when processing claims for child support enforcement beneficiaries. Providers are monitored for compliance with insurance billing requirements through a post payment recovery process by a vendor. The vendor is responsible for identifying claims with potential third-party liability where Medicaid has paid primary. The vendor will either directly bill the primary insurance or will perform disallowance by requesting the provider seek payment from the primary insurance and Wyoming’s payment will be recouped. If a provider has billed a third party and has not received payment, the provider will be required to submit a form as proof that they attempted to bill the third party two times within a 90-day period and have not received payment. The provider must have waited 90 days from the date of service and not received payment from the third party before the Agency will pay. 2. Guidelines Used to Determine When to Seek Reimbursement from a Liable Third Party (42 CFR 433.139(d)(2) – Compliance with SSA Section 1902(a)(25)(I) and 42 CFR 433.139(f)(2)): A. Health Insurance For medical claims that were paid by Wyoming prior to the TPL policy being entered into the claims system, recovery is pursued by a vendor from the provider for amounts greater than $10.00 within eleven months from the date of service. The timeframe is only one year from the date of service if the provider would need to bill Medicare. For medical claims that were paid by Wyoming prior to the TPL policy being entered into the member’s eligibility file in the claims processing system, recovery is pursued by a vendor from the liable third-party payer for amounts greater than $.01 within a timeframe of twelve months to three years of the claim from date of service. Health insurers (other than Medicare plans) shall not deny payment for an item or service (a reclamation claim) for failure to obtain the required prior authorization under the health insurer’s rules and regulations. The Agency’s payment of the claim satisfies the prior authorization requirement of the health insurer as the health insurer must accept the authorization provided by the state that the item or service is covered under the state plan (or waiver of such plan). Health insurers shall respond to reclamation claims within sixty (60) days of receipt of such claims. B. Casualty Threshold The Agency does not have a threshold amount for casualty insurance clams; however, priority is given to identifying third party liability for those members who have had at least $250.00 om trauma related claims during the month. Those individuals with less than $250.00 in claims are worked as time permits.

State/Territory: Wyoming Requirements for Third Party Liability – Payment of Claims – ATTACHMENT 4.22-B Page 3 TN: 24-0006 Supersedes TN: 23-0007 Approval Date: ϭϭͬϮϳͬϮϬϮϰ Effective Date: 10/01/2024 C. Casualty Recovery For casualty recoveries, the agency complies with 42 U.S.C Section 1396(a)(25)(B) and uses the following factors and guidelines in determining whether to pursue recovery of benefit, after deduction of the agency’s proportionate share of attorney’s fees and costs, from a liable party. (i) Ascertain the amount of the Medicaid reimbursement right and the amount of the gross settlement. (ii) Determine whether the Medicaid right to reimbursement plus attorney’s fees and costs will exhaust or exceed the settlement funds. (iii) If the answer to 2 (ii) is Yes; and if the agency: (a) Is informed the client will not pursue the claim: or (b) Cannot handle the case, once it is tendered to the agency by the client or the client’s attorney to pursue on behalf of the client; or (c) Made reasonable effort to ascertain the client’s intention regarding the claim, but could not obtain a response; then the agency shall follow procedures stated in (iv). (iv) The agency shall consider the cost-effectiveness principle in determining the estimated net recovery amount to be pursued, based on the likelihood of collections. Net recovery amount is defined as that amount of recovered dollars to apply to Medicaid costs. In determining the estimated recovery amount, the following factors will be considered: (a) Settlement as may be affected by insurance coverage or other factors relating to the liable third party; (b) Factual and legal issues of liability as may exist between the client and the liable party; (c) Problems of proof faced in obtaining the award or settlement; and (d) The estimated attorney’s fee and costs required for the agency to pursue the claim. After considering the above factors, the agency may pursue a lesser recovery amount to the extent that the agency determines that it is cost-effective to do so.

Table of Contents State/Territory Name: Wyoming State Plan Amendment (SPA) #: 24-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Se1vices 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group December 18, 2024 Lee Grossman State Medicaid Agent Division of Healthcare Financing Herschler Building 122 West 25th Street, 4 West Cheyenne, WY 82002 Re: Wyoming State Plan Amendment (SPA) 24-0007 Dear State Medicaid Agent Grossman: CENTERS FOR MEDICARE & MEOICAIO SERVICES CENTER FOR MEDICi\lD & CHIP SERVICES The Centers for Medicare & Medicaid Se1vices (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (IN) WY 24-0007. This SPA will pe1manently remove beneficiaiy cost sharing requirements for non-emergency services provided in a hospital emergency depaitments and beneficiaiy phaimacy cost shaiing requirements for claims with a date of se1vice (DOS) from July 1, 2024 fo1ward. In addition, this SPA attests Wyoming compliance with client exemptions and protections related to cost-sha1ing and clarifies M-CHIP cost-sharing. We conducted our review of your submittal according to stan1to1y requirements in Title XIX of the Social Security Act and implementing regulations. This letter infonns you that Wyoming's Medicaid SPA 1N WY 24-0007 was approved on December 18, 2024, with an effective date of July 1, 2024. Enclosed are copies of F onn CMS-179 and approved SP A pages to be incorporated into the Wyoming State Plan. If you have any questions, please contact Ford Blunt at (214) 767-6381 or via email at Ford.Blunt@cms.hhs.gov. Enclosures cc: Jennifer Comick Jesse Sp1inger Sincerely, Digitally signed by James G. Scott-5 Date: 2024.12.18 13:45:55 -06'00' James G. Scott, Director Division of Program Operations

