reglab/statecodes huggingface dataset:
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 35 - MEDICAID BENEFIT RECOVERY › Section 35-10 - Medicaid Third Party Liability Recovery

Current through July 13, 2024
(a) The Department may not agree to a
				settlement which involves the compromise or release of any portion of the
				federal medical assistance percentage, except as allowed by federal
				law.
(b) Amount of the Department's
				recovery. The Department may recover from any settlement or judgment involving
				a third party payer the full amount of Medicaid funds paid or to be paid on
				behalf of the client because of the injury, illness, or disability for which
				such payments were made.
(i) If the
				Department does not file an independent action or intervene in an existing
				action, the Department shall calculate its reduced lien by deducting:
(A) Thirty-three percent (33%) for attorney's
				fees; and
(B) A proportionate share
				of the reasonable attorney's costs incurred in obtaining the client's recovery.
(I) The Department's proportionate share of
				the reasonable costs incurred in making the client's recovery shall be
				determined by:
(1.) Dividing the amount of
				the Department's recovery (the amount of Medicaid benefits reimbursed minus
				attorney's fees as provided in this Section) by the amount of the client's
				gross recovery; and
(2.)
				Multiplying the determined fraction by the reasonable costs incurred in making
				the recovery.
(II) For
				purposes of this section, "the reasonable attorney's costs incurred in making
				the client's recovery" shall be court costs, costs of litigation, travel costs,
				expert witness fees, deposition expenses, and any other costs necessarily
				incurred in making the recovery. Reasonable costs shall be in the sole
				discretion of the Department and shall not include any items for which the
				client is not also responsible.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 35 - MEDICAID BENEFIT RECOVERY › Section 35-11 - Estate Recoveries

Current through July 13, 2024
(a) Pursuant to W.S. §
									
										42-4-207(c), the Department
				may impose a pre-death lien against a client's real property:
(i) If the client is an inpatient in a
				nursing facility, intermediate care facility for people with intellectual
				disability, or other medical institution; and the client cannot reasonably be
				expected to be discharged from the facility and return home; or
(ii) If the client has been institutionalized
				for ninety (90) days or longer without a discharge plan, it is presumed that
				the client will not be discharged and return home; however, an applicant or the
				client will be provided with a notice of their right to a hearing prior to a
				determination being made that the applicant or the client is permanently
				institutionalized.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 35 - MEDICAID BENEFIT RECOVERY › Section 35-12 - Undue Hardship Waiver

Current through July 13, 2024
(a) Notice of right to request undue hardship
				waiver. At the time the Department imposes a lien or files a probate claim, it
				shall provide written notice by mail to the personal representative or known
				heirs of the right to request an undue hardship waiver.
(b) Request for undue hardship waiver.
(i) Any individual who receives notice
				pursuant to subsection (a) may request an undue hardship waiver.
(ii) A request for an undue hardship waiver
				shall be mailed to the Department by certified mail, return receipt requested,
				within thirty-three (33) days of the date of the Department's notice pursuant
				to subsection (a). The request shall include documentation that the decedent's
				home is part of the estate, that the decedent's home is part of a business,
				including a working farm or ranch, show that recovery of the home would result
				in the heirs or beneficiaries losing their means of making a living, and
				provide other relevant documentation upon the Department's request. The failure
				to provide the information required by this paragraph with the request shall
				result in the dismissal with prejudice of the undue hardship waiver
				request.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 35 - MEDICAID BENEFIT RECOVERY › Section 35-13 - Incorporation by Reference

Current through July 13, 2024
(a) For any code, standard, rule, or
				regulation incorporated by reference in this rules:
(i) The Department has determined that
				incorporation of the full text in these rules would be cumbersome or
				inefficient given the length or nature of the rules:
(ii) The incorporation by reference does not
				include any later amendments or editions of the incorporated matter beyond the
				applicable date identified in subsection (b) of this section; and
(iii) The incorporated code, standard, rule,
				or regulation is maintained at the Department and is available for public
				inspection and copying at cost at the same location.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-2 - Purpose and Applicability

Current through July 13, 2024
This Chapter establishes the scope of administrative
				  transportation covered by Medicaid and the methods and standards of reimbursing
				  for such services. Any person, facility, or agency that furnishes
				  transportation and seeks Medicaid reimbursement for doing so shall be subject
				  to these rules. This Chapter shall apply to all administrative transportation
				  provided on or after its effective date.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-3 - General Provisions

