Wyo. Code R. 048-0037-12
Medicaid
Chapter 12: Home Health Services
Effective Date: 10/01/2001 to 09/26/2014
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.12.10012001
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.
This Chapter establishes the scope of the home health services covered by Medicaid and the methods and standards of reimbursing providers of such services.
(a) 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.
(b) The Department may issue Manuals to providers and/or other affected parties to interpret the provisions of this rule. Such manuals shall be consistent with and reflect the policies contained in this rule.
(c) The Department may issue Manuals, Provider Bulletins, or both, to providers and/or other affected parties to interpret the provisions of this Chapter. Such Manuals and Provider Bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in Manuals or Provider Bulletins shall be subordinate to the provisions of this Chapter.
Except as otherwise specified in this section, the terminology used in this Chapter is the standard terminology used in 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 home health agency.
(b) 'Certification period.' The period for which a plan of treatment is to be in effect, not to exceed sixty (60) days.
(c) 'Chapter I.' Chapter I, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
(d) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(u) “Medicaid allowable payment.” Except as provided in this subsection, the Medicaid allowable payment shall not exceed the lower of the submitted charge, the Medicare rate in effect on January 1, 1987, and the Medicaid fee schedule.
(v) “Medicaid fee schedule.” The Medicaid fee schedule established pursuant to Chapter 3 Section 10, which is incorporated by this reference.
(w) “Medical necessity” or “medically necessary.” A covered service that:
(i) Is consistent with the recipient’s diagnosis and condition; and
(ii) Is recognized as the prevailing standard or current practice among the provider’s peer group.
(x) “Medicare.” The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(y) “Mental health clinic.” A facility which is certified as a mental health clinic by the Mental Health Division of the Department.
(z) “Mental health professional.” A psychologist or a person licensed as a LPC, LMFT, LPSW or LPCDS pursuant to the Wyoming Professional Counselors, Marriage and Family Therapists, Social Workers and Chemical Dependency Specialists Act, that is associated with a mental health clinic.
(aa) “Mental health services.” Professional services provided to a recipient with a psychiatric diagnosis by a mental health professional pursuant to a plan of treatment.
(bb) “Nursing facility.” “Nursing facility” as defined by 42 U.S.C. § 1396r(a). “Nursing facility” may include a distinct part of a hospital or institution which is designated to provide skilled nursing facility services.
(cc) “Nursing services.” Services provided by or under the supervision of a Registered Nurse based on a plan of treatment signed by a physician. These services may be provided by a Registered Nurse, a Licensed Practical Nurse, Certified Nurse Assistant/Home Health Aide as appropriate.
(dd) “Occupational therapist.” A person:
(i) Registered by the American Occupational Therapy Association; or
(ii) A graduate of a program in occupational therapy approved by the Council on Medical Education of the American Medical Association and engaged in the supplemental clinical experience required before registration by the American Occupational Therapy Association.
(ee) “Overpayments.” Overpayments as defined in Chapter 39, which definition is incorporated by this reference.
(ff) “Physical therapist.” A person licensed to practice physical therapy by the Wyoming Board of Physical Therapy or a similar agency in another state.
(gg) “Physician.” A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a similar agency in another state.
(hh) “Plan of treatment.” A written treatment plan prepared on HCFA Form 485 (or such other form as may be designated by the Division), which is signed and dated by the recipient’s attending physician, and which specifies the:
(i) Recipient’s diagnosis;
(ii) Objectives of the plan;
(iii) Recipient’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.
(vi) The plan of treatment must include a statement that the home health services are appropriate and medically necessary.
(vii) The plan of treatment must be reviewed, signed and dated by the attending physician at least once every sixty (60) days.
(ii) “Prior authorized.” Approval by the Department pursuant to the prior authorization provisions of Chapter 3 which are incorporated by this reference.
(jj) “Provider.” A home health agency which has a provider agreement.
(kk) “Provider agreement.” “Provider agreement” as defined by Chapter 3 which definition is incorporated by this reference.
(ll) “Psychiatric diagnosis.” A recipient with:
(i) A primary diagnosis of a mental disorder, except as specified in (A) through (F) below, on Axis I, Axis II, or both, as set forth in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is hereby incorporated by reference. The DSM is published by the American Psychiatric Association, Washington, D.C., in Washington D.C., and is available from the publisher.:
(A) DSM diagnosis on Axis III;
(B) DSM diagnosis of mental retardation;
(C) DSM diagnosis of factitious disorder;
(D) DSM Axis I diagnosis of any V code;
(E) DSM diagnosis of 799.90 on Axis I or Axis II; or
(F) DSM diagnosis of specific developmental disorders.
(ii) That manifests itself in part by the recipient’s refusal to leave his or her home or is of such nature that it is not safe for the recipient to leave home unattended.
