Wyo. Code R. 048-0037-26
Medicaid
Chapter 26: Covered Services
Effective Date: 09/08/1995 to 02/18/1997
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.26.09081995
This rule 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.
(a) This rule defines which services are covered services, except as otherwise specified in the rules of the Department, and shall apply to all recipients and providers.
(b) The Department may issue Manuals or Bulletins to providers and/or other affected parties to interpret the provisions of this rule. Such Manuals or Bulletins shall be consistent with and reflect the policies contained in the Chapter. The provisions contained in Manuals or Bulletins shall be subordinate to the provisions of this Chapter.
Section 3. General provisions. Except as otherwise specified, the terminology used in this Chapter is the standard terminology and has the standard meaning used in accounting, health care, Medicaid and Medicare.
(a) 'Audiologist.' A person licensed to practice audiology by the Wyoming Board of Examiners of Speech Pathology and Audiologists or a similar agency in another state.
(b) 'Certified registered nurse anesthetist (CRNA).' A registered nurse who is:
(i) Certified by the National Council on Certification of Nurse Anesthetists;
(ii) Certified by the Council on Recertification of Nurse Anesthetists; or
(iii) Has graduated from a nurse anesthesia program that meets the standards of the Council on Accreditation of Nurse Anesthesia Educational Programs, and is awaiting initial certification pursuant to (i) or (ii).
(c) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(d) 'Chapter 4.' Chapter 4, Third Party Liability, of the Wyoming Medicaid Rules.
(e) 'Chapter 5.' Chapter 5, Medicaid Long Term Care Facility Remedies/Terminations, of the Wyoming Medicaid Rules.
(f) 'Chapter 6.' Chapter 6, HEALTH CHECK Services, of the Wyoming Medicaid Rules.
(g) 'Chapter 7.' Chapter 7, Wyoming Nursing Home Reimbursement System, of the Wyoming Medicaid Rules.
(h) 'Chapter 8.' Chapter 8, Inpatient Admission Certification, of the Wyoming Medicaid Rules.
(i) 'Chapter 9.' Chapter 9, Hospital Services, of the Wyoming Medicaid Rules.
(j) 'Chapter 10.' Chapter 10, Pharmaceutical Services, of the Wyoming Medicaid Rules.
(k) 'Chapter 12.' Chapter 12, Home Health Services, of the Wyoming Medicaid Rules.
(l) 'Chapter 13.' Chapter 13, Community Mental Health Services, of the Wyoming Medicaid Rules.
(m) 'Chapter 14.' Chapter 14, Dental Services, of the Wyoming Medicaid Rules.
(n) 'Chapter 15.' Chapter 15, Ambulance Services, of the Wyoming Medicaid Rules.
(o) 'Chapter 17.' Chapter 17, Nursing Facility Resident Trust Accounts, of the Wyoming Medicaid Rules.
(p) 'Chapter 19.' Chapter 19, PASARR, of the Wyoming Medicaid Rules.
(q) 'Chapter 20.' Chapter 20, Reimbursement of Intermediate Care Facilities for the Mentally Retarded, of the Wyoming Medicaid Rules.
(r) 'Chapter 22.' Chapter 22, Nursing Facility Evaluation of Medical Necessity, of the Wyoming Medicaid Rules.
(s) 'Chapter 25.' Chapter 25, ICF/MR Services, of the Wyoming Medicaid Rules.
(t) 'Chapter 28.' Chapter 28, Swingbed Services, of the Wyoming Medicaid Rules.
(u) 'Chapter 30.' Chapter 30, Chapter 30, Level of Care Inpatient Hospital Reimbursement, of the Wyoming Medicaid Rules.
(v) 'Chapter 31.' Chapter 31, Selective Contracting of Hospital Services, of the Wyoming Medicaid Rules.
(w) 'Chapter 32.' Chapter 32, Disproportionate Share Hospitals, of the Wyoming Medicaid Rules.
(x) 'Chapter 33.' Chapter 33, Reimbursement of Outpatient Hospital Services, of the Wyoming Medicaid Rules.
(y) 'Chapter 34.' Chapter 34, Home or Community-Based Waiver Services, of the Wyoming Medicaid Rules.
(z) 'Chapter 35.' Chapter 35, Medicaid Benefit Recovery, of the Wyoming Medicaid Rules.
(aa) 'Claim.' A request by a provider for Medicaid payment for covered services provided to a recipient.
(bb) 'Consultation.' An opinion or advice rendered by one physician to another as part of the evaluation or treatment of a recipient.
(cc) 'Corrective lenses.' Prescription eyeglasses or, if the recipient's vision cannot be appropriately corrected using eyeglasses, contact lenses.
(dd) 'Cost report.' An itemized statement of a provider's historical costs for the most recently completed fiscal year, prepared in accordance with GAAP, this Chapter and the cost report instructions furnished by the Division. Cost reports must be submitted on the forms and contain the information required by the Division. 'Cost report' includes any supplemental requests by the Division for additional information.
(ee) 'Covered service.' Services or supplies which are Medicaid reimbursable pursuant to the rules of the Department.
(ff) 'Dentist.' A person licensed to practice dentistry by the Wyoming Board of Dental Examiners or a similar agency in another state.
(gg) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(hh) 'Developmental center.' An agency which:
(i) Provides developmental services to developmentally disabled children under the age of six; and
(ii) Is certified to provide services to recipients under age twenty-one by the Division of Developmental Disabilities.
(ii) 'DFS.' The Wyoming Department of Family Services, its agent, designee or successor.
