reglab/statecodes huggingface dataset:
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 27-4 - Provider Participation and Enrollment

Current through July 13, 2024
(a) A provider that requests Medicaid
				reimbursement for services furnished to a participant shall meet the provider
				participation requirements of Chapter 3 and
				42 C.F.R. §
										460.200.
(b) A provider desiring the designation of
				PACE provider must complete and submit an application to CMS that describes how
				the applying organization meets all the requirements in
				42 C.F.R. §
										460.
(i)
				The application shall be competed in collaboration with the Department in
				accordance with CMS PACE application guidelines at www.cms.gov.
(ii) Upon completion of the application the
				applying organization shall submit it for review by the Department.
(iii) The Department shall review the PACE
				application to ensure compliance to State rules and regulations.
(iv) Once the Department has verified that
				the application adheres to State requirements for PACE, the application shall
				be submitted by the Department to CMS review and approval.
(A) CMS evaluates PACE program provider
				applications in accordance with CMS PACE application guidelines. The evaluation
				will include an on-site-review at the provider's place of business by CMS and
				Department representatives.
(B) CMS
				provides notification of determination based on timelines outlined in
				42 C.F.R. §
												460
(v) Upon approval of the application, CMS,
				the Department, and the PACE provider shall sign a three-way Program Agreement
				authorizing the PACE provider to market and engage in enrollment activities,
				pursuant to 42 C.F.R. §
											460, Subpart C.
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 27-5 - Eligibility, Applications, and Grievances for the PACE

Current through July 13, 2024
(a) Eligibility under this Chapter shall be
				limited to persons who:
(i) Meet current
				Medicaid income and resource eligibility through the process set forth in
				Chapter 18;
(ii) Are fifty-five
				(55) years of age or older;
(iii)
				Reside within the service area of a PACE provider;
(iv) Meet medical necessity for long-term
				care level of care determination in accordance with Chapter 22; and
(v) Meet home assessment requirements
				demonstrating that the individual is able to live in the community setting
				without jeopardizing his or her health or safety, pursuant to
				42 C.F.R. §
											460.150.
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 27-6 - Participant Disenrollment Procedures

Current through July 13, 2024
(a) Involuntary disenrollment. All
				involuntary disenrollments must meet the criteria set forth in
				42 C.F.R. §
										460.164 and be approved by the Department or
				its designee prior to thirty (30) day notification to the participant of
				involuntary disenrollment.
(b) A
				participant shall be determined to be no longer eligible for PACE program
				services and therefore involuntarily disenrolled when:
(i) The participant moves out of the PACE
				provider service area or is out of the service area for more than thirty (30)
				consecutive days, unless the PACE provider agrees to a longer absence due to
				extenuating circumstances;
(ii) The
				participant has a demonstrated history of ongoing, willful non-compliance with
				an essential treatment plan or engages in disruptive or threatening behavior
				that jeopardizes his or her health or safety or the safety of others;
(iii) The PACE provider's agreement with CMS
				and the Department is not renewed or is terminated; or
(iv) The PACE provider is unable to offer
				health care services due to the loss of contracts with outside
				providers.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 27 - RULES AND REGULATIONS FOR MEDICAID PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 27-7 - Covered Services

Current through July 13, 2024
(a) Providers shall provide services and
				conduct activities as outlined in
				42 C.F.R. §
										460, 462, 466, 473, and 476.
(i) Services shall be available twenty-four
				(24) hours a day, seven (7) days a week by a PACE provider approved by
				CMS.
(ii) Services provided by the
				PACE provider shall include:
(A) Primary
				care, including physician and nursing;
(B) Social services;
(C) Restorative therapies, including physical
				therapy and occupational therapy;
(D) Personal care and supportive
				services;
(E) Nutritional
				counseling;
(F) Recreational
				therapy; and
(G) Meals.
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 27-8 - Transfers between PACE and Other Medicaid Long Term Care programs

