reglab/statecodes huggingface dataset:
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-25 - Additional Standards for Providers that Require National Accreditation

Current through July 13, 2024
(a) Providers that are certified in Adult
				Day, Case Management, Community Living, Community Support, Companion, or
				Supported Employment Services shall receive and maintain national accreditation
				in the accreditation areas specific to the service being provided if the
				services listed in this subsection and delivered by the provider collectively
				equal or exceed $150,000 per calendar year.
(b) Providers shall obtain accreditation in
				the area applicable to each service within eighteen (18) months of qualifying
				under this provision. The eighteen (18) month clock begins on the date the
				accreditation criteria are met.
(c)
				Provider accreditation options include the Council on Quality and Leadership
				(CQL) and CARF International. Regardless of the accreditation attained, all
				references to accredited providers in this rule apply to the
				provider.
(d) The Division shall
				decertify a provider who fails to obtain or maintain accreditation.
(e) If a provider fails to obtain or maintain
				accreditation, a transition plan shall be implemented for each participant who
				is leaving the provider's services.
(i) Each
				waiver participant shall be relocated to a different provider within ninety
				(90) days of the date the Division receives confirmation that the provider did
				not receive accreditation. If a provider fails to obtain or maintain
				accreditation, the Division shall complete an immediate site survey and onsite
				assessment.
(ii) The provider's
				decertification date shall begin ninety (90) days from the date of written
				notice from the accrediting entity that the provider did not receive
				accreditation.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-26 - Mortality Review

Current through July 13, 2024
(a) The Division shall review deaths of
				participants receiving waiver services.
(b) Providers shall submit information
				requested by the Division. This may include, but is not limited to:
(i) Copies of documentation of
				services;
(ii) Copies of incident
				reports; and
(iii) Copies of any
				health related records, including assessments, results of licensed medical
				professional's office visits, and hospital visits.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-27 - Initial Provider Certification

Current through July 13, 2024
(a) An individual or entity may apply to
				become a provider by completing the Division's initial provider certification
				process and all required trainings. The applicant shall supply evidence that
				the applicant meets the qualifications for each service in which the applicant
				is seeking waiver certification.
(b) The Division shall only certify one
				provider per physical location.
(c)
				The Division shall not certify any person or entity as a waiver provider if:
(i) The person or entity has an open or
				pending corrective action plan with the Division;
(ii) The person or entity has an open case
				with the Medicaid Fraud Control Unit; or
(iii) The person has not successfully passed
				a background screening as provided in Section
				14 of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-28 - Provider Certification Renewal

Current through July 13, 2024
(a) The Division shall notify all providers
				that their waiver certification is expiring at least ninety (90) calendar days
				prior to the certification expiration date. The notification shall detail
				requirements that the provider shall meet in order to renew their
				certification.
(b) The Division
				shall renew a provider certification at least once every three years. Based on
				the services provided, an on-site visit may be required. If an on-site visit is
				required, the Division shall provide notification to the provider at least
				thirty (30) calendar days prior to the visit.
(c) Provider certification renewal includes a
				Division review of the provider's evidence of compliance with state and federal
				regulations for home and community based services, and a review of the
				provider's self-assessment of compliance. For providers who offer services in a
				setting they own, operate, or lease, the Division shall also review the
				provider's self-inspection of service settings and a current inspection report
				from an outside entity.
(d) At any
				time, the Division shall conduct an on-site visit when a concern is identified
				during a complaint, incident report, or internal referral, if there is an
				indication the provider is not complying with state or federal rules and
				regulation, or at the Division's discretion.
(e) Providers may sign a form verifying that
				they do not provide services in their home or a provider-owned, leased, or
				operated setting. The Division will not conduct on-site evaluations for
				providers signing these forms, but may verify the accuracy of these statements.
				Falsification of these forms may result in sanctions.
(f) The Division does not require an on-site
				visit for a case manager, specialized equipment, or environmental modification
				certification renewal.
(g)
				Providers shall submit verification that they have met all applicable
				certification renewal requirements to the Division at least forty-five (45)
				calendar days prior to their certification expiration date.
(h) If a provider fails to submit the
				applicable certification renewal requirements to the Division as described in
				subsection (g) of this Section, the Division shall notify the provider in
				writing of the expiration of the certification.
(i) If the provider does not meet the
				certification renewal requirements within twenty (20) calendar days of the
				certification expiration, the Division shall begin the decertification
				process.
(ii) The provider shall be
				notified in writing through certified mail that their certification has
				expired.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-29 - Corrective Action Plan Requirements