Current through July 13, 2024
(a) The Department may issue manuals or
				bulletins to providers or other affected parties to interpret the provisions of
				this Chapter. Such manuals and bulletins shall be consistent with and reflect
				the policies contained in this Chapter. The provisions contained in manuals or
				bulletins shall be subordinate to the provisions of the Wyoming Medicaid
				Rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-4 - Definitions

Current through July 13, 2024
Except as otherwise specified in Chapter 1 or this Chapter,
				  the terminology used is the standard terminology and has the standard meaning
				  used in healthcare, Medicaid, and Medicare.
(a) "Ambulance." An ambulance as defined by
				Chapter 15.
(b) "Department of
				Transportation (DOT)." The Wyoming Department of Transportation, its agent,
				designee or successor.
(c) "Excess
				payments." Medicaid funds received by a provider, to which the provider is not
				entitled for any reason, including payments which exceed the Medicaid allowable
				payment. "Excess payments" includes, but is not limited to:
(i) Overpayments;
(ii) Payments made as a result of system
				errors;
(iii) Payments for services
				furnished to an individual that is not a client;
(iv) Payments for non-covered services
				furnished to a client;
(v) Payments
				for services which are not documented or supported by medical records or
				financial records;
(vi) Payments
				for services for which admission certification has been denied or
				withdrawn;
(vii) Payments which
				exceed a provider's usual and customary charge, unless otherwise permitted by
				the Department's rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-6 - Reimbursable transportation expenses

Current through July 13, 2024
(a) Ambulance transportation. Transportation
				in an ambulance is a covered service as specified in Chapter 15.
(b) Administrative transportation to and from
				a medical appointment is reimbursable if:
(i)
				The covered services furnished to the client at the medical appointment are
				medically necessary;
(ii)
				Transportation has been approved by the Department at least three working days
				in advance of the necessary transportation; and
(iii) The transportation is the least costly
				mode of transportation selected and approved by the Department pursuant to
				subsection (c).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-7 - Excluded transportation expenses

Current through July 13, 2024
The following transportation expenses are not
				  reimbursable:
(a) Transportation to
				receive services which are not covered services;
(b) Transportation of a family member or
				friend to visit a client or consult with the client's physician or other
				provider of medical services, unless the transportation is to visit a client
				under age twenty-one and the visit is medically necessary;
(c) Transportation to pick up
				pharmaceuticals;
(d) Transportation
				of a resident of a nursing facility to receive services that are available at
				the nursing facility;
(e)
				Transportation of a client in response to detention ordered by a court or law
				enforcement agency;
(f)
				Transportation to receive covered services from a provider because another
				provider has denied services to the client due to the client's refusal to
				follow medical advice or the client's unacceptable conduct;
(g) Missed appointments. If a client misses
				or cancels a medical appointment for which Medicaid reimbursement has been pain
				pursuant to this rule, the client shall refund the cost of the appointment to
				the Department within fifteen days of the missed appointment (unless the
				medical appointment has been rescheduled). Medicaid funds that are not refunded
				shall be considered excess payments and may be recovered pursuant to Section
				12.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-8 - Procedures for obtaining reimbursement

Current through July 13, 2024
(a) Request for reimbursement. A client
				wishing to receive reimbursement for administrative travel shall contact the
				Department and request reimbursement. The request may be oral or written. The
				client shall furnish information as requested by the Department and complete
				the Department's required documentation.
(b) Payment. Payment shall be by warrant
				issued to the client or other payee.
(c) Reimbursement request and certification.
				After the client or other payee submits a request for administrative
				transportation, the client or payee shall sign the reimbursement request and
				certification and return it to the Department. Reimbursement requests and
				certifications shall become part of the client's file and be retained by the
				Department.
(d) Reimbursement to
				enrolled providers. Providers of lodging, taxi or non-taxi transportation
				services may enroll with the Wyoming Medicaid Program to be reimbursed for
				covered transportation services directly by Wyoming Medicaid.
(e) Provider Payment. Providers shall submit
				all claims to Wyoming Medicaid and reimbursement will be according to Wyoming
				Medicaid reimbursement rates for the covered procedure codes billed on the
				submitted claim as published in the Wyoming Medicaid Fee Schedule.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-9 - Prior authorization

