Wyo. Code R. 048-0037-4
Medicaid
Effective Date: 11/07/2011 to 03/24/2020
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.4.11072011
Section 1. Authority. This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. § 42-4-101, et seq., and the Wyoming Administrative Procedure Act at W.S. § 16-3-101, et seq.
(a) This Chapter shall apply to all contested cases involving Medicaid in accordance with Medicaid rules, except as otherwise specified in the Department's Medicaid rules.
(b) The Department may issue manuals, bulletins, or both to interpret the provisions of this Chapter. Such manuals and bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in manuals or bulletins shall be subordinate to the provisions of this Chapter.
(c) The incorporation by reference of any external standard is intended to be the incorporation of that standard as it is in effect on the effective date of this Chapter.
Section 3. Definitions. Except as otherwise specified in Chapter 1, the terminology used in this Chapter is the standard terminology and has the standard meaning used in health care, Medicaid, and Medicare.
(a) Applicants. An applicant has a right to a hearing if the application is denied or not acted upon within the time frames as specified by the Department rules.
(b) Clients. A client has a right to a hearing if eligibility is denied, reduced, terminated or suspended.
(c) Providers. A provider has a right to a hearing regarding an adverse action following the request for reconsideration as specified in Chapter 16.
(d) Pharmaceutical manufacturers. Pharmaceutical manufacturers shall have the same rights to a hearing as providers pursuant to this Chapter.
(a) Applicants and clients. Where the right to a hearing is provided by this Chapter, the Department shall provide notice at the time of any adverse action. The notice shall include a statement:
(i) Of the right to a hearing;
(ii) Of an explanation of:
(A) The individual's right to request a hearing; or
(B) That in cases of action based on a change in law, the circumstances under which a hearing will be granted;
(iii) Of the method for requesting a hearing;
(iv) That the applicant or client has the right to be represented by a legally authorized representative, including a lawyer admitted to practice in Wyoming, or a relative, friend or other spokesman;
(v) That the applicant or client must notify the Department in writing that they will be represented by any of the representatives listed in Section 5(a)(iv);
(vi) Of the intended action;
(vii) Of the effective date of the intended action;
(viii) Of the reason(s) for the intended action;
(ix) Of the specific regulations that support, or the change in federal or state law that requires the action;
(x) Where applicable, an explanation of the circumstances under which benefits may be continued if a hearing is requested pursuant to 42 C.F.R. § 431.231.
(b) Providers. The Department shall notify a provider of the right to a hearing following the request for reconsideration as specified in Chapter 16 at the time of the notice of adverse action, except when issuing a notice of claims payment or denial. A provider shall be notified of the right to request reconsideration and a hearing involving claims at the time the provider executes a provider agreement. Except as otherwise specified in this Chapter, notice shall be in writing and shall include:
(i) A statement of the intended action;
(ii) The effective date of the intended action;
(iii) The reason(s) for the intended action;
(iv) The specific regulations that support, or the change in federal or state law that requires the action;
(v) The provider's right to request reconsideration and subsequently a hearing; and
(vi) The right to representation by a lawyer admitted to practice in Wyoming.
Section 6. Time of Notice.
(a) Applicants. The Department shall mail notice of adverse actions within the timeframe specified in Department rules.
(b) Clients. The Department shall mail notice of adverse action at least ten (10) days before the effective date, except:
(i) The Department may shorten the period of advance notice to five (5) days before the effective date if the Department has facts indicating that action should be taken because of probable fraud by the client, and the facts have been verified, if possible, through secondary sources.
(ii) The Department may mail notice not later than the effective date if:
(A) The Department has factual information confirming the death of a client;
(B) The Department receives a clear written statement signed by a client that:
(I) The client no longer wishes services; or
(II) Gives information that requires termination or reduction of services and indicates that the client understands that this will be the result of supplying that information;
(C) The client has been admitted to an institution where he or she is ineligible under the plan for further services.
(D) The client's whereabouts are unknown and the post office returns agency mail indicating no forwarding address;
(E) The Department establishes that the client has been accepted for benefits by another local jurisdiction, state, territory or commonwealth;
(F) A change in the level of medical care is prescribed by the client's physician; or
(G) The notice involves an adverse determination made with regard to preadmission screening requirements for persons with mental illness or intellectual disability.
(c) Providers.
(i) Notice of denial or reduction of payments. The Department shall notify a provider of the denial or reduction of payments as soon as practicable after such denial or reduction.
