Healthcare Financing Division

Wyoming Medicaid
6101 Yellowstone Road, Suite 210
Cheyenne, WY 82002
(307) 777-7531 · 866-571-0944
Fax (307) 777-6964 · www.health.wyo.gov
Thomas O. Forslund Matthew H. Mead
Director Governor
You can get this notification in Spanish or in large print if that's best for you.
Call 8552942127 (TTY/TDD:855-329-5204).

Lori Cox Date: November 28, 2017

1463 Galighner Terrace Application Date: November 26, 2017
Centennial WY 82055 Case Number: 684175

Time to renew!
Every year we review your coverage to see if you and/or your family member(s) still qualify for
Medicaid health coverage. Your coverage will end January 31, 2018 if the renewal form is not
completed by January 1, 2018. To complete your renewal:

• Call us at 8552942127 or (TTY/TDD:855-329-5204).

• Go to https://uat.wesystem.wyo.gov:8443/AVANCE_ONLINE_APP.
• Send us a fax at 855-329-5205
• Send or bring to 2232 Dell Range Blvd Ste 300, Cheyenne, WY 82002

If any of the pre-populated information is not correct, cross it out and write the correct information.
All empty boxes must be filled in. If there is someone living in the home who is not on this form, write
that information in the blank area.

We are required to verify income for Medicaid and Kid Care CHIP programs. If we are unable to verify
your income, your benefits will be discontinued. We will attempt to verify this information
electronically, but providing income verification with your renewal form will ensure we have the
income information necessary to process your renewal.

We are also required to verify resource information for our Aged, Blind and Disabled programs. If we are unable to
verify your resources, your benefits will be discontinued. If you are completing an Aged, Blind and Disabled renewal
form, please submit this verification with your renewal form.

This action is based on 42 CFR 435.916 and 42 CFR 457.300-495.

Your Secure User Account: You can choose to get letters like this online. To create an account, go to
https://uat.wesystem.wyo.gov:8443/AVANCE_ONLINE_APP and click “Account Setup.”

W110 - Renewal Notice General

Sincerely,
Wyoming Medicaid
2232 Dell Range Blvd Ste 300
Cheyenne, WY 82002

We will keep your information secure and private.

Questions? Call 855-294-2127. (TTY/TDD: 855-329-5204). You can call Monday to Friday7 a.m. to 6 p.m. The
call is free. Or go to https://uat.wesystem.wyo.gov:8443/AVANCE_ONLINE_APP.

W110 - Renewal Notice General

 Rights and Responsibilities
COMPUTER MATCHES
Please be sure the facts you give us are correct. If you provide wrong or untrue information about yourself or other
household members, you may have to repay benefits or you may be taken to civil or criminal court. We will be
comparing what you tell us with information on record with other agencies including but not limited to the
Department of Workforce Services, IRS, Social Security Administration, Vital Statistics, Workers Compensation,
Department of Homeland Security, and the Department of Revenue and Taxation. You and other household
members may be asked to verify eligibility factors. This information could change the benefits you receive from the
Wyoming Department of Health (WDH); Medicaid: 42 CFR 435.948, 42 CFR 435.949 and 42 CFR 435.956.
MEDICAL SUPPORT AND RECOVERY
If the WDH pays for medical or other related services, it has the right to recover its expenditures from a liable third
party, insurance company, or from the proceeds of a settlement or judgment for the medical expenses. If you
receive any reimbursement from a liable third party or insurance company for medical expenses incurred while you
were enrolled in Wyoming Medicaid, you must reimburse WDH to the extent of its expenditures. By applying for
Medicaid benefits, you also assigned your right to any entitlements from a contractual agreement such as medical
payments coverage from your own insurance company to WDH. You are required to notify WDH of any potential
claim against a liable third party and to cooperate with WDH in pursuing liable third parties.

CIVIL RIGHTS
Following federal law, discrimination isn’t permitted on the basis of race, national origin, sex, age, sexual
orientation, gender identity or disability. You can file a complaint of discrimination with the Office of Civil Rights
(OCR) by visiting: www.hhs.gov/ocr/office/file.

ADMINISTRATIVE HEARINGS
If this letter says your benefits are going to be denied, reduced, terminated or suspended or that you have an
established overpayment, and you feel policy was incorrectly followed, you may ask for an Administrative Hearing
via telephone, online, fax, in person or through mail. WDH will schedule an informal conference prior to scheduling
an Administrative Hearing. You have the right to represent yourself or use legal counsel, a relative, a friend, or
other spokesman during this process. You must notify WDH if you will be represented by anyone other than
yourself. WDH will not be responsible for paying any legal fees or charges. 42 CFR 431, Subpart E.

Getting benefits while waiting for the Administrative Hearing decision: If you request the Administrative Hearing
before the effective date of this action, the change will not take place until the Administrative Hearing has been held
and a decision has been made unless you tell us you want the change to be made. Remember, benefits could later
change or be closed for other reasons. You will be told about any changes in benefits. If the Office of
Administrative Hearings finds our action was correct, you may be required to pay back any benefits you received
while waiting for a decision.

You must ask for a hearing within thirty (30) days from receipt of this letter.

