Medicaid and State Healthcare Benefit Plans Provider Eligibility Job Aid
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1 ame Description D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** ABIW Acquired Brain Injury X X X X X X X X X Aids Drug Assistance ADAP Program X waiver services, pays coinsurance This plan covers specific prescriptions only. nursing home Dental Vision services are limited to medical eye examinations related to eye disease or injury. Glasses and contacts are not covered under this plan. ADSS ALE Aged/Disabled SSI Related (Additional Information: Clients under 21 - no co-pay) X X X X X X X X Emergency Services for on-citizens X X X For clients 21 years and older this plan covers prescriptions, and limited dental and vision For clients under 21 years old this plan covers dental, medical, vision and outpatient hospital services, prescriptions, inpatient hospital stays and pays coinsurance Medicare claims. For clients 21 years and older this plan does not cover waiver or nursing home Dental Vision services are limited to covered under this plan. For clients under 21 years old this plan does not cover waiver or nursing home This plan only covers emergency services treated by medical providers. Emergency services are limited to situations where going without medical treatment could cause serious danger, loss of a bodily function, or severe prescriptions, dental, vision, pain (including labor and waiver or nursing home delivery).
2 ame Description D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** BCC CASI Breast and Cervical Cancer X X Child & Adolescent Service Intensity Instrument (CASII Evaluations) X X This plan covers outpatient hospital and medical services for providers who are enrolled with the Breast and Cervical Cancer Program In addition, coverage is limited to specific screening and diagnostic For more information contact the BCC Program at This plan covers CASII evaluations only CHPR CHIPRA/CME (Care Management Entity) X OTE: o covered services or limitations are spoken on the IVR. For questions contact Lisa Brockman at CMHW Children's Mental Health Waiver X X X X X X X X X X X This plan covers dental, medical, vision, outpatient hospital and waiver services, prescriptions, inpatient hospital stays and pays co-insurance Medicare claims. nursing home COAW Comprehensive Adult Waiver X X X X X X X X X waiver services, pays coinsurance nursing home Dental Vision services are limited to related to eye disease or eye injury. Glasses and Contacts are not covered under this plan.
3 ame Description D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** COCW Comprehensive Child Waiver X X X X X X X X X This plan covers dental, medical, vision, outpatient hospital and waiver services, prescriptions, inpatient hospital stays and pays co-insurance Medicare claims. nursing home COLR CSH1 CSH2 Colorectal Cancer Screening Program X X Children's Special Health - Special eeds Children X X X X X X X Children's Special Health - Moms and Babies X X X X X X This plan covers outpatient hospital and medical services related to specific screening and diagnostic The medical provider must be enrolled with the Colorectal Cancer Screening Program. For more information contact the CRC Program at This plan covers services for specific diagnoses or conditions as approved by the CSH Program. For additional information contact CSH at This plan covers services for specific diagnoses or conditions as approved by the CSH Program. For additional information contact CSH at DDAW DD Adult Waiver X X X X X X X X X waiver services, pays coinsurance o nursing home Dental Vision services are limited to covered under this plan.
4 ame Description D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** DDCW DD Children's Waiver X X X X X X X X X DDP Disability Determination X X E Employed Individual Disabled X X X X X X X X This plan covers dental, medical, vision, outpatient hospital and waiver services, prescriptions, inpatient hospital stays and pays co-insurance Medicare claims. nursing home This plan covers a physician consultation and diagnostic screening and testing for SSI determination only. and limited dental and vision o waiver or nursing home Dental coverage is limited to 2 preventive visits per year including basic cleanings and x-rays and covers emergency services and extractions. Vision services are limited to medical eye examinations related to eye disease or injury. Glasses and contacts are not covered under this plan. FPW Pregnant By Choice X X X X This plan only covers prescriptions, inpatient hospital stays, outpatient hospital and medical services related to family planning methods and products approved by the FDA. abortion, infertility services and/or treatments, or sterilization reversals.
5 ame Description D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** HSPC Hospice Only X X X X X X X X This plan covers services provided by physicians and the attending hospice provider. Prescriptions, inpatient hospital stays, outpatient hospital, medical and waiver services, coinsurance dental and vision services are covered when not related to the client's terminal illness and approved by the hospice provider. o nursing home Adult (21 yrs of age and older) dental Adult (21 yrs of age and older) vision services are limited to covered under this plan. IP65 Inpatient Psychology Services X X X X X X X X nursing home services, pays coinsurance o waiver Dental Vision services are limited to covered under this plan. KA LTCS Standard Full Coverage Child Medicaid X X X X X X X X Long Term Care Screening This plan covers dental, medical, vision, outpatient hospital, prescriptions, inpatient hospital stays and pays co-insurance and waiver. or nursing home This plan covers LT101 and PASRR screenings only.