Current through July 13, 2024
(a) Prior authorization of administrative
				transportation shall be governed by the prior authorization requirements of
				Chapter 3.
(b) All administrative
				transportation requires prior authorization.
(i) In deciding whether to authorize
				administrative transportation, the Department shall consider the:
(A) Cost of the transportation;
(B) Potential for over-utilization of the
				transportation;
(C) Availability of
				lower cost alternatives; and
(D)
				Excess payments owed by the client.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-10 - Allowable Medicaid reimbursement

Current through July 13, 2024
(a) Medicaid reimbursement for administrative
				transportation shall be as follows:
(i)
				Reimbursement to a client shall be by one of the following methods:
(A) Prospective reimbursement. The client may
				be reimbursed for projected administrative transportation expenses.
(B) Retroactive reimbursement. The client may
				be reimbursed for actual administrative transportation expenses.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-13 - Reconsideration

Current through July 13, 2024
(a) A provider or client may request that the
				Department reconsider a decision to recover excess payments or overpayments.
				The request for reconsideration, the reconsideration, and any administrative
				hearing shall be pursuant to the reconsideration provisions of Chapter
				3.
(b) Reconsideration shall be
				limited to whether the Department has complied with the provisions of this
				Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-15 - Administrative hearing

Current through July 13, 2024
(a) Clients. A client may request an
				administrative hearing pursuant to Chapter 4 regarding the termination,
				reduction or denial of covered services.
(b) Procedures. A request for an
				administrative hearing shall be made in conformance with Chapter 4, and the
				hearing shall be held pursuant to Chapter 4.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 36 - ADMINISTRATIVE TRANSPORTATION › Section 36-18 - 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 the 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 37 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 37-1 - Authority

Current through July 13, 2024
(a) The Wyoming Department of Health
				(Department) promulgates this Chapter pursuant to the Medical Assistance and
				Services Act at Wyoming Statutes
				42-4-101 through -124.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 37 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 37-2 - Purpose and Applicability

Current through July 13, 2024
(a) The Department adopts this Chapter to
				establish the Wyoming Medicaid requirements and reimbursement for services
				provided in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics
				(RHCs), as defined in 42
				U.S.C. §
										1396d(l)(2).
(b) This Chapter applies to all clients and
				providers for all Medicaid-covered services furnished in FQHCs and
				RHCs.
(c) The Department may issue
				manuals and bulletins to interpret 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 this
				Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 37 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 37-3 - Definitions

Current through July 13, 2024
Except as otherwise specified in Wyoming Medicaid Rules
				  Chapter 1, or as defined herein, the terminology used in this Chapter is the
				  standard terminology and has the standard meaning used in healthcare, Medicaid,
				  and Medicare.
(a) "Base period" means
				FQHC or RHC fiscal years 1999 and 2000; if a FQHC or RHC provided services for
				only one (1) fiscal year, that year shall be used as the "base
				period."
(b) "Medicare Economic
				Index (MEI)" means the measure of practice cost inflation used to estimate
				annual changes in physicians' operating costs and earnings levels.
(c) "Visit" means a face-to-face encounter
				between a FQHC or RHC client and a FQHC or RHC professional staff member for
				the purpose of providing FQHC or RHC services. Telehealth visits are considered
				face-to-face visits.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 37 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 37-4 - Provider Enrollment and Participation

Current through July 13, 2024
In order to receive Medicaid reimbursement for furnishing
				  services to a client, a FQHC or RHC shall be an enrolled Medicaid provider and
				  in compliance with requirements for Medicaid participation in accordance with
				  Wyoming Medicaid Rules Chapter 3.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 37 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 37-5 - Reimbursable Services

Current through July 13, 2024
(a) FQHC and RHC reimbursable services are
				outpatient services that occur during an eligible visit and include:
(i) Physician services;
(ii) Nurse practitioner, physician's
				assistant, and certified nurse midwife services;
(iii) Behavioral health services provided
				pursuant to Wyoming Medicaid Rules Chapter 13 by providers licensed to provide
				such services;
(iv) Preventive
				primary care services;
(v) Dental
				services;
(vi) Vision
				services;
(vii) Audiology
				services;
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 37 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 37-6 - General Reimbursement Methodology