(ii) Notice of termination, suspension or sanction. The Department shall notify a provider of the termination, suspension or other sanction on or before the effective date, except as otherwise specified in the Department's Medicaid rules.
(a) Clients. A request for a hearing shall be mailed or personally delivered by a client, or the client's representative authorized by Section 5(a)(iv), to the Department within thirty (30) days after the receipt of the notice of adverse action.
(b) Providers.
(i) A request for a hearing shall be mailed by a provider or the provider's lawyer admitted to practice in Wyoming, by certified mail, return receipt requested, or personally delivered to the Department within twenty (20) days after the receipt of the notice of adverse action.
(ii) A provider's request for hearing shall:
(A) State with specificity the reasons for the request. The failure to provide such a statement shall result in the dismissal of the request with prejudice; and
(B) Identify the issues to be raised at the hearing. Issues not identified in the request for hearing may not be subsequently raised at the hearing.
(a) The Department shall evaluate the request and, within ten (10) working days of receipt of the request:
(i) Notify the requesting party in writing that a determination in his or her favor has been made and specify the action to be taken by the Department;
(ii) Notify the requesting party in writing that a request for hearing has been accepted; or
(iii) Notify the requesting party in writing that the request for hearing has been denied and the reasons for the denial.
(b) Denial of hearing.
(i) The Department may deny a request for hearing if the action complained of is not an adverse action or the request does not meet the requirements of Section 4 of this Chapter.
(ii) A denial of a request for hearing is a final decision of the Department, which may be appealed to district court pursuant to the Wyoming Administrative Procedure Act.
(a) If the Department mails the notice as required pursuant to subsection 6(a) of this Chapter, and the client requests a hearing before the effective date of the action, the Department may not terminate or reduce services until the final decision is rendered after the hearing unless:
(i) It is determined at the hearing that the sole issue is one of federal or state law or policy; and
(ii) The Department promptly informs the client in writing that services are to be terminated or reduced pending the final decision.
(b) If the adverse action is affirmed, the Department may institute recovery procedures against the client to recoup the cost of any services furnished to the client, to the extent they were furnished solely by reason of this section, and may recover any overpayments made to a provider.
(c) The Department shall reinstate and continue services until a decision is rendered if the action resulted from other than the application of federal or state law or policy pursuant to 42 C.F.R. § 431.231(c)(3).
(a) In any contested case, the Department shall afford reasonable notice of the hearing to all parties.
(i) Reasonable notice, as used in this section, shall be not less than twenty (20) days prior to the hearing date. The time period may be waived by the contestant upon written or oral notification to the Department. Where notification of waiver of the time period is made orally, it shall be reduced to writing by the Department and entered in the contestant's record.
(ii) Notice shall be served personally or by certified mail, return receipt requested, to the last known address of the party, the party's lawyer admitted to practice in Wyoming, or the party's other legally authorized representative.
(iii) Where the necessary and indispensable parties are composed of a large class, notice shall be:
(A) Served upon a reasonable number of representatives of the class; or
(B) Published in newspaper(s) of the state in reasonable numbers and times, and at a minimum in a paper of general circulation in the county in which the contestant resides, and in at least one newspaper with state-wide circulation. In any county in which more than one newspaper is published, notice shall be published in the official paper of the county designated pursuant to W.S. § 18-3-517.
(b) A notice of hearing shall contain the time, place, and nature of the hearing; the legal authority and jurisdiction under which the hearing is being held; the particular sections of the statutes or rules involved; a short and plain statement of the matters asserted; the docket number assigned to the case; the right to be represented by an attorney admitted to practice in Wyoming; and the availability of legal aid.
(i) If the Department is unable to state the matters in detail at the time notice is served, the initial notice may be limited to a statement of the issues involved, and thereafter, upon request of any party, a more definite and detailed statement shall be furnished within ten (10) days of receipt of that request by the Department.
(ii) Upon written request by one of the parties, or upon his own motion, the hearing officer may reschedule the hearing to a time convenient for the parties. A party must submit such request within ten (10) days of receipt of the notice of hearing. When such request is granted, the hearing officer shall reissue the notice in accordance with these rules except that reasonable notice as used in this subsection shall be five (5) days prior to the hearing date. Only one request for rescheduling of a hearing shall be honored unless, in the Hearing Officer's judgment, additional changes must be allowed to avoid manifest injustice.
(c) A hearing shall be held within:
(i) Applicants and Clients. Forty (40) days of the applicant or client's request for a hearing, unless otherwise provided by law or by agreement of the parties.
