Wyo. Code R. 048-0037-22
Medicaid
Chapter 22: Medicaid Nursingt Facility Level of Care Determinations
Effective Date: 11/06/1990 to 08/01/1995
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.22.11061990
Date Filed 11/06/90 Expr Date Supr Date Repeal Date Document Type RULES
EVALUATION OF MEDICAL NECESSITY
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 methods and standards for evaluations of medical necessity for applicants and recipients seeking nursing facility services. The requirements of this Chapter apply to all applicants and recipients.
Section 3. General terms. This rule is intended to be read in conjunction with Chapter XIX of these rules.
a) "Admission." The act that allows an individual to officially enter a facility to receive nursing facility services.
(b) "Applicant." A person, including a patient, who has applied for Medicaid benefits and is a resident or is seeking admission to a facility.
(c) "Appropriate placement." The placement of an individual in a treatment setting when the individual's needs meet the minimum standards for admission to that treatment setting and the individual's needs for treatment do not exceed the level of services which the treatment setting is capable of providing.
(d) "Date of admission." The date an individual enters a facility and begins receiving nursing facility services.
(e) "Date of referral." The date the medical necessity evaluator receives a referral.
(f) "Department." The Wyoming Department of Health, its agent, designee or successor.
(g) "Discharge." The act by which an individual who has been a patient in a facility ceases to be a patient and the facility ceases to be legally responsible for providing care for such individual. "Discharge" does not include an individual's temporary absence from the facility for treatment in a hospital, home visits or a trial community stay provided such temporary absence is not longer than thirty consecutive days.
(h) 'Evaluation of medical necessity.' A review, pursuant to Section 5, by a medical necessity evaluator of an applicant's or recipient's physical and mental condition for the purpose of determining whether the individual requires intermediate care or skilled nursing care.
(i) 'Facility.' A skilled nursing facility (SNF), an intermediate care facility (ICF) or a nursing facility that meets all of the requirements of state licensure and certification for participation in the Medicaid program. 'Facility' may include a distinct part of a hospital or institution which is designated to provide nursing facility services.
(j) 'Hospital.' An institution that:
(1) is approved to participate as a hospital under Medicare;
(2) is maintained primarily for the treatment and care of patients with disorders other than mental diseases or tuberculosis; and
3) is licensed to operate as 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.
(k) 'Intermediate care facility (ICF) services.' Intermediate care facility services as defined by 42 C.F.R. 440.150 (1988), which is hereby incorporated by reference.
(l) 'Long Term Care Review Document (LT 101).' The Title XIX Long Term Care Review Document as prepared by the Department.
(m) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(n) 'Medically necessary.' Nursing facility services are required because of an individual's functional ability as determined by an evaluation of medical necessity pursuant to this rule.
(o) 'Medical necessity evaluator.' A public health nurse or registered nurse that is under contract to the Department to function as the medical necessity evaluator, or, in areas where no contract exists, designated staff of the Department acting in concert with local medical professionals.
(p) 'Nursing facility.' A nursing facility as defined by 42 U.S.C.A. 1396r(a) (Supp. 1990), which is hereby incorporated by reference.
(q) 'Nursing facility services.' ICF services, SNF services, or services provided in a nursing facility.
(r) 'PASARR.' Preadmission screening and annual resident review conducted pursuant to Chapter XIX.
(s) 'Patient.' A resident of a facility.
(t) 'Physician.' A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a comparable agency in another state.
(u) 'Prior authorization.' Approval by the Department before services are provided.
(v) 'Provider.' A facility which has a current provider agreement with the Department.
(w) 'Provider agreement.' A formal written agreement between the Department and a facility certified to provide services to recipients.
(x) 'Public health nurse.' A registered nurse who is either under contract to the County to perform public health nursing functions or is an employee of the Department that is assigned public health nursing functions.
(y) 'Recipient.' An individual that has been determined eligible for Medicaid.
(z) 'Referral.' A communication, written or oral, from a facility to the medical necessity evaluator indicating that an individual seeking admission to or on the premises of the facility requires an evaluation of medical necessity.
(aa) 'Registered nurse.' A person licensed to practice professional nursing by the Wyoming State Board of Nursing or a comparable agency in another state.
(bb) 'Skilled nursing care.' Skilled nursing care as defined in 42 C.F.R. 440.40 (1988), which is hereby incorporated by reference.
(cc) 'Swing bed.' A bed in a hospital which is certified for either inpatient hospital service or nursing facility services.
(dd) 'Working day.' Monday through Friday, exclusive of state holidays.
a) Purpose. To determine whether an applicant or recipient requires intermediate care or skilled nursing care.
(b) Applicability. All applicants or recipients must undergo an evaluation of medical necessity before a facility may receive Medicaid reimbursement for services provided to that individual.
(c) Criteria. The medical necessity evaluator shall determine whether nursing facility services are necessary by evaluating individuals using the factors in paragraphs (i) through (xii).