Current through July 13, 2024
(a) The PACE provider shall assist the
				participant in completing all forms or referrals necessary to enroll the
				participant in other available Medicaid long-term care programs if it is
				determined the participant will be voluntarily or involuntarily disenrolled
				from the PACE program provider.
(b)
				Participant enrollment is based on monthly coverage, so participant coverage
				under a PACE provider will be effective until the end of the month of PACE
				disenrollment. A participant cannot be enrolled with a PACE provider for part
				of a month and enroll in another Medicaid long-term care program for part of
				the same month.
(c) The PACE
				program provider shall coordinate with the Department to determine a
				participant's disenrollment date to ensure continuity of care.
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 27-9 - Provider Payment

Current through July 13, 2024
(a) Provider payment is based on a capitated
				rate calculated on a per member per month (PMPM) methodology. The payments will
				be automatically generated by the Medicaid Management Information System (MMIS)
				based on the individuals that are enrolled in the PACE provider's program on
				the system.
(b) Capitated rates
				calculation.
(i) Capitated rates shall be no
				less than ninety percent (90%) of the fee-for-service equivalent cost,
				including the cost of administration that the Department estimates would be
				payable for all services provided by the PACE provider if all of those services
				were to be provided on a fee-for-service basis.
(A) The non-PACE population group used to
				determine the PMPM capitated rate must include individuals that match the
				participant criteria for the PACE program as described in Section
				5.
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 27-10 - Recovery of Overpayments

Current through July 13, 2024
The Department shall recover overpayments pursuant to the
				  provisions of Chapter 16.
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 27-12 - Reconsideration and Administrative Hearings

Current through July 13, 2024
A provider may request reconsideration of the decision to
				  recover overpayments pursuant to the provisions of Chapter
				  16.
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 27-13 - Disposition of Recovered Funds

Current through July 13, 2024
The Department shall distribute recovered funds pursuant to
				  the provisions of Chapter 16.
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 27-14 - 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 various provisions.
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 27-15 - Superseding Effect

Current through July 13, 2024
This Chapter supersedes all prior rules or policy statements
				  issued by the Department or its designee, including manuals and bulletins,
				  which are inconsistent with this Chapter.
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 27-16 - Severability

Current through July 13, 2024
If any portion of these rules is found invalid or
				  unenforceable, the remainder shall continue in effect.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Wyoming Department of
				  Health pursuant to the 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 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter has been adopted to govern
				the provision of and reimbursement of services provided to clients in
				swing-beds and shall apply to all clients and providers.
(b) The Department may issue manuals and
				bulletins to interpret the provisions of this Chapter. Such manuals and
				bulletins shall be consistent with and reflect the policies contained in this
				Chapter. The provisions contained in manuals and bulletins shall be subordinate
				to the provisions of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-3 - Definitions

Current through July 13, 2024
Except as otherwise specified in the Rules and Regulations of
				  Wyoming Medicaid, Chapter 1, Definitions, or as otherwise specified in this
				  Section, the terminology used in this Chapter is the standard terminology and
				  has the standard meaning used in healthcare, Medicaid, and Medicare.
(a) "Chapter" used herein refers to the
				specified Chapter in the Wyoming Department of health, Medicaid
				Rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-4 - General Provisions

Current through July 13, 2024
(a) Medicaid reimbursement for swing-bed
				services and services provided to extraordinary care clients is limited to
				services furnished to individuals that are nursing facility eligible.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-5 - Provider Participation