(ii) Providers. One hundred twenty (120) days of the effective date of the adverse action, unless otherwise provided by law or by agreement of the parties.
(a) Hearings involving applicants or clients may be held in the county of the applicant or client's residence, or in Cheyenne, Wyoming. Regardless of the location, the parties shall be given the opportunity to appear by telephone or video conferencing, rather than in person.
(b) Hearings involving providers shall be held in Cheyenne, Wyoming, unless otherwise agreed to by the parties. Regardless of the location, the parties may be given the opportunity to appear by telephone or video conferencing, rather than in person.
Section 12. Consolidation of Hearings. Upon motion of one of the parties, the hearing officer may consolidate two or more hearings if the hearings involve the same parties or related parties with similar or related issues.
Section 13. Procedural Rights of Contestant. The contestant, or the contestant's representative authorized by Section 5(a)(iv), shall be given the opportunity to:
(a) Examine, at a reasonable time before the date of the hearing and during the hearing:
(i) The content of the contestant's case file; and
(ii) All documents and records to be used by the Department at the hearing.
(b) Bring witnesses, establish all pertinent facts and circumstances, present an argument, and question or refute any testimony or evidence, including the opportunity to confront and cross-examine adverse witnesses.
Section 14. Failure to Appear. If a contestant fails to appear at the place, date, and time specified in a notice, the hearing officer may:
(a) Continue the hearing to a later date and provide proper notice as prescribed in these rules; or
(b) Proceed to conduct the hearing without the contestant and dispose of the contested case, unless prohibited by federal or state statute; or
(c) Dismiss a hearing if:
(i) The contestant withdraws the request in writing; or
(ii) The contestant fails to appear at a scheduled hearing without good cause. Good cause shall be determined by considering circumstances which are beyond the contestant's control, such as illness, illness of another household member requiring the presence of the contestant, a household emergency, unavailability of transportation, lack of adequate child care or other such circumstances which the hearing officer determines were beyond the contestant's control.
Section 15. Discovery. All discovery in a contested case hearing shall be governed by the Wyoming Rules of Civil Procedure, as described in W.S. § 16-3-107(g) and (h).
Section 16. Prehearing Conference.
(a) At a time on or before the day of the hearing, the hearing officer, on his own or either party's motion, may meet with the parties for a conference to consider simplification of the issues, stipulations and admissions of fact, clarification or limitation of evidence, and any other matters that may expedite the proceeding and assure a just conclusion of the case. The meeting may be held by telephone conference.
(b) Any stipulations, limitations or agreements made at a prehearing conference shall be recited in the record and shall control the course of the proceedings, unless modified during the hearing to prevent manifest injustice.
Section 17. Informal Disposition.
(a) Settlement of a contested case by any informal means (i.e., stipulation, agreed settlement or consent order) shall be allowed at any time, unless precluded by law.
(b) Settlement conference. Any party may request that the matter be set for a settlement conference. Upon such request, the hearing officer shall schedule a conference and direct that a representative of each party attend, and such representative shall have authority to settle the matter. The hearing officer shall neither attend the conference nor be advised of the proposals of either party. The hearing officer may designate another individual, not previously involved in the matter, to attend the conference and assist the parties in attempting to reach a settlement.
(a) The Director shall appoint a hearing officer to preside over contested case hearings on a case-by-case basis, or for a scheduled period of time, as the Director sees fit or may refer the case to the Office of Administrative Hearings (OAH) for a recommended decision under its rules. If the case is referred to OAH, then notwithstanding anything to the contrary in this Chapter, the OAH Rules for contested cases shall apply.
(b) The hearing officer shall be an employee of the Department, or other individual determined by the Director to be qualified to serve in such a capacity, who has not taken part in the investigation, preparation, or earlier disposition of the case to be heard.
(i) The hearing officer shall withdraw from consideration of a case at any time he or she deems himself or herself disqualified, providing there are other qualified presiding officers available to act. Withdrawal shall be made in writing to the Director.
(ii) Any party may request in writing that the Director remove and replace the hearing officer in a contested case hearing. This request must be accompanied by a statement and affidavits setting forth the alleged grounds for disqualification. The Director may deny a party's request for removal and shall issue a written statement explaining the grounds for his denial which shall be made a part of the record. If the request is granted, the Director shall appoint a new hearing officer as soon as is practicable.
(iii) The contestant may object to the appointment of the hearing officer in the record at the hearing. The objection shall set forth the alleged grounds for disqualification.