(jj) "Diagnostic evaluation/assessment." A comprehensive, multi-disciplinary evaluation of a child five year of age or under that:
(i) Is performed after a written referral from a physician licensed in Wyoming;
(ii) Is performed using standardized assessment tools or, if no standardized assessment tools are available based on the child's chronological age or suspected developmental age, using criterion based assessments; and
(iii) Includes an assessment of the flowing:
(A) Physical development, including fine and gross motor skills; (B) Cognitive development; (C) Speech development; and (D) Social and emotional development.
(kk) "Direct supervision." Supervision in which the responsible practitioner is physically present in the building where the services are being provided.
(ll) "Division." The Health Care Financing Division of the Department, its agent, designee or successor.
(mm) "Division of Developmental Disabilities." The Division of Developmental Disabilities of the Department, its agent, designee or successor.
(nn) "Division of Public Health." The Division of Public Health of the Department, its agent, designee or successor.
(oo) "Durable medical equipment." Equipment that is:
(i) Able to withstand repeated use; (ii) Primarily used to serve a medical purpose; (iii) Generally not useful to a person in the absence of an illness or injury; and (iv) Appropriate for home use.
(pp) "Emergency." The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:
(i) Placing the patient's health in serious jeopardy;
(ii) Serious impairment to bodily functions; or
(iii) Serious dysfunction of any bodily organ or part.
(qq) "Emergency detention." A Person detained or involuntarily hospitalized pursuant to W.S. S 25-10-101 et seq.
(rr) "Emergency hospital services." "Emergency hospital services" as defined in 42 C.P.R. 440.170(e), which is incorporated by this reference.
(ss) "EPSDT." Early and periodic screening, diagnosis and treatment services for recipients under the age of 21.
(tt) "Equipment." Items, including durable medical equipment, that are designed for repeated use, have a medical purpose and are intended for home use.
(uu) "Excess payments." Medicaid funds received by a provider which exceed the Medicaid allowable payment established by the Department.
(vv) "Extended psychiatric services." "Extended psychiatric services" as defined in Chapter 30, which definition is incorporated by this reference.
(ww) "Federally-qualified health center (FQHC)." A "federally-qualified health center" as defined by 42 U.S.C. § 1396d(l)(2)(B), which is incorporated by this reference.
(xx) "Home or community-based (HCBS) services." Home or community-based services as defined by 42 C.F.R. 440.180, which is incorporated by this reference.
(yy) "Hospice program." "Hospice program" as defined by 42 U.S.C. § 1395x(dd), which is incorporated by this reference.
(zz) "HCFA." The Health Care Financing Administration of the United States Department of Health and Human Services.
(aaa) "Hospital." An institution that: (i) is approved to participate as a hospital under Medicare; (ii) is maintained primarily for the treatment and care of patients with disorders other than mental diseases or tuberculosis; (iii) has a provider agreement; (iv) is enrolled in the Medicaid program; and (v) 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.
(bbb) "Independent physical therapist." An independent physical therapist certified by Medicare. An "independent physical therapist" is neither employed by, directly affiliated with, or working under the supervision of a hospital, nursing facility, physician or other provider of health services.
(ccc) 'Inpatient.' An 'inpatient' as defined by 42 C.F.R. 440.2(a), which is incorporated by this reference.
(ddd) 'Inpatient hospital service.' 'Inpatient hospital services' as defined in 42 C.F.R. 440.10, which is incorporated by this reference.
(eee) 'Intermediate Care facility services for the mentally retarded (ICF/MR).' Intermediate care facility services as defined by 42 U.S.C. § 1396d(d), which is incorporated by this reference, and applicable HHS regulations.
(fff) 'Local agency.' The County office of DFS, its agent, designee or successor.
(ggg) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(hhh) 'Medicaid allowable payment.' The maximum Medicaid reimbursement as determined pursuant to the rules of the Department.
(iii) 'Medicaid fee schedule.' The Medicaid fee schedule as established pursuant to Chapter 3.
(jjj) 'Medically necessary' or 'medical necessity.' A health service that is required to diagnose, treat, cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected; to relieve pain; or to improve and preserve health and be essential to life. The service must be:
(i) Consistent with the diagnosis and treatment of the recipient's condition;
(ii) In accordance with the standards of good medical practice among the provider's peer group;
(iii) Required to meet the medical needs of the recipient and undertaken for reasons other than the convenience of the recipient and the provider; and
(iv) Performed in the most cost effective and appropriate setting required by the recipient's condition.
(lll) 'Medical supplies.' Disposable, semi-disposable or expendable supplies ordered by a physician for the treatment of an illness or Injury.
(mmm) 'Medicare.' The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.
(nnn) 'Nurse midwife.' A registered nurse who is certified as a nurse midwife by the
American College of Nurse-Midwives.
(ooo) 'Nurse practitioner.' An 'advanced practitioner of nursing' as defined by W.S. 33-21-120(a)(i), which is incorporated @ this reference, or a registered nurse that is certified or Licensed as a nurse practitioner pursuant to the laws of another state.
(ppp) 'Nursing facility.' 'Nursing facility' as defined by 42 U.S.C. § 1396r(a), which is incorporated by this reference. 'Nursing facility' may include a distinct part of a hospital or institution which is designated to provide nursing facility services.
(qqq) 'Ophthalmologist.' A physician who has successfully completed a postgraduate ophthalmology program of at least three years duration that is accredited by the American Board of Ophthalmology.
(rrr) 'Optometrist.' A person licensed to practice optometry by the Wyoming State Board of Examiners of Optometry or a similar agency In another state.
(sss) 'Outpatient.' An 'outpatient' as defined in 42 C.F.R. § 440.20(a), which is incorporated by this reference.
