reglab/statecodes huggingface dataset:
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-5 - Medicaid allowable payment for inpatient hospital services

Current through July 13, 2024
(a) In general. Except as otherwise specified
				in this Chapter, the Department reimburses hospitals providing inpatient
				hospital services to Medicaid recipients using Medicare principles of cost
				reimbursement. The Medicaid allowable payment shall be the lower of the
				hospital's usual and customary charges and the allowable payment determined
				pursuant to this section.
(b) New
				hospitals. A new hospital shall receive an initial rate equal to the lowest
				cost to charge ratio for combined inpatient and outpatient services established
				for a hospital located in Wyoming pursuant to paragraph (e)(i) until the
				hospital files its first Medicare cost report and a rate is determined pursuant
				to paragraphs (e)(i) or (f)(i). The initial rate shall be cost settled pursuant
				to Section
				8
				unless the hospital is located outside Wyoming and the Department determines
				that it is not cost-effective to cost settle.
(c) Reimbursement of distinct part hospital
				unit. Costs associated with distinct part hospital units shall be included in
				the hospitals general costs and shall not be separately reimbursed. The
				transfer of a recipient from a unit within a hospital to another unit within
				the hospital or to a distinct part hospital unit in the same hospital shall not
				be considered a discharge.
(d)
				Negotiated rate. A hospital may negotiate an interim rate which is lower than
				the interim rate which would otherwise be in effect pursuant to this
				Section.
(e) Hospitals located in
				Wyoming.
(i) Interim rate. The Department
				shall establish an interim rate for inpatient hospital services for each
				hospital using Medicare principles of cost reimbursement, as modified by this
				rule, based on the most recent settled cost report submitted by the hospital to
				the Medicare intermediary. The interim rate shall be the cost to charge ratio
				established by the Department using Medicare principles of cost reimbursement
				as modified by this rule.
(A) Rate effective
				date. The interim rate shall be effective for all inpatient services provided
				on or after December 1 of each year;
(B) Rate period. The interim rate shall
				remain in effect for all inpatient services until redetermined pursuant to this
				Section.
(C) Except as otherwise
				specified by this rule, the interim rate shall be applied to all claims
				submitted by the provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-6 - Medicaid allowable payment for outpatient hospital services

Current through July 13, 2024
(a) In general. Except as otherwise specified
				in this Chapter, the Department reimburses hospitals providing outpatient
				hospital services to recipients using Medicare principles of cost
				reimbursement. The Medicaid allowable payment shall be the lower of the
				hospitals usual and customary charges and the allowable payment determined
				pursuant to this section.
(b)
				Interim rate. The interim rate for outpatient hospital services shall be the
				interim rate established for inpatient services reduced by twenty
				percent.
(c) Negotiated rate. A
				hospital may negotiate an interim rate which is lower than the interim rate
				which would otherwise be in effect pursuant to this Section.
(d) New hospitals. A new hospital shall
				receive an initial rate equal to the lowest rate for outpatient services
				established for a hospital located in Wyoming pursuant to paragraph (e)(i)
				until the hospital files its most recently settled Medicare cost
				report.
(e) Hospitals located in
				Wyoming.
(i) Interim rate. The Department
				shall establish an interim rate for outpatient hospital services based on the
				most recently settled cost report submitted by the hospital to the Medicare
				intermediary.
(A) Rate effective date. The
				interim rate shall be effective for all outpatient hospital services provided
				on or after December 1, 1992;
(B)
				Rate period. The interim rate shall remain in effect for all outpatient
				hospital services until redetermined pursuant to this Section;
(C) Except as otherwise specified b this
				rule, the interim rate shall be applied to all claims submitted by the
				provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-7 - Submission and preparation of cost reports

Current through July 13, 2024
(a) Time of
				submission. Each hospital must submit a complete cost report to the Medicare
				intermediary in accordance with Medicare requirements.
(b) Preparation of cost reports. Each
				hospital shall prepare its cost report in conformance with Medicare
				requirements.
(c) Submission of
				additional information. The Department may request, in writing, that a hospital
				submit information to supplement its cost report. The hospital shall submit the
				supplement requested information within thirty days after the date of the
				request.
(d) Failure to comply with
				this Section. The failure of a hospital to comply with the provisions of this
				Section shall result in the immediate suspension of all Medicaid payments to
				the hospital and all Medicaid payments under review shall be repaid to the
				Department within ten days after written request for such payment. The
				suspension of payments shall continue until the hospital complies with this
				Section. Upon the Departments receipt of all information required by this
				Section, payments will be reinstated, without interest. This remedy does not
				affect the Departments right to withhold payments, terminate provider
				participation or invoke other remedies permitted by applicable statutes and
				rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-8 - Cost settlement

