reglab/statecodes huggingface dataset:
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-9 - Periodicity schedule

Current through July 13, 2024
(a) Frequency of
				HEALTH CHECKs. Recipients under age twenty-one should be screened pursuant to
				the
Recommendations for Preventive Pediatric Health
				Care
, which is incorporated by this reference. It is prepared and
				published by the American Academy of Pediatrics, and is available from the
				Academy.
(b) Dental examinations.
				Recipients under age twenty-one should be referred by a HEALTH CHECK provider
				to a dentist for an initial examination at approximately age three, assuming
				the recipient is able to cooperate during the examination. Thereafter,
				subsequent dental examinations are recommended every six months, or as
				frequently as recommended by a dentist or other appropriate provider.
(c) Hearing screens. All neonates should be
				screened before departing the hospital. HEALTH CHECK providers should perform
				pure tone testing at ages 4-10, 12 and 18 years. Subjective testing, by
				history, is recommended through 3 years, ages 11, 13-17 and 20+.
(d) Vision screens. Recipients under age
				twenty-one should be referred by a HEALTH CHECK provider for a vision
				examination by an eyecare practitioner at approximately age three, assuming the
				recipient is able to cooperate during the examination. Thereafter, subsequent
				vision examinations are recommended every twelve months, or as frequently as
				recommended by an eyecare practitioner.
(e) Interperiodic HEALTH CHECKs. HEALTH
				CHECKs, vision hearing and dental examinations may be provided whenever
				medically necessary to evaluate a suspected physical, developmental or mental
				problem. An interperiodic HEALTH CHECK must meet the standards of a regular
				HEALTH CHECK.
(f) School and sports
				physical. A HEALTH CHECK provider requested to do a school or sports physical
				should first determine when the most recent periodic HEALTH CHECK was
				completed.
(i) If the recipient is current
				according to the HEALTH CHECK periodicity schedule, a complete HEALTH CHECK
				should be conducted.
(ii) If the
				recipient is not current according to the HEALTH CHECK periodicity schedule,
				the provider may bill only for a limited routine physical
				examination.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-10 - Medicaid allowable payment

Current through July 13, 2024
(a) The Medicaid
				allowable payment for HEALTH CHECK services is the lower of the providers usual
				and customary charge and the Medicaid fee schedule. Laboratory tests and
				immunizations are separatey reimbursed at the lower of the provider's usual and
				customary charge and Medicaid fee schedule.
(b) Treatment and referral services. The
				Medicaid allowable payment for the referral and treatment of conditions
				detected during a HEALTH CHECK examination shall be determined pursuant to the
				rules of the Department.
(c)
				Expanded services. Expanded services are reimbursed:
(i) Pursuant to the other rules of the
				Department, if the expanded service is a covered services under any such rule;
				or
(ii) At the lower of the
				provider's usual and customary charge and the Medicaid fee schedule, if the
				expanded service is not a covered service under any of the Departments
				rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-13 - Reconsideration

Current through July 13, 2024
(a) Request for reconsideration. A provider
				may request that the Department reconsider a decision to recover excess
				payments. Such request must be mailed to the Department by certified mail,
				return receipt requested within twenty days of the date the facility receives
				notice pursuant to Section
				12.
				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.
(b) Reconsideration. The
				Department shall review the decision and send written notice by certified mail,
				return receipt requested, to the provider of its final decision within
				forty-five days after receipt of the request for reconsideration or the receipt
				of any additional information requested pursuant to (c), whichever is
				later.
(c) Request for additional
				information. The Department may request additional information from the
				provider as part of the reconsideration process. Such a request shall be made
				in writing by certified mail, return receipt requested. The provider must
				provide the requested information within thirty days after the date of the
				request. Failure to provide the requested information shall result in the
				dismissal of the request with prejudice.
(d) Reconsideration shall be limited to
				whether the Department has complied with the provisions of this
				Chapter.
(e) Informal resolution.
				The provider or the Department may request an informal meeting before the final
				decision on reconsideration to determine whether the matter may be resolved.
				The substance of the discussions and/or settlement offers made pursuant to an
				attempt at informal resolution shall not be admissible as part a subsequent
				administrative hearing or judicial proceeding.
(f) 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, return receipt requested
				or personally delivering a request for hearing to the Department within twenty
				days of the date the provider receives notice of the final decision.
(g) Failure to request reconsideration. A
				provider which fails to request reconsideration pursuant to this section may
				not subsequently request an administrative hearing regarding the recovery of
				excess payments pursuant to Chapter I.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-14 - Administrative hearing