Current through July 13, 2024
(a) The Division shall, to the extent
				practicable and consistent with the provisions of applicable law, seek the
				cooperation of providers in obtaining compliance with these standards. The
				Division may provide technical assistance to providers to help them voluntarily
				comply with any applicable provision of these rules.
(b) The Division may attempt to resolve any
				suspected noncompliance with this Chapter by requiring the provider to submit a
				corrective action plan.
(c)
				Corrective action plans shall address each area of suspected non-compliance to
				the Division's satisfaction. This includes identifying the suspected
				noncompliance area, action steps needed to address the area of noncompliance,
				the people in the organization responsible for each action item, due dates, and
				dates of completion for each recommendation.
(d) The Division may require specialized
				training for the provider organization or individual employees as part of a
				corrective action. Specialized training may include, but is not limited to,
				training on positioning, feeding protocols, positive behavior supports,
				person-centered planning, or trauma-informed care, and shall be included in the
				corrective action plan submitted by the provider.
(e) Suspected non-compliance that relates to
				the immediate health, safety, welfare, or rights of participants shall be
				addressed immediately after the situation is discovered. Providers addressing
				suspected non-compliance under this Section shall be given fifteen (15)
				business days from the date of the report issued by the Division to submit a
				corrective action plan.
(f) If a
				corrective action plan is not submitted and implemented to address all areas of
				suspected non-compliance, the Division may impose sanctions as warranted in
				Section 30 of this
				Chapter.
(g) The Division shall
				notify the provider in writing within thirty (30) business days after receipt
				of the provider's corrective action plan regarding the approval or rejection of
				the plan.
(i) If a corrective action plan is
				rejected, the provider shall receive notification in writing of the reasons for
				the rejection, and shall submit a revised plan within ten (10) business days
				from the notification of the written rejection from the Division.
(ii) The Division shall notify the provider
				in writing within thirty (30) business days after receipt of the provider's
				revised corrective action plan regarding the approval or rejection of the
				plan.
(iii) If the revised
				corrective action plan is rejected, the provider shall have ten (10) business
				days from the notification of rejection to submit an acceptable corrective
				action plan, or the Division may proceed with the sanctioning process as
				outlined in Section
				30 of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-30 - Sanctions

Current through July 13, 2024
(a) Sanctions shall be imposed in accordance
				with the provisions of Chapter 16 of the Department of Health's Medicaid
				Rules.
(b) Notwithstanding the
				provisions of Section
				29 of this Chapter, the Division may
				impose sanctions or revoke provider certification for any violation of these
				rules.
(c) If the Division revokes
				a provider's certification or suspends a national provider identification
				number, the provider shall submit transition plans to the Division detailing
				the transition of each participant to other settings within twenty (20)
				calendar days of the date that the sanction is deemed final.
(i) The transition plans shall not be
				implemented until approved by the Division.
(ii) The transition plans shall be
				implemented and participants shall move to different certified providers or
				receive non-waiver supports and services from persons approved by the
				participants or any legally authorized representative(s) within ninety (90)
				calendar days of the date the Division informed the provider of the revocation
				of certification.
(iii) Transition
				plans shall adhere to the requirements in Section
				22 of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-31 - Relative Providers

Current through July 13, 2024
(a) The Division shall allow a participant's
				relative, as defined in Section
				3 of this Chapter, to become a certified
				waiver provider and receive reimbursement for services provided to the related
				participant.
(b) A participant's
				legally authorized representative shall not directly or indirectly receive
				reimbursement for providing waiver services for their ward, except as indicated
				in the Comprehensive and Supports Waiver Service Index, which is incorporated
				by reference. Direct or indirect reimbursement shall include, but is not
				limited to, providing direct services for, or serving as the owner or officer
				of, a provider organization, residing in a provider owned service setting, or
				being married to a person providing waiver services to the
				participant.
(c) A participant's
				spouse may receive direct or indirect reimbursement only if they present the
				Division with a certified copy of a court order establishing another party as
				the legally authorized representative of the participant.
(d) To provide waiver services to a related
				participant, the relative provider shall:
(i)
				Form a Limited Liability Company (LLC) or other corporation; and
(ii) Maintain provider certification in
				accordance with this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-32 - Interpretation of Chapter

Current through July 13, 2024
(a) The order in which the provisions of this
				Chapter appear is not to be construed to mean that any one provision is more or
				less important than any other provision.
(b) The text of this Chapter shall control
				the titles of its various provisions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-33 - Superseding Effect

