Wyo. Code R. 048-0037-20
Chapter 20: Reimbursement of Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID)
Effective Date: 06/14/2017 to Current
Rule Type: Current Rules & Regulations
Reference Number: 048.0037.20.06142017
This rule is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. §§ 42-4-101 through 42-4-306.
This rule shall apply to and govern the reimbursement of the Wyoming Life Resource Center State Operated Facility and other ICFs/IID.
These rules are intended to implement and be read in conjunction with the provisions of W.S. §§ 42-4-101 through 42-4-306.
intermediate care facility as defined by 42 U.S.C. 1396d(d) that has at least fifteen certified beds. “ICF/IID” includes that portion of the Wyoming Life Resource Center which is certified to provide intermediate care facility services for those with intellectual disabilities.
(g) “Per diem rate.” The Medicaid reimbursement rate determined pursuant to this rule.
(h) “Provider.” An ICF/IID that has a provider agreement with the Department and that is certified to provide services to recipients.
(i) “Provider agreement.” A formal written agreement between the Department and an ICF/IID that is certified to provide services to recipients.
(j) “Services.” Intermediate care facility services for those with intellectual disabilities as defined in 42 U.S.C. 1396d(d).
(k) “Services and supplies included in the per diem rate.” In addition to those services and supplies specified in Chapter 7, Attachment A.
(l) “Services and supplies not included in the per diem rate.” Services and supplies which are not included in the per diem rate include, but are not limited to:
(viii) Customized wheelchairs that are fitted or fabricated to a specific individual and cannot be used by any other person, and electric wheelchairs, including batteries.
(m) “Temporary absence.” When a recipient is out of a facility for hospitalization or therapeutic home visits. Temporary absences for hospitalization:
(i) Shall not exceed fifteen (15) days per year, and
(ii) The recipient must intend to and have a reasonable expectation of returning to the facility.
(iii) Temporary absences for therapeutic home visits shall:
(A) Be part of the recipient’s plan of care, and
(B) Be limited to fifteen (15) days in duration no more than once per month, not to exceed thirty (30) days per calendar year. A recipient receiving infirmary services is not absent from the facility.
(n) “Unique costs.” The following services and supplies are unique costs and shall be included in the per diem rate if they are provided by the facility or by a third party under contract to the facility to or for the benefit of a recipient:
(xviii) Pre-vocational training services and supplies;
(xix) Psychological services;
(xx) Recreational therapy services;
(xxi) Social services;
(xxii) Speech therapy services; and
(xiii) Transportation services
(o) 'Wyoming Life Resource Center.' The Wyoming state training school as established pursuant to W.S. §§ 25-5-101 through 25-5-135.
(a) ICFs/IID shall be reimbursed using a per diem rate calculated in accordance with the methodology established below. In addition, ICFs/IID shall be subject to the rules in Chapter 7, Wyoming Nursing Home Reimbursement System, except as otherwise specified by this rule. ICFs/IID shall not be subject to the Chapter 7 rate and price setting Sections 7, 13(d), 14, 15, 16, 17(c), 18, and 19.
(b) Calculation of per diem rates for ICFs/IID. The per diem rate for ICFs/IID shall be calculated independently from the calculation of rates for facilities as defined in Chapter 7. The provider's per diem rate shall be determined utilizing either a desk reviewed or audited cost report. Costs shall not be subject to any form of cap or maximum rate for the Wyoming Life Resource Center.
(i) Effective date. The rates calculated each July 1 shall remain in effect until the following July 1.
(ii) Per diem rates are established prospectively and shall remain in effect from the rate effective date until re-determined pursuant to this rule.
(iii) Applicable cost report data. The data used in establishing the rate calculation is from the cost reports which ended two (2) calendar years ago (for example, cost reports ending during the period from January 1, 2013 to December 31, 2013, shall be used to set rates effective July 1, 2015).
(iv) Cost reports submitted by ICFs/IID shall not be used in any way to calculate per diem rates for facilities as defined in Chapter 7.
(v) Rates shall be established by inflating adjusted / reviewed costs from the midpoint of the provider's cost reporting year to the midpoint of the rate year. Inflated costs shall be divided by total patient days to arrive at the allowed per diem rate.
(c) Reimbursement of new facilities. A new facility or a newly certified facility shall receive interim payments for services provided to recipients as determined pursuant to this subsection.
(i) Submission of projected costs. A new facility shall, before receiving Medicaid funds for services provided to recipients, submit a cost report to the Department containing projected costs for the facility’s first six months of operation.
(ii) Time of submission of cost report. A new facility shall submit a cost report containing the information specified in paragraph (i) within sixty (60) days after the facility notifies the Department in writing that it wishes to participate in the Medicaid program as a provider and has been certified.
(iii) Review of projected costs. The Department shall desk audit the cost report submitted pursuant to paragraph (i) to determine the reasonableness of the facility’s allowable projected costs. An interim payment rate shall be established using the facility’s reasonable, allowable costs. The interim payment rate shall not exceed the lower of the rate determined pursuant to this subsection and seventy-five percent (75%) of the Wyoming Life Resource Center rate in effect.
(iv) Period of interim payments. Interim payments shall be effective upon the effective date of the facility’s provider agreement, and shall remain in effect until a qualifying cost report has been submitted and subjected to audit and used to calculate a rate. No payments shall be made to a new facility until an interim payment rate has been determined pursuant to this subsection.
(v) Audits of interim payments. Upon receipt of the qualifying cost report, the Department may audit a facility to determine the accuracy and reasonableness of cost reports submitted by the facility. If the audit discloses that the interim payments included non-allowable costs, costs for services and supplies not included in the per diem rate or that budgeted costs exceeded actual costs, the Department shall adjust the per diem rate retroactively to the beginning of the interim rate period and recover any excess payments.
(vi) Audits shall be conducted in accordance with Section 5(b). Providers other than Wyoming Life Resource Center shall have rates limited to the lower of the provider’s audited cost in accordance with Section 5(b) or seventy-five percent (75%) of the Wyoming Life Resource Center rate.
Section 6. ICFs/IID are subject to the requirements of Chapter 17, Nursing Facility Resident Trust Accounts.
Section 7. Superseding Effect. This chapter supersedes all prior rules or policy statements issued by the Department, including manuals and/or bulletins, which are inconsistent with this Chapter.
Section 8. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.
(a) For any code, standard, rule or regulation incorporated by reference in these rules:
(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;
(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
(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.
(b) Each rule incorporated by reference is further identified as follows:
(i) Referenced in Sections 4 and 5 is Chapter 7 - Rules and Regulations for Medicaid – Wyoming Nursing Home Reimbursement System, adopted by the Department of Health and effective on May 29, 2012, found at http://soswy.state.wy.us/Rules/RULES/8611.pdf
(ii) Referenced in Section 6 is Chapter 17, Rules and Regulations for Medicaid - Nursing Facility Resident Trust Accounts, adopted by the Office of Medicaid and effective on May 29, 2012, found at http://soswy.state.wy.us/Rules/RULES/8612.pdf.