(i) Eating/meal preparation. The individual:
(A) Independently feeds himself or herself (0 points);
(B) Requires staff supervision or assistance (2 points);
(C) Requires constant attention and hand feeding by a staff member (4 points);
(D) Has training in self-feeding, with or without devices, which is documented in accordance with an individual plan of care (3 points); or
(E) Independently feeds himself or herself, but needs someone to prepare meals (2 points).
(ii) Medications. The individual:
(C) Requires one-on-one assistance in maintaining contact with social reality (3 points).
(vii) Behavior. The individual:
(A) Behaves appropriately (0 points);
(B) Is intermittently confused, agitated or both (1 point);
(C) Is frequently (more than once month), aggressive, abusive or disruptive (3 points);
(D) Is depressed, reclusive or both, and does not interact with others more than half the time (3 points); or
(E) Is participating in a documented plan of rehabilitative therapy (2 points).
(viii) Continence. The individual:
(A) Is continent (0 points);
(B) Is occasionally incontinent or stress incontinent (1 point);
(C) Is frequently or totally incontinent and participating in a training program (3 points);
(D) Is frequently or totally incontinent and unable to participate in a training program (3 points);
(E) Requires a catheter (3 points); or
(F) Is totally incontinent of bowel and bladder and participating in a training program pursuant to an individual plan of care and reasonable goals are being reached in a generally predictable period of time (5 points).
(ix) Speech, vision and hearing. The individual is:
(A) Unimpaired (0 points);
(B) Impaired, but not dependent on staff (0 points)
(C) Impaired and requires staff assistance (2 points);
(D) Completely dependent in areas of communications and ADL (3 points); or
(E) Blind, deaf or aphasic and there is documented evidence of rehabilitative training in accordance with a plan of care (4 points).
(x) Dressing and personal grooming. The individual:
(A) Independently dresses and grooms (0 points);
(B) Requires assistance in dressing and grooming (2 points);
(C) Requires total assistance in dressing and grooming (3 points); or (D) Is undergoing rehabilitative training in dressing or grooming in accordance with a plan of care (4 points).
(xi) Bathing. The individual:
(A) Bathes independently (0 points); (B) Requires assistance and supervision while bathing (1 point); or (C) Is totally dependent on a staff member (3 points).
(xii) Mobility. The individual:
(A) Independently transfers or ambulates with or without devices (0 points); (B) Transfers or ambulates with minimal or stand-by staff assistance (2 points); (C) Is completely dependent on others to transfer or ambulate (3 points); or (D) Has a need for specialized rehabilitative training in accordance with a plan of care (4 points).
(d) Standards. After evaluating the individual pursuant to subsection (c), the medical necessity evaluator shall complete the LT 101 and determine the need for nursing facility services using the following standards:
(i) If an applicant or recipient receives fewer than thirteen points pursuant to subsection (c), nursing facility services are not medically necessary unless prior authorized pursuant to Section 7 or the individual:
A) Is intermittently confused, agitated or both, and in need of a structured environment; (B) Wanders extensively; (C) Is totally confused or totally apathetic; (D) Is dependent on an institutional environment; or (E) Is unable to be cared for in the community.
(ii) If an applicant or recipient receives thirteen or more points pursuant to subsection (c), but less than 29 points, intermediate care is medically necessary.
(iii) If an applicant or recipient receives 29 or more points pursuant to subsection (c), skilled nursing care is medically necessary.
(iv) If an applicant or recipient receives fewer than 29 points pursuant to subsection (c), skilled nursing care is not medically necessary, unless the individual requires:
(A) Intravenous feeding or intravenous medication; (B) Intermittent catheterization; (C) Sterile wound care and dressings when ordered by a physician specifically for times other than the day shift; (D) Traction; (E) Initial training for colostomy or ileostomy or complications of the same; (F) Tracheotomy aspiration or care; (G) Levine tube or gastrostomy feedings; (H) Continuous oxygen where monitoring is required; or (I) Routine suctioning of the nasopharyngeal airway by a professional.
(e) Recipients admitted to a facility before April 1, 1990 are exempt from the provisions of this Section unless the recipient:
(i) Seeks to transfer to another facility; (ii) Is discharged and seeks readmission to the discharging facility or another facility; or (iii) Loses Medicaid eligibility and subsequently reapplies for or seeks a redetermination of Medicaid eligibility.
(f) Transfers.
(i) Any recipient seeking to transfer to another facility must be screened. Recipients receiving thirteen points or more pursuant to subsection (c) shall be allowed to transfer. Individuals receiving less than thirteen points shall not be allowed to transfer, but may remain in the facility.
(ii) Recipients who are temporarily absent from a facility must return to the facility from which they are absent before a transfer may be executed unless the facility from which the recipient is absent is unable to care for the recipient.
(iii) The facility to which a recipient proposes to transfer shall not receive Medicaid reimbursement for services provided to the recipient unless the requirements of subparagraphs 5(f)(i) and (ii) are met.
(g) Readmissions. A recipient that is discharged and subsequently seeks readmission to a facility must be screened pursuant to this Section. The facility in which the individual resided prior to discharge or the facility into which admission is sought shall not receive Medicaid payment for services provided to the recipient if the recipient does not require the level of care provided by that facility.