Current through July 13, 2024
This Chapter supersedes all prior rules or policy statements
				  issued by the Division, including provider manuals and provider bulletins,
				  which are inconsistent with this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 45 - DD WAIVER PROVIDER STANDARDS, CERTIFICATION, AND SANCTIONS › Section 45-35 - Incorporation by Reference

Current through July 13, 2024
(a) For any code, standard, rule, or
				regulation incorporated by reference in these rules:
(i) The Department has determined that
				incorporation of the full text in these rules would be cumbersome or
				inefficient given the length or nature of the rules;
(ii) The incorporation by reference does not
				include any later amendments or editions of the incorporated matter beyond the
				applicable date identified in subsection (b) of this section; and
(iii) The incorporated code, standard, rule,
				or regulation is maintained at the Department and is available for public
				inspection and copying at cost at the same location.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Department of Health
				  pursuant to Wyoming Statute
										9-2-102 and the Wyoming Medical Assistance
				  and Services Act at W. S.
				  
										42-4-104 through -121.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter shall apply to and govern
				Medicaid services provided under the Wyoming Medicaid Supports and
				Comprehensive Waivers.
(b) This
				Chapter, in addition to Chapters 44 and 45 of the Department of Health's
				Medicaid Rules, shall govern services and provider requirements of the Supports
				and Comprehensive Waivers.
(c) The
				Division of Healthcare Financing, hereinafter referred to as the "Division,"
				may issue manuals and bulletins to providers or other affected parties to
				interpret the provisions of this Chapter. Such manuals and bulletins shall be
				consistent with and reflect the policies contained in this Chapter. The
				provisions contained in manuals and bulletins shall be subordinate to the
				provisions of this Chapter.
(d)
				Wyoming's currently approved Centers for Medicare and Medicaid Services (CMS)
				Comprehensive and Supports Waiver Applications and the Comprehensive and
				Supports Waiver Index apply to this Chapter.
(e) The requirements of Title XIX of the
				Social Security Act, 42 C.F.R Part 441, Subpart G and the Medicaid State Plan
				apply to this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-3 - General Provisions

Current through July 13, 2024
(a) Except as otherwise specified in Chapter
				1 of the Department of Health's Medicaid Rules, or as defined in this Section,
				the terminology used in this Chapter is standard terminology and has the
				standard meaning used in accounting, health care, Medicaid, and
				Medicare.
(b) "Case manager" means
				an individual who provides case management services, as established in Chapter
				45, Section
				9.
(c) "Level of Service score" means a
				participant's support needs for various parts of their everyday routine and
				their level of independence, which are tied to a Level of Service score ranging
				from 1 (lowest level of support) to 6 (highest level of support). The Level of
				Service scores are based on comprehensive assessments that determine an
				individual's level of functioning related to behavioral and health factors, and
				identify essential staffing and support requirements.
(d) "Relative" means a participant's
				biological, step, or adoptive parent(s).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-4 - Eligibility Requirements

Current through July 13, 2024
(a) Eligibility under this Chapter is limited
				to persons who complete the application process and who meet the requirements
				for clinical and financial eligibility established under this Section. An
				individual is not eligible for the Wyoming Medicaid Supports Waiver unless the
				individual meets the following criteria:
(i)
				The individual satisfies the citizenship, residency, and financial eligibility
				requirements established in Chapter 18 of the Department of Health's Medicaid
				Rules;
(ii) The individual
				qualifies for the relevant institutional level of care pursuant to Section
				6 of this Chapter;
(iii) The individual has received a clinical
				eligibility diagnosis pursuant to Section
				7 of this Chapter; and
(iv) The individual has received a qualifying
				Inventory for Client and Agency Planning (ICAP) score pursuant to Section
				8 of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-5 - Loss of Eligibility

Current through July 13, 2024
(a) The Division shall determine a
				participant has lost eligibility for waiver services when the participant:
(i) Does not meet clinical
				eligibility;
(ii) Does not meet
				financial eligibility; or
(iii)
				Changes residence to another state.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-6 - Institutional Level of Care Requirements

Current through July 13, 2024
(a) An individual with a developmental or
				intellectual disability diagnosis is not eligible for waiver services pursuant
				to Section
				4 of this Chapter unless the individual
				qualifies for an intermediate care facility for individuals with an
				intellectual or developmental disability (ICF/IID) level of care, as measured
				by the LT-104 assessment.
(b) An
				individual with an acquired brain injury diagnosis is not eligible for waiver
				services pursuant to Section
				4 of this Chapter unless the individual
				qualifies for a nursing facility level of care, as measured by the LT-101
				assessment.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-7 - Clinical Eligibility Diagnoses