Current through July 13, 2024
(a) Cost settlement
				methodology. Cost reports shall be cost settled by the Medicare intermediary
				using Medicare principles of cost reimbursement as modified by this Chapter and
				using data provided by the Department.
(b) TEFRA limits. A hospitals Medicaid
				allowable payment shall not exceed the TEFRA limits.
(c) Notice of Medicaid Program Reimbursement.
				The Department shall, within sixty days after receipt of the Notice of Program
				Reimbursement, send a Notice of Medicaid Program Reimbursement to the
				hospital.
(d) Repayment of
				overpayments. A hospital shall reimburse the Department for overpayments within
				thirty days after the date of the Notice of Medicaid Program Reimbursement,
				even if the provider has requested reconsideration or an administrative hearing
				regarding the determination of overpayments. If a hospital does not timely
				reimburse the Department, overpayments may be recovered pursuant to Section
				14.
				Notice of overpayments must include the hospitals right to request
				reconsideration of the cost-settlement pursuant to Section
				17.
				The reconsideration shall be limited to whether the Department has complied
				with the provisions of this rule.
(e) Payment of underpayments. The Department
				shall request the issuance of payment warrant to reimburse the hospital for
				underpayments within fifteen days after the date of the Notice of Medicaid
				Program Reimbursement.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-9 - Disproportionate share payment

Current through July 13, 2024
(a) In addition to
				the rate established pursuant to Section
				8, a
				disproportionate share hospital shall be entitled to a disproportionate share
				payment computed pursuant to this section. This section is intended to
				implement and be read in conjunction with Section 1923 of the Social Security
				Act.
(b) Determination of
				disproportionate share hospital. A disproportionate share hospital is one which
				has either a:
(i) Medicaid utilization rate
				at least one standard deviation above the mean Medicaid utilization rate for
				Wyoming providers; or
(ii) Low
				income utilization rate which exceeds twenty-five percent.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-10 - Medicaid allowable payment for other services

Current through July 13, 2024
All costs relating to services provided to recipients which
				  are reimbursed pursuant to a fee schedule or other methodology established by
				  the Department shall be deducted from the hospital's cost report prior to cost
				  settlement.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-11 - Record retention

Current through July 13, 2024
(a) Period of
				retention. A hospital which receives or has received Medicaid funds shall
				retain financial records for six (6) years following the date of submission of
				the applicable cost report to the Department. Such records may be maintained in
				hard-copy, on micro-fiche or micro-film.
(b) Record keeping requirements.
(i) Financial records. A provider must keep
				financial records in accordance with GAAP and maintain sufficient control and
				documentation to satisfy the requirements of this rule, including accommodating
				GAAS and reasonable requests by the Department for additional information. The
				provider must maintain adequate documentation for all line items on the cost
				report.
(ii) Medical records. A
				provider must maintain medical records.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-12 - Audits

Current through July 13, 2024
(a) Field audits. The Department or HCFA may
				perform a field audit of a provider at any time to determine the accuracy and
				reasonableness of cost reports, the accuracy of cost settlements or whether the
				hospital has received excess payments.
(b) Desk review. The Department or HCFA may
				perform a desk review of a provider at any time to determine the accuracy and
				reasonableness of cost reports, the accuracy of cost settlements or whether the
				hospital has received excess payments.
(c) The Department or HCFA may perform field
				audits or desk reviews through employees, agents, or through a third party.
				Audits shall be performed in accordance with GAAS.
(d) Disallowances. If a field audit or desk
				review discloses nonallowable costs, overpayments or excess payments, the
				Department shall adjust the final cost settlement and recover any excess
				payments pursuant to Section
				14.
(e) Notice of excess payments.
				After determining that a provider has received excess payments, the Department
				shall send written notice to the provider, by certified mail, return receipt
				requested, stating the amount of the excess payments, the basis for the
				determination of excess payments and the providers right to request
				reconsideration of that determination pursuant to Section
				17.
				The reconsideration shall be limited to whether the Department has complied
				with the provisions of this rule.
(f) Recovery of excess payments. A provider
				must reimburse the Department for excess payments within fifteen days after the
				provider receives written notice from the Department pursuant to subsection
				(e), even if the provider has requested reconsideration or an administrative
				hearing regarding the determination of excess payments. If the provider fails
				to timely repay excess payments, the Department may recover the excess payments
				pursuant to Sections
				14.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-13 - Repayment of credit balance

