Wyo. Code R. 048-0037-12
Medicaid
Chapter 12: Home Health Services
Effective Date: 09/26/2014 to 08/07/2017
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.12.09262014
This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S.§ 42-4-104 and the Wyoming Administrative Procedure Act at W.S. § 16-3-102.
(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 requirements of Title XIX of the Social Security Act, 42 C.F.R., Ch. IV, Subch. C, Pt. 440, Subpart A also applies to Medicaid and is incorporated by this reference as of the effective date of this Chapter, and may be cross-referenced throughout this Chapter where applicable. This incorporation by reference does not include any later amendments or editions of the incorporated matter. The incorporated rules and regulations may be viewed at http://www.ecfr.gov/cgi-bin/ECFR or may be obtained at cost from the Department.
Section 3. General Provisions. This Chapter shall apply to and govern the provision of home health services and reimbursement for those dates of service on or after its effective date.
Section 4. Definitions. Except as otherwise defined in Chapter 1 or as defined herein, 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.' The physician who prescribes home health services or reviews and certifies the plan of treatment. An 'attending physician' may not have a significant ownership in or a significant financial or contractual relationship with the provider.
(b) 'Certification period.' The period for which a plan of treatment is to be in effect, not to exceed sixty (60) days.
(c) 'Home health agency.' A home health agency as defined by 42 C.F.R. § 440.70.
(d) 'Home health aide.' 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.' A covered service provided pursuant to a plan of treatment by a home health aide under the supervision of a registered nurse.
(f) 'Intermittent.' Three or fewer visits per day for home health aide services and/or skilled nursing services, where each visit does not exceed four hours.
(g) “Plan of treatment.” 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.
(h) “Supplies.” 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:
(i) Intermittent, unless otherwise authorized by the Department; (ii) Medically necessary; (iii) Ordered by a physician; and (iv) Documented in a plan of treatment.
(b) Covered services. The following shall be covered services:
(i) Skilled nursing services provided by a registered nurse; (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 visit shall include at least one (1) or more of the following personal care services:
(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; and (8) Assisted nutrition or fluid intake (meal set-up, preparation, or feeding assist/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 or as provided by federal law; (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.
Section 8. Prior Authorization.
(a) Prior authorization of home health services shall be governed by Chapter 3. (b) The following services and supplies shall require prior authorization: (i) Any services or supplies provided by a provider located outside the State of Wyoming; and (ii) Any services or supplies provided to a client outside the State of Wyoming. (c) Failure to obtain prior authorization. The failure to obtain prior authorization shall result in the denial of Medicaid payment for the service. (d) 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. (i) The plan of treatment shall include a statement that the home health services are appropriate and medically necessary. (ii) The plan of treatment shall be reviewed, signed and dated by the attending physician at least once every sixty (60) days. (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. (f) Reauthorization. The physician shall review and recertify the client's plan of treatment at least every sixty (60) days. Recertified plans of treatment shall be subject to the prior authorization provisions of this Section.
Section 9. Medicaid Allowable Payment. Medicaid reimbursement shall be the lesser of billed charges and the Medicaid allowable payment.
Section 10. Payment of Claims. Payment of claims shall be pursuant to Chapter 3.
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.