Current through July 13, 2024
(a) Payments only to providers. No hospital
				that provides swing-bed services to a client shall receive Medicaid funds
				unless the hospital is certified to provide such services, has signed a
				provider agreement, and is enrolled.
(b) Compliance with HHS regulations. A
				hospital that wishes to receive Medicaid reimbursement for swing-bed services
				furnished to a client shall meet the requirements of applicable federal
				regulations, including
				42
				C.F.R. §
										482.58 and
				483.1 through
				483.95.
(c) Compliance Chapter 3. A hospital that
				wishes to receive Medicaid reimbursement for swing-bed services furnished to a
				client must meet the requirements of Chapter 3, Provider
				Participation.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-8 - Pre-admission Screening 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,
				Nursing Facility Preadmission Screenings.
(b) Failure to timely complete. The failure
				to timely complete the requirements Chapter 19 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 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-9 - Minimum Data Set (MDS)

Current through July 13, 2024
(a) General requirements. The MDS
				requirements for nursing facility services that are required by
				42 C.F.R. §
										483.20 shall also apply to swing-bed
				services. Each provider shall comply with the MDS requirements for nursing
				facility services.
(b) Timely
				completion. The MDS shall be completed on or before the day specified by HHS
				regulations.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-10 - Determination of Medical Eligibility

Current through July 13, 2024
All applicants or clients shall undergo an evaluation of
				  medical necessity pursuant to Chapter 22, Evaluation of Medical Necessity for
				  Medicaid Long Term Care Program, before a hospital may receive Medicaid
				  reimbursement for services provided to an individual in a swing-bed. The
				  evaluation is conducted pursuant to Medicaid policy and manual.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-11 - Medicaid Allowable Payment for Swing-bed Services

Current through July 13, 2024
(a) The per diem rate for swing-bed services
				shall be the lesser of:
(i) The hospital's
				usual and customary charges for swing-bed services; or
(ii) The lowest per diem rate currently in
				effect for nursing facility services furnished in a nursing facility in the
				community where the hospital is located, as determined pursuant to Chapter 7,
				Nursing Home Reimbursement System.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-12 - Medicaid Allowable Payment for Services Provided to Extraordinary Care Clients

Current through July 13, 2024
(a) Reimbursement for extraordinary care
				clients shall follow the rules prescribed in Chapter 7, Section
				22.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-13 - Transfer to Nursing Facility

Current through July 13, 2024
(a) Except as provided in subsection (c) an
				applicant or client receiving swing-bed services shall be transferred to the
				first available, appropriate nursing facility bed in the hospital's geographic
				region upon the availability date, as defined in
				42
				C.F.R. §
										413.114(b).
				Medicaid reimbursement to the hospital for swing-bed services shall terminate
				for services provided after the date of the transfer.
(b) The facility shall maintain records of
				its efforts to transfer each client, including the facility or facilities
				contacted and any response. Such records shall be maintained as part of the
				client's medical records kept pursuant to Chapter 3, Provider
				Participation.
(c) The requirements
				of subsection (a) shall not apply if the client's physician certifies, in
				writing, that transfer is not medically appropriate.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-14 - Payment of Claims

Current through July 13, 2024
(a) General requirements. Payment of claims
				shall be pursuant to Chapter 3, Provider Participation.
(b) Certification. Each claim shall contain a
				certification by the provider that the service was medically necessary, that it
				was provided on the date specified, that third party liability has been paid
				or, if third party liability has been denied, documentation of that denial is
				attached, and that the reimbursement sought is not in excess of the provider's
				usual and customary charge for the service.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-15 - Medicaid Allowable Payment for Medicaid Program Services

Current through July 13, 2024
(a) The Medicaid allowable payment for
				Medicaid program services furnished to a client receiving swing-bed services
				shall be determined pursuant to the rules and policies of the
				Department.
(b) The Medicaid
				allowable payment for Medicaid program services furnished to an extraordinary
				care client shall be determined pursuant to the rules and policies of the
				Department, except:
(i) Inpatient hospital
				services shall not be reimbursable unless the client is discharged from the
				swing-bed and admitted to a hospital as an inpatient; and
(ii) As otherwise agreed to by the Department
				and the hospital pursuant to Sections
				12 or
				13.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-16 - Medicaid Reimbursement for Reserve Bed Days