Current through July 13, 2024
(a) Base period allowable costs are
				considered to be reasonable costs which are related to providing covered
				services during the base period as determined pursuant to
				42 U.S.C.
				1396a(bb)(2). Graduate
				medical education costs shall be allowable costs for qualifying FQHCs and RHCs
				and shall be determined pursuant to
				42 C.F.R. §
										405.2468(f), except that the
				calculation shall be based on the FQHC's or RHC's Medicaid costs rather than
				Medicare costs.
(b) In accordance
				with 42 U.S.C. §
										1396a(bb) the Department
				shall reimburse FQHCs and RHCs for covered services using a prospective payment
				system based on each FQHC's or RHC's base period costs for that calendar year,
				per visit, inflated forward using the MEI, and adjusted for changes in
				services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 37 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 37-7 - Medicaid Allowable Payment for Services Furnished on or After January 1, 2001

Current through July 13, 2024
(a) The Department shall reimburse for
				covered services provided to clients in a FQHC or RHC using a prospective
				payment rate determined pursuant to this Chapter.
(b) The Department shall establish a separate
				payment rate for each FQHC and RHC. The rate shall be determined using the base
				period Medicaid allowable costs, which are calculated as follows:
(i) The Department shall calculate a per
				visit cost for each FQHC and RHC for the FQHC's and RHC's 1999 and 2000 fiscal
				years. A fiscal year shall be the twelve (12) month period used by a FQHC or
				RHC for accounting and tax purposes.
(ii) The Medicaid baseline rate (rate
				established using the base period for each FQHC and RHC) with 1999 and 2000
				fiscal year data shall be determined by calculating a per visit rate (total
				allowable costs divided by total patient visits) for fiscal years 1999 and
				2000; adding the two (2) rates together; and dividing the sum by two
				(2).
(iii) The Medicaid baseline
				rate for each FQHC and RHC with only 2000 fiscal year data shall be determined
				by calculating a per visit rate (total allowable costs divided by total patient
				visits) for fiscal year 2000.
(iv)
				Scope of service changes for baseline rate.
(A) An FQHC or RHC which desires an
				adjustment to its baseline rate due to an increase or decrease in its scope of
				service shall:
(I) Notify the Department, in
				writing, of the increase or decrease; and
(II) Submit a settled Medicare Cost Report
				which documents the change in services and substantiates the costs associated
				with that change.
(B) The
				Department shall assess the information provided and shall determine if a rate
				change is warranted and the amount of any such change. Those determinations
				shall be based upon:
(I) The nature of the new
				or discontinued service regarding the type, intensity, duration, and amount of
				services. A change in the cost of a service is not considered in and of itself
				a change in the scope of services; and
(II) The reasonableness of the FQHC's or
				RHC's costs.
(C) The
				Department may request that the FQHC or RHC provide additional information to
				document the change in service. The information shall be provided before the
				Department is obligated to consider the FQHC's or RHC's request.
(v) The per visit rate calculated
				pursuant to this Section, as adjusted for changes in scope of service pursuant
				to this Section, shall be the FQHC's or RHC's baseline rate for services
				provided on or after January 1, 2001, and shall be the basis for future rate
				determinations.
(vi) For any FQHC
				or RHC that was not in operation during 1999 or 2000 fiscal years, refer to
				Section 7.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 37 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 37-8 - Medicaid Allowable Payment for New Providers

Current through July 13, 2024
(a) A provider that qualifies as a FQHC or
				RHC after September 30, 1999, must submit a settled or "as filed" Medicare Cost
				Report to the Department, which will serve as the basis for the provider's rate
				calculation. Upon submission of a settled or an "as filed" Medicare Cost Report
				a visit rate will be calculated as described by the cost formula in Section
				7.
(b) If the FQHC or RHC does not have a
				settled or an "as filed" Medicare Cost Report, the provider shall submit cost
				information to the Department for services previously provided indicating
				estimates for its next fiscal year and the number of patients and services it
				expects to offer during that period.
(c) The Medicaid allowable payment for a new
				provider shall be an interim visit rate equal to one hundred (100) percent of
				the reasonable costs used in calculating the rates of FQHCs or RHCs with
				similar caseloads located in the state during the same facility fiscal year,
				adjusted by the percentage increase in MEI, as described by the cost formula in
				Section 7. Interim visit rates
				will be specific to each provider type: Independent RHCs, Hospital-based RHCs,
				and FQHCs.
(i) If there are no FQHCs or RHC's
				with similar caseloads, the Medicaid allowable payment for a new provider shall
				be an interim visit rate equal to the Medicaid statewide average visit rate for
				the calendar year, adjusted by the percentage increase in MEI, as described by
				the cost formula in Section
				7. Interim visit rates will be specific to
				each provider type: Independent RHCs, Hospital-based RHCs, and FQHCs.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 37 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 37-9 - Medicaid Allowable Payment for Out-of-State FQHCs and RHCs

