Wyo. Code R. 048-0037-12
Medicaid
Chapter 12: Home Health Services
Effective Date: 12/15/1994 to 10/01/2001
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.12.12151994
These rules are 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 rule establishes the scope of the home health services covered by Medicaid and the methods and standards of reimbursing providers of such services.
(a) This rule shall apply to and govern the provision of home health services and reimbursement for those dates of service on or after January 1, 1995.
(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.
(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 62 days.
(c) 'Chapter I.' Chapter I, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
(d) 'Chapter III.' Chapter III, Provider Participation, of the Wyoming Medicaid Rules.
(e) 'Claim.' A request by a provider for Medicaid payment for covered services provided to a recipient.
(f) 'Covered services.' Services which are Medicaid reimbursable pursuant to this Chapter.
(g) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(h) 'Disposable supplies.' Supplies that are not intended to be reused.
(i) 'Division.' The Division of Health Care Financing of the Department.
(j) 'Excess payments.' Medicaid funds received by a provider which exceed the reimbursement limit established by this rule.
(k) 'HCFA.' The Health Care Financing Administration of the United States Department of Health and Human Services.
(l) 'Home.' A recipient's primary place of residence. 'Home' does not include a nursing facility or hospital.
(m) 'Home-bound.' A recipient that:
(i) Cannot leave his or her home without the assistance of another person;
(ii) Cannot safely leave home unattended because of mental or emotional problems;
(iii) Refuses to leave home because of mental or emotional problems;
(iv) Is under a physician's orders to avoid stress and physical activity; or
(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.
(n) 'Home health agency.' A home health agency as defined by 42 C.F.R. § 440.70, which is incorporated by this reference.
(o) 'Home health aide.' A person that is certified as a nursing assistant/nurse aide by the Wyoming Board of Nursing, and employed by a home health agency.
(p) 'Home health aide service.' Covered services provided pursuant to a plan of treatment by a home health aide under the supervision of a registered nurse.
(q) 'Hospital.' An institution that: (i) is approved to participate as a hospital under Medicaid; (ii) is maintained primarily for the treatment and care of patients with disorders other than tuberculosis or mental diseases; (iii) has a provider agreement; (iv) is enrolled in the Medicaid program; (v) is licensed to operate a hospital by the State of Wyoming or, if the institution is out-of-state, licensed by the state in which the institution is located.
(r) 'Intermittent.' Three or fewer daily visits for home health aide services and/or skilled nursing services, where each visit does not exceed four hours.
(s) “Medicaid.” Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(t) “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.
(u) “Medicaid fee schedule.” The Medicaid fee schedule established pursuant to Chapter III, Section 10, which is incorporated by this reference.
“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.
(w) “Medicare.” The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
“Mental health clinic.” A facility which is certified as a mental health clinic by the Behavioral Health Division of the Department.
(y) “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.
(z) “Mental health services.” Professional services provided to a recipient with a psychiatric diagnosis by a mental health professional pursuant to a plan of treatment.
(aa) “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.
“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.
(cc) “Physical therapist.” A person licensed to practice physical therapy by the Wyoming Board of Physical Therapy or a similar agency in another state.
“Physician.” A person licensed to practice medicine or osteopathy by the Wyoming State
Board of Medical Examiners or a similar agency in another state.
(ee) “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 recipient is home-bound and that home health services are appropriate.
(vii) The plan of treatment must be reviewed and signed by the attending physician at least once every sixty-two days.
(ff) “Prior authorized.” Approval by the Department pursuant to the prior authorization provisions of Chapter III, which are incorporated by this reference.
(gg) “Provider.” A home health agency which has or had a provider agreement.
(hh) “Provider agreement.” “Provider agreement” as defined by Chapter III, which definition is incorporated by this reference.
(ii) “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.
(mm) “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.
(nn) “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.
(oo) “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.
(pp) “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” 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 and/or physical, speech or occupational therapy; 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.
“Supplies.” Medical supplies authorized for Medicaid payments under W.S. § 42-4-103 and the rules of the Department.
(tt) “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 III. 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 III, which are incorporated by this reference.
Section 6. Provider records. A provider must comply with the record keeping requirements of Chapter III, 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 III, 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; (iv) Documented in a plan of treatment; and (v) The recipient is home-bound.
(b) Covered services.
(i) Skilled nursing services provided by a registered nurse; (ii) Home health aide services; (iii) Physical therapy services as defined by Medicare and provided by a physical therapist; (iv) Speech therapy services as defined by Medicare and provided by a speech therapist; (v) Occupational therapy services provided by an occupational therapist;
(vi) Medical social services as defined by Medicare, not to exceed three visits per certification period;
(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:
(a) Homemaker services;
(b) Respite services;
(c) Meals on wheels;
(d) Personal care attendants;
(e) Private-duty nursing services;
(f) Services for recipients that are patients in a hospital or residents of a nursing facility;
(g) Services that are inappropriate in the patient’s home;
(h) Services that are not cost-effective; and
(i) Services or supplies provided for the comfort of a patient.
Section 10. Prior authorization.
(a) Incorporation of Chapter III. Prior authorization of home health services shall be governed by the prior authorization requirements of Chapter III, 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.
(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-two days. Recertified plans of care 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 III, which are incorporated by this reference.
Section 13. Recovery of excess payments. Excess payments may be recovered pursuant to the recovery of excess payments provisions of Chapter III, which are incorporated by this reference.
(a) A provider from which the Department seeks to recover excess payments may request reconsideration, followed by and administrative hearing, pursuant to Chapter III, Section 13, which is incorporated by this reference.
(b) Informal resolution. The provider or the Department may request an informal meeting before the final decision on reconsideration to determine whether the matter may be resolved. The substance of the discussions and/or settlement offers made pursuant to an attempt at informal resolution shall not be admissible as part of a subsequent administrative hearing or judicial proceeding.
(c) 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.
(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. 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 17. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in effect.