WY.7422.R00.00 - Jul 01, 2024 Medicaid Premiums and Cost Sharing: Summary Page (CMS 179) State/Tenitory name: Wyoming Transmittal Number: Enter tlte Transmittal Number (TN), including dashes, in the format SS-YY-NNNN or SS-YY-NNNN-xxxx (with xxxx being optional to specific SP A types), wltere SS = 2-cltaracter state abbreviation, YY = last 2 digits of submission year, NNNN = 4-digit number witlt leading zeros, and xxxx = OPTIONAL, 1- to 4-cltaracter a/pita/numeric suffix. I WY-24-0007 Proposed Effective Date I 07/01/2024 1 (mm/dd/yyyy) Federal Statute/Regulation Citation Sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50-447.57 Federal Budget Impact. Federal Fiscal Yea1· Amount First Year Second Year I 2026 I Subject. of Amendment This SPA will permanently remove beneficiary pharmacy cost sharing requirements for claims with DOS from July I, 2024 forward. In addition, this SPA attests Wyoming compliance with client exemptions and protections related to cost sharing, and clarifies M-CHIP cost sharing. Gove1·nor's Office Review 0 Governo1·'s office reported no comment 0 Comments of Governo1·'s office received Describe: 0 No reply received within 45 days of submittal 0 Other, as specified Describe: LEE.GI.OSSM.\N SfAI'E MEDJCAID A.GENT DIVISIO!'i Of HE.ALTBCAll FnlA.."K:tNG BE1SCHI.D. BtlILDING 1nW1tc:.T .... ,sncc:.nnT 4.WF~~ Signature of State Agency Official Submitted By: Last Revision Date: Submit Date: Denzel Clifton Nov 4, 2024 Oct. 31, 2024 https://wms-mmdl.cms.gov/MMDU faces/protected/mpc/fOl/print/PrintSelector.jsp[l l/25/2024 2:03 :31 PM]

Medicaid Premiums and Cost Sharing State Name:I ~W_ y_o_rm_·n_g _______________ ~ 0MB Control Number: 09381148 Transmittal Number: WY - 24 - 0007 Cost Sharing Requirements Gt 1916 1916A 42 CFR 447.50 through 447.57 (excluding 447.55) The state charges cost sharing (deductibles, co-insmance or co-payments) to individuals covered under Medicaid. [ZI The state assmes that it administers cost sharing in accordance with sections 1916 and 1916A of the Social Security Act and 42 CFR 447.50 through 447.57. General Provisions [ZI The cost sharing amounts established by the state for services are always less than the amount the agency pays for the service. ~ No provider may deny services to an eligible individual on account of the individual's inability to pay cost sharing, except as elected by the state in accordance with 42 CFR 447.52(e)(l). ~ The process used by the state to infonn providers whether cost sharing for a specific item or service may be imposed on a beneficia1y and whether the provider may require the beneficiaiy to pay the cost sharing charge, as a condition for receiving the item or service, is (check all that apply): i:gJ The state includes an indicator in the Medicaid Management Info1mation System (MMIS) D The state includes an indicator in the Eligibility and Enrollment System [gJ The state includes an indicator in the Eligibility Verification System D The state includes an indicator on the Medicaid card, which the beneficiary presents to the provider D Other process Iii Contracts with managed care organizations (MCOs) provide that any cost-shaimg chai·ges the MCO imposes on Medicaid enrollees are in accordance with the cost sharing specified in the state plan and the requirements set forth in 42 CFR 447.50 through 447.57. Cost Sharing fo1· Non-Emergency Services Provided in a Hospital Emergency Depa11ment The state imposes cost sharing for non-emergency services provided in a hospital emergency department. Cost Sharing fo1· Drngs The state charges cost shai·ing for drugs. TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date: 12-18-24 Effective Date: 07-01-24 Page 1 of2