Current through July 13, 2024
(a) The Medicaid allowable payment for
				out-of-state FQHCs and RHCs shall be the statewide average Medicaid allowable
				payment in effect in Wyoming as of October 1st of that year.
(b) The statewide average Medicaid allowable
				payment shall not be affected by a subsequent change in a FQHC's or RHC's
				rate.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter shall apply to and govern
				the furnishing of inpatient psychiatric services for individuals under age
				twenty-one (21) in psychiatric residential treatment facilities (PRTFs) as
				defined by 42 C.F.R. §
										483.354.
(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 bulletins shall be subordinate to the provisions of this
				Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-3 - Definitions

Current through July 13, 2024
Except as otherwise specified in Medicaid Rules Chapter 1,
				  the terminology used in this Chapter is the standard terminology and has the
				  standard meaning used in healthcare, Medicaid, and Medicare.
(a) "Certification of need for services." A
				certification pursuant to Section
				8 that meets the requirements of
				42 C.F.R. §§
										441.152-.153, which requirements are
				incorporated by this reference.
(b)
				"Chapter" used herein refers to the specified Chapter in the Wyoming Department
				of Health, Medicaid Rules.
(c)
				"COA." The Council on Accreditation for Children and Family Services.
(d) "Facility." A PRTF which has been
				certified by the Centers for Medicare and Medicaid Services (CMS) pursuant to
				42 C.F.R
				483.354 and also maintains compliance with
				the conditions of participation found at 42 C.F.R Subpart G.
(e) "Financial Report." A report of a
				facility's costs for a specified fiscal period prepared and submitted in the
				form and manner specified by the Department. Financial report includes any
				supplemental request by the Department for additional information relating the
				facility's costs.
(f) "Foster
				home." A home certified by the Wyoming Department of Family Services (DFS) as a
				foster home.
(g) "Group Home." An
				institution certified by DFS as a group home.
(h) "Individual written plan of care (plan of
				care)." A written treatment plan, prepared by an interdisciplinary team, that
				meets the requirements of 42
				C.F.R. §
										441.155, except that the plan
				must be completed within fourteen (14) calendar days of an individual's
				admission to the facility.
(i)
				"Usual and customary per diem charge." A provider's per diem charge for
				comparable services provided to non-Medicaid recipients other than persons
				eligible for payment on a reduced or sliding fee schedule.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-4 - Provider participation

Current through July 13, 2024
(a) Except as otherwise specified in this
				Chapter, no facility that furnishes covered services to a recipient shall
				receive Medicaid funds unless the provider has signed a provider agreement, and
				is enrolled.
(b) Compliance with
				Medicaid Rules Chapter 3, Provider Participation. A facility that wishes to
				receive Medicaid reimbursement for covered services furnished to a recipient
				must meet the provider participation requirements of Medicaid Rules Chapter
				3.
(c) Additional provisions.
(i) A PRTF must be certified. In-state PRTFs
				shall be certified by the Division of Healthcare Financing in conjunction with
				Healthcare Licensing and Surveys and CMS approval. Out-of-state PRTFs shall be
				certified by their own state's licensing and survey agency and CMS.
(ii) A PRTF shall be licensed. For in-state
				PRTFs, a PRTF shall be licensed by the State of Wyoming, Department of Family
				Services. For out-of-state PRTFs, a PRTF shall be licensed by that state's
				licensing authority.
(iii) A PRTF
				shall have one of the following accreditations: JCAHO, CARF, COA, or any other
				accrediting organization with comparable standards recognized by the
				State.
(iv) No facility shall
				become a provider or receive Medicaid funds for services furnished before the
				date on which an authorized individual signs an attestation letter which meets
				the requirements regarding restraint, seclusion, and death reporting policies
				of 42 C.F.R. §
											441.51 and 42 C.F.R. Subpart G.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-8 - Prior authorization