(c) The hearing officer shall have all powers necessary to conduct a fair and impartial hearing, including, but not limited to, the following authority:
(i) To administer oaths and affirmations;
(ii) To subpoena witnesses and require the production of any books, papers or other documents relevant or material to the inquiry;
(iii) To rule upon offers of proof and relevant evidence; (iv) To provide for discovery and determine its scope; (v) To regulate the course of the hearing; (vi) To hold conferences for the settlement or simplification of the issues; (vii) To dispose of procedural requests or similar matters; (viii) To dismiss cases as specified by this rule or on agreement of the parties; and (ix) To take any other action authorized by the Department's rules.
(d) Failure or refusal to appear or obey orders of the hearing officer may result in the sanctions provided in W.S. § 16-3-107(c) and (f).
(e) Except to the extent required for the disposition of ex parte matters authorized by law, the hearing officer shall not consult with any individual or party on any fact at issue except as allowed in W.S. § 16-3-111.
Section 19. Evidence and Testimony.
(a) Burden of proof. The Department shall have the burden of proof. (b) Admissibility of evidence.
(i) The parties shall be entitled to present any oral or documentary evidence, submit rebuttal evidence and conduct cross-examinations, as may be required for a full disclosure of the facts. All documentary or physical evidence submitted for consideration shall be marked as exhibits. The Department's exhibits shall be marked by letters of the alphabet beginning with "A." Contestant's exhibits will be marked by numbers beginning with "1."
(ii) The hearing officer shall allow any oral or documentary evidence, except irrelevant, immaterial or unduly repetitious evidence.
(c) Objections.
(i) The grounds for objection to any evidentiary ruling by the hearing officer shall be briefly stated. Rulings on all objections shall appear in the record. Only those objections made before the hearing officer, or specifically stipulated to by both parties, may be relied on in a subsequent proceeding.
(ii) Formal exception to an adverse ruling is not required.
(d) Privileged and confidential information.
(i) Any privilege at law shall be recognized by the hearing officer in considering evidence.
(ii) No employee of the Department shall be compelled to testify or to divulge information which is confidential or privileged at law and which is contained within the records of the Department or acquired within the scope of his or her employment except as provided in W.S. § 16-3-107, et seq.
(e) The hearing officer may take official notice of any material fact not appearing in evidence in the record that is of the nature of traditional matters of judicial notice or within the special technical or scientific knowledge or files of the Department. Parties shall be given an opportunity to contest matters officially noticed prior to a final decision by the Department in accordance with W.S. § 16-3-108, et seq.
(f) Each witness who is present to give testimony must identify himself or herself by stating his or her name and address, indicate on whose behalf he or she will testify, and be administered the following oath by the hearing officer: 'Do you swear or affirm to tell the truth, the whole truth, and nothing but the truth?'
(g) A party or his or her representative authorized by Section 5(a)(iv) may examine or cross-examine witnesses.
(h) The hearing officer may examine witnesses.
(a) Any applicant, client, or individual provider has the right to represent themselves, to be represented by a lawyer admitted to practice in Wyoming, or, if the contestant is an applicant or client, by a representative authorized by Section 5(a)(iv).
(i) If an applicant or client chooses a representative who is not legally authorized to speak for that applicant or client, the applicant shall provide written notice of appointment of the spokesman to the Department.
(ii) A non-lawyer authorized to represent an applicant or client under this provision may advocate for the applicant or client in a representative capacity, draft pleadings or other documents. However, this provision does not authorize a person who is not a lawyer admitted to practice in Wyoming to provide legal advice or services, or represent any person before the courts of the State of Wyoming.
(b) A provider which is a corporation, professional corporation, limited liability company, partnership, governmental entity, or any other legal entity, may appear and be represented by a lawyer admitted to practice in Wyoming.
(c) The Department may request the Attorney General to assist in contested case hearings to the extent required by W.S. § 16-3-112(c).
(d) If the contestant is represented by an attorney, payment of attorney's fees and costs are the responsibility of the contestant.
(a) As nearly as practicable, the following order of procedure shall be followed:
(i) The hearing officer shall announce the hearing is open and call by docket number and title of the case to be heard. The hearing officer shall ask if parties are ready to proceed and will allow parties an opportunity to dispose of any preliminary matters.
(ii) The hearing officer shall administer the oath to all witnesses who will present testimony.
(iii) The hearing officer may, in his or her discretion, allow evidence to be heard in an order other than that prescribed here.
(iv) Opening statements may be made.