(ttt) 'Physician.' A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a similar agency in another state.
(uuu) 'Physician assistant.' A person certified as a physician assistant by the Wyoming State Board of Medical Examiners or a similar agency in another state.
(vvv) 'Physical therapist.' A person licensed as a physical therapist by the Wyoming State Board of Physical Therapy or a similar agency in another state.
(www) 'Practitioner.' A physician, dentist, registered nurse, nurse practitioner or other licensed health professional acting within the scope of his or her license.
(xxx) 'Preventive services.' Any routine service or examination which is performed in the absence of a diagnosed illness, injury or complaint.
(yyy) 'Prior authorization or prior authorized.' Approval by the division pursuant to Section 43.
(zzz) 'Provider.' Any individual or entity that has qualified as a provider pursuant to the rules of the Department
(aaaa) 'Psychologist.' A person licensed to practice psychology by the Wyoming Board of Psychologist Examiners or a similar agency in another state.
(bbbb) 'Psychiatric services.' 'Psychiatric services' as defined in Chapter 30, which definition is incorporated by this reference.
(cccc) 'Recipient.' A person who has been determined eligible for Medicaid.
(dddd) 'Recipient under age twenty-one.' A recipient before or during the month in which he or she turns twenty-one years of age.
(eeee) 'Registered nurse.' A person licensed to practice nursing by the Wyoming Board of Nursing or a similar agency in another state.
(ffff) 'Rural health clinic (FHC).' A 'rural health clinic' as defined by 42 C.F.R. § 491.2(3), which is incorporated by this reference.
(gggg) 'Rural health clinic services.' 'Rural health clinic services' as defined by 42 C.F.R. § 440.20(b), which is incorporated by this reference.
(hhhh) 'Service limitations.' Limits on the quantity of covered services which are Medicaid reimbursable as set forth in the rules of the Department, except as prior authorized.
(iiii) 'Services.' Health services, medical supplies or equipment.
(jjjj) 'Social worker.' A person licensed as a licensed clinical social worker by the Wyoming Board of Mental Health Professionals or a similar agency in another state.
(kkkk) 'Standing orders.' Orders from a provider that a certain service or services be provided to every patient.
(llll) 'Supervisor.' An individual licensed to provide services who takes professional responsibility for such services, even when provided by another individual or individuals.
(mmmm) 'Supervision.' The ready availability of the supervisor for consultation and direction of the individual providing services. Contact with the supervisor by telecommunications is sufficient to show ready availability if such contact is sufficient to provide quality care.
(nnnn) 'Swing-bed services.' Nursing facility services provided to a recipient in a hospital bed which is certified for either inpatient hospital services or nursing facility services.
(oooo) 'Usual and customary charge.' A provider's charge to the general public for the same service.
(a) The services and supplies specified in subsection (b) are covered services if medically necessary, subject to the rules of the Department.
(b) Covered services:
(i) Ambulance services; (ii) Ambulatory surgical center services; (iii) Audiology services; (iv) Certified registered nurse anesthetist services; (v) Community mental health services; (vi) CORF (Comprehensive outpatient rehabilitation facility) services; (vii) Dental services; (viii) Developmental center services; (ix) Emergency hospital services; (x) EPSDT (Early and periodic screening, diagnosis and treatment) services furnished to recipients under twenty-one years of age; (xi) End-stage renal dialysis center services (ESRD); (xii) Family planning clinic services; (xiii) FQHC services; (xiv) Home and community-based waiver services (xv) Home health services; (xvi) Hospice services; (xvii) Hospital services (inpatient and outpatient); (xviii) ICF/MR services; (xix) Institution for mental disease (IMD) services furnished to individuals sixty-five years of age and older; (xx) Laboratory services; (xxi) Medical supplies and equipment; (xxii) Nurse midwife services;
(a) Services furnished without the consent of the recipient or the recipient's legal guardian, except in an emergency;
(b) Experimental procedures. For purposes of this Chapter, 'experimental procedures' means procedures or services which are not generally accepted or used by a provider's peer group as current or standard practice;
(c) Examinations or reports required for legal purposes or other purposes not specifically related to medical care;
(d) Services furnished outside the United States;
(e) Services furnished to an individual who is an inmate of a public institution, or an individual that is in the custody of a state, local, or federal law enforcement agency;
(f) Services provided to an individual in emergency detention;
(g) Services which exceed the service limitations established by the rules of the Department, unless prior authorized;
(h) Services provided pursuant to a court order if such services:
(i) Are not covered services;
(ii) Exceed service limitations;
(iii) Are furnished by a health care practitioner or facility that is not a provider on the date(s) of services; or
(iv) Have not received prior authorization, if so required.
(h) The following medical services:
(i) Abortions, except as specified in Section 37;
(ii) Acupuncture;
(iii) Alcohol and chemical rehabilitation, except as specified in Chapter 9;
(iv) Autopsies;
(v) Biofeedback therapies and equipment;
(vi) Chiropractic services;
(vii) Chronic pain rehabilitation;
(viii) Community mental health services furnished outside Wyoming;
(ix) Cosmetic procedures, except as specified in Section 37;
(x) Custodial care;
(xi) Hysterectomies, except as specified in Section 37;
(xii) Infertility services, including counseling, reverse sterilization and artificial insemination;
(xiii) Missed or canceled appointments;
(ix) Personal comfort items;
(x) Private-duty nursing services;
(xi) Routine physical examinations, except as specified in Section 37;
(xii) Services rendered by an independently practicing
(A) Occupational therapist;
(B) Psychologist;
(C) Social worker; or (D) Speech therapist.