Current through July 13, 2024
(a) Recipients. A
				recipient may request an administrative hearing pursuant to Chapter I regarding
				the denial or reduction of services.
(b) Procedures. A request for an
				administrative hearing must be made in conformance with Chapter I, and the
				hearing shall be held pursuant to Chapter I.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-15 - Superseding effect

Current through July 13, 2024
When promulgated, this Chapter supersedes all prior rules or
				  policy statements issued by the Department regarding the EPSDT/HEALTH CHECK
				  program, 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 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Department of Health
				  pursuant to the Wyoming Medical Assistance and Services Act at Wyoming Statutes
				  §§
									
										42-4-101
				  through
				  42-4-306.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter has been adopted to
				establish methods and standards for Medicaid reimbursement rates for nursing
				facilities which provide services to clients. It shall apply to and govern all
				payments of Medicaid funds to facilities for services.
(b) The Department may issue manuals and
				bulletins to providers and 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 provider bulletins shall be subordinate to the provisions of this
				Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-3 - Definitions

Current through July 13, 2024
Except as otherwise specified in Chapter 1 of the Wyoming
				  Medicaid Rules, Definitions, the terminology used in this Chapter is the
				  standard terminology and has the standard meaning used in health care,
				  Medicaid, and Medicare.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-4 - General Provisions

Current through July 13, 2024
(a) Cost terms and hierarchy. This rule
				includes the following cost terms, even though such cost may not be
				reimbursable because of other provisions of this rule, in the following
				hierarchy:
(i) General ledger cost. A cost
				properly recorded on a nursing facility's general ledger in accordance with
				GAAP. This includes cost incurred at an individual nursing facility as well as
				central office or pooled cost reasonably allocated to an individual nursing
				facility;
(ii) Reported cost.
				General ledger cost properly reported on the cost report. It is composed of
				allowable cost and non-allowable cost;
(iii) Non-allowable cost. Cost which is not
				reasonably related to covered services; and
(iv) Allowable cost, as defined in Chapter 1
				of the Wyoming Medicaid Rules, Definitions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-5 - Submission and Preparation of Cost Reports

Current through July 13, 2024
(a) Time of submission. Complete cost reports
				shall be submitted by the end of the fifth (5th)
				month following the provider's fiscal period end.
(i) Complete cost report. A cost report shall
				be deemed complete upon receipt of the completed and certified cost report and
				the information specified in subsections (c)(iii)(A)-(K). The per diem rate
				shall not be computed, however, until the receipt of the information specified
				in subsections (c)(iii)(A)-(K). The Department may request additional
				information, in writing, by certified mail, return receipt requested. Any such
				information shall be submitted, by certified mail, return receipt requested,
				within thirty (30) days after the date of the request. A cost report shall not
				be amended after submission. The version of the Medicare cost report submitted
				to Wyoming Medicaid shall agree with the cost report submitted to
				Medicare.
(ii) Extension. A thirty
				(30) day extension of the submission date may be granted by the Department for
				good cause if requested by a provider, in writing, prior to the due date. A
				cost report shall not be deemed past due while an extension term is in effect.
				Only one (1) request for an extension may be granted for each cost reporting
				period.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-6 - Joint Use of Resources