Current through July 13, 2024
(a) Prior authorization of PRTF services
				shall be governed by Medicaid Rules Chapter 3, Provider
				Participation.
(b) All inpatient
				psychiatric services for individuals under age twenty-one (21) furnished in a
				facility shall be prior authorized.
(c) The failure to obtain prior authorization
				shall result in the denial of Medicaid payment for the service.
(d) The facility shall submit a request for
				prior authorization in the manner specified by the Department before the
				submission of a claim for such services. The Department may request, and the
				facility shall provide additional information as necessary to review the plan
				of care.
(e) Reauthorization. The
				physician or the interdisciplinary team must review and reauthorize the
				client's plan of care every seven (7) to thirty (30) days. Reauthorized plans
				of care are subject to the prior authorization provisions of this
				Section.
(f) For the court ordered
				placement of a client in a PRTF, after a clinical review and determination that
				the PRTF placement no longer meets the medical necessity criteria outlined in
				Section 7, a transition period
				of up to thirty (30) days may be authorized permitting time for the necessary
				court hearings, MDT meetings and court orders to be updated. Upon expiration of
				an approved transitional period, no further reimbursement shall be
				authorized.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-10 - Educational services

Current through July 13, 2024
Education services shall be provided and reimbursed in
				  accordance with Chapter 14 of the Wyoming Department of Education Rules,
				  Education Program Approval of Public and Private Institutions Receiving State
				  Funds For the Education Costs of Students Placed by a Court Order.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-11 - Excluded services

Current through July 13, 2024
The following services are not Medicaid reimbursable when
				  provided in a PRTF:
(a) Services
				provided in an emergency;
(b)
				Services provided pursuant to a physician's standing orders; and
(c) Acute psychiatric services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-12 - Out-of-state facilities

Current through July 13, 2024
Covered services provided in a facility located outside of
				  Wyoming shall be Medicaid reimbursable to the same extent as services provided
				  in a facility inside Wyoming.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-13 - Medicaid allowable payment for covered services

Current through July 13, 2024
(a) The Department reimburses for covered
				services provided to clients under age twenty-one (21) using an all-inclusive
				per diem rate determined pursuant to this Section.
(b) The rates shall be established by the
				Department of Health based on reasonable, actual costs for services and
				treatment of residents in the PRTF. Rates are provider-specific, all-inclusive
				for room and board and the treatment services specified in the treatment
				plan.
(c) Reported PRTF costs and
				adjustments are used to develop the data set to calculate the room and board
				and licensed treatment rate components.
(i)
				Reported costs and days data from providers using Medicaid's PRTF cost
				report.
(ii) Reported costs are
				adjusted to standardize data for analysis and to remove non-allowable
				costs.
(iii) Administrative cost
				adjustments occur.
(iv) Adjustments
				to reported days occur.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-14 - Preparation and submission of financial reports

Current through July 13, 2024
(a) Each facility shall submit a complete
				financial report in accordance with the instructions of the
				Department.
(b) Submission of
				additional information. The Department may request, in writing, that a facility
				submit information to supplement its financial report. The facility shall
				submit the requested information within thirty (30) days after the date of the
				request.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-16 - Title IV-E clients

Current through July 13, 2024
(a) Title IV-E of the Social Security Act
				(42 U.S.C. §§
										671-679b) is a funding stream for foster care
				costs. It provides for federal reimbursement for a portion of the maintenance
				and administrative costs of foster care for children who meet specified federal
				eligibility requirements.
(b)
				Wyoming Medicaid clients on a Title IV-E adoption program and placed in a PRTF
				out of state shall transfer to the receiving state's Medicaid program. 45
				C.F.R. Part 1356 redefines the client's residency to that of the receiving
				state. Therefore, the receiving state's Medicaid program shall be notified of
				the placement by Wyoming Medicaid's Utilization Management vendor.
(c) If the receiving state refuses to accept
				the transfer of Medicaid coverage, the Wyoming Department of Health shall
				maintain primary clinical and placement oversight and coverage responsibility
				as determined medically necessary.
(d) Wyoming Medicaid's Utilization Management
				vendor shall engage in an agreement with the admitting facility to remain
				involved in the treatment and progress of the client in order to certify
				ongoing medical necessity of the placement.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-17 - Third-party liability