(xiii) Sleep disorder clinic services;
(xiv) Solid organ transplants, unless:
(A) Provided to a recipient under the age of twenty-one; and
(B) Prior authorized.
(xv) Sterilizations, except as specified in Section 37;
(xvi) Telephone calls.
(xvii) Transsexual surgery;
(xviii) Weight reduction surgery, including intestinal bypass surgery, gastric bypass surgery, gastric stapling; and
(xix) Weight reduction treatment.
(i) Payment for noncovered services. Except as specified in subsection (j), a provider that provides a noncovered service to a recipient may seek payment from the recipient only if the provider informed the recipient, in writing, of the recipient's potential liability before providing the service, and the recipient agreed in writing to pay for such services before they were furnished.
(j) A provider may seek payment from a recipient for services in excess of the service limitations established by the rules of the Department without complying with subsection (i).
(a) Payments only to providers. No provider that furnishes covered services to a recipient shall receive Medicaid funds unless the provider has signed a provider agreement and is enrolled.
(b) Compliance with Chapter 3. A provider that wishes to receive Medicaid reimbursement for covered services furnished to a recipient must meet the requirements of Chapter 3, which requirements are incorporated by this reference.
Section 8. Provider records. A provider must comply with the record-keeping requirements of Chapter 3, which requirements are incorporated by this reference.
Section 9. Verification of recipient data. A provider must comply with the verification of recipient data requirements of Chapter 3, which requirements are incorporated by this reference.
Section 10. Third party liability. A provider must comply with Chapter 4 and Chapter 35.
Section 11. Ambulance services.
Ambulance services are subject to the requirements of Chapter 15.
Section 12. Ambulatory surgical center (ASC) services.
(a) Definition. Surgical procedures or other services which do not require overnight inpatient hospital care.
(b) Eligible providers. A facility or distinct portion of a facility certified under Medicare to provide ASC services.
(c) Covered services.
(i) All surgical procedures covered by Medicare; and
(ii) Additional surgical procedures approved by Medicaid and which may be provided as outpatient hospital services. The Division shall distribute a list of additional approved procedures in a provider manual or bulletin.
(d) Medicaid allowable payment. The Medicaid allowable payment shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
Section 13. Audiology services.
(a) Definition. Services necessary to test hearing function with evaluation of medical problems and evaluate for hearing aid use.
(b) Eligible providers. Physicians or independently practicing audiologists.
(c) Covered services.
(i) Audiologic function tests; and
(ii) Hearing aid examinations.
(d) Medicaid allowable payment. Medicaid payment shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
Section 14. Certified registered nurse anesthetist (CRNA) services.
(a) Definition. Anesthesia services provided by a CRNA at a hospital or ambulatory surgical center.
(b) Eligible providers. Hospitals or physicians that employ a CRNA or independently practicing CRNAs.
(c) Covered services. Anesthesia services, except as otherwise specified by the rules of the Department.
(d) Excluded services. Anesthesia services when performed in conjunction with a surgical procedure:
(i) That is not a covered service;
(ii) For which prior authorization is required, but has not been obtained;
(iii) The recipient has not given informed consent to the procedure; and
(iv) That is a stand by service.
(e) Medicaid allowable payment. Medicaid payment shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
Section 15. Community mental health services.
Community mental health services are subject to Chapter 13.
Section 16. CORF services.
(a) Definition. Comprehensive outpatient rehabilitation facility services furnished at one fixed location and directed to the restoration of safe, functional independence. CORF services must include:
(i) Physician services;
(ii) Physical therapy; and
(iii) Social or psychological services.
(b) Eligible providers. Facilities certified by Medicare as comprehensive outpatient rehabilitation facilities.
(c) Covered services. In addition to the services specified in subsection (a), the following services are covered services;
(i) Drugs and biologicals that cannot be self-administered;
(ii) Medical supplies and equipment;
(iii) Nursing services;
(iv) Occupational therapy;
(v) Orthotics and prosthetics; and
(vi) Speech therapy.
(d) Excluded services.
(i) Services directed at general conditioning and/or maintenance; and
(ii) Services that exceed the limitations imposed by this and the other rules of the Department
(e) Medicaid allowable payment. The lower of the provider's usual and customary charge and the Medicare rate for CORF services.
Dental services are subject to Chapter 14.
(a) Definition. Services provided to developmentally disabled recipients under age twenty-one as part of an individualized education plan or as part of an individualized family services plan.
(b) Eligible providers. Developmental centers certified by the Division of Developmental Disabilities and under contract to that Division to provide such services.
(c) Covered services. Diagnostic assessment/evaluation, speech, physical and occupational therapy services and case management services.
(d) Medicaid allowable payment. The Medicaid allowable payment shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
(a) Definition. Emergency hospital services.
(b) Eligible providers. The most accessible hospital available that is equipped to furnish appropriate emergency hospital services, even if that hospital does not meet or is not approved to participate as a hospital under Medicare.
(c) Covered services. Emergency hospital services.
(d) Medicaid allowable payment. Medicaid payment shall be pursuant to Chapter 33.
EPSDT services are subject to Chapter 6.
(a) Definition. Outpatient dialysis and other treatment for persons with end-stage renal disease.
(b) Eligible providers. Free-standing or hospital-based facilities certified by Medicare to provide ESRD services.
(c) Covered services. ESRD services as defined by Medicare.
(d) Medicaid allowable payment. The Medicaid allowable payment shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
(a) Definition. Medically approved diagnosis, treatment, counseling, drugs, supplies or devices which are prescribed or furnished to individuals of child-bearing age for purposes of enabling such individuals to determine the number and spacing of their children.