(h) Redetermination of Medicaid eligibility. A recipient that loses Medicaid eligibility and subsequently seeks a redetermination of Medicaid eligibility must be screened pursuant to this Section, even if the individual has not been discharged. The facility in which the individual resides or into which admission is sought shall not receive Medicaid payment for services provided to the recipient if the the level of care provided by that facility is not medically necessary.
(i) Evaluations of medical necessity shall be performed by the medical necessity evaluator.
(ii) The facility shall be responsible for referrals. A referral shall be timely if performed no later than the end of the first working day after the date of admission.
(iii) An evaluation of medical necessity shall be timely if performed by the end of the third working day after the date of referral.
(iv) An evaluation of medical necessity performed as a result of a timely referral shall be effective on the date of admission to the facility. An evaluation of medical necessity performed as a result of a referral that is not timely shall be effective no sooner than the date the referral is made.
(v) The Department shall give written notice to the the applicant or recipient if the evaluation of medical necessity determines that the level of care offered by the facility is not medical necessary.
(j) Validity of evaluation of medical necessity. An evaluation of medical necessity pursuant to this section that results in thirteen points or more is valid for forty-five days after the date of the evaluation, after which a new evaluation will be required prior to admission or transfer.
(k) Scheduled reevaluations. The medical necessity evaluator may limit the duration of an evaluation of medical necessity to a specified period, after which a new evaluation will be required as a prerequisite to Medicaid reimbursement for services provided to the individual after the end of the period specified in the evaluation of medical necessity.
(l) Not a guarantee of eligibility. An evaluation of medical necessity that determines that nursing facility services are medically necessary is not a guarantee of the individual's eligibility for Medicaid nor of Medicaid reimbursement for services provided to the individual.
(a) Completion of evaluation of medical necessity. No facility shall receive Medicaid reimbursement for nursing facility services provided to a recipient until:
(i) The completion of an evaluation of medical necessity which indicates that nursing facility services are medically necessary; and
(ii) Compliance with Chapter XIX.
(b) Retroactive payments. Retroactive payments are available pursuant to Chapter XIX, subsection 8(b), of these Rules, which is hereby incorporated by reference.
(a) If an applicant or recipient receives less than thirteen points pursuant to paragraph 5(d)(i) and nursing facility are not deemed necessary by the medical necessity evaluator pursuant to subparagraphs 5(d)(i)(A) through (E), such services may be deemed medically necessary if prior authorized by the Department. The individual or entity requesting such authorization must submit such information as the Department specifies in the format specified by the Department.
(b) Criteria for review. Prior authorization shall be granted if the proposed services:
(c) Denial of prior authorization.
(i) The Department shall notify the facility and the recipient or applicant, in writing, of the denial of prior authorization.
(ii) The provider may submit a revised request for prior authorization or additional documentation as necessary for the Department to reconsider the matter; or
(iii) The recipient may request reconsideration of the denial of prior authorization pursuant to Chapter I.
(iv) The denial of prior authorization precludes Medicaid reimbursement for the services in question.
(d) Failure to timely request prior authorization. The failure to obtain prior authorization before providing services precludes Medicaid reimbursement for such services.
(e) Effect of prior authorization. Granting prior authorization shall constitute approval for the provider to receive Medicaid reimbursement for the services to be furnished, subject to the other requirements of this rule and post payment review. Prior authorization is not a guarantee of the recipient's eligibility nor of Medicaid reimbursement.
Section 8. Reconsideration.
(a) Request for reconsideration. An applicant, a patient or a person that is legally responsible for an applicant or a patient may request that the Department reconsider a determination that nursing facility services are not appropriate or medically necessary. Such request must be mailed to the Department by certified mail within thirty days of the date the Department mails notice pursuant to paragraphs 5(i)(v) or 7(c)(i). A facility may request reconsideration of any decision made pursuant to this Chapter other than a determination that nursing facility services are not appropriate or medically necessary. Such request must be mailed to the Department by certified mail within twenty days of the date the facility receives notice of the decision. All requests for reconsideration 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 individual or facility that requested reconsideration of its final decision within forty-five days after receipt of the request for reconsideration. The
Department may request additional information from the individual, the facility or the medical necessity evaluator as part of the reconsideration process.
(c) Administrative hearing. An applicant or patient may request an administrative hearing pursuant to Chapter I of these rules regarding the final decision that nursing facility services are not appropriate or medically necessary. An applicant or patient may request an administrative hearing by mailing by certified mail or personally delivering a request for hearing to the Department within thirty days of the date the individual receives notice of the final decision pursuant to paragraph (b). A facility may request an administrative hearing pursuant to Chapter I of these rules regarding any final decision made pursuant to this Chapter other than a determination that nursing facility services are not appropriate or medically necessary. A facility may request an administrative hearing by mailing by certified mail or personally delivering a request for hearing to the Department within twenty days of the date the facility receives notice of the final decision pursuant to paragraph (b). All requests for administrative hearings must comply with the requirements of Chapter I.
Section 9. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.