Ch. 16, § 13. Adverse Actions for Clients

(a) The Department may impose or refer a client to the appropriate agency for adverse actions for instances including, but not limited to: (i) Fraud, waste, or abuse in obtaining services; (ii) Alteration or duplication of the client's Medicaid identification card; (iii) Permitting, authorizing or assisting a non-client to use the client's Medicaid identification card to obtain services; (iv) Using another client's Medicaid identification card to obtain services; (v) Alteration or duplication of a prescription; (vi) Knowingly misrepresenting material facts regarding the client's physical or mental condition for the purpose of obtaining services; (vii) Knowingly furnishing incorrect information regarding eligibility to a provider; (viii) Knowingly furnishing incorrect information to a provider to obtain services which are not medically necessary; (ix) Pending the completion of an on-going investigation conducted by the MFCU, Eligibility Integrity Unit or another law enforcement agency; (x) Refusing to complete education; or (xi) Obtaining services by any false or incorrect pretenses. (b) The decision to take action pursuant to this Section shall be made by the State Medicaid Agent, or the Agent's designee, who shall consider, among other things: (i) The nature and extent of the client's violations; and (ii) The client's history of previous violations. (c) The Department may take any of the following adverse actions against a client: (i) Refer the client to educational intervention to correct inappropriate or dangerous utilization of services; (ii) Recover overpayments from the client, to the extent permitted by law; (iii) Restrict the client's future participation in Medicaid to receiving services from the provider or providers designated by the Department. Medicaid payments shall be limited to the designated provider, except for payments for emergency care; or (iv) Any other action allowed by state or federal law. (d) The Department shall send written notice of the adverse action, to the client, via certified mail, return receipt requested. The notice shall include: (i) An explanation of: (A) The individual's right to request a hearing; or (B) An explanation of circumstances where a hearing will be granted based on a change in the law. (ii) The method for requesting a hearing; (iii) The individual's right to be represented by a legally authorized representative, including a lawyer admitted to practice in Wyoming, a relative, friend or other spokesperson; (iv) Notice that the individual shall notify the Department in writing that they will be represented; (v) The intended action; (vi) The effective date of the intended action; (vii) The reason(s) for the intended action; (viii) The specific regulations that support, or the change in federal or state law that requires the action; (ix) Where applicable, an explanation of the circumstances under which benefits may be continued if a hearing is requested pursuant to 42 C.F.R. § 431.231; and (x) The client's right to request a reconsideration of the adverse action.