Medicaid Premiums and Cost Sharing Beneficiary and Public Notice Requirements IZJ Consistent with 42 CFR 447.57, the state makes available a public schedule describing cwrent cost sharing requirements in a manner that ensw-es that affected applicants, beneficiaries and providers are likely to have access to the notice. Prior to submitting a SP A which establishes or substantially modifies existing cost sharing amounts or policies, the state provides the public with advance notice of the SP A, specifying the amount of cost sharing and who is subject to the charges, and provides reasonable opportunity for stakeholder comment. Documentation demonstrating that the notice requirements have been met are submitted with the SP A. The state also provides opportunity for additional public notice if cost sharing is substantially modified dming the SP A approval process. Othe1· Relevant Info1·mation All cost sharing is published at https://health.,,.,yo.gov/healthcarefin/medicaid/cost-sharing/ for Medicaid clients. Cost sharing is published at https://health.wyo.gov/healthcarefin/chip/ for M-CHIP children. PRA Disclosure Statement According to the Pape1work Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 09381148. The time required to complete this information collection is estimated to average 40 how-s per response, including the time to review instrnctions, search existing data resow-ces, gather the data needed, and complete and review the information collection. If you have comments concerning the accw-acy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Secw-ity Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C42605, Baltimore, Maryland 212441850. TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date: 12-18-24 Effective Date 07-01-24 V.20160722 Page 2 of2

Page 1 of 2 Medicaid Premiums and Cost Sharing State Name: Wyoming OMB Control Number: 09381148 Transmittal Number: WY - 24 - 0007 Cost Sharing Amounts - Categorically Needy Individuals G2a 1916 1916A 42 CFR 447.52 through 54 The state charges cost sharing to all categorically needy (Mandatory Coverage and Options for Coverage) individuals. Yes Services or Items with the Same Cost Sharing Amount for All Incomes Add Service or Item Amount Dollars or Percentage Unit Explanation Remove Add Office Visits 2.45 $ Visit Procedure code range 99201 – 99215 Office Visits only when place of service is 11. Remove Add Home Visits 2.45 $ Visit Procedure code range 99341 -99350 Remove Add Eye Exams 2.45 $ Visit Procedure code range 92002, 92004, 92014 Remove Add Rural Health Center 3.65 $ Visit T1015 and 0521 Revenue Code Remove Add Federally Qualified Health Center 3.65 $ Visit T1015 and 0521 Revenue Code Remove Services or Items with Cost Sharing Amounts that Vary by Income Service or Item: Not applicable. Remove Service or Item Indicate the income ranges by which the cost sharing amount for this service or item varies. Add Incomes Greater than Incomes Less than or Equal to Amount Dollars or Percentage Unit Explanation Remove Add Remove Add Service or Item Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-preferred drugs (entered above), answer the following question: The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. No Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-emergency services provided in the hospital emergency department (entered above), answer the following question: TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date:  Effective Date: 07-01-24 - D D I I I I I I D I I I I I I I 11 1l1 11 I I I I - □

Page 2 of 2 Medicaid Premiums and Cost Sharing The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise exempt individuals. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C42605, Baltimore, Maryland 212441850. V.20181119 TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date:  Effective Date: 07-01-24 □

Page 1 of 1 Medicaid Premiums and Cost Sharing State Name: Wyoming OMB Control Number: 09381148 Transmittal Number: WY - 24 - 0007 Cost Sharing Amounts - Medically Needy Individuals G2b 1916 1916A 42 CFR 447.52 through 54 The state charges cost sharing to all medically needy individuals. No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C42605, Baltimore, Maryland 212441850. V.20181119 TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date:  Effective Date: 7-01-24 - D

Page 1 of 2 Medicaid Premiums and Cost Sharing State Name: Wyoming OMB Control Number: 09381148 Transmittal Number: WY - 24 - 0007 Cost Sharing Amounts - Targeting G2c 1916 1916A 42 CFR 447.52 through 54 The state targets cost sharing to a specific group or groups of individuals. Yes Population Name (optional): M-CHIP Eligibility Group(s) Included: M-CHIP individuals that are not native americans Incomes Greater than 134% FPL TO Incomes Less than or Equal to 200% FPL Add Service Amount Dollars or Percentage Unit Explanation Remove Add Office Visits 2.45 $ Visit Procedure code range 99201 – 99215 Office Visits only when place of service is 11. Remove Add Home Visits 2.45 $ Visit Procedure code range 99341 -99350 Remove Add Eye Exams 2.45 $ Visit Procedure code range 92002, 92004, 92014 Remove Add Rural Health Center 3.65 $ Visit T1015 and 0521 Revenue Code Remove Add Federally Qualified Health Center 3.65 $ Visit T1015 and 0521 Revenue Code Remove The state permits providers to require individuals to pay cost sharing as a condition for receiving items or services, subject to the conditions specified at 42 CFR 447.52(e)(1). This is only permitted for non-exempt individuals with family income above 100% FPL. No Cost Sharing for Non-preferred Drugs Charged to Otherwise Exempt Individuals If the state targets cost sharing for non-preferred drugs to specific groups of individuals (entered above), answer the following question: The state charges cost sharing for non-preferred drugs to otherwise exempt individuals. No Cost Sharing for Non-emergency Services Provided in the Hospital Emergency Department Charged to Otherwise Exempt Individuals If the state charges cost sharing for non-emergency services provided in the hospital emergency department to specific individuals (entered above), answer the following question: The state charges cost sharing for non-emergency services provided in the hospital emergency department to otherwise exempt individuals. No TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date:  Effective Date: 07-01-24 D I I I I I I □ II I II I DI I I I 11 I I 11 □ - □ - □