Current through July 13, 2024
(a) Multiple business enterprises. If a
				provider owns, controls, or manages multiple business enterprises, the
				revenues, expenses, statistical, and financial records of each separate
				enterprise shall be clearly identifiable. If a field audit or desk review
				establishes that the provider's records do not clearly identify the information
				required by this rule, none of the commingled cost shall be an allowable cost
				for purposes of the nursing facility's per diem rate.
(b) Control, ownership or management by third
				party.
(i) Separate records. When the nursing
				facility is owned, controlled or managed by a person or entity that owns,
				controls, or manages one (1) or more other nursing facilities, records of
				central office and other costs incurred outside the nursing facility shall be
				maintained so as to separately identify revenues and expenses of, and
				allocations to, individual facilities.
(ii) Allocation of pooled costs shall be
				reasonable and conform to GAAP, the provisions of this rule, and the
				instructions of the Department. Pooled cost is allowable only to the extent
				that the pooled cost is incurred in providing patient-related services and the
				provider can demonstrate that pooled cost improves efficiency, economy, or
				quality of care. All patient-related pooled costs allocated to a nursing
				facility that meet these requirements shall be reported in the operating cost
				component.
(iii) Direct patient
				service costs. Direct patient service costs incurred by multiple nursing
				facility organizations may be reported in the health care component if the
				service was rendered to the client at the nursing facility and is separately
				identified, rather than allocated, in the provider's accounting records.
				Patient service costs which do not meet these criteria shall be reported in the
				operating cost component.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-7 - New Facilities and Changes of Ownership Per Diem Rate Determination

Current through July 13, 2024
(a) New nursing facilities. A new nursing
				facility is defined as a newly constructed facility for a provider that did not
				previously exist, a newly designated portion of a hospital which has not
				previously been designated as a facility, or an existing facility which has not
				previously been certified. An addition to a certified facility is not a "new
				facility." An existing provider that constructs a new building to move into is
				not a "new facility" but the new building may be subject to a re-age adjustment
				per Section
				18.
(i) A
				new nursing facility rate shall be calculated by rate category as follows:
(A) Health care portion of rate. The new
				facility will receive the same starting price as all other facilities with a
				quarterly case mix adjustment using the new provider's case mix scores. If the
				provider does not have the qualifying case mix data at the time rates are
				calculated, the health care component will be calculated using the statewide
				Medicaid average case mix score from the prior quarter.
(B) Capital portion of rate. The new facility
				will receive a property rental rate based on the age of their building. If the
				age cannot be determined at the time of rate-setting or if the provider does
				not supply the appropriate data to calculate the age of the building when
				requested, the provider will receive a property rental rate based on a 40-year
				old building. The rate will not be adjusted retrospectively if the provider
				later supplies the needed documentation. The rate will be adjusted to reflect
				the revised age at the beginning of the next rate quarter.
(C) Exempt portion of rate. The new facility
				will receive the exempt portion of their rate using the statewide average
				calculated in the previous quarter.
(D) Operating portion of rate. The new
				facility will receive the same fixed price the rest of the state is receiving
				for that quarter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-8 - Medicaid Reimbursement for Reserve Bed Days

Current through July 13, 2024
(a) Reserved bed days.
(i) Medicaid shall not reimburse for reserve
				bed days.
(ii) A provider may not
				bill a client or the client's family for reserved bed days that are not
				reimbursed pursuant to this section unless the nursing facility has informed
				the client, in writing, before the period for which reimbursement is sought of
				the client's option to make payments to hold the bed.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-9 - Cost and Rate Categories

Current through July 13, 2024
(a) General requirements. Costs shall be
				allocated among the following cost categories as specified in this section:
(1) health care costs;
(2) capital costs;
(3) exempt costs; and
(4) operating costs. For purposes of this
				section, "labor costs" includes the cost of employee benefits and taxes.
				Services and supplies used in providing patient-related services include, but
				are not limited to, those specified in Attachment A. Reimbursement will be a
				combination of a cost based system and a fixed price system as described in
				Section 15.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-10 - Determination of Capital Cost

Current through July 13, 2024
(a) Depreciation.
(i) The depreciation of a tangible asset used
				to deliver patient-related services is an allowable cost if the asset is:
(A) In use;
(B) Identifiable to patient care;
(C) Available for physical inspection;
				and
(D) Recorded in the provider's
				records.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-11 - Working Capital Interest

Current through July 13, 2024
(a) Working capital interest. Working capital
				interest is patient-related financing other than permanent financing.
(i) Generally. Interest on working capital
				loans is an allowable cost only if the loans were costs that must be incurred
				to provide patient-related services.
(ii) Limitation. Interest on working capital
				loans may not exceed the actual reported interest less any investment income
				revenue.
(iii) Reporting. Interest
				on working capital loans shall be reported as an operating cost.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-12 - Cost of Services and Supplies not Included in the Per Diem Rate