(b) Eligible providers. A clinic, which is neither located on the premises of a hospital nor owned by a hospital, which meets the minimum requirements for routine contraceptive management as specified by the Division of Public Health Maternal Child Health Program, which standards are incorporated by reference. A laboratory in a clinic must be licensed by the State of Wyoming.
(c) Covered services. The following services when furnished under the supervision of a physician who is directly affiliated with the clinic. A physician is directly affiliated with the clinic if there is a contract between the physician and the clinic under which the physician is obligated to supervise the care furnished to the clinic's patients:
(i) Office visits;
(ii) Contraceptive supplies and devices; and
(iii) Laboratory tests.
(d) Non-covered services:
(i) Infertility services, including counseling.
(e) Medicaid allowable payment. Reimbursement for family planning services shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
(a) Definition. Rural health clinic services or preventive services provided in an FQHC.
(b) Eligible providers. Public or not-for-profit entities, including community and migrant health centers, health care for the homeless programs or entities which can meet the same requirements.
(c) Covered services. Medically necessary services furnished in an FQHC:
(i) By or under the direction of a physician;
(ii) In a face to face encounter between a recipient and a covered health care professional; and
(iii) That are covered services.
(d) For purposes of this Section, the following terms have the following meanings:
(i) 'Encounter' means a face to face visit with a covered health care professional. The encounter may occur in the covered health care professional's office, the emergency room of a hospital, the recipient's home or a nursing facility.
(ii) 'Covered health care professional' means a physician, physician's assistant, nurse practitioner, nurse midwife, psychologist or social worker.'
(iii) 'Under the direction of a physician' means that each recipient's care is furnished under the supervision of a physician who:
(A) Is directly affiliated with the FQHC; and
(B) Meets with the recipient face-to-face at least once;
(C) Prescribes the necessary care; and
(D) Periodically reviews the care.
(ii) A physician is directly affiliated with the FQHC if there is a contract between the physician and the FQHC under which the physician is obligated to supervise the care furnished to the RHC's patients.
(d) Medicaid allowable payment. Except as otherwise specified in this subsection, payment for services shall be a specific encounter rate established by the Division for each FQHC.
(i) In-state providers.
(A) During the FQHC's first fiscal year of operation, the encounter rate shall be the HCFA statewide Medicare encounter rate for FQHC's in rural areas.
(B) In subsequent years, the FQHC shall receive an interim payment which is subject to cost settlement.
(I) The interim payment shall be based on one-hundred percent of the FQHC's reasonable cost per encounter for the prior fiscal year.
(II) At the end of the FQHC's fiscal year, the FQHC shall submit a cost report to the Division as part of the cost reporting requirements of Chapter 30. The Division shall conduct a cost settlement, reconciling the FQHC's reasonable costs, number of encounters and interim payments.
(III) If the FQHC fails to submit a cost report, the Division may obtain cost reporting information from the Medicare intermediary and conduct a cost settlement pursuant to Chapter 30.
(ii) Out-of-state providers. The encounter rate shall be the HCFA statewide Medicare encounter rate for FQHC's in rural areas. There will be no cost settlement.
(iii) Multiple encounters. Multiple encounters within a twenty-four hour period shall be considered a single encounter for reimbursement purposes unless, between the encounters, the recipient suffers an additional illness or injury that requires additional diagnosis or treatment.
HCBS services are subject to Chapter 34.
Home health services are subject to Chapter 12.
(a) Definition. A program of care delivered in a person's home or health care facility that provides reasonable and necessary medical and support services for the management of a terminal illness.
(b) Eligible providers. Hospice programs that are certified by Medicare and located within the State of Wyoming.
(c) Covered services. The following services are covered if provided pursuant to a written plan of care established by the Hospice and approved by the recipient's attending physician:
(i) Routine home care;
(ii) Continuous home care;
(iii) Inpatient respite care;
(iv) General inpatient care; and
(v) Other hospice, nursing facility room and board.
(d) Limitations. During the time a recipient elects to receive hospice services, the recipient must waive all rights to Medicaid payments for the following services:
(i) Hospice services provided by a hospice other than the hospice designated by the individual (unless provided under arrangements by the designated hospice); and
(ii) Any Medicaid services that are related to the treatment of the terminal condition (or a related condition) for which hospice services were elected, or services that are equivalent to hospice services, except for services:
(A) Provided by the designated hospice, either directly or by arrangement with another provider;
(B) Provided by the individual's attending physician if that physician is neither an employee of the designated hospice nor receiving compensation from the hospice for furnishing such services; or
(C) Provided as room and board by a nursing facility if the individual is a resident of a nursing facility.
(e) Medicaid allowable payment. The Medicaid allowable payment shall be the lower of the provider's usual and customary charge and the Medicare allowable payment for the same or similar services.
(i) If a hospice program arranges for a nursing facility to furnish room and board to a recipient of hospice services, the Medicaid allowable payment to the hospice program shall be ninety-five (95) percent of the nursing facility's per diem rate as determined pursuant to Chapter 7. The hospice program shall be responsible for paying the nursing facility for the room and board services furnished to a recipient of hospice services.
(ii) Total Medicaid payments to a hospice program for inpatient care furnished to recipients of hospice services shall not exceed twenty percent of the aggregate number of days of hospice care provided by the hospice program to all Medicaid recipients during the relevant twelve-month period. The limit shall be applied as follows:
(A) For the twelve-month period beginning November 1 of 1994, and for each twelve month period beginning on each November 1 thereafter, the Department shall determine the aggregate number of days of inpatient care furnished by each hospice program to recipients of hospice services (the number of days of inpatient care shall include general inpatient care and inpatient respite care); and
(B) If payments for inpatient services exceed twenty percent of the total days of Medicaid services, the Medicaid payments for such services in excess of twenty percent shall be considered excess payments, and shall be recovered pursuant to Section 45.