Current through July 13, 2024
(a) Claims for which third-party liability
				exists shall be submitted in accordance with Medicaid Rules Chapter 35,
				Medicaid Benefit Recovery.
(b) 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 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-18 - On-Site Compliance Review

Current through July 13, 2024
(a) All enrolled PRTFs shall be subject to
				the On-Site Compliance Review (OSCR) which monitors a PRTF's overall operations
				for compliance with state and federal conditions of participation as referenced
				in Section
				4, as well as evaluate the quality of
				clinical programs and services.
(b)
				An OSCR may be conducted at any time, and may be conducted as a partial
				off-site (review of records) and partial on-site (facility tour and
				staff/resident interviews) compliance review. An interim review may be
				scheduled at any time at the discretion of the Department to address specific
				concerns.
(c) OSCR Ratings:
(i) Probation. A PRTF receiving this rating
				shall be subject to the following actions by the Department:
(A) A hold on new admissions;
(B) Youth transfers shall be
				considered;
(C) Guardian
				notifications of PRTF ratings shall be initiated for all Wyoming Medicaid
				clients receiving services from the PRTF; and
(D) Notification of facility rating shall be
				provided to the PRTF's licensing and survey authority and the PRTF's Board of
				Directors.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-19 - Audits

Current through July 13, 2024
(a) The Department, the Medicaid Fraud
				Control Unit (MFCU), or CMS may audit a provider's financial records or medical
				records at any time to determine whether the provider received excess payments
				or overpayments. An audit may be a desk review or a field audit.
(b) The Department, MFCU, or CMS may perform
				audits through employees, agents, or a third party. Audits shall be performed
				in accordance with generally accepted auditing standards.
(c) Disallowances. The Department shall
				recover excess payments or overpayments pursuant to Section
				18 of this Chapter.
(d) Reporting audit results. If, at any time,
				during a financial audit or medical audit, the Department discovers evidence
				suggesting fraud or abuse by a provider, that evidence, in addition to the
				Department"s final audit report regarding that provider, shall be referred to
				the MFCU.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-21 - Reconsideration

Current through July 13, 2024
A provider may request that the Department reconsider a
				  decision to recover excess payment or overpayments. The request for
				  reconsideration, the reconsideration, and any administrative hearing shall be
				  pursuant to the reconsideration provisions of Medicaid Rules Chapters 16,
				  Program Integrity and 4, Administrative Hearings.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-1 - 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. §
									
										42-4-101
et seq.
and
				  the Wyoming Administrative Procedures Act at W. S. §
									
										16-3-101
et
				  seq
.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter
				shall apply to and govern Medicaid services provided under the Wyoming Medicaid
				Adult Developmental Disabilities Home and Community Based Waiver on or after
				June 1, 2006.
(b) The provisions
				contained in this Chapter shall be subordinate to the provisions in the Wyoming
				Medicaid Adult Developmental Disabilities Home and Community Based Waiver
				submitted to the Centers for Medicare and Medicaid Services pursuant to Section
				1915(c) of the Social Security Act codified as
				42 U.S.C. §
										1396 n.
(c) The Division may issue Provider Manuals,
				Provider Bulletins, or both, to providers and/or other affected parties to
				interpret the provisions of this Chapter. Such Provider Manuals and Provider
				Bulletins shall be consistent with and reflect the policies contained in this
				Chapter. The provisions contained in Provider Manuals or Provider Bulletins
				shall be subordinate to the provisions of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-3 - General Provisions