Current through July 13, 2024
(a) Quarterly
				request. The Department shall quarterly request the repayment of any credit
				balance. Such request shall be made in writing and mailed by certified mail,
				return receipt requested. The hospital shall repay the credit balance within
				sixty days after the date of receipt of the request for repayment.
(b) A hospital shall repay any credit balance
				within sixty days after the date such credit balance is identified by the
				Department, the hospital or the intermediary.
(c) Lump sum adjustment. If a credit balance
				identified pursuant to paragraphs (a) or (b) is not timely paid to the
				Department, the Department may recover the credit balance pursuant to Section
				14.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-14 - Recovery of overpayments, excess payments or credit balance

Current through July 13, 2024
If a provider does not timely reimburse the Department for
				  overpayments pursuant to subsection
				  8(d), excess payments
				  pursuant to subsection
				  12(f), or a credit
				  balance pursuant to Section
				  13,
				  the Department may recover the overpayments, excess payments or credit balance,
				  even if the provider has appealed the Departments determination, by:
(a) Withholding all or part of Medicaid
				payments until the overpayments are recovered
(b) Initiating a civil lawsuit against the
				provider; or
(c) Any other method
				of collecting a debt or obligation permitted by law.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-15 - Request to Reopen

Current through July 13, 2024
(a) Medicare
				standards and procedures. A request to reopen shall be made in the manner
				specified By Medicare, directed to the entity specified by Medicare, and shall
				be disposed of pursuant to the methods and standards specified by
				Medicare.
(b) Sole remedy. A
				provider which has an issue which may be resolved through a request to reopen
				may not request a rate adjustment or reconsideration pursuant to this rule or
				an administrative hearing pursuant to Chapter I.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-16 - Request for TEFRA target rate adjustment

Current through July 13, 2024
(a) Request for
				TEFRA target rate adjustment. A provider may request a rate adjustment by
				mailing a written request to the Department by certified mail within sixty days
				after the date of the Notice of Medicaid Program Reimbursement provided
				pursuant to subsection
				8(c). The request must
				include the information included in subparagraphs (i) through (iii). A request
				for rate adjustment shall be dismissed with : this subsection.not comply with
				the requirements of this subsection.
(i) The
				nature of the rate adjustment sought;
(ii) The amount of the requested rate
				adjustment, the methodology used to calculate the requested rate adjustment,
				the specific calculation for the requested rate adjustment, and documentation
				which supports the above; and
(iii)
				The specific reasons, including references to a applicable federal and State
				law, that justify the rate adjustment.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 24 - WYOMING HOSPITAL REIMBURSEMENT SYSTEM › Section 24-17 - Reconsideration

Current through July 13, 2024
(a) Request for reconsideration. A provider
				may request that the Department reconsider a decision to recover overpayments
				pursuant to Section
				8, a
				decision to recover excess payments pursuant to Section
				12,
				or the computation of disproportionate share payments pursuant to section
				9.
				Such request must be mailed to the Department by certified mail within twenty
				days of the date the facility receives notice pursuant to subsections B(c),
				9(f) or 12(e). The request must state with specificity the reasons for the
				request. Failure to provide such a statement shall result in the dismissal of
				the request with prejudice. The reconsideration shall be limited to whether the
				Department has complied with the provisions of this rule.
(b) Reconsideration. The Department shall
				review the decision and send written notice, by certified mail, to the provider
				of its final decision within forty-five days after receipt of the request for
				reconsideration. The Department may request additional information from the
				provider as part of the reconsideration process.
(c) Administrative hearing. A provider may
				request an administrative hearing regarding the final decision pursuant to
				Chapter I of these rules by mailing by certified mail or personally delivering
				a request for hearing to the Department within twenty days of the date the
				provider receives notice of the final decision.
(d) Failure to request reconsideration. A
				provider which fails to request reconsideration pursuant to this section may
				not subsequently request an administrative hearing regarding the decision to
				recover overpayments pursuant to Chapter I.
(e) A provider may not request
				reconsideration or an administrative hearing regarding a denial or reduction of
				payment or recovery of overpayments or excess payments caused by a change in
				the reimbursement methodology or any change in state or federal law.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 25 - ICF/MR SERVICES › Section 25-1 - Authority

Current through July 13, 2024
This rule is promulgated by the Department of Health pursuant
				  to the Medical Assistance and Services Act at
				  W.S.
				  42-4-101 et seq) and the Wyoming
				  Administrative Procedures Act at W.S. 16-3101 et seq.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 25 - ICF/MR SERVICES › Section 25-2 - Applicability