Current through July 13, 2024
(a) Reserve bed days.
(i) Medicaid shall not reimburse for reserve
				bed days.
(ii) A provider shall 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 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-18 - Medical Necessity Reviews

Current through July 13, 2024
(a) The Department may review medical records
				or conduct on-site medical necessity reviews to determine whether the services
				a patient is receiving are medically necessary.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-20 - Reconsideration

Current through July 13, 2024
A provider may request reconsideration of the decision to
				  recover overpayments pursuant to the provisions of Chapter 16, Medicaid Program
				  Integrity.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-21 - 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 various provisions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-22 - Superseding Effect

Current through July 13, 2024
This Chapter supersedes all prior rules or policy statements
				  issued by the Department, including manuals and bulletins, which are
				  inconsistent with this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 28 - REIMBURSEMENT OF SWING-BED SERVICES › Section 28-24 - 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 these 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 29 - MEDICAID CASE MANAGEMENT › Section 29-2 - Purpose and applicability

Current through July 13, 2024
This Chapter governs case management by establishing the
				  responsibilities and powers of the Department, clients, providers, and
				  facilities to address the most efficient and cost-effective means of delivering
				  care.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 29 - MEDICAID CASE MANAGEMENT › Section 29-3 - Hospital Reporting Requirements

Current through July 13, 2024
(a) A hospital is not entitled to receive the
				full Medicaid allowable payment for covered services furnished to a client
				unless the hospital has reported the client to the Department on an Inpatient
				Census Report ("ICR"), subject to the following provisions:
(i) A hospital shall submit an ICR to the
				Department by 5:00 p.m. on Friday of each week.
(ii) An ICR must:
(A) Be submitted electronically in the form
				and manner established by the Department; and
(B) Report each client admitted to the
				hospital since the last ICR deadline.
(iii) If a hospital fails to timely report a
				client on an ICR, the hospital may not report the client on a subsequent ICR
				unless the client has not yet been discharged from the hospital.
(iv) If a hospital makes a late report of a
				client on an ICR, the Department may reduce, by up to twenty-five percent
				(25%), the Medicaid allowable payment to the hospital for all covered services
				furnished to the client.
(v) If a
				hospital altogether fails to report a client on an ICR, the Department may
				reduce, by up to one hundred percent (100%), the Medicaid allowable payment to
				the hospital for all covered services furnished to the client.
(vi) If a hospital makes a late report of a
				client on an ICR late or altogether fails to report a client on an ICR and,
				nonetheless, the Department pays the hospital the full Medicaid allowable
				payment, the Department may recoup the overpayment pursuant to the procedures
				under Chapter 3 of
Rules, Wyoming Department of Health,
				Medicaid
("the Medicaid Rules").
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 29 - MEDICAID CASE MANAGEMENT › Section 29-4 - Case Management

Current through July 13, 2024
(a) The Department may subject a client to
				case management if the Department determines the client requires assistance in
				using covered services appropriately for any reason, including:
(i) The client appears unfamiliar with the
				Medicaid program or the delivery of services;
(ii) The client has a severe medical problem;
				or
(iii) The client is receiving
				high-cost services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 29 - MEDICAID CASE MANAGEMENT › Section 29-5 - Client Lock-in

Current through July 13, 2024
(a) The Department may lock-in a client if:
(i) The Department determines the client has
				engaged in fraud, theft, or abuse of services pursuant to Chapter 16 of the
				Medicaid Rules; or
(ii) The
				Department receives a referral from another Medicaid program which demonstrates
				that the client has previously engaged in fraud, theft, or abuse of
				services.
(iii) The client is
				receiving high-cost services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 29 - MEDICAID CASE MANAGEMENT › Section 29-6 - Stay of Client Lock-in

