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 only. nursing home Dental ADSS Aged/Disabled SSI Related (Additional Information: Clients under 21 - no co-pay and no cap limits) X X X X X X X X 20 20 20 20 12 20 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 For clients 21 years and older this plan does not cover waiver or nursing home Dental coverage is limited to one clients under 21 years old this plan does not cover waiver or nursing home For
ALE Description Emergency Services for on- Citizens X X X BCC Breast and Cervical Cancer X X Child & Adolescent Service Intensity Instrument (CASII CASI Evaluations) X X 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, prescriptions, dental, vision, or severe pain (including labor waiver or nursing home and delivery). 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 800-264-1296. 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 307-777-7531 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 nursing home
Description COAW Comprehensive Adult Waiver X X X X X X X X X 20 20 20 20 12 20 waiver services, pays coinsurance dental and vision nursing home Dental disease or eye injury. Glasses and Contacts are not covered under 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 nursing home COLR CSH1 Colorectal Cancer Screening Program X X Children's Special Health - Special eeds Children X 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 1-866-205-5292. This plan covers services for specific diagnoses or conditions as approved by the CSH Program. For additional information contact CSH at 1-800-438-5795.
CSH2 Description Children's Special Health - Moms and Babies X X X X X X This plan covers services for specific diagnoses or conditions as approved by the CSH Program. For additional information contact CSH at 1-800-438-5795. DDAW DD Adult Waiver X X X X X X X X X 20 20 20 20 12 20 waiver services, pays coinsurance dental and vision o nursing home Dental coverage is limited to one 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 20 20 20 20 12 20 This plan covers dental, medical, vision, outpatient hospital and waiver services, prescriptions, inpatient hospital stays and pays co-insurance This plan covers a physician consultation and diagnostic screening and testing for SSI determination only. and limited dental and vision nursing home o waiver or nursing home Dental coverage is limited to one preventative visit per year (including basic cleaning and x-rays) and covers basic fillings, emergency services, and full and partial dentures. Vision services are limited to medical eye examinations related to eye
Description 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. HSPC Hospice Only X X X X X X X X 20 20 20 12 20 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 and partial dentures. Adult (21 yrs of age and older) vision IP65 Inpatient Psychology Services X X X X X X X X 20 20 20 12 20 nursing home services, pays coinsurance dental and vision o waiver Dental KA Standard Full Coverage Child Medicaid 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 waiver or nursing home
Description LTCS Long Term Care Screening This plan covers LT101 and PASRR screenings only. MATR Maternity X X X X X X X X 20 20 20 20 12 20 and limited dental and vision waiver or nursing home Adult (21 yrs of age and older) dental and partial dentures. Adult (21 yrs of age and older) vision this plan for adults. MCAD Standard Full Coverage Adult Medicaid X X X X X X X X 20 20 20 20 12 20 and limited dental and vision waiver or nursing home Dental coverage is limited to one this plan for adults.
Description MDP Marginal Dental Program X MMRX Renal Program X Medicare Qualified Individual MQIB - B Premium X Medicare Qualified Individual - B Premium and MQIP Prescriptions X 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)777-7945. This plan covers specific renal prescriptions only. This plan pays Medicare Part B premiums only. This plan covers 3 prescriptions per month, pays Medicare Part B premiums. H ursing Home X X X X X X X X 20 20 20 20 12 20 nursing home services, pays coinsurance dental and vision o waiver Adult (21 yrs of age and older) dental and partial dentures. Adult (21 yrs of age and older) vision this plan for adults.
Description OH o ursing Home or Wavier X X X X X X X 20 20 20 20 and limited dental and vision o waiver or nursing home Adult (21 yrs of age and older) dental coverage is limited to one preventative visit per year (including basic cleaning and x-rays) and covers basic fillings, emergency services, and full and partial dentures. Adult (21 yrs of age and older) vision services are limited to medical eye examinations related to eye this plan for adults.
PACE PDAP /MMP Description Program of All-Inclusive Care for the Elderly Prescription Drug Assistance Program X X PE Presumptive Eligibility X X X X X X 20 20 20 12 20 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)777-7531. This plan covers 3 prescriptions per month. 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 this plan for adults. POUT Project Out X QMB Qualified Medicare Beneficiary X 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 1-855-203-2823. This plan pays Medicare Part B premiums and co-insurance and only.
QMBP QWDI Description Qualified Medicare Beneficiary with Prescriptions X X X Qualified Working Disabled Individual X 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.
Description SCM Targeted Case Management X SHPS State Licensed Shelter Care X X Special Low-Income SLMB Medicare Beneficiaries X Special Low-Income Medicare Beneficiaries with SLMP 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 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 20 20 20 20 12 20 waiver services, pays coinsurance dental and vision nursing home Dental disease or eye injury. Glasses and Contacts are not covered under 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 nursing home
Description TBI Tuberculosis Infected X X X X X X X 20 20 20 12 Tuberculosis State Only TBRX Program X T25 Title 25 Inpatient Psychiatric Progam X X and limited dental and vision This plan covers specific prescriptions only This plan covers inpatient psychiatric hospital stays and medical All other services are not covered under waiver or nursing home Adult (21 yrs of age and older) dental and partial dentures. Adult (21 yrs of age and older) vision This plan covers services for individuals only during a Title 25 inpatient psychiatric hospital stay.
Description WLTC Waiver Long Term Care X X X X X X X X X 20 20 20 20 12 20 waiver services, pays coinsurance dental and vision nursing home Adult (21 yrs of age and older) dental and partial dentures. Adult (21 yrs of age and older) vision this plan for adults. OTE: Co-payments and cap limitations do not apply to clients under the age of 21 years of age even though the plan may have a copayments and cap limitations. For specific information (procedure codes, etc.) refer to Chapter 6 in the Provider Manuals. *Key D Dental Cap Limits = umber of visits per calendar year RX Pharmacy I Inpatient O Outpatient M Medicaid / CMS-1500 V Vision W Waiver ursing Home AP Part A Premiums BP Part B Premiums C/D Medicare Co-Insurance and Deductible T Transportation Coverage OT Occupational Therapy PT Physical Therapy Revision Date: 10/1/2016 ST Speech Therapy CV Chiropractic Visits OV Office Visits DV Dietitian Visits