Current through July 13, 2024
(a) An individual is not eligible for waiver
				services pursuant to Section
				4 of this Chapter unless the individual
				meets one of the following clinical eligibility diagnoses:
(i) A diagnosis of an intellectual
				disability, as defined by the Diagnostic and Statistical Manual of Mental
				Disorders (DSM 5), which is incorporated by reference, and is determined by a
				Medicaid enrolled psychiatrist, neurologist, or clinical psychologist who is
				licensed in Wyoming and is free of conflicts with other providers chosen by the
				participant.
(A) The diagnosis shall be
				verified in a written and signed psychological evaluation that is submitted to
				the Division.
(B) The psychological
				evaluation shall reflect adaptive behavior scores as determined through a
				standard measurement of adaptive behavior using a validated test of adaptive
				functioning such as the most current form of the Vineland Adaptive Behavior
				Scales or Adaptive Behavior Assessment System.
(C) A child applicant who takes an
				Intelligence Quotient test shall meet a qualifying clinical diagnosis like an
				adult. A child too young to complete an Intelligence Quotient test may meet the
				criteria of a developmental disability as described in subsection (a)(i)(B)
				through medical records of a related condition using a standardized test of
				development, such as the Bayley Scales of Infant and Toddler Development or
				other similar instrument.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-8 - Inventory for Client and Agency Planning Assessment

Current through July 13, 2024
(a) An individual is not eligible for waiver
				services pursuant to Section
				4 of this Chapter unless the individual
				receives a qualifying Inventory for Client and Agency Planning (ICAP)
				assessment score for the individual's age.
(i) If an individual is age zero (0) through
				one (1), the adaptive behavior quotient shall be .50 or below.
(ii) If an individual is age two (2) through
				five (5):
(A) The ICAP service score shall be
				between 30 and 44, depending on age; or
(B) The adaptive behavior quotient shall be
				.50 or below.
(iii) If an
				individual is age six (6) through twenty (20):
(A) The ICAP service score shall be between
				48 and 70, depending on age; or
(B)
				The adaptive behavior quotient shall be .70 or below.
(iv) If an individual is age twenty-one (21)
				or older:
(A) The ICAP service score shall be
				70 or less; or
(B) The individual
				shall have a functional limitation in at least three (3) of the following ICAP
				areas: self-care, language, learning/cognition, mobility, self-direction, or
				independent living.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-9 - Statewide Data Registry

Current through July 13, 2024
All individuals who have been determined eligible for waiver
				  services shall be included in the statewide data registry used by the Division
				  for planning, monitoring, and analysis for the waiver system. Information in
				  the registry is considered confidential and will not be released without proper
				  authorization, or otherwise as required by law. Providers shall submit data on
				  programs, participant outcomes, costs, and other information as required by the
				  Division.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-10 - Waiver Services, Service Requirements, and Restrictions

Current through July 13, 2024
(a) Waiver services specified in the
				individualized plan of care shall be based on the participant's assessed needs;
				meet the service definition(s); be considered medically or functionally
				necessary; align with the participant's preferences for services, supports, and
				providers; and be prioritized based on the availability of funding in the
				participant's individual budget amount.
(b) Services shall have prior authorization
				before being provided to a participant.
(c) Waiver services shall support and assist
				the participant in acquiring, retaining, and improving the skills necessary for
				the individual to function with as much independence as possible, exercise
				choice and self-management, and participate in the rights and responsibilities
				of community membership.
(d) The
				individualized plan of care shall reflect the services and actual units that
				providers agree to provide over the plan year. The individualized plan of care
				shall also include details regarding the specific support, settings, times of
				day, and activities requiring more support than others.
(e) Providers shall not serve children under
				age eighteen (18) and adults at the same time unless authorized in writing by
				the Division.
(f) Waiver services
				shall not be used to duplicate the same service or a similar service that is
				available to the participant through one of the following programs:
(i) Section
				110 of the Rehabilitation Act of
				1973;
(ii) Section
				504 of the Rehabilitation Act of
				1973;
(iii) Individuals with
				Disabilities Education Act (IDEA) (
				20
				U.S.C. 1401 et seq.); or
(iv) Medicaid State Plan.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-11 - Waiver Cost Limits and Individual Budget Amounts