Current through July 13, 2024
This rule shall apply to and govern the participation in the
				  Medicaid program by providers of ICF/ MR services. ICF/MR services are also
				  subject to the provisions of Chapter XX.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 25 - ICF/MR SERVICES › Section 25-3 - General Terms

Current through July 13, 2024
(a) This rule shall
				apply to and govern services provided in ICFs/MR. It is intended that this rule
				implement and be read in conjunction with the provisions of
				W.S.
				42-4-103(a)(xxii) and
				Chapter XX.
(b) The Department may
				issue Manuals to providers and/or other affected parties to interpret the
				provisions of this rule. Such manuals shall be consistent with and reflect the
				policies contained in this rule.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 25 - ICF/MR SERVICES › Section 25-5 - Provider Participation

Current through July 13, 2024
(a) Compliance with
				Chapter III. A facility which wishes to receive Medicaid reimbursement for
				covered services furnished to a recipient must meet the requirements of Chapter
				III, Sections
				4
				through
				6,
				which are incorporated by this reference.
(b) Conditions of participation. A facility
				which wishes to participate in the Medicaid program must meet the conditions of
				participation as set forth in
				42 C.F.R.
				483.400 through 483.480, which are
				incorporated by this reference.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 25 - ICF/MR SERVICES › Section 25-8 - Evaluation of need for ICF/MR services

Current through July 13, 2024
(a) Purpose. To
				determine whether ICF/MR services are medically necessary.
(b) Applicability. All applicants or
				recipients must undergo an evaluation of need for ICF/MR services before a
				facility may receive Medicaid reimbursement for services provided to that
				individual.
(c) Criteria. The
				medical necessity of ICF/MR services shall be determined using the factors in
				paragraphs (i) through (iv).
(i) The
				individual:
(A) Is mentally retarded or is a
				person with a related condition;
(B) Requires specialized services directed
				toward the development of skills necessary for maximum independence or the
				prevention of regression or loss of current skills and abilities:
(C) Meets the criteria of paragraphs (ii) or
				(iii); and
(D) Has at least one
				functional need specified in paragraph (iv).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 25 - ICF/MR SERVICES › Section 25-9 - Discharge planning

Current through July 13, 2024
(a) Discharge plan.
				At least 30 days before the date a recipient is discharged from a facility, a
				discharge plan must be developed by the IDT.
(b) Contents of discharge plan. A discharge
				plan shall be in writing and shall include:
(i) In-person interviews of the recipient by
				the prospective referral agency;
(ii) A tour by the recipient of the
				prospective placement; and
(iii)
				Counselling with the recipient and his or her family, if possible, about the
				transition.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 25 - ICF/MR SERVICES › Section 25-11 - Superseding effect

Current through July 13, 2024
When promulgated, this Chapter supersedes all prior rules or
				  policy statements issued by the Department, 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 26 - COVERED SERVICES › Section 26-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Wyoming Department of
				  Health pursuant to the Wyoming Medical Assistance and Services Act at Wyoming
				  Statutes §§
									
										42-4-101
				  through -122.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-2 - Purpose and Applicability

Current through July 13, 2024
This Chapter has been adopted to establish the scope of
				  covered services, except as otherwise specified by the Wyoming Department of
				  Health, and shall apply to all clients and providers for all services furnished
				  on or after the Chapter's effective date.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-3 - Definitions

Current through July 13, 2024
Except as otherwise specified in Chapter 1, or as specified
				  herein, the terminology used in this Chapter is the standard terminology and
				  has the standard meaning as used in health care, Medicaid and Medicare
(a) "Applied Behavior Analysis (ABA)
				Treatment." Services provided to children between the ages of 0-20 years of age
				with a diagnosis of Autism Spectrum Disorder in order to improve social,
				communication, and learning skills.
(b) "Ambulatory Surgical Center (ASC)
				Facility." A health care facility that specializes in providing surgery, pain
				management, and certain diagnostic services in an outpatient setting.
				ASC-qualified procedures are typically more complex than those done in a
				doctor's office but not so complex as to require an overnight stay.
(c) "Ambulatory Surgical Center (ASC)
				Services." Surgical procedures or other services offered by an ASC facility
				that do not require overnight inpatient hospital care.
(d) "Dental Services." Professional services
				and dental appliances furnished by a dentist within the scope of his
				practice.
(e) "Developmental
				Center." An agency which:
(i) Provides
				developmental services to developmentally disabled children under the age of
				six; and
(ii) Is certified to
				provide services to clients under age twenty-one by the Developmental
				Disabilities Section of the Health Care Financing Division.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-4 - Covered Services