(C) The limitations of this subsection shall not apply to inpatient services furnished to recipients diagnosed with HIV and/or AIDS.
Hospital services are subject to Chapters 8, 9, 24, 30, 31, 32 and 33.
ICF/MR services are subject to Chapters 20 and 27.
IMD services are subject to Chapter 18.
(a) Definition. Professional or technical laboratory services.
(b) Eligible providers. Independent laboratories certified by Medicare, hospitals, or physicians with a laboratory licensed by the state in which the laboratory is located.
(c) Covered services. Professional or technical laboratory services ordered by a practitioner which are directly related to the diagnosis and treatment of the patient as specified in the treatment plan developed by the ordering practitioner.
(d) Excluded and limited services:
(i) Handling charges where a specimen is referred by one laboratory to another are not covered;
(ii) Post-mortem examinations are not covered;
(iii) Services furnished pursuant to standing orders of a physician are not covered;
(iv) Specimen collection fees will be paid only to the provider that collects the specimen from the recipient;
(v) Fees charged to obtain immediate results are not covered; and
(vi) Technician callback fees are not covered.
(e) Medicaid allowable payment. Reimbursement for laboratory services shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
Medical supplies and equipment are subject to Chapter 11.
(a) Definition. 'Nurse midwife services' as defined in 42 C.F.R. § 440.165, which is incorporated by this reference.
(b) Eligible providers. Nurse midwives.
(c) Covered services. Professional services furnished by a nurse midwife, under the supervision of a physician, throughout the maternity period, which are within the scope of the nurse midwife's practice.
(d) Excluded and limited services. Services furnished in a hospital or a clinic are covered only to the extent the facility permits such services.
(e) Medicaid allowable payment. The Medicaid allowable payment shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
(a) Definition. 'Advanced nursing acts' and 'medical acts' performed by a nurse practitioner as permitted by W.S. § 33-21-201(a).
(b) Eligible providers. Nurse practitioners.
(c) Covered services. Professional services furnished a nurse practitioner, under the supervision of a physician, which are within the scope of the nurse practitioner's practice.
(d) Excluded and limited services. Services furnished in a hospital or a clinic are covered only to the extent the facility permits such services.
(e) Medicaid allowable payment. The Medicaid allowable payment shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
Nursing facility services are subject to Chapters 5, 7, 17, 19 and 22.
Pharmaceutical services are subject to Chapter 10.
(a) Definition. Outpatient services provided by or under the direct supervision of a physical therapist pursuant to written orders of a physician
(b) Eligible providers. Independent physical therapists, physicians, hospitals and developmental centers that employ physical therapists. Physical therapy services provided through a home health agency or by a nursing facility are covered by other rules of the Department.
(c) Covered services.
(i) Restorative physical therapy services furnished in response to physical debilitation caused by acute physical trauma or physical illness;
(ii) Physical therapy services prescribed while the recipient was an inpatient and continuing on an outpatient basis;
(iii) Physical therapy services prescribed as a direct result of outpatient surgery required as a result of an injury; and
(iv) Physical therapy services provided to a recipient under age twenty-one with chronic disabilities when furnished by a developmental center pursuant to an:
(A) Individualized education plan developed by the school system; or
(B) Individualized family services plan developed by a developmental center.
(d) Medicaid allowable payment.
(i) Medicaid reimbursement for physical therapy services provided by an independent physical therapist or a physician shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
(ii) Services furnished in a facility. Services furnished by an independent physical therapist to a recipient in a nursing facility or in a hospital that is a separately enrolled Medicaid provider must be billed by the facility.
(e) Service limitations. Medicaid reimbursement for physical therapy visits shall be limited to a total of twenty visits per calendar year to a hospital, independent physical therapist or a physician's office, unless prior authorized.
(a) Definition. Professional services furnished by or under the supervision of a physician.
(b) Eligible providers. Physicians.
(c) Covered services. Medically necessary professional services furnished by or under the supervision of a physician, except as otherwise specified by this Chapter.
(d) Excluded or limited services:
(i) Abortions are not covered except to the extent required by Federal law;
(ii) Anesthesia services are limited as follows:
(A) An anesthesiologist may not receive Medicaid reimbursement for a consultation in addition to any other anesthesia services for the same surgery.
(B) Excluded services. Anesthesia services are not covered when performed in conjunction with a:
(I) Non-covered surgical procedure; and
(II) Procedure requiring recipient consent if proper consent was not obtained.
(iii) The following allergy and clinical immunotherapy services:
(A) Sublingual, intracutaneous and subcutaneous provocative and neutralization testing; and
(B) Neutralization therapy for food allergies.
(iv) Biofeedback;
(v) Cosmetic surgery;
(A) Services intended solely to improve an individual's physical appearance and which do not restore bodily function or correct a physical deformity are not covered.
(B) Reconstructive surgery procedures which are intended to improve bodily functions and the appearance of a body area which has been altered by disease, trauma, congenital or developmental anomalies or previous surgical procedures are covered only if prior authorized.
(vi) Critical care is covered only if the physician is in constant attendance with the recipient;
(vii) Dermatology. The following are excluded:
(A) Removal of lesions not suspected to be precancerous, unless medically necessary to restore a bodily function; and
(B) Services performed primarily for cosmetic reasons.
