Health, Department of

Medicaid

Chapter 12: Home Health Services

Effective Date: 06/21/1990 to 12/15/1994

Rule Type: Superceded Rules & Regulations

Reference Number: 048.0037.12.06211990

Date Filed 06/21/90 Expr Date Supr Date Repeal Date Document Type RULES

CHAPTER XII

HOME HEALTH SERVICES

Section 1. Authority

These rules are promulgated by the Department of Health and Social Services 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.

Section 2. Purpose and applicability.

This rule establishes the scope of home health services covered by Medicaid and the methods and standards of reimbursing providers of such services.

Section 3. Definitions.

(a) 'Attending physician.' The physician who prescribes home health services or reviews and certifies the plan of care. An 'attending physician' may not have a significant ownership in or a significant financial or contractual relationship with the home health agency.

(b) 'Business agent.' A person or entity that submits a claim or receives Medicaid payment on behalf of a provider.

(c) 'Claim.' A request by a provider for Medicaid payment for covered services provided to a recipient.

(d) 'Covered services.' Services which are Medicaid reimbursable pursuant to subsections 4(c) through 4(e) of this rule.

(e) 'Department.' The Wyoming Department of Health and Social Services, its agent or successor.

(f) 'Excess payments.' Medicaid funds received by a provider which exceed the reimbursement limit established by this rule.

(g) 'HCFA.' The Health Care Financing Administration of the United States Department of Health and Human Services.

(h) 'Home.' A recipient's primary place of residence. 'Home' does not include a nursing facility or a hospital.

(i) 'Home-bound.' A recipient that:

1. (i) Cannot leave his or her home without assistance;
2. (ii) Cannot safely leave home unattended because of mental or emotional problems;
3. (iii) Refuses to leave home because of mental or emotional problems;
4. (iv) Is under a physician's orders to avoid stress and physical activity because of heart disease or recent surgery; or
5. (v) Has an active communicable disease or immune system dysfunction and is under physician's orders to avoid contact with others as a result of such disease or condition.(j) 'Home health agency.' An agency certified as a Home Health Agency under Medicare and Medicaid, and licensed under applicable State law.(k) 'Home health aide.' A person employed by a home health agency that provides home health aide services.(l) 'Home health aide service.' Covered services provided pursuant to a plan of care by a home health aide under the supervision of a registered nurse. 'Supervision' means that the registered nurse is available for consultation in person or by telephone and makes personal visits to the home at least every two weeks.(m) 'Hospital.' A hospital that is maintained primarily for the treatment and care of patients with disorders other than tuberculosis or mental diseases, licensed by the State of Wyoming and qualified to participate as a hospital under Medicare.(n) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.(o) '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 in effect on July 1, 1989, which is hereby incorporated by reference. The fee schedule is available from Medical Assistance Services of the Department. The Department may adjust the Medicaid fee schedule when necessary to:- (i) Enlist enough providers so that services are available to recipients to the extent that those services are available to the general population; and
6. (ii) Ensure that payments are consistent with efficiency, economy and quality of care.(p) 'Medical necessity' or 'medically necessary.' A covered service that:- (i) Is consistent with the recipient's diagnosis and condition;
7. (ii) Is recognized as the prevailing standard or current practice among the provider's peer group; and
8. (iii) Can be provided in the recipient's home for less than comparable services provided in another setting.(q) 'Medical record.' All documents, in whatever form, in the possession of or subject to the control of the provider which describe the recipient's diagnosis, treatment or condition.

(r) 'Medicare.' The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.

(s) 'Mental health clinic.' A facility which is certified as a mental health clinic by the Division of Community Services of the Department.

(t) '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.

(u) 'Mental health services.' Professional services provided to a recipient with a psychiatric diagnosis by a mental health professional pursuant to a plan of care.

(v) 'Nursing facility.' A skilled nursing facility, an intermediate care facility, an intermediate care facility for the mentally retarded or a nursing facility as defined by applicable federal law. 'Nursing facility' may include a distinct part of a hospital or institution which is designated to provide nursing facility services.

(w) '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.

(x) 'Physical therapist.' A person licensed to practice physical therapy by the Wyoming Board of Physical Therapy.

(y) 'Physician.' A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners.