Current through July 13, 2024
(a) The services and supplies specified in
				subsection (b) are covered services if medically necessary, subject to any
				exclusions or limitations contained in this Chapter and the Wyoming Department
				of Health.
(b) Covered services:
(i) ABA Treatment, for individuals between
				the ages of 0-20 with a diagnosis of Autism Spectrum Disorder;
(ii) Administrative Transportation;
(iii) Advanced Practitioner of Nursing (APN)
				services
(iv) Ambulance
				Services;
(v) ASC
				Services;
(vi) Audiology Services
				and hearing aids;
(vii) Certified
				Registered Nurse Anesthetist (CRNA) services;
(viii) Certified Community Mental Health
				Center Services (CMHC);
(ix)
				Comprehensive Outpatient Rehabilitation Facility (CORF) Services;
(x) Dental Services;
(xi) Dietician Services;
(xii) Developmental Center
				Services;
(xiii) Emergency Hospital
				Services;
(xiv) Early and Periodic
				Screening, Diagnosis and Treatment (EPSDT) Services;
(xv) ESRD services;
(xvi) Family Planning Clinic
				Services;
(xvii) Federally
				Qualified Health Center (FQHC) services;
(xviii) Certified Substance Abuse Treatment
				Center (SATC) Services;
(xix) Home
				and Community Based Services (HCBS);
(xx) Home Health Services;
(xxi) Hospice Services;
(xxii) Hospital Services (inpatient and
				outpatient);
(xxiii) Intermediate
				Care Facility for People with Intellectual Disabilities (ICF/ID)
				Services;
(xxiv) Institution for
				Mental Disease (IMD) Services furnished to individuals under twenty-two years
				of age and sixty-five years of age and older;
(xxv) Interpretation Services;
(xxvi) Laboratory Services;
(xxvii) Medical Supplies and
				Equipment;
(xxviii) Nurse Midwife
				Services;
(xxix) Nursing Facility
				Services;
(xxx) Occupational
				Therapy Services;
(xxxi)
				Pharmaceutical Services;
(xxxii)
				Physical Therapy Services;
(xxxiii)
				Physician Services;
(xxxiv)
				Psychiatric Residential Treatment Facility (PRTF) Services;
(xxxv) Psychological Services;
(xxxvi) Radiology Services;
(xxxvii) Rural Health Clinic (RHC)
				Services;
(xxxviii) Solid organ
				transplants and bone marrow transplants;
(A)
				For clients over the age of 21, transplants are limited to bone marrow, kidney,
				and liver;
(xxxix)
				Speech Therapy Services;
(xl) Swing
				bed Services;
(xli) Targeted case
				management;
(xlii) Vision Services
				and
(xliii) Weight reduction
				treatment, including intestinal bypass surgery, gastric bypass surgery, and
				gastric stapling.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-5 - Services Not Covered

Current through July 13, 2024
(a) The Wyoming Department of Health shall
				not cover the following services and supplies:
(i) Except in an emergency, services
				furnished without the consent of the client or the client's legal
				guardian;
(ii) Experimental
				procedures which are not generally accepted or used by a provider's peer group
				as current or standard practice;
(iii) Examinations or reports required for
				legal purposes or other purposes not specifically related to medical
				care;
(iv) Services furnished
				outside the United States;
(v)
				Services furnished to an individual who is an inmate of a public institution,
				or an individual that is in the custody of a state, local, or federal law
				enforcement agency;
(vi) Services
				provided to an individual during the first seventy-two (72) hours of emergency
				detention;
(vii) Services provided
				to clients age 22 - 64 in an IMD, including Medicare secondary
				claims;
(viii) Unless pre-approved,
				services which exceed the service limitations;
(ix) Services provided pursuant to a court
				order if such services:
(A) Are not covered
				services;
(B) Exceed service
				limitations;
(C) Are furnished by a
				health care practitioner or facility that is not a provider on the date(s) of
				services;
(D) Have not received
				prior authorization, if applicable; or
(E) Have not received admission
				certification, if applicable.
(x) Abortions, except to the extent required
				by
				42 C.F.R. §
											441.200§
										441.208;
(xi) Acupuncture;
(xii) Alcohol and chemical rehabilitation
				furnished to an inpatient, except for purposes of detoxification or
				stabilization of acute conditions;
(xiii) Autopsies;
(xiv) Biofeedback therapies and
				equipment;
(xv) Chronic pain
				rehabilitation;
(xvi) Community
				mental health services furnished outside Wyoming;
(xvii) Cosmetic procedures;
(xviii) Custodial care including but not
				limited to non-skilled, personal care. Personal care would include help with
				activities of daily living, such as bathing, dressing, eating, getting in or
				out of a bed or chair, moving around, and using the bathroom;
(xix) Infertility services, includes but is
				not limited to counseling, reverse sterilization and artificial
				insemination;
(xx) Missed or
				canceled appointments;
(xxi)
				Personal comfort items;
(xxii)
				Private-duty nursing services;
(xxiii) Sterilizations, unless the
				requirements of
				42
				C.F.R. §
											441.250§
										441.259 are
				satisfied; and
(xxiv) Gender
				reassignment surgery.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-6 - ASC Services