Current through July 13, 2024
(a) The allocation of Medicaid waiver funds
				that may be available to a participant to purchase services shall be based on
				his or her assessed needs.
(b)
				Eligible individuals shall be assigned a Level of Service score.
(c) Participants enrolled in the Supports
				Waiver shall be assigned a designated budget amount outlined in the most
				current Supports Waiver application, which is incorporated by reference.
				Transition to the Comprehensive Waiver shall only occur as funding and a slot
				on the Comprehensive Waiver becomes available.
(d) Participants shall meet criteria outlined
				in Section
				4(d) of this Chapter to be
				eligible for Comprehensive Waiver Services.
(i) Participants enrolled on the
				Comprehensive Waiver shall be assigned an individual budget amount based on the
				following factors:
(A) Functional and medical
				assessments;
(B) The participant's
				age group;
(C) The participant's
				living situation;
(D) The
				participant's need for a higher level of services;
(E) An amount for annual case management
				services; and
(F) Any temporary or
				permanent increase or decrease as determined by the ECC.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-12 - Self-Directed Service Delivery

Current through July 13, 2024
(a) The services that may be self-directed
				are outlined in the Comprehensive and Supports Waiver Service Index, which is
				incorporated by reference.
(b) At
				least once a year, each participant's case manager shall provide the
				participant or legally authorized representative information regarding the
				option to self-direct waiver services. Information shall include requirements
				of the employer of record, not limited to:
(i) Hiring, firing, and training
				staff;
(ii) Setting staff work
				schedules; and
(iii) Monitoring and
				working within the participant's individual budget amount.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-13 - Wait List Process

Current through July 13, 2024
(a) The Division shall maintain a Supports
				Waiver wait list to add additional participants as funding is appropriated and
				as approved by CMS.
(b) The
				Division shall prioritize eligible individuals on the Supports Waiver wait list
				on a first come, first serve basis. Funding opportunities shall be given to the
				person who has waited the longest for services, based on the date that the
				individual was determined eligible.
(c) Before being added to the Supports Waiver
				wait list, the individual shall be determined eligible as specified in Section
				4 of this Chapter.
(d) For people with the same date of
				eligibility, the Division shall use the date that the Case Manager Selection
				form was received by the Division to determine which individual shall receive
				the next funding opportunity.
(e)
				The Level of Service score and individual budget amount shall be determined for
				each individual on the wait list. An eligible individual who needs services in
				excess of the Supports Waiver may request placement on the Comprehensive
				Waiver, and may be placed on the Comprehensive Waiver wait list, if a funding
				opportunity is not available. Preference on the Comprehensive Waiver wait list
				is given to individuals with a Level of Service score of four (4) or
				higher.
(f) The Comprehensive
				Waiver shall reserve capacity each year for eligible individuals who have
				resided in a Wyoming institution, such as an ICF/IID, nursing home, Psychiatric
				Residential Treatment Facility, residential treatment facility, BOCES, or an
				inpatient psychiatric hospital, and who have been:
(i) In residence at the
				institution;
(ii) On a Division
				wait list; or
(iii) On a Division
				waiver prior to being institutionalized.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-14 - Emergency Waiver Services

Current through July 13, 2024
(a) An emergency case involves an eligible
				person who requires immediate action or has an urgent need for waiver services,
				including placement in the least restrictive and most appropriate environment
				necessary to maintain the person's vital functions because of one of the
				following criteria:
(i) An immediate threat,
				or a high probability of immediate danger to the life, health, property, or
				environment of the eligible person or another individual because of the
				eligible person's medical, mental health, or behavioral condition.
(ii) A loss of the person's primary caregiver
				due to death, incapacitation, critical medical condition, or inability to
				provide continuous care. A caregiver is defined as any person, agency, or other
				entity responsible for the care, both physical and supervisory, of a person
				because of:
(A) A family
				relationship;
(B) Voluntary
				assumption of responsibility for care;
(C) Court ordered responsibility or
				placement;
(D) Rendering services
				in a residential program;
(E)
				Rendering services in an institution or in a community-based program;
				or
(F) Acceptance of a legal
				obligation or responsibility of care to the person.
(iii) Homelessness, which means a situation
				where, for a period of thirty (30) days, a person lacks access to an adequate
				residence with appropriate resources to meet his or her support and supervision
				needs, and without such support, there is evidence of serious harm to the
				person's life or health.
(iv) A
				case involving a person removed from the home by an appropriate agency due to
				abuse, neglect, abandonment, exploitation, or self-neglect.
(v) A residential service request for a
				waiver participant or a person on the wait list not receiving 24-hour
				residential services, whose health or safety is at significant risk due to
				extraordinary needs that cannot be met in the current living arrangement
				because of one of following criteria:
(A) A
				substantial threat to a person's life or health that is corroborated by the
				Department of Family Services, Protection & Advocacy System, Inc., or law
				enforcement;
(B) A situation where
				the person's health condition or significant and frequently occurring
				behavioral challenges pose a substantial threat to the person's own life or
				health, or to others in the home;
(C) A situation where the person's critical
				medical condition requires ongoing twenty-four (24) hour support and
				supervision to maintain the person's health and safety that cannot be met in
				the current living situation; or
(D) The loss of the eligible person's primary
				caregiver due to death, incapacitation, critical medical condition, or
				inability to provide continuous care.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-15 - Extraordinary Care Committee