(viii) Diet instruction is not covered if obesity is the sole diagnosis;
(ix) Hysterectomies are not covered unless the requirements of 42 C.F.R. 441 Subpart F are satisfied. Such requirements are incorporated by reference;
(x) Medical supplies. Expendable medical supplies normally used in a physician's office are included in the Medicaid payment for the office visit or test performed. The actual cost of special expendable supplies prescribed for home use by a recipient may be separately billed to Medicaid;
(xi) Preventive services are not covered, except:
(A) Cancer screening services, inclusive of mammography and pap tests;
(B) Immunizations;
(C) Newborn care furnished in a hospital; and
(D) EPSDT services.
(xii) Prolonged care is limited to a total of three hours per day unless there is documentation in the medical records that additional prolonged care was medically necessary.
(xiii) Psychiatric services. Biofeedback services are excluded;
(xiv) Speech therapy is not covered;
(xv) Sterilizations are not covered unless the requirements of 42 C.F.R. 441 Subpart F are satisfied. Such requirements are incorporated by reference;
(xvi) Therapeutic injections are not covered unless:
(A) The drug cannot be administered orally;
(B) The drug cannot be self-administered; and
(C) The drug is reasonable and necessary for treatment of the recipient's diagnosed condition.
(xvii) Vitamin injections are not covered except vitamin B12 injections;
(e) Medicaid allowable payment. The Medicaid allowable payment for physician's services shall be the lower of the physician's usual and customary charge and the Medicaid fee schedule.
(f) Copayments. Recipients must pay a $1.00 copayment for each office visit or home visit. The following recipients are exempt from the copayment requirement:
(i) Recipients under age twenty-one;
(ii) Recipients seeking family planning services;
(iii) Pregnant women;
(iv) Residents of a nursing facility;
(v) Recipients seeking emergency services; and
(vi) Recipients of LTC waiver services.
(g) Collection of copayment. Providers are responsible for collecting the copayment. The amount of the copayment shall be automatically deducted by the Department from the allowable Medicaid payment, regardless of whether the copayment is actually paid.
(h) Prohibition on denial of services. A provider may not deny services to a recipient because of the recipient's inability to make the copayment.
(i) Regular refusal to make copayment. A provider may refuse services, other than emergency services, to a recipient who regularly refuses to make copayments.
(j) Service Limitations. Medicaid reimbursement for recipient visits to a physician, ophthalmologist or optometrist and to the outpatient department of a hospital shall be limited to a total of twelve visits per calendar year, unless prior authorized. The limitations of this subsection shall not apply to:
(i) Emergency services;
(ii) Family planning services;
(iii) Recipients under age twenty-one; or
(iv) Ancillary services.
Section 38. Radiology services.
(a) Definition. Professional or technical services in which X-rays or rays from radioactive substances are used for diagnostic or therapeutic purposes.
(b) Eligible providers. Independent radiology practices, hospitals and physician practices.
(c) Excluded services:
(i) Reinterpretations, unordered X-rays and second opinions;
(ii) Routine chest X-rays;
(iii) Separate consultations procedures unless ordered by the attending physician;
(iv) X-rays based on standing orders;
(v) X-rays performed as a screening mechanism; and
(vi) Technician-call back fees.
(d) Limited services. Routine Mammography is limited as follows:
(i) One mammography between the ages of thirty-five and thirty-nine; and
(ii) One mammography per year after age forty.
(e) Medicaid allowable payment. Subject to paragraphs (i) and (ii), reimbursement for radiology services shall be pursuant to Chapter 3.
(i) Services performed in physician's office are covered only if performed by or under the direct supervision of the physician;
(ii) Services performed in hospital using equipment owned by the physician. The physician may bill for the total procedure if the technical component is not billed by the hospital.
(a) Definition. Health services furnished by a facility that is qualified to participate as an RHC under Medicare.
(b) Eligible providers. RHCs which are: qualified to participate as a rural health clinic under Medicare, certified under Wyoming law or the laws of another state, and staffed with appropriately licensed, certified or registered personnel. Laboratories in rural health clinics must be licensed by the state in which the clinic is located.
(c) Covered services. Medically necessary services furnished in an RHC:
(i) By or under the direction of a physician;
(ii) In a face-to-face encounter between the recipient and the appropriate health professional; and
(iii) That are covered services.
(d) For purposes of this Section, the following terms have the following meanings:
(i) 'Under the direction of a physician' means that each recipient's care is furnished under the supervision of a physician who:
(A) Is directly affiliated with the RHC; and
(B) Meets with the recipient face-to-face at least once;
(C) Prescribes the necessary care; and
(D) Periodically reviews the care.
(ii) A physician is directly affiliated with the RHC if there is a contract between the physician and the RHC under which the physician is obligated to supervise the care furnished to the RHC's patients.
(ii) A physician is directly affiliated with the RHC if there is a contract between the physician and the RHC under which the physician is obligated to supervise the care furnished to the RHC's patients.
(iii) 'Encounter' means a face to face visit between a recipient and a covered health care professional. The encounter may occur in the office of the covered health care professional, the emergency room of a hospital, the recipient's home, or a nursing facility.
(iv) 'Covered health care professional' means a physician, physician's assistant, nurse practitioner, nurse midwife, psychologist or social worker.
(e) Medicaid allowable payment. The Medicaid allowable payment for each encounter shall be:
(i) Provider-based RHCs.
(A) In-state providers.
(I) During the RHC's first fiscal year of participation in Medicaid, the encounter rate shall be the lower of the provider's usual and customary charge and the Medicare regional intermediary rate for independent RHCs.
