reglab/statecodes huggingface dataset:
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-10 - Reassessments

Current through July 13, 2024
A participant shall be reassessed for clinical eligibility
				  at least every five years, and more frequently at the option of the Division.
				  The reassessment shall include a review of the Inventory for Client and Agency
				  Planning and the psychological evaluation.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-11 - Transitions

Current through July 13, 2024
(a) Participants and/or guardians shall have
				the right to informed choice in providers and services.
(b) Participants and/or guardians may choose
				to change individually-selected service coordinators pursuant to Chapter 1,
				Rules for Individually-selected Service Coordinators of the Rules of the
				Developmental Disabilities Division.
(c) Participants may choose to change any
				providers, other than individually-selected service coordinators, anytime
				during the plan year pursuant to Chapter 45, Section
				11.
(d) Applicants for the waiver may
				change individually-selected service coordinators at any time during the
				application process.
(e) When a
				participant or guardian chooses to change providers, they shall inform the
				individually-selected service coordinator of the decision. The
				individually-selected service coordinator shall then complete the required
				steps pursuant to Chapter 45, Section
				11.
(f) If a provider providing
				residential services to a participant requires a participant to move to another
				residential location, the provider and participant's individually selected
				service coordinator shall complete the required steps pursuant to Chapter 45,
				Section
				11.
(g) Providers who are terminating
				services with a participant shall notify the participant/guardian in writing at
				least 30 days prior to ending services unless a shorter transition period is
				approved in advance by the Division. Failure to provide services during this 30
				day period shall be considered abandonment of services and may result in
				decertification of the provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-12 - Extraordinary Care Committee

Current through July 13, 2024
(a) The
				Extraordinary Care Committee has the following authority:
(i) Determining if a funding request for an
				emergency case or an emergency referral shall be funded.
(ii) Determining if a funding request due to
				a material change in circumstance, a potential emergency, or other condition
				justifying an increase in funding shall be funded.
(iii) Approving or denying rates for services
				that are not commensurate with the average rates as defined in the Adult DD
				Waiver document approved by Centers for Medicare and Medicaid
				Services.
(iv) Approving rate
				changes due to increased or decreased funding from legislative appropriations
				or under utilization of approved individualized budgeted amounts.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-13 - Waiting List Process

Current through July 13, 2024
(a) Waiting List.
				When there is insufficient funding to add additional participants, the Division
				shall maintain one waiting list for the Adult DD Home and Community Based
				Waiver as specified below.
(b)
				Factors. The Division shall assign two rankings to each person on the waiting
				list based on the following two factors:
(i)
				The severity of the person's condition based on the Inventory for Client and
				Agency Planning according to the service score.
(ii) The person's placement date on the
				waiting list.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-14 - Emergency Services

Current through July 13, 2024
(a) The emergency
				criteria used by the Division includes:
(i) A
				substantial threat to a person's life or health caused by:
(A) The loss of the person's primary
				caregiver.
(B)
				Homelessness.
(C) Abuse or neglect
				that is either substantiated by the Wyoming Department of Family Services or
				corroborated by the Division or Protection and Advocacy of Wyoming.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-15 - Provider Participation

Current through July 13, 2024
(a) Payments only
				to providers. No person or entity that furnishes covered services to a
				participant shall receive Medicaid funds unless the person or entity has signed
				a provider agreement, is enrolled, and is certified by the Division as a
				provider at the time of service delivery.
(b) Compliance with Chapter 3, Provider
				Participation, of the Wyoming Medicaid Rules. A provider that wishes to receive
				Medicaid reimbursement for services furnished to a participant shall meet the
				provider participation requirements of Chapter 3, Provider Participation, of
				the Wyoming Medicaid Rules, Sections
				4
				through
				6,
				which are incorporated by this reference.
(c) Compliance with Chapter 45, Provider
				Certification and Sanctions, of the Wyoming Medicaid Rules. A provider that
				wishes to provide Waiver services shall also meet the applicable criteria for
				Division certification set forth in Chapter 45, which is incorporated by this
				reference.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-16 - Provider Records