Page 2 of 2 Medicaid Premiums and Cost Sharing Remove Population Add Population PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C42605, Baltimore, Maryland 212441850. V.20181119 TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date:  Effective Date: 07-01-24 I I

Medicaid Premiums and Cost Sharing State Name:I ~W_ y_o_rm_·n_g _______________ ~ 0MB Control Number: 09381148 Transmittal Number: WY - 24 - 0007 Cost Sharing Limitations G3 42 CFR447.56 1916 1916A IZJ The state administers cost sharing in accordance with the limitations described at 42 CFR 447.56, and 1916(a)(2) and (j) and 1916A(b) of the Social Secmity Act, as follows: Exemntions Groups of Individuals - Mandato1-y Exemptions The state may not impose cost sharing upon the following groups of individuals: Ii] Individuals ages 1 and older, and under age 18 eligible under the Infants and Children under Age 18 eligibility group ( 42 CFR435.118). Ii] Infants under age 1 eligible under the Infants and Children under Age 18 eligibility group (42 CFR 435.118), whose income does not exceed the higher of: ~ 133% FPL; and Ii] If applicable, the percent FPL described in section 1902(1)(2)(A)(iv) of the Act, up to 185 percent. Ii] Disabled or blind individuals under age 18 eligible for the following eligibility groups: Ii] SSI Beneficiaries (42 CFR 435.120). Ii] Blind and Disabled Individuals in 209(b) States (42 CFR 435.121). ~ Individuals Receiving Mandatory State Supplements (42 CFR 435. 130). Ii] Children for whom child welfare services are made available under Patt B of title IV of the Act on the basis of being a child in foster care and individuals receiving benefits under Part E of that title, without regai·d to age. ~ Disabled children eligible for Medicaid under the Family Opportunity Act (1902( a)(l 0)(A)(ii)(XIX) and 1902( cc) of the Act). Ii] Pregnant women, dw-ing pregnancy and through the postpaitum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends, except for cost sharing for services specified in the state plan as not pregnancy-related. Ii] Any individual whose medical assistance for services furnished in an institution is reduced by amounts reflecting available income other than required for personal needs. ~ An individual receiving hospice care, as defined in section 1905(0) of the Act. Ii] Indians who are ctm-ently receiving or have ever received an item or service furnished by an Indian health cai·e provider or through refe1rnl under contract health services. ~ Individuals who ai·e receiving Medicaid because of the state's election to extend coverage to the Ce1tain Individuals Needing Treatment for Breast or Cervical Cancer eligibility group (42 CFR 435.213). GroupsN>Nln~g7- Optional Exemptions Annroval Date: 12-18-24 Supersedes WY 24-0004 Effective Date: 07-01-24

Medicaid Premiums and Cost Sharing The state may elect to exempt the following groups of individuals from cost sharing: The state elects to exempt individuals under age 19, 20 or 21, or any reasonable category of individuals 18 years of age or over. Indicate below the age of the exemption: (' Under age 19 (' Under age 20 (e Under age 21 (' Other reasonable category The state elects to exempt individuals whose medical assistance for services fumished in a home and community-based ly:=7 setting is reduced by amounts reflecting available income other than required for personal needs. ~ Services - Mandatory Exemptions The state may not impose cost sharing for the following services: ~ Emergency services as defined at section 1932(b)(2) of the Act and 42 CFR 438. l 14(a). ~ Family planning services and supplies described in section 1905(a)(4)(C) of the Act, including contraceptives and pha1maceuticals for which the state claims or could claim federal match at the enhanced rate under section 1903(a)(5) of the Act for family planning services and supplies. Ii] Preventive services, at a minimum the services specified at 42 CFR 457.520, provided to children under 18 years of age regardless of family income, which reflect the well-baby and well child care and irnmunizations in the Bright Futures guidelines issued by the American Academy of Pediatrics. ~ Pregnancy-related services, including those defined at 42 CFR 440.210(a)(2) and 440.250(p), and counseling and dtugs for cessation of tobacco use. All services provided to pregnant women will be considered pregnancy-related, except those services specificially identified in the state plan as not being related to pregnancy. ~ Provider-preventable services as defined in 42 CFR 44 7 .26(b ). Enforceability of Exemptions The procedures for implementing and enforcing the exemptions from cost sharing contained in 42 CFR 447.56 are (check all that apply): ~ To identify that American Indians/Alaskan Natives (AI/AN) are ctmently receiving or have ever received an item or service fumished by an Indian health care provider or through refen-al under contract health services in accordance with 42 CFR 447.56(a)(l)(x), the state uses the following procedures: igJ The state accepts self-attestation i:gJ The state mns periodic claims reviews D The state obtains an Active or Previous User Letter or other Indian Health Services (IHS) document [gJ The Eligibility and Enrollment and MMIS systems flag exempt recipients D Other procedure TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date: 12-18-24 Effective Date 07-01-24 Page 2 of5