Current through July 13, 2024
(a) Services and supplies which are not
				included in the per diem rate include, but are not limited to:
(i) Ambulance services;
(ii) Audiology services;
(iii) Barber and beauty shop services other
				than routine personal hygiene items and services;
(iv) Cigarettes, cigars, pipes and
				tobacco;
(v) Clothing;
(vi) Cosmetics;
(vii) Dental services (unless under purchase
				for service contract);
(viii) Dry
				cleaning;
(ix) Eye examinations and
				other optical supplies and services;
(x) Hearing aids;
(xi) Hospital services;
(xii) Laboratory services;
(xiii) Orthotic services;
(xiv) Physician services;
(xv) Podiatry services;
(xvi) Prosthetic devices; and
(xvii) Customized wheelchairs that are fitted
				or fabricated to a specific individual and cannot be used by any other person,
				and electric wheelchairs, including batteries.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-13 - Rate Period

Current through July 13, 2024
(a) Effective date. A provider's per diem
				shall become effective on the rate effective date, which is July 1 of each
				year, with quarterly acuity case mix adjustments. Per diem rates are
				established prospectively and shall remain in effect from the rate effective
				date until re-determined pursuant to this rule.
(b) Effective period of rate. A facility
				shall be bound by the per diem rate until a new rate is computed pursuant to
				this rule, unless the rate is changed as the result of a desk review, field
				audit, or legislative budget change.
(c) Applicable cost report data. The data
				used in establishing the rate calculation effective each July 1 is the cost
				reports that ended two (2) calendar years ago (for example, cost reports ending
				during the period from January 1, 2013 to December 31, 2013, will be used to
				set rates effective July 1, 2015).
(d) Rates will be adjusted quarterly to
				reflect case mix acuity adjustments.
(e) Notice of rate. The Department shall
				notify providers of the per diem rate by certified mail, return receipt
				requested.
(f) If there is a need
				to issue an interim rate, the rate will be issued as interim and the rate will
				later be revised and issued as final. Any amounts paid pursuant to the interim
				rate which exceed the final rate shall be overpayments and shall be recovered
				pursuant to Section
				31 of this Chapter. If the interim rate is
				less than the final rate, the Department shall pay the difference to the
				provider within sixty (60) days.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-14 - Creation of Database

Current through July 13, 2024
(a) Creation of database. Each year the
				Department shall create a database using the latest complete desk reviewed cost
				reports for each provider. "Latest complete" means the cost report used to
				compute the provider's most recent per diem for the applicable year.
(b) Adjustment of cost reports. Cost reports
				included in the database shall be adjusted so that transactions with owners or
				parties related to providers are limited pursuant to this rule.
(c) The database shall separate costs from
				the reviewed or audited cost report into the categories for (1) health care
				costs; (2) capital costs; (3) exempt costs; and (4) operating costs as defined
				in Section
				9.
(d) Bed ranges. Providers will be grouped by
				bed range group. Providers will be grouped into ranges based on the number of
				licensed beds.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-15 - Price and Rate Setting - Legislative Appropriation

Current through July 13, 2024
(a) Reimbursement will be a combination of a
				prospective fixed price system and a cost-based system with the health care
				component subject to an acuity adjustment. The legislature will provide an
				annual budget each year. The budget will be used to set the cost and price
				based rates as follows:
(b)
				Property Price. The first round of legislative allocations will be used to
				determine the reimbursement necessary to fund the price-based property rental
				rate system. The property rental rate methodology is defined at Section
				18 of this Chapter.
(c) Exempt Cost Per Diem. The second round of
				allocations will be to determine the reimbursement necessary to fund the exempt
				cost-based reimbursement category. Exempt costs are defined at Section
				9(d) of this
				Chapter.
(d) Health care and
				Operating Prices. The balance of the legislative appropriation will be used to
				fund the prices for the health care and operating categories. The balance of
				the funding will be allocated between the operating and health care categories
				based on the statewide total percentage of audited or desk reviewed costs
				classified to these categories.
(i) The
				operating price will be the same price reimbursed to all providers, regardless
				of their cost.
(ii) The health care
				price will begin with the same price to all providers, regardless of their
				cost. Each provider's starting price will be further adjusted up or down based
				on the provider's case mix acuity score for each quarter as is described in
				Section 16.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-16 - Health Care Case Mix Acuity Adjustment