Current through July 13, 2024
(a) Eligible providers. A facility or
				distinct portion of a facility certified under Medicare to provide ASC
				services.
(b) Covered services.
(i) All surgical procedures covered by
				Medicare; and
(ii) Additional
				surgical procedures pre-authorized and which may be provided as outpatient
				hospital services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-7 - Audiology Services and Hearing Aids

Current through July 13, 2024
(a) Eligible providers. Physicians,
				independently practicing licensed Audiologists, and hearing aid equipment
				providers.
(b) Covered services.
(i) Audiological function tests;
(ii) Hearing aid examinations; and
(iii) Hearing aid equipment.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-8 - CRNA Services

Current through July 13, 2024
(a) Eligible providers. Hospitals and
				physicians that employ a CRNA or independently practicing CRNAs.
(b) Covered services. Anesthesia services,
				except as otherwise specified by the Wyoming Department of Health.
(c) Excluded services. Anesthesia services
				when performed in conjunction with a surgical procedure that:
(i) Is not a covered service;
(ii) Requires prior authorization that has
				not been obtained; or
(iii)
				Requires informed consent by the client that has not been obtained.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-9 - CORF Services

Current through July 13, 2024
(a) Eligible providers. Facilities certified
				by Medicare as a CORF.
(b) CORF
				services are limited to:
(i) Drugs and
				biologicals that cannot be self-administered;
(ii) Medical supplies and
				equipment;
(iii) Nursing
				services;
(iv) Occupational
				therapy;
(v) Orthotics and
				prosthetics;
(vi) Physician
				Services;
(vii) Physical
				therapy;
(viii) Respiratory
				therapy;
(ix) Social or
				psychological services; and
(x)
				Speech therapy.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-10 - Dental Services

Current through July 13, 2024
(a) Covered services for clients under the
				age of twenty-one (21):
(i) Preventive
				visits;
(ii) Restorative fillings,
				crowns, and tooth replacement;
(iii) Extractions;
(iv) Partial or complete dentures;
(v) Root canal therapy;
(vi) Periodontal treatment;
(vii) Oral and maxillofacial
				surgery;
(viii) Orthodontic
				treatment for severe malocclusions; and
(ix) Palliative treatment.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-11 - Dietitian Services

Current through July 13, 2024
(a) Eligible providers. Dietitians.
(b) Covered services.
(i) Medically necessary professional services
				furnished by a dietitian, as prescribed by a physician.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-12 - Developmental Center Services

Current through July 13, 2024
(a) Eligible providers. Developmental Centers
				certified by the Developmental Disabilities Section and under contract with
				that office to provide such services.
(b) Covered services. Diagnostic assessment
				and evaluation, behavioral health, speech, physical therapy services,
				occupational therapy services
,
and case management
				services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-14 - ESRD Services

Current through July 13, 2024
(a) Eligible Providers. Free-standing or
				hospital-based facilities certified by Medicare to provide ESRD
				services.
(b) Covered services.
				ESRD services for outpatient dialysis and other treatment for persons with
				end-stage renal disease.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-15 - Family Planning Clinic Services

Current through July 13, 2024
(a) Eligible Providers. A clinic, which is
				neither located on the premises of a hospital nor owned by a hospital and meets
				the minimum requirements for routine contraceptive management as specified by
				the state Public Health Division. A laboratory in a clinic shall be licensed by
				the State of Wyoming.
(b) Covered
				Services. The following services are covered when furnished under the
				supervision of a Physician who is directly affiliated with the clinic. A
				physician is directly affiliated with the clinic if there is a contract between
				the Physician and the clinic under which the Physician is obligated to
				supervise the following care furnished to the clinic's patients:
(i) Office visits;
(ii) Contraceptive supplies and
				devices;
(iii) Laboratory tests;
				and
(iv) Counseling.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-16 - Hospice Services