Current through July 13, 2024
(a) A provider
				shall comply with Chapter 3, Provider Participation, of the Wyoming Medicaid
				Rules, Section
				7,
				which is incorporated by this reference.
(b) Individually-selected service
				coordinators shall maintain copies of documentation from other providers for a
				twelve month period.
(c) For
				documentation of case management services, individually-selected service
				coordinators shall comply with Chapter 3, Section
				7,
				which is incorporated by this reference.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-19 - Excluded Services

Current through July 13, 2024
(a) Services not
				covered under the waiver include:
(i)
				Services furnished to a participant while in an institution.
(ii) Room and board of participant; which are
				the responsibility of the participant or representative payee.
(iii) Room and board expenses of a live-in
				personal caregiver or provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-20 - 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 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-22 - Recovery of Excess Payments or Overpayments

Current through July 13, 2024
(a) The
				Department may recover excess payments pursuant to Chapter 39.
(b) The Department may recover overpayments
				pursuant to Chapter 16.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-23 - Audits

Current through July 13, 2024
(a) The Division or the Centers for Medicare
				and Medicaid Services may audit a provider's financial records, medical
				records, or employment records, at any time to determine whether the provider
				has received excess payments or overpayments.
(b) The Division or the Centers for Medicare
				and Medicaid Services may perform audits through employees, agents, or through
				a third
-
party. Audits shall be performed in accordance
				with generally accepted auditing standards.
(c) Disallowance. The Division shall recover
				excess payments or overpayments pursuant to Section
				22
				of this Chapter.
(d) Reporting
				audit results. If at anytime during a financial audit or a medical audit, the
				Division discovers evidence suggesting fraud or abuse by a provider, that
				evidence, in addition to the Division's final audit report regarding that
				provider, shall be referred to the Medicaid Fraud Control Unit.
(e) The Division shall share the results of
				the audit with the provider before excess payments or overpayments are
				recovered. However, nothing in this section shall abrogate the rights of the
				State to recover excess payments or overpayments in accordance with Chapter 16
				or Chapter 39.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-24 - Reconsideration

Current through July 13, 2024
A provider 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, Chapter 16 or Chapter
				  39 as applicable.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-26 - Interpretation of Chapter

Current through July 13, 2024
(a) The order in
				which the provisions of this Chapter appear is not to be construed to mean that
				any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control
				the titles of its various provisions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-27 - Superseding Effect

Current through July 13, 2024
This Chapter supersedes all prior rules or policy statements
				  issued by the Division, including Provider Manuals and Provider Bulletins,
				  which are inconsistent with this Chapter, except Chapter 1, Rules for
				  Individually-selected Service Coordinators of the Rules of the Developmental
				  Disabilities Division, which remains in effect.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 41 - ADULT DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY BASED WAIVER › Section 41-28 - Severability

Current through July 13, 2024
If any portion of this Chapter is found to be invalid or
				  unenforceable, the remainder shall continue in full force and
				  effect.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-1 - 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 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter
				shall apply to and govern Medicaid services provided under the Wyoming Medicaid
				Children's 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 Children's 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 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-3 - 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
				Children's 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 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-5 - 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 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-6 - 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) Under 21 years of age.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-7 - 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 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-8 - 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.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-10 - Reassessments

Current through July 13, 2024
A participant shall be reassessed for clinical eligibility at
				  least every five years, and more frequently at the option of the Division. The
				  reassessment shall include a review of the Inventory for Client and Agency
				  Planning and the psychological evaluation.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-11 - Transitions