Current through July 13, 2024
(a) If a client requests a contested case
				proceeding regarding lock-in pursuant to Chapter 4 of the Medicaid Rules, the
				client lock-in remains in effect during the contested case proceeding unless
				the Department stays the lock-in according to the following provisions:
(i) In order for a stay of the lock-in to be
				granted, the client, client's guardian, or an individual authorized to act on
				the client's behalf, shall submit a written request for a stay to the
				Department concurrent with the request for a contested case proceeding. The
				request for a stay must include a statement regarding the potential impact on
				the client's health and welfare if the lock-in were to remain in
				effect.
(ii) The Department may not
				grant a request for a stay unless the Department finds that the lock-in would
				cause the client irreparable harm.
(iii) If the Department grants a request for
				a stay, the Department may impose whatever conditions it finds necessary to
				protect the health and welfare of the client or the interests of the Medicaid
				program.
(iv) The Department shall
				provide written notice of its decision to grant or deny a request for a stay.
				The written notice must provide the grounds in support of the Department's
				decision.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-1 - Authority

Current through July 13, 2024
(a) The Wyoming Department of Health
				(Department) promulgates this Chapter pursuant to the Wyoming Medical
				Assistance and Services Act at Wyoming Statutes §
									
										42-4-104(a)(iv).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter shall apply to and govern
				Medicaid reimbursement of inpatient hospital services, other than specialty
				services.
(b) The Department may
				issue manuals or bulletins to providers to interpret the sections of this
				Chapter. Such manuals and bulletins shall be consistent with and reflect the
				rules contained in this Chapter. The provisions contained in manuals or
				bulletins shall be subordinate to the sections of this Chapter.
(c) This Chapter is subject to Wyoming
				Medicaid State Plan.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-3 - General Provisions

Current through July 13, 2024
(a) The Department shall use the APR DRGs and
				relative weights developed by 3M Health Information Systems (3M) to assist in
				reimbursement calculations for inpatient hospital services. The Department
				shall update the APR DRG software, and update the version of DRGs assigned for
				reimbursement, as needed.
(b) The
				Department shall calculate reimbursement for all inpatient hospital services
				for Wyoming Medicaid recipients at participating and non-participating Wyoming
				Medicaid enrolled hospitals using a prospective per discharge system based-on
				APR DRGs for acute care services, a per diem-based reimbursement method for
				rehabilitation services, or a percent of billed charges for transplants, as
				applicable.
(c) The Department
				shall designate certain services to be reimbursed based on negotiated rates as
				specialty services. The Department shall notify providers of services that are
				reimbursed as specialty services.
(d) The Department shall distribute
				additional annual supplemental payments to disproportionate share hospitals
				pursuant to Wyoming Medicaid State Plan Attachment 4.19A.
(e) The Department shall distribute Qualified
				Rate Adjustment (QRA) payments to qualifying hospitals pursuant to 4.19A, Part
				1, Addendum 1 of the Wyoming Medicaid State Plan.
(f) The Department shall distribute Private
				Hospital Supplemental (PHS) payments to qualifying hospitals pursuant to
				Wyoming Medicaid State Plan Attachment 4.19A, Addendum 3.
(g) The Department considers the following
				services and providers as exempt from APR DRG reimbursement:
(i) The Department shall continue to
				reimburse rehabilitation claims using a per diem payment.
(ii) The Department shall reimburse eligible
				transplant services at a level that covers the provider's eligible costs as
				calculated using billed charges. The most recently available provider-specific
				cost-to-charge ratios developed annually by the Department as part of the
				Department's Medicaid hospital supplemental payment policy calculations will
				also be used.
(iii) The Department
				may designate certain services to be reimbursed through negotiated rates or
				through other reimbursement methodologies.
(iv) Swing bed services are exempt from the
				APR DRG methodology.
(v) The
				Department shall not allow acute care hospitals to submit interim claims for
				APR DRG services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-4 - Definitions