Current through July 13, 2024
(a) Eligible providers. Hospice providers
				certified by Medicare and located within the State of Wyoming. Services
				provided by a hospice provider located outside the State of Wyoming shall not
				be eligible for Medicaid reimbursement unless the services are
				pre-approved.
(b) Covered services.
				The following services shall be covered if provided pursuant to a written plan
				of care established by the hospice provider and approved by the client's
				attending physician:
(i) Routine home
				care;
(ii) Continuous home
				care;
(iii) Inpatient respite
				care;
(iv) General inpatient
				care;
(v) Hospice, nursing facility
				room and board; and
(vi) Hospice,
				inpatient hospice facility room and board.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-17 - Hospital Services

Current through July 13, 2024
(a) Hospital Services (including ancillary
				services provided in a hospital) shall be covered services if provided:
(i) Pursuant to the written orders of a
				licensed physician; and
(ii) By or
				under the supervision of a licensed physician.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-18 - Interpretation Services

Current through July 13, 2024
(a) Interpreters shall adhere to national
				standards developed by the National Council on Interpreting in Healthcare
				(NCIHC), to include accuracy, confidentiality, impartiality, role boundaries,
				professionalism, professional development, and advocacy.
(b) Covered Services. The interpretation
				provider shall only bill for time spent with the client.
(i) Excluded services. Interpreter services
				in conjunction with the following services:
(A) Inpatient and outpatient
				services;
(B) Services in an
				Intermediate Care Facility for persons with Intellectual Disabilities
				(ICF/ID);
(C) Nursing Facility
				services;
(D) Ambulance Services by
				public providers;
(E) PRTF
				services;
(F) Comprehensive
				Inpatient and Outpatient Rehabilitation Facility Services;
(G) Services provided by other agencies and
				organizations receiving federal funding;
(H) Interpreter services provided by a family
				member, volunteer, associate, or friend; and
(I) Reimbursement for interpreter travel to
				and from the appointment.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-19 - Laboratory Services

Current through July 13, 2024
(a) Eligible providers. Independent
				laboratories certified by Medicare, hospital laboratories, and physician
				offices with a laboratory licensed by the state in which the laboratory is
				located.
(b) Covered services.
				Professional or technical laboratory services ordered by a licensed provider
				under their scope of practice. Services shall be directly related to the
				diagnosis and treatment of the patient as specified in the ordering provider"s
				treatment plan.
(c) Excluded
				services:
(i) Handling charges where a
				specimen is referred by one (1) laboratory to another;
(ii) Post-mortem examinations;
(iii) Fees charged to obtain immediate
				results;
(iv) Technician callback
				fees; and
(v) Services that are not
				FDA approved.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-20 - Nurse Midwife Services

Current through July 13, 2024
(a) Covered services. Professional services
				furnished by a licensed nurse midwife that are:
(i) In collaboration with a
				physician;
(ii) Throughout the
				maternity period; and
(iii) Within
				the scope of the nurse midwife's practice as permitted by the Wyoming Nursing
				Practice Act.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-21 - Occupational Therapy Services

Current through July 13, 2024
(a) Eligible providers. Licensed independent
				occupational therapists, hospitals, physicians, PRTFs, and developmental
				centers that employ licensed occupational therapists.
(b) Covered services.
(i) Prescribed rehabilitative occupational
				therapy services furnished in response to physical debilitation caused by acute
				physical trauma or physical illness;
(ii) Occupational therapy services prescribed
				while the client was an inpatient and continuing on an outpatient
				basis;
(iii) Occupational therapy
				services furnished in a developmental center or PRTF to a client pursuant to:
(A) An individualized education plan (IEP)
				developed by the school system or PRTF; or
(B) An individualized family services plan
				developed by a developmental center.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-22 - Physical Therapy Services

Current through July 13, 2024
(a) Eligible providers Licensed independent
				physical therapists, physicians, hospitals, PRTFs, and developmental centers
				that employ licensed physical therapists.
(b) Covered services.
(i) Prescribed rehabilitative physical
				therapy services furnished in response to physical debilitation caused by acute
				physical trauma or physical illness as prescribed by a physician;
(ii) Physical therapy services prescribed
				while the client was an inpatient and continuing on an outpatient
				basis;
(iii) Physical therapy
				services prescribed as a direct result of outpatient surgery required as a
				result of an injury; and
(iv)
				Physical therapy services provided to a client under age twenty-one (21) with
				chronic disabilities when furnished by a developmental center or PRTF pursuant
				to an:
(A) Individualized education plan
				developed by the school system or PRTF; or
(B) Individualized family services plan
				developed by a developmental center.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-23 - Physician Services

