Wyo. Code R. 048-0037-12
Medicaid
Chapter 12: Home Health Services
Effective Date: 08/07/2017 to 09/06/2018
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.12.08072017
This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at Wyoming Statutes § 42-4-101 through -306 and the Wyoming Administrative Procedure Act at W.S. § 16-3-101 through -115.
(a) This Chapter establishes the scope of the home health services covered by Medicaid and the methods and standards of reimbursing providers of such services.
(b) The Department may issue Provider Manuals, Provider Bulletins, or both, to providers or other affected parties to interpret the provisions of this Chapter. Such Provider Manuals or 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.
(a) For any code, standard, rule or regulation incorporated by reference in these rules:
(i) The Department of Health has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules.
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of this section; and
(iii) The incorporated code, standard, rule or regulation is maintained at the Department of Health and is available for public inspection and copying at cost at the same location.
(b) Each item incorporated by reference and is further identified as follows:
(i) Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. C, Pt. 440, Subpart A, incorporated as of the effective date of this Chapter which can be found at http://www.ecfr.gov.
(ii) Wyoming's Medicaid State Plan, incorporated as of the effective date of this Chapter, which can be found at http://www.health.wyo.gov/healthcarefin/medicaid/spa.html.
Section 4. Definitions. Except as otherwise defined in Chapter 1, the terminology
used in this Chapter is the standard terminology and has the standard meaning used in accounting, health care, Medicaid, and Medicare.
(a) “Attending physician” means the physician who prescribes home health services or reviews and certifies the plan of treatment.
(b) “Encounter” means a single episode of care on a date of service during which all ordered services are provided, regardless of length of time, except those that cannot be provided at the time due to medical necessity or specific physician orders to frequency or scheduling, i.e. services ordered “every 12 hours” or “3 times a day”.
(c) “Home health agency” means a home health agency as defined by 42 C.F.R. § 440.70.
(d) “Home health aide” means a person that is certified as a nursing assistant/nurse aide by the Wyoming State Board of Nursing, and employed by a home health agency.
(e) “Home health aide service” means a covered service provided pursuant to a plan of treatment by a home health aide under the supervision of a registered nurse.
(f) “Intermittent” means three or fewer encounters per day for home health aide services or skilled nursing services.
(g) “Plan of treatment” means a written treatment plan prepared on CMS Form 485 (or such other form as may be designated by the Department), which is signed and dated by the client’s attending physician, and which specifies the:
(h) “Supplies” means medical supplies authorized for Medicaid payments under W.S. § 42-4-103 and the Rules and Regulations for Medicaid.
(a) Payments only to providers. No provider that furnishes home health services to a client shall receive Medicaid funds unless the provider is enrolled.
(b) Compliance with Chapter 3. A provider that wishes to receive Medicaid reimbursement for home health services furnished to a client shall meet the requirements of Chapter 3.
(5) Safe transfers/assisted ambulation; (6) Assist with dressing; (7) Assisted range of motion/positioning; and (8) Assisted nutrition or fluid intake (meal set-up, meal preparation, feeding assistance or meal supervision). (iii) Physical therapy services provided by a physical therapist; (iv) Speech therapy services provided by a speech therapist; (v) Occupational therapy services provided by an occupational therapist; (vi) Medical social services provided by a social worker. (vii) Disposable supplies provided by a provider in accordance with the plan of treatment.
Section 7. Excluded Services. The following shall not be covered services:
(a) Homemaker services; (b) Respite services; (c) Home delivered meals; (d) Services for clients that are in a hospital or a nursing facility; (e) Services that are inappropriate in the client's home; (f) Services that are extensive or for long periods and/or are not cost effective. (g) Services where the desired outcome could be better and faster accomplished in another setting; (h) Services where the client must be compliant to achieve measured success and the client is not compliant. (i) It is inappropriate to break up personal care into multiple episodes for the convenience of the home health agency staff or due to scheduling issues with home health staff.
Section 8. Prior Authorization.
(a) Prior authorization of home health services shall be governed by Chapter 3.
(b) All home health services require prior authorization.
(c) The failure to obtain prior authorization shall result in the denial of Medicaid payment for the service.
(d) The provider shall submit the following as part of the prior authorization request. The Department may request additional information as necessary to review the prior authorization.
(i) Submission of plan of treatment. The provider shall submit a written request for prior authorization on the forms specified by the Department, including the plan of treatment, before the submission of a claim for such services. The Department may request additional information as necessary to review the plan of treatment.
(A) The plan of treatment shall include a statement that the home health services are appropriate and medically necessary.
(B) The plan of treatment shall be reviewed, signed, and dated by the attending physician at least once every sixty (60) days.
(ii) Face to face visit. All new home health orders must be accompanied by documentation of a face to face visit having occurred between the client and the attending physician (ordering provider) within the ninety (90) days prior to the start of home health services.
(iii) Documentation of Medicare status. For clients eligible under both Wyoming Medicaid and Medicare, documentation from the ordering provider must be included indicating the client is not home-bound and would not qualify for home health services under their Medicare benefits.
(e) Denial of plan of treatment. If a plan of treatment is disapproved, the provider may submit a revised plan of treatment or additional documentation as necessary for the Department to reconsider the plan of treatment.
Section 9. Medicaid Allowable Payment. Medicaid reimbursement shall be the lesser of billed charges and the Medicaid allowable payment.
(a) Payment of claims shall be pursuant to Chapter 3.
(b) Providers must bill each date of service on a separate line of the claim. Span billing is not allowed.
Section 11. Recovery of Overpayments. The Department may recover overpayments pursuant to Chapter 16.
(a) A provider may request that the Department reconsider a decision to recover overpayments. The request for reconsideration, the reconsideration and any administrative hearing shall be pursuant to the provisions of Chapters 16 and 4.
(b) A client may request an administrative hearing pursuant to Chapter 4 regarding the denial of any services or supplies.
(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.
Section 14. Superseding Effect. When promulgated, this Chapter supersedes all prior rules or policy statements issued by the Department, including provider manuals and provider bulletins, which are inconsistent with this Chapter.
Section 15. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in effect.
(a) For any code, standard, rule or regulation incorporated by reference in these rules:
(i) The Department of Health has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules.
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of this section; and
(iii) The incorporated code, standard, rule or regulation is maintained at the Department of Health and is available for public inspection and copying at cost at the same location.
(b) Each rule incorporated by reference and can be found at http://soswy.state.wy.us/rules/ and is further identified as follows:
(i) Referenced in Section 1 is Wyoming Medicaid Rule, Chapter 1 – Definitions, adopted by the Department of Health and effective on November 7, 2011.
(ii) Referenced in Sections 5, 8, and 10 is Wyoming Medicaid Rule, Chapter 3 – Provider Participation, adopted by the Department of Health and effective on December 16, 1998.
(iii) Referenced in Section 12 is Wyoming Medicaid Rule, Chapter 4 – Administrative Hearings, adopted by the Department of Health and effective on November 7, 2011.
(iv) Referenced in Sections 11 and 12 is Wyoming Medicaid Rule, Chapter 16 – Program Integrity, adopted by the Department of Health and effective on November 7, 2011.
(v) Referenced in Section 2 is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. C, Pt. 440, Subpart A, incorporated as of the effective date of this Chapter and can be found at http://www.ecfr.gov.
(vi) Referenced in Section 4 is 42 CFR § 440.70, incorporated as of the effective date of this Chapter and can be found at http://www.ecfr.gov.