If you wish to use this form to request an informal conference or an Administrative Hearing, fill out the following
information and mail or bring this letter to Wyoming Department of Health, 2232 Dell Range Blvd Ste 300,
Cheyenne, WY 82002

Name (Please print) Address

/
Telephone Number Signature Date
( ) I want a formal conference.
( ) I want an Administrative Hearing.
( ) I want to continue to get the benefit I now receive until the hearing decision is made.
( ) I accept the denial, reduction, termination or suspension of my benefits until the hearing decision is made.

Why do you want a hearing?

You can also request an informal conference or an Administrative Hearing in the following ways:

♦ Call us at 855-294-2127 (TTY/TDD: 855-329-5204).

♦ Go to https://uat.wesystem.wyo.gov:8443/AVANCE_ONLINE_APP
♦ Send us a fax at 855-329-5205
 Medicaid Eligibility Renewal/Review Form - Aged, Blind and Disabled Programs
Case Name: Lori Cox Case Number: 684175 Information is due by01/01/2018

This form is being sent to you so your Medicaid eligibility can be reviewed. Please review the shaded sections and
make any changes or additions in the space provided. If you need more room, space is provided on the signature page
or use the back of any page. Complete and return this form by January 1, 2018.

If you have questions, please call 8552942127 for Medicare Savings or Employed Individuals with Disabilities (EID)
programs, or the Long Term Care Unit at 855-203-2936 .
Household Address
Current information on file Note any corrections below
Primary Individual’s name: Lori Cox Name: __________________________________________
Mailing address Residence address Mailing address Residence address
1463 Galighner Terrace _______________________ _______________________

_______________________ _______________________

Centennial WY 82055 _______________________ _______________________

Phone number(s) Phone type Phone number(s) Phone type

_______________________ _______________________

_______________________ _______________________

E-mail Address: E-mail Address: ______________________________

Authorized Representatives
Authorized representative for Lori Cox
If the person below should no longer be an authorized representative, please cross out the shaded section.
Current information on file Note any corrections below
Representative’s name Mailing address Name Mailing address
_______________________

_______________________

_______________________

Phone number(s) Phone type Phone number(s) Phone type

_______________________ _______________________

_______________________ _______________________

E-mail Address: E-mail Address: ______________________________

If you would like an authorized representative (adult) to assist you with your Medicaid, please provide his or
her contact information below.
Authorized representative for: Mailing address Phone number(s) Phone type
______________________ ________________ ___________
Representative’s full name: ______________________ ________________ ___________
______________________ ________________ ___________
E-mail address: ____________________________________

Case 684175 November 28, 2017 pg. 1 of 6

Please update any information that is incorrect.
• Check all boxes that apply for each household member.
• If you have new household members, provide their Requesting In a Nursing Home
information in the blank spaces. Medicaid Disabled or Institution
• Social Security Number is required for all members
requesting Medicaid.
Name SSN Date of Birth Yes No Yes No Yes No
Lori Cox xxx-xx-5425 06/25/1940
Debbie Wong xxx-xx-1842 11/09/1944

Household Relationships
Each household member’s relationship to the current Primary Individual is listed below. Please mark any corrections.
Current information on file Note any corrections below
Lori Cox Primary Individual Primary Individual
Household Member Relationship to
Lori Cox Household Members’ Relationship to Primary Individual

Debbie Wong Child _______________________________________________

_______________________________________________

Resources
General Resources (including bank accounts, cash, property, trusts, life insurance, stocks, etc.)
Please update any resource information that is no longer correct. Cross out any resources that you no longer own,
and enter any new resources in the blank lines. Please attach current proof of all resources/assets added at this
time. Bank statements for all accounts MUST be attached yearly.
Type Description Full Value Owner(s)' names % Own

Vehicles (including cars, trucks, motorcycles, boats, snowmobiles, ATVs, trailers, campers, etc.)
Please update any vehicle information that is no longer correct. Cross out any vehicles that you no longer own, and
enter any new vehicles in the blank lines. Please attach current proof of any new vehicles.
Vehicle Owner(s)' names % Amount
Year/Make/Model/Type Full Value
Use Own Owed

Case 684175 November 28, 2017 pg. 2 of 6

Resources Transferred
Question Yes No
1. Did you or your spouse sell, trade, or give away money, vehicles, property (including your home)
or anything of value in the past 60 months?
2. Did you or your spouse transfer any assets to a trust in the past 60 months?
3. Did you or your spouse forgive a debt owed to you in the past 60 months?
If you answered Yes to any question, please explain:

Unearned Income
This includes income such as Social Security, child support, unemployment, workers comp, retirement, VA, loans,
gifts, contracts, etc. The source is who pays the income.
Please update any income information that is no longer correct, and cross out any incomes that are no longer received.
If there is new unearned income to report, write it in the blank lines. Provide proof for the last two months for new
or changed income.
Remember to report changes within 10 days.
Who receives How often
Income type Source Amount Date last received
income received