6 ame Description D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** MATR Maternity X X X X X X X X and limited dental and vision waiver or nursing home Adult (21 yrs of age and older) dental Adult (21 yrs of age and older) vision services are limited to covered under this plan for adults. MCAD Standard Full Coverage Adult Medicaid X X X X X X X X and limited dental and vision waiver or nursing home Dental Vision services are limited to covered under this plan for adults. MDP Marginal Dental Program X This plan receives Dental coverage only, with a maximum of 1,000 dollars total payment limitation per year and receives 85% of billed charges, the client is responsible for remaining 15%. Eligibility is determined annually. For additional information contact the Marginal Dental Program at (307)
7 Co- ame Description pay* D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** This plan covers specific renal MMRX Renal Program X prescriptions only. Medicare Qualified This plan pays Medicare Part B MQIB Individual - B Premium X premiums only. MQIP Medicare Qualified Individual - B Premium and Prescriptions X X H ursing Home X X X X X X X X This plan covers 3 prescriptions per month, pays Medicare Part B premiums. nursing home services, pays coinsurance o waiver Adult (21 yrs of age and older) dental Adult (21 yrs of age and older) vision services are limited to covered under this plan for adults. OH o ursing Home or Wavier X X X X X X X and limited dental and vision o waiver or nursing home Adult (21 yrs of age and older) dental coverage is limited to 2 preventive visits per year including basic cleanings and x-rays and covers emergency services and extractions. Adult (21 yrs of age and older) vision services are limited to medical eye examinations related to eye disease or injury. Glasses and contacts are not covered under this plan for adults.
8 ame PACE PDAP /MMP Description Program of All-Inclusive Care for the Elderly Prescription Drug Assistance Program X X D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** This plan covers Medicaid eligible medical services as well as home and community based services for participants 55 years of age and older who meet nursing home level of care. All services must be provided by a PACE provider in Wyoming. For additional information contact Wyoming Medicaid at (307) This plan covers 3 prescriptions per month. PE Presumptive Eligibility X X X X X X and limited vision waiver, nursing home or dental Adult (21 yrs of age and older) vision services are limited to medical eye examinations related to eye disease or injury. Glasses and contacts are not covered under this plan for adults. POUT Project Out X Project Out is a transition/diversion program designed to provide supportive services to individuals who are at risk of being admitted to a skilled nursing facility without these services, or individuals who are in a skilled nursing facility and wish to transition back to a community-based placement. There is no medical coverage whatsoever under this program. For more information, contact the Home Care Services Unit at
9 ame QMB QMBP QWDI Description Qualified Medicare Beneficiary X X Qualified Medicare Beneficiary with Prescriptions X X X Qualified Working Disabled Individual X D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** This plan pays Medicare Part B premiums and co-insurance and only. This plan covers 3 prescriptions per month, pays co-insurance Medicare claims, pays Medicare Part B premiums. This plan pays Medicare Part A premiums only.
10 ame Description D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** SCM SHPS SLMB SLMP Targeted Case Management X State Licensed Shelter Care X X Special Low-Income Medicare Beneficiaries X Special Low-Income Medicare Beneficiaries with Prescriptions X X This plan covers screening services for the Developmentally Disabled Waiver Program only. This plan covers nursing home services only and pays coinsurance Medicare claims. This plan pays Medicare Part B premiums only. This plan covers 3 prescriptions per month, pays Medicare Part B premiums. SUAW Supports Adult Waiver X X X X X X X X X waiver services, pays coinsurance nursing home Dental Vision services are limited to related to eye disease or eye injury. Glasses and Contacts are not covered under this plan. SUCW Supports Child Waiver X X X X X X X X X This plan covers dental, medical, vision, outpatient hospital and waiver services, prescriptions, inpatient hospital stays and pays co-insurance Medicare claims. nursing home
11 ame Description D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** and limited dental and vision TBI Tuberculosis Infected X X X X X X X Tuberculosis State Only This plan covers specific TBRX Program X prescriptions only This plan covers inpatient psychiatric hospital stays and medical All other Title 25 Inpatient services are not covered under T25 Psychiatric Progam X X this plan. waiver or nursing home Adult (21 yrs of age and older) dental Adult (21 yrs of age and older) vision services are limited to covered under this plan. This plan covers services for individuals only during a Title 25 inpatient psychiatric hospital stay.
12 ame Description D RX I O M V W AP BP C/D T OT PT ST CV DV BV** OV** WLTC Waiver Long Term Care X X X X X X X X X waiver services, pays coinsurance nursing home Adult (21 yrs of age and older) dental Adult (21 yrs of age and older) vision services are limited to covered under this plan for adults. D RX I O M V W AP BP C/D T OT PT ST CV DV BV OV *Key Dental Pharmacy Inpatient Outpatient Medicaid / CMS-1500 Vision Waiver ursing Home Part A Premiums Part B Premiums Medicare Co-Insurance and Deductible Transportation Coverage Occupational Therapy Physical Therapy Speech Therapy Chiropractic Visits Dietitian Visits Behavioral Health Visits Office Visits OTE: Co-payments do not apply to clients under 21 years of age even though the plan may have a co-payment. For specific information (procedure codes, etc.) refer to Chapter 6 in the Provider Manuals. **Clients under the age of 21 do not have a threshold for office visits or behavioral health visits. Threshold = umber of visits per calendar year
Medicaid and State Healthcare Benefit Plans Provider Eligibility Job Aid
Description ABIW Acquired Brain Injury X X X X X X X X X 20 20 20 20 12 20 Aids Drug Assistance ADAP Program X waiver services, pays coinsurance dental and vision This plan covers specific prescriptions
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