(II) At the end of the RHC's first fiscal year of participation, the hospital shall submit its RHC costs as part of the cost reporting requirements of Chapter 30. The fiscal intermediary shall review the RHC costs and adjust the RHC's reimbursement rate for the next fiscal year to be the lower of the RHC's reasonable costs or charges. The RHC shall receive the adjusted rate until the rate is redetermined at the conclusion of the fiscal year.
(III) Using the cost report submitted pursuant to (II), the fiscal intermediary shall cost settle the RHC's cost report for each fiscal year of participation using Medicare principles.
(B) Out-of-state providers. The encounter rate shall be the lower of the provider's usual and customary charge and the Medicare regional intermediary rate.
(ii) Independent RHCs. The Medicaid allowable payment shall be the lower of the provider's usual and customary charge and the Medicare regional intermediary rate.
(iii) Multiple encounters. Multiple encounters within a twenty-four hour period shall be considered a single encounter for reimbursement purposes, unless between the encounters, the recipient suffers an additional illness or injury that requires additional diagnosis or treatment.
Swing-bed services are subject to Chapter 28.
(a) Definition. Professional services and corrective lenses furnished by an optometrist or ophthalmologist within the scope of their practice.
(b) Eligible providers. Optometrist, opticians and ophthalmologists.
(c) Covered services for all recipients. Medical treatment of eye diseases or eye injuries.
(d) Covered services for recipients under twenty-one years of age:
(i) Contact lenses if medically necessary;
(ii) Eyeglasses;
(iii) Photosensitive lenses if medically necessary;
(iv) Routine eye examinations; and
(v) Vision therapy, if prior authorized.
(e) Medicaid allowable payment. Medicaid reimbursement for vision services shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
(f) Copayment and service limitations. Office visits to an optometrist or an ophthalmologist are subject to the provisions of subsections 38(f) through (j).
(a) Medicaid reimbursement for covered services may be limited as specified in this Chapter and the other rules of the Department.
(b) Provider's responsibilities.
(i) Determining number of visits. Providers are responsible for determining whether a recipient has exceeded the service limitations specified in the Rules of the Department.
(ii) A provider may charge the recipient for any services in excess of service limitations services without providing prior notification to the recipient.
(c) Exceptions. Service limitations shall not apply to:
(i) Recipients under age twenty-one;
(ii) Emergency services; and
(iii) Prior authorized services.
(a) Procedures. Prior authorization shall be pursuant to the prior authorization procedures of Chapter 3, which are adopted by this reference.
(b) Services that require prior authorization.
(i) This and other rules of the Department specify services that require prior authorization.
(ii) Designation of additional services. The Division may designate additional services that require prior authorization. In so designating additional services, the Division shall consider:
(A) The cost of the service;
(B) The potential for over-utilization of the services; and
(C) The availability of lower cost alternatives.
(D) The Division shall disseminate a current list of additional services that require prior authorization to providers through Provider Manuals or Provider Bulletins.
(iii) Failure to obtain prior authorization. The failure to obtain prior authorization shall result in the denial of Medicaid payment for the service.
Section 44. Payment of claims. Payment of claims shall be pursuant to the payment of claims provisions of Chapter 3, which are incorporated by this reference.
Section 45. Recovery of excess payments. The Department may recover excess payments pursuant to the recovery provisions of Chapter 3, which are incorporated by this reference.
(a) Request for reconsideration. A provider may request that the Department reconsider a decision to recover excess payments or deny payments. Such request must be mailed to the Department by certified mail, return receipt requested within twenty days of the date the facility receives notice pursuant of the recovery or denial of payments. 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 or rate and send written notice by certified mail, return receipt requested, to the provider of its final decision within forty-five days after receipt of the request for reconsideration or the receipt of any additional information requested pursuant to (c), whichever is later.
(c) Request for additional information. The Department may request additional information from the provider as part of the reconsideration process. Such a request shall be made in writing by certified mail, return receipt requested. The provider must provide the requested information within the time specified in the request. Failure to provide the requested information shall result in the dismissal of the request with prejudice.
(d) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.
(e) 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.
(f) 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, return receipt requested or personally delivering a request for hearing to the Department within twenty days of the date the provider receives notice of the final decision.
(g) 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.
(a) Recipients. A recipient may request an administrative hearing pursuant to Chapter 1 regarding the termination, reduction or denial of covered services.
(b) Procedures. A request for an administrative hearing must be made in conformance with Chapter 1, and the hearing shall be held pursuant to Chapter 1.
Section 48. Superseding effect. 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 49. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in effect.
The Wyoming Department of Health (the Department) is the single state agency appointed pursuant to the Social Security Act (the Act) to administer the Medicaid program in Wyoming. The Wyoming Medical Assistance and Services Act of 1967 (the Wyoming Act) requires the Department to administer the Medicaid program in conformance with federal standards.
The Wyoming Act authorizes the Department to promulgate necessary rules. The Wyoming Administrative Procedure Act requires all agency statements of general applicability that implement, interpret or prescribe law or policy be promulgated as rules.
The Health Care Financing Administration of the United States Department of Health and Human Services (HCFA) is the federal agency for administering the Medicaid program.
The Act and HCFA regulations require the Department to reimburse providers that furnish certain services to Medicaid recipients. The Act and HCFA regulations further authorize the Department to determine which additional or optional services to cover. The Department is required to establish policies and methods for reimbursing providers which furnish any such covered services to Medicaid recipients.
Existing Chapter 26 establishes the scope of services covered by the Wyoming Medicaid program, as well as policies and methods for reimbursing the providers of such services. The Department is amending Chapter 26 to reflect changes in Federal and State Medicaid policies.