Current through July 13, 2024
(a) "All Patients Refined Diagnosis Related
				Groups (APR DRGs)." A classification system that classifies inpatient services
				based on their reason for admission, severity of illness, risk of mortality,
				and resources used during treatment.
(b) "Extraordinary circumstances." A
				catastrophic occurrence, beyond the control of a hospital, which results in
				substantially higher costs. An "extraordinary circumstance" includes, but is
				not limited to fire, earthquakes, floods, or other natural disasters.
(c) "Participating Providers." All in-state
				Wyoming providers and out-of state providers that are currently enrolled in the
				Wyoming Medicaid program and/or Wyoming Medicaid providers that received at
				least eight-hundred thousand dollars ($800,000) in cumulative Wyoming Medicaid
				payments for inpatient services during state fiscal years 20152017.
(d) "Present on Admission." A patient's
				health condition as defined by a diagnosis code that was identified at the time
				of a patient's admission to a hospital.
(e) "Rehabilitation Services." Covered
				services furnished to an individual with a primary diagnosis for rehabilitation
				therapy.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-5 - Medicaid Allowable Payment for Inpatient Acute Care Hospital Services

Current through July 13, 2024
(a) The Department shall calculate APR DRG
				base rates using historical claims data with dates of payment in at least two
				of the most recent state fiscal years for which complete data is available as
				the base periods for development. The Department shall:
(i) Assign each certified hospital providing
				inpatient hospital services to Wyoming Medicaid recipients to one of the
				following three base rate categories for APR DRG services:
(A) In-state Level II Trauma providers, for
				which hospital-specific base rates are determined;
(B) In-state free-standing psychiatric
				providers; or
(C) All other
				providers;
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-6 - Payment for Rehabilitation Claims

Current through July 13, 2024
(a) Payment of a rehabilitation claim shall
				include a per diem operating cost payment and a per diem capital cost payment,
				as determined for purposes of the 2010 rehabilitation level of care
				rebasing.
(b) The Department shall
				calculate the allowable cost of each rehabilitation claim for each
				participating hospital using each hospitals' as-filed Medicare cost reports for
				hospital fiscal years ending in state fiscal years 2005 and 2006 and each
				hospitals' inpatient claims paid in state fiscal years 2006 and 2007 (base
				period).
(c) Medical education
				costs are not considered allowable.
(d) The Department shall identify base period
				allowable costs as the sum of routine per diem costs and ancillary service
				costs. The following shall apply to such base period allowable costs:
(i) Base period allowable costs shall be
				inflated forward from the date of service to the midpoint of SFY 2007 using the
				CMS-PPS Hospital Market Basket.
(ii) The Department shall determine the
				number of days of rehabilitation services provided by each hospital from the
				adjusted base period claims data.
(iii) The Department shall calculate a cost
				per day for each hospital for rehabilitation services. The following shall
				apply to such calculations:
(A) For each
				hospital, the Department shall divide total costs for rehabilitation services
				in the base period by total days from the base period claims data.
(B) High and low-cost Medicaid outlier costs
				shall be identified for rehabilitation costs per diem.
(iv) The Department shall determine the base
				period allowable Medicaid cost per diem for rehabilitation services for each
				hospital by subtracting high and low-cost Medicaid outliers from the costs
				determined in subparagraph (A) of this Section.
(v) The Department shall calculate a
				ventilator payment per day for qualifying services not to exceed a fixed amount
				per diem. The ventilator payment shall be calculated as an incremental cost of
				rehabilitation services when a patient is receiving ventilator services. The
				Department shall calculate the ventilator payment per day to reflect the
				difference in resources used to provide rehabilitation services to patients
				with more intensive rehabilitation needs, as measured by an examination of
				prior year's claims, the relative weights for rehabilitation services under the
				Medicare MS-DRG methodology and research about other states' payment
				methodologies.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-7 - Reimbursement of New Hospitals