“Recipient.” A person who has been determined eligible for Medicaid.
“Registered nurse.” A person licensed to practice nursing by the Wyoming Board of Nursing or a similar agency in another state.
“Services.” Goods or services authorized for Medicaid payments under W.S. § 42-4-103 and the rules of the Department.
(pp) “Significant financial or contractual relationship.” Business transactions with a home health agency that exceed $25,000.00 per year or five percent or more of the home health agency’s operating expenses.
(qq) “Significant ownership interest.” Direct ownership or control of five percent or more of a home health agency; or an officer, director or partner of a home health agency.
(rr) “Skilled nursing service.” Professional nursing services provided on a part-time or intermittent basis by a home health agency which are included within the definition of “practice of professional nursing” as set forth in the Wyoming Nursing Practice Act, which definition is incorporated by this reference.
(ss) “Social worker.” An individual that has received a BSW or a MSW. A social worker that does not have an MSW must be supervised by a social worker with a MSW. “Supervised” means that the supervisor is available for consultation by telephone.
“Speech pathologist.” A person licensed to practice speech pathology by the Wyoming Board of Speech Pathology and Audiology or a similar agency in another state.
“Supervision of the Home Health Aide” means that a registered nurse:
(i) Is available for consultation in person or by telephone; and
(ii) Makes personal visits to the home:
(A) At least every two weeks if the recipient is receiving skilled nursing care;
or
(B) At least every sixty days if the only services the recipient is receiving are home health aide services. The supervisory visit must occur while the aide is furnishing services. Such a supervisory visit is not a covered service.
(vv) “Supplies.” Medical supplies authorized for Medicaid payments under W.S. § 42-4-103 and the rules of the Department.
(ww) “Usual and customary charges.” A provider’s charges for comparable services provided to non-recipients.
Section 5. Provider Participation.
(a) Eligible providers. Home health agencies.
(b) Compliance with Chapter 3. A person or entity that wishes to receive Medicaid reimbursement for covered services furnished to a recipient must meet the provider participation requirements of Chapter 3, which are incorporated by this reference.
Section 6. Provider Records. A provider must comply with the record keeping requirements of Chapter 3, which are incorporated by this reference.
Section 7. Verification of Recipient Data. A provider must comply with the verification of recipient data requirements of Chapter 3, which are incorporated by this reference.
Section 8. Covered Services.
(a) The services and supplies specified in subsection (b) are covered services if:
(i) Intermittent, unless otherwise authorized by the Division;
(ii) Medically necessary;
(iii) Ordered by a physician; and
(iv) Documented in a plan of treatment.
(b) Covered services.
(i) Skilled nursing services provided by a registered nurse;
(ii) Home health aide services;
(iii) Physical therapy services and 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 home health agency in accordance with the plan of treatment.
Section 9. Excluded Services. The following are not covered services:
Section 10. Prior Authorization.
(a) Incorporation of Chapter 3. Prior authorization of home health services shall be governed by the prior authorization requirements of Chapter 3, which are incorporated by this reference.
(b) Services and supplies which 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 recipient outside the State of Wyoming.
(iii) Failure to obtain prior authorization. The failure to obtain prior authorization shall result in the denial of Medicaid payment for the service.
(c) Submission of plan of treatment. The home health agency 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.
(d) 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.
(e) Reauthorization. The physician must review and recertify the recipient’s plan of treatment at least every sixty (60) days. Recertified plans of treatment are subject to the prior authorization provisions of this Section.
Section 11. Medicaid Allowable Payment. Medicaid reimbursement shall be the lesser of billed charges and the Medicaid allowable payment.
Section 12. Payment of Claims. Payment of claims shall be pursuant to the payments of claims provisions of Chapter 3, which are incorporated by this reference.
Section 13. Recovery of Excess Payments or Overpayments.
(a) The Department may recover excess payments pursuant to Chapter 39, which is incorporated by this reference.
(b) The Department may recover overpayments pursuant to Chapter 16, which is incorporated by this reference.
Section 14. Reconsideration or Administrative Hearing.
(a) 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 provisions of Chapter 3, which provisions are incorporated by this reference.
(b) A recipient may request an administrative hearing pursuant to Chapter I regarding the denial of any services or supplies. Such request must be submitted in accordance with the requirements of that Chapter.
Section 15. Out-of-State Providers.
(a) Services provided by a home health agency located outside the state of Wyoming are not eligible for Medicaid reimbursement unless the services are prior authorized.
(b) Reimbursement. Medicaid reimbursement for such services shall be the lesser of the provider’s billed charges and the Medicaid allowable payment.
Section 16. 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 17. 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 18. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall remain in full force and effect.