(v) The party with the burden of proof shall offer evidence first, followed by the other party. The party which proceeded first may then offer rebuttal evidence. Parties may cross-examine.
(vi) No testimony shall be received by the hearing officer unless given under oath/affirmation administered by the hearing officer.
(vii) Closing statements may be made.
(viii) The hearing officer may limit the time for opening and closing statements.
(ix) After all parties have had an opportunity to be heard, the hearing officer shall excuse all witnesses and close the evidence.
(x) Evidence may be reopened only upon a motion by a party to the proceeding on a showing of good cause.
(b) Upon their own motion, all parties or other interested persons may submit legal briefs after the close of the hearing. The hearing officer shall allow a reasonable time, not less than ten (10) working days from the date of hearing, for preparation of the briefs. The time may be extended upon agreement between the parties with the approval of the hearing officer.
(a) The hearing officer shall make proposed findings of fact and conclusions of law within twenty (20) working days of the close of the hearing and forward them to the Director for final determination. This time may be extended if the parties or other interested persons are to submit briefs; but may not be extended by more than ten (10) working days, unless the parties stipulate, in writing or on the record at the hearing, to a later date.
(i) Within ten (10) working days of the close of the hearing, or such additional time as the hearing officer may allow, each party shall be allowed to file with the hearing officer any proposed findings of fact and conclusions of law, together with a supporting brief. Such proposals and briefs shall be served on all other parties.
(ii) Within ten (10) working days after the issuance of the hearing officer's proposed findings of fact and conclusions of law, any of the parties may submit exceptions. Such exceptions shall be filed with the Director and served on all other parties.
(b) Within ten (10) working days after the period for submitting exceptions pursuant to subsection (a)(ii), the Director shall make and enter into the record the final decision. The final decision shall be served on all parties to the proceedings. The final decision shall include:
(i) A statement of the findings of fact and conclusions of law; and
(ii) The appropriate rule, order, relief or denial thereof. The decision shall be based upon the contested case record or any portion stipulated to by the parties. The decision shall include facts officially noticed as provided by W.S. § 16-3-108(d). It shall be made on the basis of a preponderance of evidence contained in the record.
(c) Final decisions of the Department shall be effective immediately after being entered in the record and served upon all parties. Service shall be in-person or by mailing a copy of any decision or order to each party or the party's attorney of record within a reasonable time after the entry of the decision into the record.
Section 23. Appeals. Appeals from a final decision of the Department shall be in accordance with W.S. § 16-3-114 through 16-3-115, and Rule 12 of the Wyoming Rules of Appellate Procedure.
(a) When a contested case is set for hearing, the Department shall assign a docket number to the case and enter the case with its number and date of filing on a docket. The Department shall maintain a separate file for each docketed case in which all pleadings, transcriptions, correspondence, papers, and exhibits for that case shall be maintained. All such items shall have noted thereon the assigned docket number and the date of filing.
(b) The Department shall record all contested case hearing proceedings electronically, through the use of a qualified court reporter, or any other appropriate means determined by the agency or the hearing officer. Transcriptions of oral proceedings or written transcripts of a witness's testimony may be obtained by contestant from the Department upon payment of the cost.
(i) In a nonpublic investigatory proceeding, requests for copies or transcripts may be limited to testimony of the requesting party.
(ii) Where contestant can demonstrate that he or she is indigent and cannot effectively perfect his or her appeal without such transcription, the Department may waive the payment of the fee.
(c) The record of the hearing shall contain:
(i) All formal or informal notices, pleadings, motions and intermediate rulings;
(ii) Evidence received or considered, including matters officially noticed;
(iii) Questions and offers of proof, objections and rulings;
(iv) Any proposed findings and conclusions of law;
(v) The proposed findings of fact and conclusions of law of the hearing officer;
(vi) Any exceptions to the hearing officer's proposed findings of fact and conclusions of law; and (vii) The agency's final decision.
(d) A stipulation resolving the matter shall not be part of the record unless otherwise agreed by the parties.
Section 25. Delegation of Duties. The Department may delegate any of its duties under this rule to the Wyoming Attorney General, Health and Human Services, any other agency of the federal, state or local government, or a private entity which is capable of performing such functions, provided that the Department shall retain the authority to impose sanctions, recover overpayments, or take any other final action authorized by this Chapter.
Section 26. Interpretation of Chapter.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of various provisions.
Section 27. Superseding Effect. This Chapter supersedes all prior rules or policy statements issued by the Department, including manuals or bulletins, which are inconsistent with this Chapter.
Section 28. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.