Current through July 13, 2024
(a) Health care prices will be paid using a
				starting fixed price that is the same for all facilities. The fixed price will
				be adjusted for each individual provider on a quarterly basis based on each
				facility's Medicaid case mix index to reflect the case mix of that facility's
				Medicaid residents in a certain quarter. The case mix adjustment will be
				calculated by taking the fixed starting price times each provider's weighted
				average Medicaid case mix index divided by the statewide average Medicaid case
				mix index for each quarter.
(b)
				Applicable Case Mix Index (CMI). The Medicaid CMI used in establishing each
				facility's rate is calculated based on the weighted average assessment for each
				Medicaid resident in the nursing facility in the prior quarter where an MDS
				assessment was completed and successfully transmitted to the QIES ASAP system.
				The CMI is recalculated quarterly and each nursing facility's health care
				component rate is adjusted accordingly.
(i)
				In the event that a facility's Medicaid CMI is zero (0.000), the provider's
				average case mix score from the most recent quarter will be used. If there is
				no data for the previous quarters, they will receive the statewide average
				Medicaid case mix index score from the prior quarter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-17 - Determination of Per Diem Rate

Current through July 13, 2024
(a) Except as otherwise provided in this
				Chapter, the Department shall determine per diem rates to be effective for
				services furnished as follows:
(b)
				Per diem rate. The Department reimburses facilities providing nursing facility
				services, as defined by
				42
				U.S.C. §
										1396d(f), to
				clients using the per diem rates established pursuant to this
				Chapter.
(c) Except as otherwise
				specified in (a), a provider shall receive four (4) rate changes per year on
				the quarterly rate effective date, unless:
(i) The rate is changed as the result of a
				desk review or field audit; or
(ii)
				Changes in federal or state statutes or regulations cause increases in health
				care costs, as defined in subsection
				9(b) of this Chapter, or
				operating costs, as defined in subsection
				9(e) of this Chapter, in
				which case the Department shall determine whether and how to reimburse for such
				costs. Any changes pursuant to this paragraph shall be subject to the minimum
				and maximum budget provided by the legislature.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-19 - State Owned Nursing Facilities

Current through July 13, 2024
Any state owned nursing facility will be subject to all rules
				  within this chapter with the exception of the rate and price setting Sections
				  7,
				  8,
				  13(d),
				  14,
				  15,
				  16,
				  17(c), and
				  18.
(a) Per diem rates shall be calculated
				separately from other facilities in this chapter and the state owned nursing
				facility data will not be included in the database of providers identified in
				Section 14.
(b) The provider's per diem rate shall be
				determined utilizing either a desk reviewed or audited cost report. Costs will
				not be subject to any form of cap or maximum rate.
(i) Effective date. The provider's per diem
				rate shall become effective on July 1 of each year.
(ii) Per diem rates are established
				prospectively and shall remain in effect from the rate effective date until
				re-determined pursuant to this rule.
(iii) The most currently reviewed cost report
				will be used to set the future rate. The same year will not be used
				twice.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-20 - Hold Harmless

Current through July 13, 2024
(a) If the provider's July 1, 2015 calculated
				rate is less than their rate in effect on June 30, 2015, the provider will
				qualify for a hold harmless rate adjustment as follows:
(b) For the rate quarters effective on July
				1, 2015 and October 1, 2015, the provider will continue to receive their rate
				that was in effect on June 30, 2015.
(c) For the rate quarters effective on
				January 1, 2016 and April 1, 2016, the provider will receive their rate that is
				calculated for the rate quarter using the rate methodology effective for that
				quarter plus 50% of the difference between that rate and their rate that was
				effective on June 30, 2015.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-21 - Legislative Appropriations