Earned Income
This includes wages from all jobs (including spot jobs and work study), tips, bonuses, and commissions.
Please update any income information that has changed or that is expected to change in the next two months. Cross
out any income that is no longer received. Provide proof for the last two months for new or changed income.
Remember to report changes within 10 days.
Who earns
Income type Employer Amount How often paid Pay date
income

If anyone in the household has started a new job, please provide information below foreach new job.
Name of wage earner: ___________________ Start Date: ____/_____/_____ Wage: $__________ . ____
Employer: ____________________________ Per Hour Per Week Per Month
Per Pay Period Other __________________

Employer’s address: Average tips per pay period: $_________ . ____

__________________________________________ Average hours worked per pay period: ____________
__________________________________________ How often paid (weekly, every other week, twice a month,
monthly, etc.): ________________________________________

Employer’s phone number: _______________ Next two scheduled pay dates: ____________, ___________

Case 684175 November 28, 2017 pg. 3 of 6

Lori Cox Jobs (Wages, Tips, ABC Corp 700.00 Monthly 10/31/2017
Bonus &
Commissions, etc)

W110 - Renewal Notice General

Name of wage earner: ___________________ Start Date: ____/_____/_____ Wage: $__________ . ____
Employer: ____________________________ Per Hour Per Week Per Month
Per Pay Period Other __________________

Employer’s address: Average tips per pay period: $_________ . ____

__________________________________________ Average hours worked per pay period: ____________
__________________________________________ How often paid (weekly, every other week, twice a month,
monthly, etc.): _____________________________________

Employer’s phone number: _______________ Next two scheduled pay dates: ____________, ___________
Self-Employment Income
Please update any self-employment information that is no longer correct, and cross out any income that is no longer
received. Enter any new self-employment in the blank lines provided. Provide proof of self-employment income.
Remember to report changes within 10 days.
Who earns income Type of business Business name Annual income

Question Yes No
Is anyone in your household newly self-employed? If yes, please contact your Eligibility Worker.

Child Support, Dependent Care, and Alimony Expenses That You Pay
Please update any expenses that are no longer correct, and cross out any expenses that are no longer paid. This
includes any payments made for a dependent outside of the home. Enter any new expenses in the blank lines provided.
Please attach proof.
Who pays expense Type of expense Who it is paid for Amount How often paid Date last paid

Blind and Disabled Expenses That You Pay

Please update any expenses that are no longer correct, and cross out any expenses that are no longer paid. Enter any
new expenses in the blank lines provided. Please attach proof.
Who pays expense Type of expense Amount How often paid Date last paid

Medical Expenses That You Pay

Please update any expenses that are no longer correct, and cross out any expenses that are no longer paid. Enter any
new expenses in the blank lines provided. Please attach proof.
Who is it paid for Type of expense Amount How often paid Date last paid

Case 684175 November 28, 2017 pg. 4 of 6

Medicare Information
This includes information about enrollment in Medicare Part A, Part B, Part C or Part D or Railroad Retirement
coverage.
Please update any Medicare information that is no longer correct, and cross out any information that is no longer
valid. Enter information about any new Medicare coverage in the blank lines provided. Please attach proof.

Who is enrolled Medicare Beneficiary Identifier Type of Coverage Medicare Status

Debbie Wong xxxxxx5MT73 A (Hospital Insurance) Entitled - enrolled
Lori Cox xxxxxx5GA73 A (Hospital Insurance) Entitled - enrolled

Other Health Insurance

Please update any information about health insurance (other than Medicaid) that is no longer correct, and cross out
any information that is no longer valid.

Current information on file

If any household members have new health insurance coverage, please provide information below.
Insurance Company: __________________________ Policy number: ______________________________
Insurance company address: Group/certification No.: _______________________
_________________________________________________ Persons covered by this policy:
_________________________________________________ Name Start date of coverage
_________________________________________________ _______________________ ______/______/_____

Subscriber’s name: ___________________________ _______________________ ______/______/_____

Subscriber’s SSN: ____________________________ _______________________ ______/______/_____

Type of health plan: COBRA Continuation _______________________ ______/______/_____

Group Individual Student

Before you return this form:

______ Make sure all questions are answered

______ Form is signed and dated

______ ALL resources/assets have proof attached - this includes bank statements, Cash Surrender Value of Life
Insurance and any other resources that you indicate that you currently own, with the exception of:
• a home that has already been reported and verified.
• an exempt burial plan that has already been reported and verified.
• any vehicles that have already been reported and verified.

Case 684175 November 28, 2017 pg. 5 of 6

______ALL income verification is attached

______ Provide proof of all changes reported.

Additional Information
If you need more room to provide information requested on this form, use this space or attach a separate piece of paper.

I certify under penalty of perjury the information I have provided on this form is true and correct to the best
of my knowledge.

I do allow any person having this information about me or other household members to give any requested
information, including confidential information, to any authorized agent of the State of Wyoming or the
Federal Government. This information will be used for the purpose of determining eligibilityfor medical
benefits. I also agree to provide information necessary to verify any statement given on this
application. A copy of this authorization is as valid as the original authorization form.

Signature: ___________________________________________________________ Date: __________________

Authorized Representative Signature: ______________________________________ Date: __________________

Case 684175 November 28, 2017 pg. 6 of 6