Current through July 13, 2024
(a) The ECC shall be composed of a Division
				waiver manager, a Medicaid manager, the Participant Support Specialist
				presenting the case, and a representative from the Department's fiscal unit.
				When appropriate, the ECC may also include the Division's licensed
				psychiatrist, the Medicaid Medical Director, the Division's registered nurse,
				or a behavioral specialist. Members may also consult other specialists in the
				field as appropriate.
(b) The ECC
				shall only approve additional funds for participant cases if funding is
				available in the Division's waiver budget appropriation.
(c) The ECC shall review:
(i) Emergency cases as defined by Section
				14 of this Chapter;
(ii) Extraordinary cases that include a
				significant change in service need due to the onset of a behavioral or medical
				condition or injury including:
(A) A
				temporary change in circumstances, which requires a higher level of service or
				support to ensure the health, safety, and welfare of the participant;
(B) Temporary funding increases under Section
				11(d) of this
				Chapter;
(C) Concerns about a Level
				of Service score; or
(D) Requests
				requiring ECC approval under these Rules; and
(iii) Other supplemental requests as defined
				in the Comprehensive and Supports Service Index, which is incorporated by
				reference.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-16 - Prohibited Use of Waiver Funds

Current through July 13, 2024
(a) The following services are not eligible
				for waiver services reimbursement:
(i) The
				care of individuals residing in a hospital, nursing facility, ICF/IID, or other
				institutional placement;
(ii)
				Wavier services provided by:
(A) A spouse of
				the participant, if the spouse is also the participant's legally authorized
				representative;
(B) A legally
				authorized representative of a participant who is eighteen (18) years of age or
				older; or
(C) An owner or officer
				of a provider organization if the organization is serving a participant for
				whom they are the legally authorized representative;
(iii) Room and board, except when provided as
				part of respite in a facility, other than a private residence, approved by
				Medicaid;
(iv) Services currently
				covered under the Medicaid State Plan;
(v) Services to an individual if it is
				reasonably expected that the cost of these services would exceed the
				institutional cost limit specified in the most current Comprehensive Waiver
				application approved by CMS, which is incorporated by reference; or
(vi) Service settings reimbursed by another
				state agency, such as the Department of Family Services or Department of
				Education.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-17 - Denial of Funding for Waiver Services

Current through July 13, 2024
(a) The Division may deny or revoke
				authorization for waiver services for any of the following reasons:
(i) The individual fails to meet waiver
				eligibility criteria as established in Section
				4;
(ii) The eligible individual has not met
				emergency criteria and no other waiver funding opportunities are
				available;
(iii) The individual or
				legally authorized representative has not consented to waiver
				services;
(iv) The individual or
				legally authorized representative has chosen to receive ICF/IID or nursing
				facility services;
(v) The
				individual, his or her legally authorized representative, or other person on
				his or her behalf has not supplied needed information;
(vi) The participant's needs are not being
				met through waiver services;
(vii)
				The individualized plan of care has not been implemented;
(viii) The legislature has not appropriated
				sufficient fiscal resources to fund all services for all persons determined
				eligible for waiver services;
(ix)
				Funding for requested waiver services is available as a similar service from
				other sources, such as a school district or the Division of Vocational
				Rehabilitation;
(x) The eligible
				individual or legally authorized representative has failed to apply for, and
				accept any federal Medicaid benefits for which she or he may be eligible, or
				benefits from other funding sources within the Department of Health, the
				Department of Education, Department of Workforce Services, or other agencies to
				the maximum extent possible.
(xi)
				The eligible individual or legally authorized representative has not signed
				documentation required by the Department;
(xii) The eligible individual or legally
				authorized representative has failed to cooperate with, or refused the services
				funded by the Division; or
(xiii)
				The individual could receive educational services during a regular or adjusted
				school day, through the end of the school year in which the individual turns
				twenty-one (21) years old.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-18 - Interpretation of Chapter