Current through July 13, 2024
(a) If the Wyoming Legislature passes a
				special appropriation to be used to increase nursing facility reimbursement for
				any specific purpose defined by the Legislature in such appropriation, this
				section shall control the allocation of such appropriate among nursing
				facilities in Wyoming.
(b) The
				Department shall develop a methodology to allocate the appropriation among
				nursing facilities in Wyoming.
(i) The
				Department may consult with representatives of nursing homes, such as
				representatives of associations which represent nursing homes in Wyoming, about
				how to allocate the appropriation.
(ii) The Department shall collect the
				information it deems necessary to allocate the appropriation. The Department
				shall request information in writing, by certified mail, return receipt
				requested. Providers shall furnish the requested information in the format and
				according to the schedule established by the Department. All such information
				shall be submitted to the Department by certified mail, return receipt
				requested. Any information provided to the Department shall contain a
				certification statement substantially in the form specified in subsection
				5(d) of this
				Chapter.
(iii) After collecting
				information pursuant to subsection (b)(i) and (b)(ii), the Department shall
				develop a methodology to distribute the appropriation among nursing facilities
				in Wyoming. The methodology shall:
(A)
				Effectuate the legislative purpose of the appropriation in a timely and
				cost-effective manner;
(B) Benefit
				Wyoming nursing facilities equitably, such that no nursing facility benefits
				disproportionately, based on the intent of the appropriation; and
(C) Include safeguards to ensure that
				appropriated funds are spent for the purposes specified in the appropriation.
				Such safeguards shall include reporting and documentation requirements for
				facilities,
(iv) The
				Department shall disseminate the methodology to facilities through a manual or
				bulletin.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-22 - Reimbursement Rate for Extraordinary Care Clients

Current through July 13, 2024
(a) Medicaid reimbursement for services
				provided to an extraordinary care client may be negotiated for clients who
				require skilled nursing facility care and require special care as recognized
				with prior authorization by the Department. Services for these clients shall be
				the per diem rate calculated in accordance with other sections of this Chapter,
				plus a negotiated rate to cover the cost of medically necessary services
				(equipment and staffing) and supplies that are not included in the per diem
				rate.
(i) The only items that may qualify for
				an extraordinary rate are as follows:
(A)
				Tracheostomy;
(B)
				Ventilator;
(C) Morbid
				obesity;
(D) Psychiatric care for
				clients with significant behaviors that cannot otherwise be safely cared for in
				a standard nursing facility setting without increased staffing or special
				accommodations, including clients with significant physical aggression,
				delirium and/or psychosis; or
(E)
				Case by case situations where the Department has determined that the condition
				requires special care or clinically complex care.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-23 - Contracted Rate for Distressed Facilities

Current through July 13, 2024
(a) The Department may pay a contracted rate
				to a nursing facility determined by the Department to be in distress. The
				contracted rate may exceed the nursing facility's per diem rate as determined
				pursuant to Section
				17 of this Chapter.
(b) The Department shall negotiate and enter
				into contracts for a temporary contracted rate using the following procedures:
(i) Determine what constitutes a distressed
				facility, taking into consideration for each nursing facility, the factors
				specified in (A) and the objectives specified in (B):
(A) Factors:
(I) Financial stability and
				solvency;
(II) Occupancy (low
				occupancy as a percentage of capacity or drops quickly);
(III) Whether or not the Department has
				assumed temporary management of the facility; and
(IV) Geographic location of the
				facility.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-24 - Nursing Care Facility Assessment Act

Current through July 13, 2024
(a) Nursing facility adjustment payments to
				providers based on the upper payment limit calculation.
(i) The Department will make adjustment
				payments to nursing facilities under the provisions of the Nursing Care
				Facility Assessment Act, W.S. §§
										
