048-47 Wyo. Code R. §§ 47-5 - Eligibility

(a) Enrollment for CME 1915(b) services is mandatory for the following populations:

(i) Youth qualifying under Section 1931 of the Social Security Act and related populations, to include poverty-level related groups and optional groups of older youth;

(ii) Blind/Disabled youth and related populations, to include beneficiaries, generally under age 18, who are eligible for Medicaid due to blindness or disability;

(iii) Youth in Foster Care in the State of Wyoming, or youth receiving adoption assistance under Title IV-E, or are otherwise in out-of-home placement.

(iv) Targeting Criteria for the populations includes:

(A) Medicaid youth ages four to twenty (4-20) at risk of out-of-home placement (defined and identified as youth with two hundred (200) days or more of behavioral health services within one State fiscal year);

(B) Medicaid youth ages four to twenty (4-20) who currently meet Psychiatric Residential Treatment Facility (PRTF) level of care as outlined in Chapter 40, Psychiatric Residential Treatment Facilities;

(C) Medicaid youth ages four to twenty (4-20) who currently meet acute psychiatric stabilization hospital level of care as determined by a licensed clinician; had an acute hospital stay for mental or behavioral conditions in the last three hundred sixty-five (365) days; or are currently placed in an acute hospital stay for mental or behavioral health conditions;

(D) Youth enrolled in the Children's Mental Health Waiver (Section 1915(c) WY Waiver #0451); or

(E) Medicaid youth ages four to twenty (4-20) referred to the pre-paid ambulatory health plan (PAHP) and who meet defined eligibility, including clinical eligibility and SED criteria.

(v) Medical Eligibility Criteria is a condition for enrollment in the CME after initial targeting criteria is met. The Medical Eligibility Criteria includes:

(A) Youth ages six to twenty (6-20) who have a minimum CASII composite score of twenty (20), and youth ages four (4) and five (5) who have an ECSII score of eighteen (18) to thirty (30) or the appropriate social and emotional assessment information provided to illustrate level of service needs; and

(I) CASIIs administered for the purpose of establishing medical eligibility shall not be administered by the CME but instead be administered by a neutral third party to ensure conflict free case management.

(B) Youth who have a DSM Axis 1 or International Classification of Disease (ICD) diagnosis that meets the State's diagnostic criteria.

(b) Enrollment for CME 1915(c) services is mandatory for the following populations:

(i) Targeting Criteria for the populations includes:

(A) Medicaid youth ages four to twenty-one (4-21) at risk of out-of-home placement (defined and identified as youth with two hundred (200) days or more of behavioral health services within one State fiscal year);

(B) Medicaid youth ages four to twenty-one (4-21) who currently meet PRTF level of care as outlined in Chapter 40, Psychiatric Residential Treatment Facilities or are placed in a PRTF;

(C) Medicaid youth ages four to twenty-one (4-21) who currently meet acute psychiatric stabilization hospital level of care as determined by a licensed clinician; had an acute hospital stay for mental or behavioral conditions in the last three hundred sixty-five (365) days; or are currently placed in an acute hospital stay for mental or behavioral health conditions; or

(D) Medicaid youth ages four to twenty-one (4-21) referred to the PAHP and who meet defined eligibility, including clinical eligibility and SED/SMI criteria.

(ii) Medical Eligibility Criteria is a condition for enrollment in the CME after initial targeting criteria is met. The Medical Eligibility Criteria includes:

(A) Youth ages six to twenty-one (6-21) who have a minimum CASII composite score of twenty (20), and youth ages four (4) and five (5) who have an ECSII score of eighteen (18) to thirty (30) or the appropriate social and emotional assessment information provided to illustrate level of service needs; and

(I) CASIIs administered for the purpose of establishing medical eligibility shall not be administered by the CME but instead be administered by a neutral third party to ensure conflict free case management.

(B) Youth who have a DSM Axis 1 or primary ICD diagnosis that meets the State's diagnostic targeting criteria as specified above.

(c) Those listed as "Excluded Populations" in Section 4(f) of this Rule are not eligible for the CME or CMHW Program.

(d) A person is not considered financially eligible when the Department expects the costs of HCBS furnished to the individual would exceed the per member, per month (PMPM) amount specified by the Department in the 1915 (c) waiver's cost neutrality equation.

Notes

048-47 Wyo. Code R. §§ 47-5

Adopted, Eff. 9/23/2019.