Current through July 13, 2024
(a) The order in which the provisions of this
				Chapter appear is not to be construed to mean that any one provision is more or
				less important than any other provision.
(b) The text of this Chapter shall control
				the titles of its various provisions
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-19 - Superseding Effect

Current through July 13, 2024
This Chapter supersedes all prior rules or policy statements
				  issued by the Division, including provider manuals and provider bulletins,
				  which are inconsistent with this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS › Section 46-21 - Incorporation by Reference

Current through July 13, 2024
(a) For any code, standard, rule, or
				regulation incorporated by reference in these rules:
(i) The Department has determined that
				incorporation of the full text in these rules would be cumbersome or
				inefficient given the length or nature of the rules;
(ii) The incorporation by reference does not
				include any later amendments or editions of the incorporated matter beyond the
				applicable date identified in subsection (b) of this Section; and
(iii) The incorporated code, standard, rule,
				or regulation is maintained at the Department and is available for public
				inspection and copying at cost at the same location.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 47 - CHILDREN'S MENTAL HEALTH WAIVER (CMHW) AND CARE MANAGEMENT ENTITY (CME) RULES › Section 47-1 - Authority

Current through July 13, 2024
This Chapter is promulgated pursuant to the Wyoming Medical
				  Assistance and Services Act at Wyoming Statutes §§
									
										42-4-101
et seq
. and 2006 - Enrolled Act 0021, House Bill 91, Section
				  4.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 47 - CHILDREN'S MENTAL HEALTH WAIVER (CMHW) AND CARE MANAGEMENT ENTITY (CME) RULES › Section 47-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter applies to Medicaid services
				provided under the Wyoming Care Management Entity (CME) and the Children's
				Mental Health Waiver (CMHW) programs.
(b) The Department may issue manuals and
				bulletins to interpret provisions in this Chapter. Such manuals and bulletins
				shall be consistent with and reflect the policies contained in this chapter.
				Provisions contained in manuals and bulletins shall be subordinate to the
				provisions outlined in this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 47 - CHILDREN'S MENTAL HEALTH WAIVER (CMHW) AND CARE MANAGEMENT ENTITY (CME) RULES › Section 47-3 - General Provisions

Current through July 13, 2024
(a) This Chapter has been adopted to
				establish rules for all-inclusive Care Management Entity (CME) and Children's
				Mental Health Waiver (CMHW) Programs that improve clinical, functional, and
				cost outcomes for eligible participants.
(b) Through this Rule, the CME shall be
				required to collaborate with a network of providers in order to comprehensively
				serve the intensive care coordination needs of enrollees receiving care under
				the CME and CMHW Program.
(c) The
				CME shall provide services for both 1915(b) and 1915(c) waiver eligible
				populations.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 47 - CHILDREN'S MENTAL HEALTH WAIVER (CMHW) AND CARE MANAGEMENT ENTITY (CME) RULES › Section 47-5 - Eligibility

Current through July 13, 2024
(a) Enrollment for CME 1915(b) services is
				mandatory for the following populations:
(i)
				Youth qualifying under Section 1931 of the Social Security Act and related
				populations, to include poverty-level related groups and optional groups of
				older youth;
(ii) Blind/Disabled
				youth and related populations, to include beneficiaries, generally under age
				18, who are eligible for Medicaid due to blindness or disability;
(iii) Youth in Foster Care in the State of
				Wyoming, or youth receiving adoption assistance under Title IV-E, or are
				otherwise in out-of-home placement.
(iv) Targeting Criteria for the populations
				includes:
(A) Medicaid youth ages four to
				twenty (4-20) at risk of out-of-home placement (defined and identified as youth
				with two hundred (200) days or more of behavioral health services within one
				State fiscal year);
(B) Medicaid
				youth ages four to twenty (4-20) who currently meet Psychiatric Residential
				Treatment Facility (PRTF) level of care as outlined in Chapter 40, Psychiatric
				Residential Treatment Facilities;
(C) Medicaid youth ages four to twenty (4-20)
				who currently meet acute psychiatric stabilization hospital level of care as
				determined by a licensed clinician; had an acute hospital stay for mental or
				behavioral conditions in the last three hundred sixty-five (365) days; or are
				currently placed in an acute hospital stay for mental or behavioral health
				conditions;
(D) Youth enrolled in
				the Children's Mental Health Waiver (Section 1915(c) WY Waiver #0451);
				or
(E) Medicaid youth ages four to
				twenty (4-20) referred to the pre-paid ambulatory health plan (PAHP) and who
				meet defined eligibility, including clinical eligibility and SED
				criteria.
(v) Medical
				Eligibility Criteria is a condition for enrollment in the CME after initial
				targeting criteria is met. The Medical Eligibility Criteria includes:
(A) Youth ages six to twenty (6-20) who have
				a minimum CASII composite score of twenty (20), and youth ages four (4) and
				five (5) who have an ECSII score of eighteen (18) to thirty (30) or the
				appropriate social and emotional assessment information provided to illustrate
				level of service needs; and
(I) CASIIs
				administered for the purpose of establishing medical eligibility shall not be
				administered by the CME but instead be administered by a neutral third party to
				ensure conflict free case management.
(B) Youth who have a DSM Axis 1 or
				International Classification of Disease (ICD) diagnosis that meets the State's
				diagnostic criteria.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 47 - CHILDREN'S MENTAL HEALTH WAIVER (CMHW) AND CARE MANAGEMENT ENTITY (CME) RULES › Section 47-6 - Participant Application and Enrollment Process