											42-8-101
				through 109.
(A) Adjustment payments will be
				calculated prospectively on an annual basis to be effective from October 1
				through September 30 of each year. The adjustments will be paid quarterly. New
				providers opening during that assessment year will not be included in the
				program until the next assessment year.
(B) The quarterly adjustment payments will be
				due to the providers not later than thirty (30) days after the end of each
				calendar quarter.
(C) Change of
				ownership. If a facility changes ownership, beginning at the start of the
				calendar quarter following the date of the change of ownership, the new owner
				will collect the adjustment payment that was calculated using the prior owner's
				data.
(D) Adjustment payments will
				be calculated based on Medicaid days paid by the Wyoming Medical Assistance
				Program.
(I) Wyoming Medicaid days will be
				collected for the dates of service represented in cost reports ended in the
				calendar year that precedes the assessment effective each October 1. The
				Medicaid days will be generated by the Department from their MMIS payment
				system.
(II) New facilities without
				a qualifying cost report. For new facilities that opened prior to the October 1
				annual calculation that do not have either a full year cost report or a
				qualifying cost report, as described in Section
				5(c) of this Chapter,
				resident days will be determined using more current information and will be
				annualized.
(E) State
				operated facilities are exempt from this program.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-25 - Medicaid Allowable Payment for Medicaid Program Services

Current through July 13, 2024
(a) Any Medicaid program service other than
				nursing facility services reimbursable within this Chapter shall be reimbursed
				according to the rules and policies of the Department for that specific
				program.
(b) Nursing Facility Gap
				payments. The Department shall annually reimburse non-State government owned
				nursing facilities that qualify for nursing facility gap payments pursuant to
				state plan amendment section 4.19 -D of the State Plan Amendment incorporated
				herein by reference.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-26 - Billing Requirements

Current through July 13, 2024
(a) Submission of claims. A provider seeking
				Medicaid reimbursement for services provided to a client shall submit claims on
				the forms and in the manner specified by the Department.
(b) Medicaid payment as payment in full. A
				provider which receives or requests Medicaid payment for services and supplies
				included in the per diem rate shall accept Medicaid payment as payment in full
				for such services and supplies. A provider shall not attempt to collect or
				retain payment in addition to the per diem rate, except as permitted state or
				federal law.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-27 - Change in Provider Status

Current through July 13, 2024
(a) Termination of participation. If a
				provider's participation in the Medicaid program is terminated or suspended for
				any reason, the provider shall submit a cost report for the period ending with
				the effective date of the termination or suspension if that cost report is
				needed for rate setting. The cost report is due within forty-five (45) days
				after the date of termination or suspension, even though the provider's tax
				period does not end on the date of termination or suspension. The final month's
				payment due a provider shall be withheld until its cost report is filed and the
				Department has a reasonable time to perform a desk review and field audit of
				the cost report and patient funds account.
(b) Change of ownership.
(i) Notice of change of ownership. The
				parties to a transaction involving a change of ownership shall notify the
				Department, in writing, of the proposed transaction no later than thirty (30)
				days before the effective date of the change.
(ii) Representation agreement. Upon a change
				of ownership, all parties to the transaction shall have thirty (30) days after
				the change to complete and sign a representation statement, in written form
				specified by the Department, which details the persons or entities which have
				assumed the assets and liabilities of a nursing facility. If a representation
				statement is not timely submitted, both the original provider and any
				subsequent provider shall be jointly and severally responsible for all Medicaid
				liabilities which exist either before or after the change of
				ownership.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-28 - Reimbursement of Out-of-State Providers

Current through July 13, 2024
(a) The reimbursement rate for out-of-state
				facilities providing services to Wyoming clients shall be the lesser of:
(i) The Medicaid reimbursement rate the
				nursing facility receives on July 1 of the rate year for the same or similar
				services from the Medicaid program in the state where the nursing facility is
				located;
(ii) The average Medicaid
				day weighted average rate in effect in Wyoming as of July 1 of the rate year
				that the provider needs a rate calculated; or
(iii) The nursing facility's usual and
				customary rate.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-29 - Pre-Admission Screening and Resident Review (PASRR)

Current through July 13, 2024
(a) General requirements. A patient that
				receives swing bed services is subject to the requirements of Chapter 19 of the
				Wyoming Medicaid Rules, Nursing Facility Preadmission Screenings.
(b) Failure to timely complete. The failure
				to timely complete the requirements of Chapter 19 of the Wyoming Medicaid
				Rules, Nursing Facility Preadmission Screenings, shall result in nonpayment for
				services provided after the date of admission until the date of
				completion.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-30 - Record Retention