Current through July 13, 2024
(a) Terminology.
				Except as otherwise specified, the terminology used in this Chapter is the
				standard terminology and has the standard meaning used in accounting, health
				care, Medicaid, and Medicare.
(b)
				Methodology. This Chapter establishes a person-centered methodology that is
				designed to match the needs of a participant with the services appropriate to
				meet those needs. Accordingly, participants with higher needs shall be assigned
				higher budget amounts that will allow them to select and access the services
				appropriate for their needs. By contrast, participants with lower needs shall
				be assigned lower budget amounts that will allow them to select and access the
				services they need.
(c) This
				Chapter is intended to be read in conjunction with the Wyoming Medicaid Adult
				Developmental Disabilities Home and Community Based Waiver submitted to the
				Centers for Medicare and Medicaid Services pursuant to Section 1915(c) of the
				Social Security Act, Chapter 44, Rules for Environmental Modifications and
				Specialized Equipment of the Medicaid Rules, Chapter 45, Provider Standards and
				Certification of the Medicaid Rules, and Chapter 1, Rules for
				Individually-selected Service Coordinators of the Rules of the Developmental
				Disabilities Division.
(d) Unless
				otherwise specified, the incorporation by reference of any external standard is
				intended to be the incorporation of that standard as it is in effect on the
				effective date of this Chapter, including any applicable amendments,
				corrections, or revisions, but excluding any subsequent amendments or
				changes.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-5 - Philosophy

Current through July 13, 2024
(a) All persons possess inalienable rights
				under the Constitutions of the United States and the State of Wyoming. Persons
				with developmental disabilities also possess the rights outlined in the
				Developmental Disabilities Assistance and Bill of Rights Act of 2000,
				42 U.S.C. §
										15001, and which are included as Appendix A
				to this Chapter.
(b) It is the
				philosophy of the Division to develop reasonable and enforceable rules for the
				provision of services to individuals with developmental disabilities in
				community settings in lieu of unnecessary institutionalization. This philosophy
				is mandated in the Supreme Court ruling on
Olmstead v. L.C ex rel.
				Zimring,
527 U.S.
				581 (1999).
(c) This Chapter is designed not only to
				support the philosophy of community-based services but to also protect the
				health, welfare, and safety of participants.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-6 - Assessment and Eligibility

Current through July 13, 2024
(a) Eligibility
				under this Chapter is limited to persons who complete the application process
				and who meet the following requirements for clinical eligibility and financial
				eligibility. In addition, in order to be eligible for the waiver all persons
				shall be:
(i) A United States Citizen as
				determined by the Department of Family Services.
(ii) A resident of Wyoming as determined by
				the Department of Family Services.
(iii) 21 years of age or older.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-7 - Covered Services, Service Requirements, and Restrictions

Current through July 13, 2024
(a)
				The services listed in this section are covered services if they are
				functionally necessary and part of a current individual plan of care approved
				by the Division.
(i) Case management
				services.
(A) Case management is a stand
				alone service. A participant (or guardian, if applicable) may choose any
				individually-selected service coordination provider, and shall not be expected
				or required to receive any other service from that provider.
(B) Individually-selected service
				coordinators shall be required to provide a minimum of 60 minutes per calendar
				month of person-to-person contact with the participant or guardian.
(I) This may include face-to-face meetings
				and telephone conversations between the individually-selected service
				coordinator, the participant, and/or the guardian.
(II) Individually-selected service
				coordinators shall be required to complete one monthly visit to participant in
				his or her home.
(C)
				Individually-selected service coordinators shall schedule and facilitate six
				month review team meetings and annual individual plan of care meetings,
				including:
(I) Notifying all individual plan
				of care team members of the scheduling of the meetings at least 30 days in
				advance unless a shorter notification time is approved by the
				Division.
(II) Notifying the
				Division in writing of the scheduling of the meetings at least 30 days in
				advance unless a shorter notification time is approved by the
				Division.
(III) Following Division
				requirements for facilitating team meetings; and for documenting minutes of the
				team meetings in the form and manner prescribed by the Division in provider
				manuals and bulletins issued by the Division.
(D) Individually-selected service
				coordinators shall facilitate other team meetings when requested by the
				participant, guardian, member of the team, or the Division.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-8 - The Individualized Budget Amount

Current through July 13, 2024
(a) Eligibility
				shall be determined pursuant to Section
				6 of
				this Chapter before an individualized budget amount is determined.
(b) Determination of the targeted
				individualized budget amount.
(i) The
				Division's methodology to determine the amount of Medicaid waiver funds that
				shall be available to a participant to meet his or her needs shall include the
				following factors:
(A) The services the
				participant has received in the past or that are determined by projected
				services.
(B) Participant
				characteristics, including the participant's needs, as measured on the
				Inventory for Client and Agency Planning, and
(C) Economic factors, such as the cost of
				receiving services in different geographical areas or where the participant
				resides.