Current through July 13, 2024
(a) Participants and/or guardians shall have
				the right to informed choice in providers and services.
(b) Participants and/or guardians may choose
				to change individually-selected service coordinators pursuant to Chapter 1,
				Rules for Individually-selected Service Coordinators of the Rules of the
				Developmental Disabilities Division.
(c) Participants may choose to change any
				providers, other than individually-selected service coordinators, anytime
				during the plan year pursuant to Chapter 45, Section
				11.
(d) Applicants for the waiver may
				change individually-selected service coordinators at any time during the
				application process.
(e) When a
				participant or guardian chooses to change providers, they shall inform the
				individually-selected service coordinator of the decision. The
				individually-selected service coordinator shall then complete the required
				steps pursuant to Chapter 45, Section
				11.
(f) If a provider providing
				residential services to a participant requires a participant to move to another
				residential location, the provider and participant's individually selected
				service coordinator shall complete the required steps pursuant to Chapter 45,
				Section
				11.
(g) Providers who are terminating
				services with a participant shall notify the participant/guardian in writing at
				least 30 days prior to ending services unless a shorter transition period is
				approved in advance by the Division. Failure to provide services during this 30
				day period shall be considered abandonment of services and may result in
				decertification of the provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-12 - Extraordinary Care Committee

Current through July 13, 2024
(a) The
				Extraordinary Care Committee has the following authority:
(i) Determining if a funding request for an
				emergency case or an emergency referral shall be funded.
(ii) Determining if a funding request due to
				a material change in circumstance, a potential emergency, or other condition
				justifying an increase in funding shall be funded.
(iii) Approving or rejecting rates for
				services that are not commensurate with the average rates as defined in the
				Children's DD Waiver Document approved by the Centers for Medicare and Medicaid
				Services.
(iv) Approving rate
				changes due to increased or decreased funding from Legislative Appropriations
				or under utilization of approved individualized budgeted amounts.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-13 - Waiting List Process

Current through July 13, 2024
(a) Waiting List.
				When there is insufficient funding to add additional participants, the Division
				shall maintain one waiting list for the Children's Developmental Disabilities
				Home and Community Based Waiver as specified below.
(b) Factors. The Division shall assign two
				rankings to each person on the waiting list based on the following two factors:
(i) The severity of the person's condition
				based on the Adaptive Behavior Quotient of the Inventory for Client and Agency
				Planning.
(ii) The person's
				placement date on the waiting list.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-14 - Emergency Services

Current through July 13, 2024
(a) The emergency
				criteria used by the Division includes:
(i) A
				substantial threat to a person's life or health caused by:
(A) The loss of the person's primary
				caregiver.
(B)
				Homelessness.
(C) Abuse or neglect
				that is either substantiated by the Wyoming Department of Family Services, or
				corroborated by the Division or Protection and Advocacy of Wyoming.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-15 - Provider Participation

Current through July 13, 2024
(a) Payments only
				to providers. No person or entity that furnishes covered services to a
				participant shall receive Medicaid funds unless the person or entity has signed
				a provider agreement, is enrolled, and is certified by the Division as a
				provider at the time of service delivery.
(b) Compliance with Chapter 3, Provider
				Participation, of the Wyoming Medicaid Rules. A provider that wishes to receive
				Medicaid reimbursement for services furnished to a participant shall meet the
				provider participation requirements of Chapter 3, Provider Participation, of
				the Wyoming Medicaid Rules, Sections
				4
				through
				6,
				which are incorporated by this reference.
(c) Compliance with Chapter 45, Provider
				Certification and Sanctions, of the Wyoming Medicaid Rules. A provider that
				wishes to provide Waiver services shall also meet the applicable criteria for
				Division certification set forth in Chapter 45, which is incorporated by this
				reference.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-16 - Provider Records

Current through July 13, 2024
(a) A provider
				shall comply with Chapter 3, Provider Participation, of the Wyoming Medicaid
				Rules, Section
				7,
				which is incorporated by this reference.
(b) Individually-selected service
				coordinators shall maintain copies of documentation from other providers for a
				twelve month period.
(c) For
				documentation of case management services, individually-selected service
				coordinators shall comply with Chapter 3, Section
				7,
				which is incorporated by this reference.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-19 - Excluded Services

Current through July 13, 2024
(a) Services not
				covered under the waiver include:
(i)
				Services furnished to a participant while in an institution.
(ii) Room and board of participant, which are
				the responsibility of the participant or representative payee.
(iii) Room and board expenses of a live-in
				personal caregiver or provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-20 - 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 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-22 - Recovery of Excess Payments or Overpayments