Current through July 13, 2024
(a) Providers shall comply with the Provider
				Records requirements of Chapter 3 of the Wyoming, Provider
				Participation.
(b) Explanation of
				records. In the event of a field audit, the provider shall have available at
				the field audit location one (1) or more knowledgeable persons who can explain
				the provider's financial records, the accounting and control system, and cost
				report preparation, including attachments and allocations, to the
				auditors.
(c) Failure to maintain
				records. A provider unable to satisfy any of the requirements of this Section
				shall be given a written notice of deficiency and shall have sixty (60) days
				after the date of the written notice to correct such deficiency. If, at the end
				of the sixty (60) days, the Department determines that the deficiency has not
				been corrected, the Department shall withhold twenty-five (25) percent of the
				provider's per diem rate for services provided on or after the sixtieth
				(60th) day. If, at the end of one hundred and twenty
				(120) days after the mailing of the written notice of deficiency, the
				Department determines that the deficiency has not been corrected, the
				Department shall suspend all Medicaid payments for services provided after such
				date. Reimbursement shall not be reinstated until the Department determines
				that adequate records are being maintained. After the deficiency is corrected,
				the Department shall release any withheld payments.
(d) Out-of-state records. If a provider
				maintains financial or medical records out of state, the provider shall either
				transfer the records to an in-state location that is suitable for the
				Department to perform the field audit or reimburse the Department for
				reasonable costs, including travel, lodging and meals, incurred in performing
				the field audit in an out-of-state location.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-31 - Repayment of Credit Balance

Current through July 13, 2024
(a) Report on cost report. A provider shall
				report a credit balance on the provider's cost report. A credit balance shall
				be repaid pursuant to subsection (c).
(b) Annual request. The Department may
				request the repayment of any credit balance annually. Such request shall be
				made in writing and mailed by certified mail, return receipt requested. The
				provider shall repay the credit balance within sixty (60) days after the date
				of receipt of the request for repayment.
(c) A provider shall repay any credit balance
				within sixty (60) days after the date such credit balance is identified by the
				Department or the provider.
(d)
				Lump sum adjustment. If a credit balance identified pursuant to subsections (a)
				or (b) is not timely paid to the Department, the Department may recover the
				credit balance pursuant to Section
				33 of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-33 - Recovery of Overpayments

Current through July 13, 2024
The Department may recover overpayments pursuant to Chapter
				  16 of the Wyoming Medicaid Rules, Medicaid Program Integrity.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-34 - Reconsideration

Current through July 13, 2024
(a) A provider may request reconsideration of
				the decision to recover overpayments pursuant to the provisions of Chapter 16
				of the Wyoming Medicaid Rules, Medicaid Program Integrity.
(b) A provider may request reconsideration of
				the determination of the provider's per diem rate following the procedures
				outlined in Chapter 16 of the Wyoming Medicaid Rules, Medicaid Program
				Integrity.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-35 - Disposition of Recovered Funds

Current through July 13, 2024
The Department shall dispose of recovered funds pursuant to
				  the provisions of Chapter 16 of the Wyoming Medicaid Rules, Medicaid Program
				  Integrity.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-36 - 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 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-37 - Superseding Effect

Current through July 13, 2024
When promulgated, this Chapter supersedes all prior rules or
				  policy statements issued by the Department, including manuals or bulletins,
				  which are inconsistent with this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 7 - WYOMING NURSING HOME REIMBURSEMENT SYSTEM › Section 7-39 - 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 of Health 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 of Health 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 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-1 - 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. §
									
										42-4-104 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 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter
				has been adopted to establish the standards and procedures for admission
				certification to be followed by attending physicians and hospitals seeking
				Medicaid payment for inpatient hospital services provided to clients. This
				Chapter shall apply to all admissions which occur after its effective
				date.
(b) The requirements of the
				Medicaid State Plan Amendment, Attachment 4.19a, Part 1, also apply to Medicaid
				and are incorporated by this reference as of the effective date of this
				Chapter, and may be cross-referenced throughout this Chapter where applicable.
				This incorporation by reference does not include any later amendments or
				editions of the incorporated matter. The incorporated State Plan Amendment may
				be viewed at http://www.health.wyo.gov or may be obtained at cost from the
				Department.