Health, Department of

Medicaid

Chapter 12: Home Health Services

Effective Date: 09/06/2018 to 02/20/2026

Rule Type: Superceded Rules & Regulations

Reference Number: 048.0037.12.09062018

CHAPTER 12

HOME HEALTH SERVICES

Section 1. Authority.

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.

Section 2. Purposes and Applicability.

1. (a) This Chapter establishes the scope of the home health services covered by Medicaid and the methods and standards of reimbursing providers for such services.
2. (b) The Department may issue Provider Manuals and Provider Bulletins 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.
3. (c) The requirements of Title XIX of the Social Security Act, 42 C.F.R., Chapter IV, Subchapter C, Part 440, Subpart A applies to this Chapter.
4. (d) Wyoming's Medicaid State Plan applies to this Chapter.

Section 3. Incorporation by Reference.

1. (a) For any code, standard, rule or regulation incorporated by reference in these rules:
2. (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.
3. (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
4. (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.
5. (b) Each item is incorporated by reference and is further identified as follows:
6. (i) Referenced in Section 2 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. C, Pt. 440, Subpart A which is incorporated as of the effective date of this Chapter and can be found at http://www.ecfr.gov.
7. (ii) Referenced in Section 2 of this Chapter is Wyoming's Medicaid State Plan,

which is incorporated as of the effective date of this Chapter and, can be found at http://www.health.wyo.gov/healthcarefin/medicaid/spa.

Section 4. Definitions. Except as defined in this Section or as 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 and skilled nursing services combined.

(g) “Long-term custodial care” means care that has moved beyond the acute phase (has become clinically stable) and is expected to be needed for the rest of the client’s life.

(h) “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:

(i) Client’s diagnosis;

(ii) Objectives of the plan;

(iii) Client’s prognosis;

(iv) Covered services which are medically necessary for the implementation of the plan; and

(v) Person or persons to provide such services or supplies.

(i) “Supplies” means medical supplies authorized for Medicaid payments under W.S.

§ 42-4-103 and the Rules and Regulations for Medicaid.

Section 5. Provider Participation.

(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.

Section 6. Covered Services.

(a) The services and supplies specified in subsection (b) shall be covered services if the services are:

1. (i) Intermittent;
2. (ii) Medically necessary;
3. (iii) Ordered by a physician;
4. (iv) Documented in a plan of treatment; and
5. (v) Expected to last six (6) months or less.

(b) Covered services. The following shall be covered services:

(i) Skilled nursing services provided by a registered nurse for a client's condition while in the acute phase;

(ii) Home health aide services supervised by a registered nurse;

(A) Supervision shall be as follows:

(1) The registered nurse shall be available for consultation in person or by telephone; and

(2) The registered nurse shall make personal visits to the home:

(I) At least every two (2) weeks if the client is receiving skilled nursing care; or

(II) At least every sixty (60) days if the only services the client is receiving are home health aide services. The supervisory visits shall occur while the aide is furnishing services. Supervisory visits shall not be a covered service.

(B) Each home health aide encounter shall include at least one (1) of the following personal care services, but shall include all ordered services that can be provided in one encounter unless medically indicated otherwise:

(1) Bath (bed, sponge, tub, shower, or shampooing hair); (2) Nail or skin care (applying lotion to clients shall not constitute personal care); (3) Oral hygiene; (4) Toileting and elimination; (5) Safe transfers/assisted ambulation; (6) Assist with dressing; (7) Assisted range of motion/positioning; or (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, hearing, and language 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 medical supplies provided by a provider in accordance with the plan of treatment.

Section 7. Excluded Services.

(a) The following shall not be covered services: (i) Long-term custodial care; (ii) Homemaker services; (iii) Respite care; (iv) Home delivered meals;

(v) Services for clients that are in a hospital or a nursing facility;

(vi) Services that are inappropriate in the client’s home;

(vii) Services that are extensive or for long periods;

(viii) Services that are not cost effective;

(ix) Services where the desired outcome could be better and faster accomplished in another setting; and

(x) Services not included in Section 6 of this Chapter.

(b) Services where the client must be compliant to achieve measured success and the client is not compliant are not covered services.

(c) 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. This shall be considered a non-covered service.

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.

(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 shall 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 shall be included indicating the client is not home-bound and would not qualify for home health services under their Medicare benefits.

(iv) The Department or their designee may request additional information as necessary to review the prior authorization.

(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’s reconsideration.

Section 9. Medicaid Allowable Payment. Medicaid reimbursement shall be the lesser of billed charges and the Medicaid allowable payment.

Section 10. Payment of Claims.

(a) Payment of claims shall be pursuant to Chapter 3.

(b) Providers shall 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.

Section 12. Reconsideration or Administrative Hearing.

(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.

Section 13. Interpretation of Chapter.

(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.