(z) 'Plan of care.' A written treatment plan signed and dated by the recipient's attending physician 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.

The plan of care must include a statement that the recipient is home-bound or meets the requirements of subsection 4(d) and that home health services are appropriate. The plan of care must be reviewed and signed by the attending physician at least once every sixty-two days.

(aa) 'Prior authorization.' Approval by the Department before services are provided.

(bb) 'Provider.' A home health agency which has or had a provider agreement.

(cc) 'Provider agreement.' A written contract between a home health agency and the Department in which the home health agency agrees to comply with the provisions of the contract and applicable federal and state statutes and regulations as a prerequisite to receiving Medicaid funds for covered services provided to recipients.

(dd) '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 Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM IIIR), which is hereby incorporated by reference:

(A) DSM IIIR diagnosis on Axis III;

(B) DSM IIIR diagnosis of mental retardation;

(C) DSM IIIR diagnosis of factitious disorder;

(D) DSM IIIR Axis I diagnosis of any V code;

(E) DSM IIIR diagnosis of 799.90 on Axis I or Axis II; or

(F) DSM IIIR 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.

(ee) 'Recipient.' A person who has been determined eligible for Medicaid.

(ff) 'Registered nurse.' A person licensed to practice nursing by the Wyoming Board of Nursing or a similar agency in another state.

(gg) 'Services.' Goods or services authorized for Medicaid payments under W.S. 42-4-103 and the rules of the Department.

(hh) '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.

(ii) '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.

(jj) 'Speech pathologist.' A person licensed to practice speed pathology by the Wyoming Board of Speech Pathology and Audiology.

(kk) 'Usual and customary charges.' A provider's charges for comparable services provided to non-recipients.

Section 4. Covered Services

(a) Recipients age nineteen or over. The services and supplies specified in subsection (c) are covered services if:

(i) Medically necessary;

(ii) Provided pursuant to a plan of care by or under the direction of a home health agency; and

(iii) The recipient is home-bound, except as specified in subsection (d).

(b) Recipients under age nineteen. The services and supplies specified in subsection (c) are covered services if the criteria of subsection (a) are met and the services or supplies are prior authorized.

(c) Covered services.

(i) Home health aide services;

(ii) Medical social services as defined by Medicare;

(iii) Medical supplies prescribed by a physician which;

(A) Do not exceed $150.00 per plan of care period; or

(B) Have received prior authorization.

(iv) The following supplies and pharmaceuticals:

(A) Disposable supplies provided by a home health agency which:

(I) Do not exceed $150.00 per month per recipient; or

(II) Have received prior authorization.

(B) Insulin and diabetic supplies;

(C) IV antibiotics;

(D) Orthotics;

(E) Ostomy supplies;

(F) Oxygen supplies;

(G) Parenteral and enteral supplies; and

(H) Prosthetics.

(v) Mental health services for a recipient with a psychiatric diagnosis, not to exceed three visits per plan of care period;

(vi) Nursing services provided by a registered nurse;

(vii) Occupational therapy services provided by an occupational therapist, not to exceed four visits per calendar year;

(viii) Physical therapy services provided by a physical therapist or by a home health aide under the supervision of a physical therapist; and

(ix) Speech therapy services as defined by Medicare and provided by a speech therapist.

(d) Services provided to persons age nineteen or over who are not home-bound. The services specified in subsection (c) are covered services when provided to a recipient age nineteen years or over who is not home-bound if:

(i) The combined cost of transportation to an appropriate vendor of comparable services and the services exceed the cost of a home health services visit;

(ii) The recipient's approved plan of care includes absences from the home for health related reasons;

(iii) The recipient is unable or unwilling to leave the home to receive necessary services, and will, in all probability, have to be admitted to a hospital or nursing facility if such services are not provided in the home; or

(iv) The visits are for health care instruction to the recipient which can better be accomplished in the home.

(e) Services provided to persons under age nineteen who are not home-bound. The services specified in subsection (c) are covered services when provided to a recipient who is under the age of nineteen years and is not home-bound if the criteria of subsection (d) are satisfied and the services are prior authorized.