Current through July 13, 2024
(a) The Department shall automatically enroll
				eligible youth into the CME.
(b) A
				youth and his or her family may choose to disenroll at any time pursuant to
				Section 7 of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 47 - CHILDREN'S MENTAL HEALTH WAIVER (CMHW) AND CARE MANAGEMENT ENTITY (CME) RULES › Section 47-7 - Participant Disenrollment Process

Current through July 13, 2024
(a) The Department will review and approve
				all requests by the CME to disenroll youth based on the medical necessity of
				the HFWA service plan. An individual may be disenrolled from the CME if:
(i) The youth is no longer Medicaid
				eligible;
(ii) The youth moves out
				of the State;
(iii) The youth ages
				out of the program;
(iv) The youth
				is incarcerated;
(v) The youth is
				no longer financially eligible;
(vi) The youth is no longer clinically
				eligible;
(vii) The youth is
				determined eligible for any excluded program/population pursuant to Section
				4;
(viii) The youth is in
				out-of-home placement longer than one hundred eighty (180) days;
(ix) The youth needs related services (for
				example a cesarean section and tubal ligation) to be performed at the same
				time; not all related services are available within the network; and the
				youth's Primary Care Provider (PCP) or another provider determines that
				receiving the services separately would subject the youth to unnecessary risk;
				or
(x) Other reasons, including but
				not limited to, poor quality of care, lack of access to services covered under
				the contract, or lack of access to providers experienced in dealing with the
				youth's specific health care needs.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 47 - CHILDREN'S MENTAL HEALTH WAIVER (CMHW) AND CARE MANAGEMENT ENTITY (CME) RULES › Section 47-8 - Loss of Eligibility

Current through July 13, 2024
(a) A participant shall be determined no
				longer eligible for CME program services when:
(i) The youth is no longer Medicaid
				eligible;
(ii) The youth moves out
				of the State;
(iii) The youth ages
				out of the program;
(iv) The youth
				is incarcerated;
(v) The youth is
				no longer financially eligible;
(vi) The youth is no longer clinically
				eligible;
(vii) The youth is
				determined eligible for any excluded program/population pursuant to Section 4
				of this Chapter;
(viii) The youth
				is an out-of-home placement longer than one hundred eighty (180)
				days;
(ix) The CME provider's
				agreement with CMS and the Department is not renewed or is terminated;
				or
(x) The CME provider is unable
				to offer health care services due to the loss of contracts with outside
				providers.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 47 - CHILDREN'S MENTAL HEALTH WAIVER (CMHW) AND CARE MANAGEMENT ENTITY (CME) RULES › Section 47-9 - Availability of Services/Accessibility

Current through July 13, 2024
(a) Any youth enrolled with the CME who meets
				the eligibility criteria as outlined in Section 5 of this Chapter is eligible
				for HFWA and respite services. Each enrollee maintains full access to all
				Medicaid state plan services. Special health care needs shall be identified and
				treated through primary and specialty care providers in Medicaid fee for
				service.
(b) Appropriately trained,
				credentialed, and Medicaid-enrolled providers may contract with the CME as part
				of the CME's provider network for the provision of HFWA and respite services.
(i) HFWA and respite is available to all
				enrolled youth statewide.