Current through July 13, 2024
(a) The
				Department may recover excess payments pursuant to Chapter 39.
(b) The Department may recover overpayments
				pursuant to Chapter 16.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-23 - Audits

Current through July 13, 2024
(a) The Division or the Centers for Medicare
				and Medicaid Services may audit a provider's financial records, medical
				records, or employment records, at any time to determine whether the provider
				has received excess payments or overpayments.
(b) The Division or the Centers for Medicare
				and Medicaid Services may perform audits through employees, agents, or through
				a third party. Audits shall be performed in accordance with generally accepted
				auditing standards.
(c)
				Disallowance. The Division shall recover excess payments or overpayments
				pursuant to Section
				22
				of this Chapter.
(d) Reporting
				audit results. If at anytime during a financial audit or a medical audit, the
				Division discovers evidence suggesting fraud or abuse by a provider, that
				evidence, in addition to the Division's final audit report regarding that
				provider, shall be referred to the Medicaid Fraud Control Unit.
(e) The Division shall share the results of
				the audit with the provider before excess payments or overpayments are
				recovered. However, nothing in this section shall abrogate the rights of the
				State to recover excess payments or overpayments in accordance with Chapter 16
				or Chapter 39.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-24 - Reconsideration

Current through July 13, 2024
A provider 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, Chapter 16, or Chapter
				  39 as applicable.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-26 - Interpretation of Chapter

Current through July 13, 2024
(a) The order in
				which the provisions of this Chapter appear is not to be construed to mean that
				any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control
				the titles of its various provisions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-27 - Superseding Effect

Current through July 13, 2024
This Chapter supersedes all prior rules or policy statements
				  issued by the Division, including Provider Manuals and Provider Bulletins,
				  which are inconsistent with this Chapter, except Chapter 1, Rules for
				  Individually-selected Service Coordinators of the Rules of the Developmental
				  Disabilities Division, which remains in effect.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER › Section 42-28 - Severability

Current through July 13, 2024
If any portion of this Chapter is found to be invalid or
				  unenforceable, the remainder shall continue in full force and
				  effect.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-1 - 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 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter
				shall apply to and govern Medicaid services provided under the Wyoming Medicaid
				Acquired Brain Injury 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
				Acquired Brain Injury Home and Community Based Waiver submitted to 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 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-3 - 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 Acquired Brain
				Injury 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 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-4 - Definitions

Current through July 13, 2024
The following definitions shall apply in the interpretation
				  and enforcement of these rules. Where the contexts in which words are used in
				  these rules indicate that such is the intent, words in the singular number
				  shall include the plural and vice versa. Throughout these rules gender pronouns
				  are used interchangeably. The drafters have attempted to utilize each gender
				  pronoun in equal numbers, in random distribution. Words in each gender include
				  individuals of the other gender.
(a)
				"Acquired brain injury."
(i) Any combination
				of focal and diffuse central nervous system dysfunction, both immediate and/or
				delayed, at the brain stem level and above.
(ii) These dysfunctions are acquired through
				the interaction of any external forces and the body, oxygen deprivation,
				infection, toxicity, surgery, and vascular disorders not associated with
				aging.
(iii) It is an injury to the
				brain that has occurred since birth.
(iv) It may have been caused by an external
				physical force or by a metabolic disorder(s).
(v) It includes traumatic brain injuries such
				as open or closed head injuries and non-traumatic brain injuries such as those
				caused by strokes, tumors, infectious disease, hypoxic injuries, metabolic
				disorders, and toxic products taken into the body through inhalation or
				ingestion.
(vi) It does not include
				brain injuries that are congenital or brain injuries induced by birth
				trauma.
(vii) These dysfunctions
				are not developmental or degenerative.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-5 - Philosophy

Current through July 13, 2024
(a) All persons possess inalienable rights
				under the Constitutions of the United States and the State of Wyoming,
				including persons with acquired brain injuries.
(b) It is the philosophy of the Division to
				develop reasonable and enforceable rules for the provision of services to
				individuals with acquired brain injuries 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 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-6 - 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 medical determination, 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) Aged 21 through 6 4 years.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-7 - 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 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-8 - 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.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-10 - Reassessments