Current through July 13, 2024
(a) The Medicaid APR DRG base payment rate
				for new hospitals shall be the APR DRG base payment rate for other providers as
				described in Section
				5(c)(i)(C). Rates shall
				remain in effect until the APR DRG system or the rehabilitation per diem
				payment is rebased.
(b) The
				Medicaid rehabilitation payment rate for new hospitals is the average
				rehabilitation per diem payment for all participating providers and includes
				reimbursement for capital costs.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-8 - Reimbursement of Merged Hospitals

Current through July 13, 2024
(a) When two hospitals merge the rate will be
				the APR DRG and rehabilitation payment rates of the surviving hospital and a
				capital payment add on.
(b) The
				capital payment shall be the statewide capital payment per diem
				amount.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-9 - Reimbursement of Capital Costs

Current through July 13, 2024
(a) The Department shall calculate capital
				payment for eligible APR DRG services as follows:
(i) Using the per discharge capital payment
				rate determined for nonrehabilitation levels of care during the 2010 level of
				care rebasing;
(ii) Calculating the
				allowable capital cost for each participating hospital using hospitals'
				as-filed Medicare cost reports for hospital fiscal years ending in state fiscal
				years 2005 and 2006 and hospitals' inpatient claims paid in state fiscal years
				2006 and 2007;
(iii) Calculating a
				capital cost per discharge for each participating hospital by dividing total
				capital costs by total discharges; and
(iv) Arraying the average capital cost per
				discharge of all participating hospitals and selecting the median capital cost
				per discharge for the capital payment rate for all participating
				hospitals.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-10 - Hospital specific levels of care

Current through July 13, 2024
(a) The Department
				shall reimburse the following levels of care using hospital specific payment
				rates, unless reimbursed as specialty services:
(i) Major surgery;
(ii) Intensive care unit ("ICU")/Cardiac care
				unit ("CCU") services/Burn Care.
(iii) Level of care psychiatric services;
				and
(iv) Rehabilitation
				services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-11 - Third Party Liability

Current through July 13, 2024
(a) The Medicaid payment for a claim for
				which third party liability exists shall be the difference between the Medicaid
				allowable payment and the third party payment.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-12 - Preparation and Submission of Cost Reports

Current through July 13, 2024
(a) A hospital shall submit a complete cost
				report to the Medicare intermediary in accordance with Medicare
				requirements.
(b) A hospital shall
				prepare cost reports in conformance with Medicare requirements.
(c) The Department may request, in writing,
				that a hospital submit information to supplement its cost report. The hospital
				shall submit the requested information within 30 days after the date of the
				request.
(d) The failure of a
				hospital to comply with reporting requirements shall immediately result in
				suspension of all Medicaid payments to the hospital.
(i) All Medicaid payments under review shall
				be repaid by the hospital to the Department within ten days of the
				suspension.
(ii) The suspension of
				payments shall continue until the hospital complies with this
				Section.
(iii) Upon the
				Department's receipt of all information required, payments shall be reinstated,
				without interest.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-13 - Rebasing

Current through July 13, 2024
(a) The Department shall rebase operating
				costs when the rates determined no longer meet the requirements of the Social
				Security Act.
(b) The Department
				may update rates based on changes to hospital peer groups, hospital billing
				practices, or changes in hospital operations.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 30 - REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES › Section 30-14 - Partial Eligibility

Current through July 13, 2024
(a) The Department shall maintain a partial
				eligibility policy in which providers may only submit claims for days the
				recipient is an eligible Medicaid recipient.
(b) The claim admit date shall be the actual
				admit date, and the number of days billed to the Department shall include only
				the dates for which the recipient is eligible even if s/he stayed
				longer.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Department of Health
				  pursuant to the Medical Assistance and Services Act at Wyoming Statutes
				  §§
									
										42-4-101
				  through
				  42-4-412.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter has been adopted to govern
				Medicaid reimbursement of specialty services, except as otherwise specified in
				the rules of the Department, and shall apply to all clients and providers for
				all specialty services provided on or after this Chapter's effective
				date.
(b) The Department may issue
				manuals and bulletins to interpret the provisions of this Chapter. Such manuals
				and bulletins shall be consistent with and reflect the policies contained in
				this Chapter. The provisions contained in manuals and bulletins shall be
				subordinate to the provisions of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-3 - General Provisions