(f) Excluded services. The following are not covered services:

(i) Audiology services;

(ii) Domestic or housekeeping services which are unrelated to patient care and which materially increase the time of the visit;

(iii) Educational services, unless related to patient diagnosis and treatment and provided by a qualified provider;

(iv) Equipment and supplies which are not medically necessary and are requested for patient convenience;

(v) Meals on Wheels or similar food service arrangements;

(vi) Services and supplies which are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, including but not limited to:

(A) Baby formula;

(B) Cosmetic items;

(C) Dental adhesives; (D) Dentifrices; (E) Food products or supplements; (F) Infant disposable diapers; and (G) Non-medicated shampoo.

(vii) Services and supplies related to cosmetic surgery;

(viii) Services and supplies which are not reimbursed by Medicaid if provided to a recipient admitted to a hospital as an inpatient, including but not limited to:

(A) Private-duty nursing services; or (B) Services or supplies provided for the comfort of a patient.

(ix) Space conditioning equipment, including but not limited to room humidifiers and air conditioners.

Section 5. Verification of recipient data.

(a) Medicaid Identification Cards. The Department issues Medicaid Identification cards to recipients. Such cards are valid only for the month and year shown on the card.

(b) Services provided to a recipient who does not possess a valid Medicaid Identification card are not Medicaid reimbursable. A client without a valid Medicaid Identification card who seeks services is responsible for all charges for such services unless the provider receives written verification of eligibility from the Department or local agency before providing services and so advises the client.

Section 6. Prior authorization. The following procedures must be followed in requesting prior authorization for services to be provided to a recipient who is under nineteen years of age:

(a) Submission of plan of care. The physician shall submit a written request for prior authorization on the forms specified by the Department, including the plan of care, before or with the first claim. The Department may request additional information as necessary to review the plan of care.

(b) Criteria for review. A plan of care shall be approved if it:

(i) Is consistent with the recipient's diagnosis; (ii) Meets the Medicaid criteria for home health services; and (iii) Meets the criteria of this rule.

(c) Denial of plan of care. If a plan of care is disapproved, the provider may submit a revised plan of care or additional documentation as necessary for the Department to reconsider the plan of care.

(d) Effect of prior authorization. Prior authorization for the home health services to be provided during the period specified by the Department shall constitute approval for the provider to receive Medicaid reimbursement for the services to be provided, subject to the other requirements of this rule and post payment review pursuant to the rules and policies of the Department. Prior authorization is not a guarantee of eligibility or payment.

(e) Reauthorization. The physician must review and recertify the recipient's plan of care at least every sixty days. Recertified plans of care are subject to the prior authorization provisions of this Section.

(f) Change in plan of care. If there is a change in the approved plan of care, the provider must submit a completed HCFA-486, or such other form as the Department designates, to the Department. Failure to do so shall result in the denial of claims.

Section 7. Reimbursement.

Medicaid reimbursement shall be the lesser of billed charges and the Medicaid allowable payment.

Section 8. Payment of claims.

(a) Payer of last resort. Medicaid is the payer of last resort. A provider may not seek Medicaid payment for services provided to a recipient until payment from other third parties has been sought pursuant to Chapter IV of these rules.

(b) Payment in full of covered services. If the service is a covered service under this Chapter, a provider may not request, receive or attempt to collect any payment from the recipient for the service. The provider must accept the amount paid by Medicaid as payment in full for the services.

(c) Payment for noncovered services. A provider who provides a noncovered service to a recipient may seek payment from the recipient if the provider informed the recipient of the recipient's potential liability before providing the service, and the recipient agreed in writing to pay for such services before they were provided.

(d) Submission of claims.

(i) Claims must be submitted to the Department in the manner and on the forms specified by the Department, must include documentation of required prior authorization, and such other documentation or records as the Department may request.

(ii) Claims must be submitted to the Department on or before twelve months after the date of service, except that Medicare cross-over claims must be submitted within six months after the date Medicare acts on the claim. The date of submission is the date the claim is received by the Department. Claims not timely submitted shall be rejected.

(iii) A provider shall not bill the Department in excess of the provider's usual and customary charge for the service.

(iv) Each claim must contain a certification by the provider that the service was medically necessary, that it was provided on the date specified, that the provider is not aware of any third parties who might be liable for the service and that the reimbursement sought is not in excess of the provider's usual and customary charge for the service.