Medicaid Premiums and Cost Sharing Additional description of procedures used is provided below (optional): ~ To identify all other individuals exempt from cost sharing, the state uses the following procedures (check all that apply): i:gJ The MMIS system flags recipients who are exempt IZ] The Eligibility and Enrollment System flags recipients who are exempt D The Medicaid card indicates ifbeneficia1y is exempt IZ] The Eligibility Verification System notifies providers when a beneficiruy is exempt IZ] Other procedure Description: 270/271 eligibility transaction reports cost shru·ing information. A client can be searched in combination with a certain procedure code in the Agency's MMIS provider screens to see if the client has cost sharing specific to that service. Additional description of procedures used is provided below (optional): The additional procedures supplement methods in the MMIS, Eligibility and Enrollment System, and Eligibility Verification System to ensure cost sharing is cleat· to beneficia1y and provider. Payments to Providers !Z] The state reduces the payment it makes to a provider by the runount of a beneficiruy's cost sharing obligation, regardless of whether the provider has collected the payment or waived the cost sharing, except as provided under 42 CFR 447.56(c). Pavments to Manae:ed Ca1·e Onrnnizations The state contracts with one or more managed care organizations to deliver services under Medicaid. !Z] The state calculates its payments to managed care organizations to include cost sharing established under the state plan for beneficiru-ies not exempt from cost sharing, regardless of whether the organization imposes the cost sha1-ing on its recipient members or the cost shai-ing is collected. &. !J'!J'l'el!ate Limits !Z] Medicaid premiums and cost shai-ing incwred by all individuals in the Medicaid household do not exceed an aggregate limit of 5 percent of the frunily's income applied on a qua1tedy or monthly basis. ~ The percentage of frunily income used for the aggregate limit is: TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date: 12-18-24 Effective Date 07-01-24 Page 3 of5

Medicaid Premiums and Cost Sharing (i' 5% (' 4% (' 3% (' 2% (' 1% (' Other: D % Ii] The state calculates family income for the purpose of the aggregate limit on the following basis: (i' Qua1terly (' Monthly The state has a process to track each family's incwTed premiums and cost sharing through a mechanism that does not rely on beneficia1y documentation. ~ Describe the mechanism by which the state tracks each family's incw1·ed premiums and cost sharing ( check all that apply): [gJ As claims are submitted for dates of services within the family's current monthly or quarterly cap period, the state applies the incurred cost sharing for that service to the family's aggregate limit. Once the family reaches the aggregate limit, based on incurred cost sharing and any applicable premiums, the state notifies the family and providers that the family has reached their aggregate limit for the cwTent monthly or quait erly cap period, and are no longer subject to premiums or cost sharing. D Managed care organization(s) track each family's incurred cost sharing, as follows: D Other process: ~ Describe how the state info1ms beneficiaries and providers of the beneficiaries' aggregate family limit and notifies beneficiaries and providers when a beneficia1y has incwTed premiums and cost sharing up to the aggregate family limit and individual family members are no longer subject to premiums or cost sharing for the remainder of the family's cwTent monthly or qua1t erly cap period: The Benefit Management System has a cost sharing indicator on each member or family, that will change from Yes to No when quarterly cost sharing obligations are met. Due to Wyoming's ve1y low member cost sharing, we have not identified any individual or family that has met or exceeded the 5% threshold but have recurring repo1ts nm monthly that identify member cost sharing assigned. Providers can view in real-time whether a member is subject to cost sharing at all or for a specified service using the 270/27 1 real-time or batch transactions, or view this in the provider portal of the Benefit Management System. Members may view assigned cost sharing in the Benefit Management System member po1tal and also the time period where they are subject to cost sharing. The state has a documented appeals process for families that believe they have incurred premiums or cost sharing over the aggregate limit for the cwTent monthly or quait erly cap period. Describe the appeals process used: Any individual calling or emailing about copays will be directed to submit a question using the Google form at: https://health.wyo.gov/healthcarefin/medicaid/cost-sharing/ If the member is not able to submit a form, a State staff member will complete the sw-vey by phone with that member so that the record is submitted into the fonnal process. TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date: 12-18-24 Effective Date 07-01-24 Page 4 ofS

