Medicaid Eligibility - Wyoming Department of Health

Medicaid Eligibility

AFDC Income Standards

OMB Control Numher 0938- 1148 OGIB Expiration date: 10/ 31:' O14

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 C` Standard varies in some other way

I

I

mteL!he statewide standard

J

TN: WY- 1 3- 0008- M M 1

Wyoming

Approval Date: June 12, 2014 S14, Page 1

Effective Date: January 1, 2014

Pae,e I oi' 7

00

4( C:MS

Medicaid Eligibility

I lousehold size Standard($)

219

x

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

13

g-), 1

14

115

16

943

x

964

x

984

17

1. 004

Additional incremental amount Yes C Na

Increment amount

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_0- 001-- M--m1

S14. Paae 2

e-.-JmU-a-q1- 2J1 4 Page 2 of' 7

Medicaid Eligibility

by C' Standard varies

region

i

C' Standard varies by living arrangement

Standard varies in sonic other xvay

Enter the statewide standard Household size

Additional incremental amount

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

I 15

1. 870

16

1. 916

17

2, 054

The dollar amounts increase automatically each year C Yes 6i No

MGI-equivaleut AF-DC P4ymetit Staudard in Effect As of July 16 1996 I

TNI- I.AN- 13- 0008- A.U.41

Wyoming

Apprnv;;] Datp- 111ne 12 2014 S14, Page 3

te January 1. 2014_ Page 3 oi' 7

Medicaid Eligibility

Income Standard Entry- Dollar Amount Automatic Increase Option

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

Household size Standard

1

529

x

2

737

x

Additional incremental amount

Yes

No

Increment amount $

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

I1

1168

x

12

2. 299

x

13

2, 493

x

14

2, 622

1

2. 845

x

16

3, 145

S13a

TN: WY- 13- 0008- MM1

Wyoming

Approval Date: June 12, 2014 S14, Page 4

Effective Date: January 1, 2014

fc: M S

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

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

Sl3a

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

Wyoming

U ate: june 12, ZU14 S14, Page 5

tive Date. janadly 1, totav-

11&_, e

of 7

0

CMS

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

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

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

S13a S 13a

TN: WY- 13- 0008- MM1

Wyoming

PRA Disclosure Statement............--..--.-................

Approval Date: June 12, 2014 S14, Page 6

Effective Date: January 1, 2014 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

Wyoming

Approval Date: June 12, 2014 S14, Page 7

Effective Date: January 1, 2014 Page 7 of 7

11- W Ymfua mewnwoOWN A AwOmZa.,WAI m1o" 1M@

Medicaid Eligibility

State Name: Wyoming

Transmittal Number: WY - 14- 0020

Presumptive Eligibility by H6& ah

42 CFR 435. 1110

OMB Control Number: 0938- 1148 Expirationdate: 10/ 31/ 2014

S2

One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435. 1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision.

Yes r No

0 The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions:

0 A qualified hospital is a hospital that:

Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of 0 its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations

consistent with state policies and procedures.

Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility detenninations in accordance 0 with applicable state policies and procedures or for failure to meet any standards that may have been established by the

Medicaid agency.

Assists individuals in completing and submitting the full application and understanding any documentation requirements.

Yes r No

0 The eligibility groups or populations for which hospitals detennine eligibility presumptively are:

0 Pregnant Women

0 Infants and Children under Age 19

0 Parents and Other Caretaker Relatives

0 Adult Group, if covered by the state

0 Individuals above 133% FPL under Age 65, if covered by the state

0 Individuals Eligible for Family Planning Services, if covered by the state

0 Fonner Foster Care Children

0 Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state

0 Other Family/ Adult groups:

0 Eligibility groups for individuals age 65 and over

0 Eligibility groups for individuals who are blind

0 Eligibility groups for individuals with disabilities

0 Other Medicaid state plan eligibility groups

0 Demonstration populations covered under section 1115

WY- 16- 0020- MM7

Approved Date: 9/ 19/ 2016

Effective Date: 10/ 1/ 2016

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