Current through July 13, 2024
(a) Terminology. Except as otherwise
				specified in the Rules and Regulations of Wyoming Medicaid, Chapter 1,
				Definitions, or as otherwise specified in this Chapter, the terminology used in
				this Chapter is the standard terminology and has the standard meaning used in
				accounting, health care, Medicaid and Medicare.
(b) General methodology. The Department shall
				reimburse providers of specialty services pursuant to contracts with the
				providers. Except as otherwise specified by contract, selective services shall
				be provided pursuant to this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-4 - Provider Participation

Current through July 13, 2024
(a) Payments only to providers. Except as
				otherwise specified in this Chapter, no provider that furnishes specialty
				services to a recipient shall receive Medicaid funds unless the provider is
				certified, has signed a provider agreement, is enrolled, and has signed a
				contract with the Department.
(b)
				Qualified provider. A provider or group of providers that contracts to provide
				specialty services must meet the criteria that the Department establishes as
				part of the selective contracting process.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-5 - Provider Records

Current through July 13, 2024
(a) A provider shall comply with Chapter 3's
				provider records requirements.
(b)
				Out-of-state records. If a provider maintains financial or medical records in a
				state other than the state where the provider is located, the provider shall
				either transfer the records to an in-state location that is acceptable to the
				Department, or reimburse the Department for reasonable costs, including travel,
				lodging and meals, incurred in performing the audit in an out-of-state
				location, unless otherwise agreed by the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-7 - Medicaid allowable payment for specialty services

Current through July 13, 2024
(a) All-inclusive rate. No additional
				Medicaid reimbursement will be given to providers of specialty services. The
				only remuneration will be as specified in the all-inclusive contract
				rate.
(b) Services that require
				prior authorization or admission certification. The Department may require
				prior authorization or admission certification as a prerequisite to Medicaid
				payment. Failure to obtain prior authorization or admission certification shall
				result in the denial of Medicaid payment.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-8 - Reimbursement of readmissions

Current through July 13, 2024
Medicaid shall not reimburse for a readmission if the
				  readmission is for continuation of treatment begun in the initial admission,
				  and the Department determines that the treatment should have been provided
				  during the initial admission.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-9 - Reimbursement to non-contracting providers

Current through July 13, 2024
(a) Medicaid reimbursement for specialty
				services furnished by non-contracting providers shall be limited to
				reimbursement for services provided in response to an emergency.
(b) The Medicaid reimbursement rate for
				specialty services furnished by a non-contracting provider to a recipient, in
				response to an emergency, shall be the average Medicaid rate paid to
				contracting providers for such services.
(c) Retroactive eligibility. Specialty
				services furnished by a non-contracting provider to an individual that becomes
				eligible for Medicaid after the date of admission, shall be reimbursed at the
				average Medicaid rate paid to a contracting provider for the same or similar
				services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-10 - Third party liability

Current through July 13, 2024
(a) Submission of claims. Claims for which
				third party liability exists shall be submitted in accordance with Chapter
				35.
(b) Medicaid payment. The
				Medicaid payment for a claim for which third party liability exists shall be
				the difference between the Medicaid allowable payment and the third party
				payment. In no case shall the Medicaid payment exceed the payment otherwise
				allowable pursuant to this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-13 - Reconsideration

Current through July 13, 2024
A provider may request reconsideration of a request to
				  recover overpayments pursuant to the provisions of Chapter 16, Medicaid Program
				  Integrity.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 31 - SELECTIVE CONTRACTING OF SERVICES › Section 31-14 - 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 various provisions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 32 - REIMBURSEMENT OF DISPROPORTIONATE SHARE HOSPITALS › Section 32-1 - 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.