(v) A provider may seek Medicaid payment through a business agent for services provided to a recipient if: the business agent's compensation is related to the actual cost of processing the billing and is not related on a percentage or other basis to the amount of the claim and is not dependent upon payment of the claim.

Section 9. Out-of-state providers.

(a) Services provided by home health agency located outside the state of Wyoming are not eligible for Medicaid reimbursement unless:

(i) The home health agency has a provider agreement;

(ii) The services are prior authorized; and

(iii) The recipient is a foster child not covered by Title IV-E of the Social Security Act and resides with a foster family out of state.

(b) Reimbursement. Medicaid reimbursement for such services shall be the lesser of the provider's billed charges and the Medicaid allowable payment.

Section 10. Recovery of excess payments.

(a) Notice of excess payments. After determining that a provider has received excess payments, the Department shall send written notice to the provider stating the amount of the excess payments, the basis for the determination of excess payments and the provider's rights to request reconsideration of that determination pursuant to Section 11.

(b) Reimbursement of excess payments. A provider must reimburse the Department for excess payments within 30 days after the provider receives written notice from the Department of the excess payments, even if the provider has requested reconsideration of or appealed the determination of excess payments.

(c) Methods of recovery of excess payments. If a provider does not timely reimburse the Department, the Department may recover the excess payments by:

(i) Withholding all or part of Medicaid payments until the excess payments are recovered, even if the provider has requested reconsideration of or appealed the determination of excess payments;

(ii) Initiating a civil lawsuit against the provider; or

(iii) Any other method of collecting a debt or obligation permitted by law.

Section 11. Reconsideration.

(a) Request for reconsideration. A provider may request that the Department reconsider a decision to recover excess payments. Such request must be mailed to the Department by certified mail within twenty days of the date the facility receives notice pursuant to Section 10. The request must state with specificity the reasons for the request. Failure to provide such a statement shall result in the dismissal of the request with prejudice.

(b) Reconsideration. The Department shall review the decision and send written notice to the provider of its final decision within forty-five days after receipt of the request for reconsideration. The Department may request additional information from the provider as part of the reconsideration process.

(c) Administrative hearing. A provider may request an administrative hearing regarding the final decision pursuant to Chapter I of these rules by mailing by certified mail or personally delivering a request for hearing to the Department within twenty days of the date the provider receives notice of the final decision. The request for hearing must comply with the requirements of Chapter I.

(d) Failure to request reconsideration. A provider which fails to request reconsideration pursuant to this section may not subsequently request an administrative hearing pursuant to Chapter I regarding the decision to recover excess payments.

Section 12. Sanctions

(a) Medicare sanctions. A facility which has its participation in Medicare suspended, terminated, not renewed or otherwise sanctioned, shall have its Medicaid provider agreement suspended, terminated or not renewed for the same period of time. The facility shall be entitled to its Medicare appeal rights as specified in 42 C.F.R. 498, and shall not be entitled to reconsideration or an administrative hearing pursuant to this rule or any other rules of the Department. The final decision entered under the Medicare procedures shall be binding on the facility and the Department.

(b) Medicaid sanctions. The Medicare sanctions described in subsection (a) are in addition to and not a limitation on the Department's ability to impose sanctions pursuant to the rules of the Department.

Section 13. Provider Records.

(a) Retention. A provider shall maintain medical and financial records, including information regarding dates of services, diagnoses, services provided, and bills for services, for at least six years after the end of the federal fiscal year (September 30) in which the services were rendered. If an audit is in progress, the records must be maintained until the audit is resolved. Such records must be maintained for three years in hard-copy, after which they may be maintained on micro-fiche or micro-film.

(b) Availability of records. A provider shall make financial or medical records available upon request to representatives of the Department, the United States Department of Health and Human Services, HCFA, the Wyoming Attorney General or the Wyoming Auditor.

(c) Refusal to produce or maintain records. The refusal of a provider to make financial or medical records available and accessible shall result in the immediate suspension of all Medicaid payments to the provider and all Medicaid payments made to the provider during the record retention period for which records supporting such payments are not produced shall be repaid to the Department within ten days after written request for such repayment, and the Department shall suspend all Medicaid payments for services provided after such date. Reimbursement shall not be reinstated until the Department determines that adequate records are being maintained.

Section 14. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.