Medicaid Premiums and Cost Sharing I Once any question on cost shanng 1s subrmtted, mcludmg appeals, thIS to1m routes to a team ot state statt that will contact the member or family head, and research the issue. If a family is determined to have not exceeded the aggregate limit for the qua1ter, the reasoning and suppo1ting documentation will be provided in a phone call, and also mailed to the member using USPS mail. ~ Describe the process used to reimburse beneficiaries and/or providers if the family is identified as paying over the aggregate limit for the month/qua1ter: Due to the automated nature of the aggregate limit in the claims processing system (Benefit Management System), provider claims should be paid without cost sharing assigned once the aggregate limit is made for the quarter. If possible, the State will reprocess the claim to pay the claim in full, and the provider should refund any assigned cost sharing. If needed, the State team will notify the member and issue a payment using the MMIS travel reimbursement system, using the type "Cost sharing" refund. Ii] Describe the process for beneficiaries to request a reassessment of their family aggregate limit if they have a change in circumstances or if they are being te1minated for failure to pay a premium: The family or individual aggregate limit is calculated automatically from info1mation on the case provided from the Wyoming Eligibility System to the Benefit Management System. If the income in the Wyoming Eligibility System is inaccurate, the member would be required to update the family or individual income so that the case can be updated. That info1mation is sent nightly to the claims processing system, which would update the family aggregate limit to reflect the new income on file. No Medicaid or M-CHIP individuals are subject to premiums, except the Employed Individuals with Disabilities group. Only Employed Individuals with Disabilities individuals (EID eligibility group) have premiums on Wyoming Medicaid. If an individual is subject to premiums, but fails to pay the premium the following process is followed. Once the client is 10 days late on a premium, Wyoming Medicaid mails a late notice through USPS with the amount due. If the client still does not pay and they get 60 days past due then the customer service center mails a notice through USPS to the client letting them know being tenninated for failing to pay premiums with the amount past due. This notice is sent at least 15 days prior to their last day of coverage. A beneficiary's coverage is not tenninated until the beneficia1y has not paid a premium for 60 days, as required by 447.55(b)(2). The state waits the full 60-day period required by CFR before tenninating coverage for unpaid premiums. Clients have appeal rights and if they make their premium payment their benefits are restored. If they make the payment more than 90 days after closure, the beneficia1y is required to submit a new application. Clients cannot be placed on the EID program until the premiums are made but they can be moved to another Medicaid coverage group that does not require premiums if they qualify. The state imposes additional aggregate limits, consistent with 42 CFR 447.56(f)(5). PRA Disclosure Statement According to the Pape1work Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 09381148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instrnctions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C42605, Baltimore, Maryland 212441850. TN No. WY 24-0007 Supersedes: WY 24-0004 Approval Date: 12-18-24 Effective Date 07-01-24 V.20160722 Page 5 of5

Table of Contents State/Territory Name Wyoming State Plan Amendment (SPA) #: 25-0005 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group August 29, 2025

Lee Grossman State Medicaid Agent Division of Healthcare Financing Herschler Building 122 West 25th Street, 4 West Cheyenne, WY 82002

Re: Wyoming State Plan Amendment (SPA) 25-0005

Dear State Medicaid Agent Grossman:

The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) WY 25-0005. This SPA revises the personal needs allowance to authorize a $20 monthly deduction for administrative fees associated with maintaining a Medicaid-compliant Irrevocable Income Trust (Miller Trust).

We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and implementing regulations. This letter informs you that Wyoming’s Medicaid SPA TN WY 25-0005 was approved on August 29, 2025, with an effective date of July 1, 2025.

Enclosed are copies of Form CMS-179 and approved SPA pages to be incorporated into the Wyoming State Plan.

If you have any questions, please contact Ford Blunt at (214) 767-6381 or via email at Ford.Blunt@cms.hhs.gov.

Sincerely,

Shantrina Roberts, Acting Director Division of Program Operations

Enclosures

cc: Jennifer Conrick

Denzel Clifton CENTERS FOR MEDICARE & ME0ICAI0 SERVICES CENTER FOR MEDICAID & CHIP SERVICES

07/28/2025 Acting Director, Division of Program Operations August 29, 2025 July 28, 2025 July 1, 2025 Shantrina Roberts DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2.STATE 2 5 - 0 0 0 5 WY -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (!> XIX 0 XXI 4. PROPOSED EFFECTIVE DATE 07/01/2025 FORM APPROVED 0MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) 42 CFR 435. 725 a FFY 2025 $ 0 b. FFY 2026 $ 0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Supplement 12A, Attachment 2.6-A, Page 2 Supplement 12A, Attachment 2.6-A, Page 2 (Supersedes TN# WY-15-0006) 9. SUBJECT OF AMENDMENT This amendment revises the personal needs allowance section to authorize a $20 monthly deduction for administrative fees associated with maintaining a Medicaid-compliant Irrevocable Income Trust (Miller Trust). 10. GOVERNOR'S REVIEW (Check One) 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED {!) OTHER, AS SPECIFIED: 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 15. RETURN TO Lee Grossman ------, State Medicaid Agent f 2. TYPED NAME Division of Healthcare Financing Lee Grossman ---------------------- 122 West 25th, St. 4 West 13. TITLE Cheyenne, WY 82002 State Medicaid Agent 14. DATE SUBMITTED CC: FOR CMS USE ONLY 16. DATE RECEIVED 117. DATE APPROVED PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL I -1n c-1~"'-I/\TI 10c Ac: 11.oooA,,1~,~ f"\cc 1f"'11\1 20. TYPED NAME OF APPROVING OFFICIAL 21 . TITLE OF APPROVING OFFICl/•.i... 22. REMARKS FORM CMS-179 (09/24) Instructions on Back