Current through July 13, 2024
A participant shall be reassessed for clinical eligibility at
				  least every five years, and more frequently at the option of the Division. The
				  reassessment shall include a review of the Inventory for Client and Agency
				  Planning and the neuropsychological evaluation.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-11 - Transitions

Current through July 13, 2024
(a) Participants and/or guardians shall have
				the right to informed choices in providers and services.
(b) Participants and/or guardians may choose
				to change individually-selected service coordinators pursuant to Chapter 1,
				Rules for Individually-selected Service Coordinators of the Rules of the
				Developmental Disabilities Division.
(c) Participants may choose to change any
				providers, other than individually-selected service coordinators, anytime
				during the plan year pursuant to Chapter 45, Section
				11.
(d) Applicants for the waiver may
				change individually-selected service coordinators at any time during the
				application process.
(e) When a
				participant or guardian chooses to change providers, they shall inform the
				individually-selected service coordinator of the decision. The
				individually-selected service coordinator shall then complete the required
				steps pursuant to Chapter 45, Section
				11.
(f) If a provider providing
				residential services to a participant requires a participant to move to another
				residential location, the provider and participant's individually selected
				service coordinator shall complete the required steps pursuant to Chapter 45,
				Section
				11.
(g) Providers who are terminating
				services with a participant shall notify the participant/guardian in writing at
				least 30 days prior to ending services unless a shorter transition period is
				approved in advance by the Division. Failure to provide services during this 30
				day period shall be considered abandonment of services and may result in
				decertification of the provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-12 - Extraordinary Care Committee

Current through July 13, 2024
(a) The
				Extraordinary Care Committee has the following authority:
(i) Determining if a funding request for an
				emergency case or an emergency referral shall be funded.
(ii) Determining if a funding request due to
				a material change in circumstance, a potential emergency, or other condition
				justifying an increase in funding shall be funded.
(iii) Approving or rejecting rates for
				services that are not commensurate with the average rates as defined in the
				Acquired Brain Injury Waiver document approved by the Centers for Medicare and
				Medicaid Services.
(iv) Approving
				rate changes due to increased or decreased funding from legislative
				appropriations or under utilization of approved individualized budgeted
				amounts.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-13 - Waiting List Process

Current through July 13, 2024
(a) Waiting list.
				When there is insufficient funding to add additional participants, the Division
				shall maintain one waiting list for the Acquired Brain Injury Home and
				Community Based Waiver as specified below.
(b) Factors. The Division shall assign two
				rankings to each person on the waiting list based on the following two factors:
(i) The severity of the person's condition
				based on weighted scores of all 4 eligibility tests.
(ii) The person's placement date on the
				waiting list.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-14 - Emergency Services

Current through July 13, 2024
(a) The emergency
				criteria used by the Division includes:
(i) A
				substantial threat to a person's life or health caused by:
(A) The loss of the person's primary
				caregiver.
(B)
				Homelessness.
(C) Abuse or neglect
				that is either substantiated by the Wyoming Department of Family Services or
				corroborated by the Division or Protection and Advocacy of Wyoming.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER › Section 43-15 - Provider Participation

Current through July 13, 2024
(a) Payments only
				to providers. No person or entity that furnishes covered services to a
				participant shall receive Medicaid funds unless the person or entity has signed
				a provider agreement, is enrolled, and is certified by the Division as a
				provider at the time of service delivery.
(b) Compliance with Chapter 3, Provider
				Participation, of the Wyoming Medicaid Rules. A provider that wishes to receive
				Medicaid reimbursement for services furnished to a participant shall meet the
				provider participation requirements of Chapter 3, Provider Participation, of
				the Wyoming Medicaid Rules, Sections
				4
				through
				6,
				which are incorporated by this reference.
(c) Compliance with Chapter 45, Provider
				Certification and Sanctions, of the Wyoming Medicaid Rules. A provider that
				wishes to provide Waiver services shall also meet the applicable criteria for
				Division certification set forth in Chapter 45, which is incorporated by this
				reference.