Wyo. Code R. 048-0063-1
Effective Date: 01/03/2024 to Current
Rule Type: Current Rules & Regulations
Reference Number: 048.0063.1.01032024
Section 1. Authority. The Wyoming Department of Health (Department) promulgates these rules pursuant to Wyoming Statutes 35-25-203 and -204.
Section 2. Purpose. These rules implement the Department's Wyoming Colorectal Cancer Screening Program (WCCSP), as contemplated by the Wyoming Cancer Control Act at W.S. 35-25-204.
(a) For the purpose of these rules, the following definitions apply:
(i) 'Adverse event' means an injury or complication resulting from the colorectal cancer screening procedure.
(ii) 'Underinsured' means an applicant has a large out-of-pocket cost sharing required by their health insurance plan that they cannot afford.
(iii) 'Participating healthcare provider' means an entity that has executed a contract with Wyoming Medicaid and has a qualifying taxonomy code.
(iv) 'Applicant' means an individual who has completed an enrollment form for the WCCSP.
(v) 'Client' means an individual that has been accepted to participate in the WCCSP.
(vi) 'Evidence-based colorectal cancer screening' means a test to screen for colorectal cancer that is supported by a large amount of scientific research.
(a) An individual is eligible to participate in the WCCSP as a client if the individual:
(i) has been a resident of the State of Wyoming for at least one (1) year immediately prior to receiving their evidence-based colorectal cancer screening;
(ii) meets appropriate age requirements in accordance with national evidence-based recommendations which is publicly available on the program's website; and
(iii) is uninsured or underinsured; and
(iv) has a gross income before taxes at or below 250% of the Federal Poverty Guidelines.
(b) To participate in the WCCSP as a client, an eligible individual shall submit a completed application in the form and manner prescribed by the Department.
(a) Upon receipt of a complete application, the Department shall determine if the applicant is eligible to enroll in the WCCSP as a client.
(i) If the Department determines that an applicant is eligible, the Department shall enroll the applicant in the WCCSP as a client and provide written notice of its decision.
(A) The Department may dis-enroll a client at any time if the Department determines that the client is no longer eligible to participate in the WCCSP.
(B) The Department shall provide the client written notice of the Department’s decision to dis-enroll, including the basis for its decision.
(ii) If the Department determines that an applicant is not eligible, the Department shall provide the individual written notice of its decision, including the basis for its decision.
(iii) If the Department determines that an applicant is ineligible to enroll or that a client is no longer eligible to participate in the WCCSP, the applicant or client may submit a request for reconsideration in the form and manner prescribed by the Department. An applicant or client is not entitled to request a contested case proceeding pursuant to the Wyoming Administrative Procedure Act.
(a) A client is enrolled in the WCCSP for a period of one (1) year from the client’s enrollment date.
(b) A client may receive colorectal cancer screening services only from a WCCSP participating healthcare provider.
(i) A client may receive coverage for one (1) evidence-based colorectal cancer screening every year. Colonoscopy coverage is limited to one (1) every ten (10) years.
(ii) A client may apply, in the form and manner prescribed by the Department, to receive an additional evidence-based colorectal cancer screening if medically indicated based on national evidence-based guidelines. If the Department denies the application, the client may submit a request for reconsideration, with clinical documentation from the participating healthcare provider, in the form and manner prescribed by the Department. The client is not entitled to request a contested case proceeding pursuant to the Wyoming Administrative Procedure Act.
(a) For a client enrolled in the WCCSP, the Department shall cover the costs related to an evidence-based colorectal cancer screening, according to the following provisions:
(i) The Department shall reimburse a participating healthcare provider only for the services and at the rates identified on the WCCSP’s Current Procedural Terminology (CPT) codes list which is publicly available on the program’s website; and
(ii) The Department may not reimburse a participating healthcare provider for:
(A) Services related to adverse events; and
(B) Follow-up surgery or additional care needed if cancer or another condition requiring additional medical care is found.
(a) A healthcare provider may automatically participate in the WCCSP if they are approved as a Wyoming Medicaid provider with a qualifying taxonomy code.
(b) A participating healthcare provider may not receive reimbursement for covered services rendered to a client enrolled in the WCCSP unless the provider submits the appropriate clinical documentation for the services performed, in the form and manner prescribed by the Department.
(c) The Department shall reimburse a participating healthcare provider for covered services rendered to a client enrolled in the WCCSP at the current Wyoming Medicaid allowable rates for the date of service.
(d) A participating healthcare provider shall accept the Department’s payment for covered services as paid in full.
(e) A participating healthcare provider may not bill the client, or any member of the client’s family, for services covered by the WCCSP. This prohibition includes imposing additional charges for covered services.
(f) A participating healthcare provider may bill a client enrolled in WCCSP if services provided are not covered by the WCCSP, and, prior to providing services, the provider informs the client in writing that the service is non-covered and the client is responsible for those charges.
(g) For persons who are underinsured, the program shall only pay for expenses not covered by insurance.