Revision: Supplement 1 2A Attachment 2.6-A Page2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: Wyoming VARIATIONS FROM THE BASIC PERSONAL NEEDS ALLOWANCE .An additional personal needs allowance for guardianship fees, income trust administrative Fees, and other expenses such as court ordered liability for child support, for institutionalized individuals, shall be as follows: TN No: 25-0005 Supersedes TN No.15-0006 Approval Date 08/29/2025 Effective Date 07/01/2025 Guardianship fees: An amount up to $500 for the cost of establishing a guardianship. An amount up to $75 per month for guardianship fees, subsequent to the initial establishment of the guardianship. These additional personal needs allowances will support the establishment of a guardianship for institutionalized individuals to assure their legal rights are protected and they receive appropriate and timely medical treatment. Income trust fees: An amount up to $20 per month for individuals who incur an administrative fee associated with maintaining a Medicaid-compliant irrevocable income trust (also known as a Miller Trust). Court ordered liability for child support: An additional personal needs allowance, for institutionalized individuals, up to the amount of their court ordered liability for child support.

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State/Territory Name: Wyoming State Plan Amendment (SPA) #: 26-0004 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group

June 12, 2026

Jesse Springer Medicaid State Agent Division of Healthcare Financing (Medicaid & CHIP) Wyoming Department of Health 122 West 25th Street, 4 West Cheyenne, WY 82002

Re: Wyoming State Plan Amendment (SPA) 26-0004

Dear Mr. Springer:

The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) WY 26-0004. This SPA increases the home equity limit for individuals applying for Wyoming Medicaid long-term care services to $1,000,000.

We conducted our review of your submittal according to statutory requirements in Section 1917(f) of the Social Security Act and implementing regulations. This letter informs you that Wyoming’s Medicaid SPA TN WY 26-0004 was approved on June 12, 2026, with an effective date of July 1, 2026.

Enclosed are copies of Form CMS-179 and approved SPA pages to be incorporated into the Wyoming State Plan.

If you have any questions, please contact Ford Blunt at (214) 767-6381 or via email at Ford.Blunt@cms.hhs.gov.

Sincerely,

Nicole McKnight Acting Director, Division of Program Operations

Enclosures

cc: Denzel Clifton CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2.STATE 2 6 - 0 0 0 4 WY -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (i) XIX () XXI 4. PROPOSED EFFECTIVE DATE 07/01/2026 FORM APPROVED 0MB No. 0933-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) Section 191 ?(f) of the Social Security Act a FFY 2026 $ 0 b. FFY 2027 $ 0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable) Supplement 15 to Attachment 2.6-A (WY-26-0004) Supplement 15 to Attachment 2.6-A (WY-06-010) 9. SUBJECT OF AMENDMENT 10. GOVERNOR'S REVIEW (Check One) 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED f""'l NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL ENCY OFFICIAL 15. RETURN TO 12. TYPED NAME Jesse Springer 13. TITLE State Medicaid Agent 14. DATE SUBMITTED 5/14/2026 16. DATE RECEIVED Ma 14, 2026 FOR CMS USE ONLY 17. DATE APPROVED June 12, 2026 PLAN APPROVED· ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL I 19. SIGNATURE OF APPROVING OFFICIAL 20. TYPED NAME OF APPROVING OFFICIAL Nicole McKnight 22. REMARKS FORM CMS-179 (09/24) 21. TITLE OF APPROVING OFFICIAL Actin Director, Division of Pro Instructions on Back

Transmittal Number: 26-0004 Supersedes Transmittal Number: 06-010 Approval Date: June 12, 2026 Effective Date: July 1, 2026 SUPPLEMENT 15 TO ATTACHMENT 2.6-A • STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: WYOMING DISQUALIFICATION FOR LONG-TERM CARE ASSISTANCE FOR INDIVIDUALS WITH SUBSTANTIAL HOME EQUITY 1917(f) The State agency denies reimbursement for nursing facility services and other long-term care services covered under the State plan for an individual who does not have a spouse, child under 21 or adult disabled child residing in the individual's home, when the individual's equity interest in the home exceeds the following amount: $500,000 (increased by the annual percentage increase in the urban -- component of the consumer price index beginning with 2011, rounded to the nearest $1,000). X An amount that exceeds $500,000 but does not exceed $750,000 (increased by the annual percentage increase in the urban component of the consumer price index beginning with 2011, rounded to the nearest $1,000). The amount chosen by the State is $1,000,000 x_ This higher standard applies statewide. 1bis higher standard does not apply statewide. It only applies in the following areas of the State: · X This higher standanl applies to all eligibility groups. This higher standard only applies to the following eligibility groups: The State bas a process under which this limitation will be waived in cases of undue hanlship.

This amendment adds coverage and reimbursement for Freestanding Birthing Center services.

Approval Document

This plan amendment proposes to adopt a single consolidated “Fee Schedule Frontispiece” within Section 4 of the Wyoming Medicaid State Plan.

Approval Document

This SPA increases the home equity limit for individuals applying for Wyoming Medicaid long-term care services to $1,000,000.