Current through July 13, 2024
(a) Covered services. Medically necessary
				professional services furnished by or under the supervision of a licensed
				Physician, except as otherwise specified by this Chapter.
(b) Excluded or limited services.
(i) Anesthesia services shall be limited as
				follows:
(A) An anesthesiologist shall not
				receive Medicaid reimbursement for a consultation in addition to any other
				anesthesia services for the same surgery.
(B) Anesthesia services shall not be covered
				when performed in conjunction with:
(I) A
				non-covered surgical procedure; or
(II) A procedure requiring client consent if
				proper consent was not obtained.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-24 - Radiology Services

Current through July 13, 2024
(a) Eligible providers. Licensed independent
				radiology practices, hospitals, and physician practices.
(b) Excluded services:
(i) Unordered X-rays; and
(ii) Separate consultations procedures unless
				ordered by the attending physician;
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-25 - Speech Therapy Services

Current through July 13, 2024
(a) Eligible Providers. Independent licensed
				speech therapists, physicians, hospitals, PRTFs, and developmental centers that
				employ licensed speech therapists.
(b) Covered Services.
(i) Prescribed rehabilitative speech therapy
				services furnished in response to physical debilitation caused by acute
				physical trauma or physical illness as prescribed by a Physician;
(ii) Speech therapy services prescribed while
				the client was an inpatient and continuing on an outpatient basis;
(iii) Speech therapy prescribed as a direct
				result of outpatient surgery required as a result of an injury; and
(iv) Speech therapy services provided to a
				client under age twenty-one (21) with chronic disabilities when furnished by a
				developmental center or a PRTF pursuant to an:
(A) Individualized Education Plan (IEP)
				developed by the school system or PRTF; or
(B) Individualized family services plan
				developed by a developmental center.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-27 - Vision Services

Current through July 13, 2024
(a) Eligible providers. Optometrist,
				opticians and licensed ophthalmologists.
(b) Covered services. Medical treatment for
				clients:
(i) At risk of eye diseases,
				including eye disease secondary to chronic illness; or
(ii) With eye injuries.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 26 - COVERED SERVICES › Section 26-28 - Client Co-Payments

Current through July 13, 2024
(a) Clients who receive the following
				services shall make a co-payment:
(i) Eye
				examinations;
(ii) FQHC
				services;
(iii) Physician office
				visits;
(iv) Physician home
				visits;
(v) Psychiatric
				services;
(vi) RHC
				services;
(vii) Non-Emergent
				hospital emergency services; and
(viii) Pharmaceutical products.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 27 - RULES AND REGULATIONS FOR MEDICAID PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 27-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Department of Health
				  pursuant to the Medical Assistance and Services Act at W.S. §
									
										42-4-121 and the Wyoming Administrative
				  Procedure Act at W.S. §
									
										16-3-102.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 27 - RULES AND REGULATIONS FOR MEDICAID PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 27-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter shall apply to the Medicaid
				services provided under the Wyoming Program of All-Inclusive Care for the
				Elderly (PACE) submitted to and approved by the Centers for Medicare and
				Medicaid Services (CMS) pursuant
				42 C.F.R. §§
										460, 462, 466, 473, and 476.
(b) The requirements of Title XIX of the
				Social Security Act; 42
				C.F.R. §§
										460, 462, 466, 473, and
				476; the Medicaid State Plan; and the three-way Program Agreement between the
				Sate, CMS and the PACE provider also apply to Medicaid and are incorporated by
				this reference, and may be cross-referenced throughout this Chapter where
				applicable. This incorporation by reference is effective as of the filing date
				of this Chapter with the Secretary of State, and does not include any later
				amendments or editions of the incorporated matter. The incorporated rules and
				regulations may be viewed at http://www.ecfr.gov/cgi-bin/ECFR, www.ssa.gov,
				http://www.health.wyo.gov/healthcarefin/medicaid/spa.html section 3.1 -A, and
				http://www.health.wyo.gov/healthcarefin/medicaid/homecareservices.html or may
				be obtained at cost from the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 27 - RULES AND REGULATIONS FOR MEDICAID PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 27-3 - Definitions

Current through July 13, 2024
Except as otherwise specified in Chapter 1, the terminology
				  used in this Chapter is the standard terminology and has the standard meaning
				  used in health care, Medicaid, and Medicare.
(a) "Program of All-Inclusive Care for the
				Elderly (PACE)." A capitated health care program designed to offer
				comprehensive health services and in-home care, including supportive services
				to help individuals maintain independence in the community for as long as
				possible.
(b) "Program of
				All-Inclusive Care for the Elderly Interdisciplinary Team (PACE IDT)." A team
				of medical and other professionals responsible for individualized care planning
				for PACE participants.