Approval Document

This SPA removes the sunset date from Attachment 3.1-M and permanently attests to Wyoming's mandatory compliance with Section 5121 of the Consolidated Appropriations Act of 2023.

Approval Document

This plan amendment provides updates to inpatient hospital reimbursement including the removal of provider categories receiving DRG base rates, and specific categories for which policy adjustors are applied for.

Approval Document

This SPA updates and clarifies language regarding the eligible prescriber of physical therapy, occupational therapy, and speech pathology services.

Approval Document

This SPA attests to Wyoming’s compliance with sections 5121 and 5122 of the Consolidated Appropriations Act, 2023, establishing Medicaid coverage for screening, diagnostic services, and targeted case management for eligible incarcerated individuals under 21 and former foster care youth 18-26, and electing to provide full Medicaid benefits to juveniles pending disposition of charges.

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This SPA revises the personal needs allowance to authorize a $20 monthly deduction for administrative fees associated with maintaining a Medicaid-compliant Irrevocable Income Trust (Miller Trust).

Approval Document

This amendment proposes an exception to the four walls requirement for clinic services provided by Indian Health Service (IHS) or Tribal facilities and for clinic services delivered to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address.

Approval Document

This SPA provided an exemption to the State requirements to contract with a Medicaid Recovery Audit Contractor from July 1, 2025 - June 30, 2027.

Approval Document

This Amendment updates state plan assurances in accordance with federally mandated quality reporting requirements for the Child Core Set and the behavioral health quality measures on the Adult Core Set outlined in 42 CFR 431.16 and 437.10 through 437.15. This SPA attests to Wyoming Medicaid's adherence with federal reporting requirements.

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This plan continues outpatient hospital supplemental payments and authorizes a new supplemental payment for physicians.

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This plan amendment allows for a new supplemental payment for in-state ground ambulance providers.

Approval Document

This SPA will permanently remove beneficiary cost sharing requirements for non-emergency services provided in a hospital emergency departments and beneficiary pharmacy cost sharing requirements for claims with a date of service (DOS) from July 1, 2024 forward.

Approval Document

This amendment temporarily suspends beneficiary cost sharing for pharmacy claims with dates of service from February 22, 2024 to June 30, 2024. The terms of this State Plan Amendment sunset at midnight on June 30, 2024.

Approval Document

This amendment complies with the Consolidated Appropriations Act of 2022 and makes changes to the state plan so that health insurance companies cannot deny reclamation claims for the Agency not obtaining prior authorization for the item or service through the health insurance company and requiring health insurance companies to process reclamation claims within 60 days of receipt of such claims.

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This amendment moves the Applied Behavior Analysis (ABA) services from the Rehabilitative Services – Mental Health and Substance Abuse section to the Preventive Services Section of the plan with a reference in the Early Periodic Screening Diagnosis and Treatment (EPSDT) services to Preventive services.

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This amendment is to ensure all minimum requirements outlined in Section 1902(a)(87) of the Social Security Act are met.

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This amendment is to add Psychosocial Rehabilitation - Clubhouse services to the Rehabilitation Services section of the Wyoming State Plan.

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This amendment updates the coverage of preventive services when recommended by a physician or other licensed practitioner.

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This SPA proposes to update the the State’s Excluded Drug listing.

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This amendment is to include pharmacists as a recognized practitioner type allowed to charge for services given to Medicaid clients under Attachment 3.1-A, Section 6.d. and Attachment 4.19-B, Section 6.d of the state plan.

Approval Document

Updates to the Diagnosis Related Group (DRG) payment methodology for hospital inpatient services.

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This amendment updates the reimbursement methodology for durable medical equipment/supplies and allows for a non-rural and rural rate according to the member's physical address.

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This SPA amendment is to elect the option described in section 1902(e)(16) of the Social Security Act to provide 12 months of postpartum coverage to Medicaid-eligible pregnant women.

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This SPA updated the reimbursement methodology for hospice services when quality data is not submitted by a provider.

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This SPA eliminates the Program of All-Inclusive Care for the Elderly (PACE) as a Medicaid state plan option.

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This SPA amends the payment methodology for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DME/POS).

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Reimbursement update for Behavioral Health Services

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Updates the targeted case management state plan to include eligible services provided to children with a serious emotional disturbance (as defined in Federal, Register; volume 58, no. 96, published May 20; 1993, pp. 29422 through 2942) who are between the ages of four (4) and twenty one (21) and who are being served by the Care Management Entity (CME) or by the Children' s Mental Health Waiver.

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Demonstrates coverage of concurrent care for children section 2302 of the Affordable Care Act, amending sections 1905( o)( I) and 21 10( a)( 23) of the Social Security Act, removing prohibition of receiving curative treatment upon election of hospice for Medicaid eligible children.

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Free Standing Birthing Centers.

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This SPA concerns the State/Medicaid agency asking for an exception to the implementation date of January 1, 2012 for the Recovery Audit Program. The State anticipates any implementation date of June 1, 2012.

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Tribal Consultation Compliance Requirements.

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