Wyo. Code R. 048-0037-26
Medicaid
Chapter 26: Covered Services
Effective Date: 07/01/1992 to 09/08/1995
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.26.07011992
Date Filed 07/01/92 Expr Date
Supr Date
Repeal Date
Document Type RULES
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 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 the rule.
(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) 'Chapter III.' Chapter III, Provider Participation, of the Wyoming Medicaid Rules.
(c) 'Chapter V.' Chapter V, Medicaid Long Term Care Facility/Remedies/Terminations, of the Wyoming Medicaid Rules.
(d) 'Chapter VII.' Chapter VII, Wyoming Nursing Home Reimbursement System, of the Wyoming Medicaid Rules.
(e) 'Chapter VIII.' Chapter VIII, Inpatient Admission Certification, of the Wyoming Medicaid Rules.
(e) 'Chapter IX.' Chapter IX, Hospital Services, of the Wyoming Medicaid Rules.
(f) 'Chapter X.' Chapter X, Pharmaceutical Services, of the Wyoming Medicaid Rules.
(g) 'Chapter XII.' Chapter XII, Home Health Services, of the Wyoming Medicaid Rules.
(h) 'Chapter XIII.' Chapter XIII, Community Mental Health Services, of the Wyoming Medicaid Rules.
(i) 'Chapter XVII.' Chapter XVII, Nursing Facility Resident Trust Accounts, of the Wyoming Medicaid Rules.
(j) 'Chapter XIX.' Chapter XIX, Nursing Facility Preadmission Screenings, of the Wyoming Medicaid Rules.
(k) 'Chapter XX.' Chapter XX, Reimbursement of Intermediate Care Facilities for the Mentally Retarded, of the Wyoming Medicaid Rules.
(l) 'Chapter XXII.' Chapter XXII, Nursing Facility Evaluation of Medical Necessity, of the Wyoming Medicaid Rules.
(m) 'Chapter XXIV.' Chapter XXIV, Wyoming Hospital Reimbursement System, of the Wyoming Medicaid Rules.
(n) 'Consultation' means an opinion or advice rendered by one physician to another as part of the evaluation or management of a recipient.
(o) 'Corrective lenses.' Prescription eyeglasses or, if the recipient's vision cannot be appropriately corrected using eyeglasses, contact lenses.
(p) 'Certified registered nurse anesthetist (CRNA).' A registered nurse who is:
(i) Certified by the national Council on Certification of Nurse Anesthetists; or
(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).
(q) 'Covered service.' Services which are Medicaid reimbursable pursuant to the rules and policies of the Department.
(r) 'Dentist.' A person licensed to practice dentistry by the Wyoming Board of Dental Examiners or a similar agency in another state.
(s) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(t) 'Direct supervision.' Supervision in which the responsible practitioner is physically present in the building where the services are being provided.
(u) 'Division.' The Health Care Financing Division of the Department, its agent, designee or successor.
(v) 'Division of Developmental Disabilities.' The Division of Developmental Disabilities of the Department, its agent, designee or successor.
(w) '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.
(x) '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.
(y) 'Emergency detention.' A Person detained or involuntarily hospitalized pursuant to W.S. 25-10-101 et seq.
(z) 'Emergency hospital services.' 'Emergency hospital services' as defined in 42 C.F.R. 440.170(e), which is incorporated by this reference.
(aa) 'EPSDT.' Early and periodic screening, diagnosis and treatment services for recipients under the age of 21.
(bb) 'Equipment.' Items, including durable medical equipment, that are designed for repeated use, have a medical purpose and are intended for home use.
(cc) 'Federally-qualified health center (HQFC).' A 'federally-qualified health center' as defined by 42 C.F.R. 1396d(1)(2)(B), which is incorporated by this reference.
(dd) 'Home or community-based (HCBW) services.' Home or community-based services as defined by 42 C.F.R. 440.180, which is incorporated by this reference.
(ee) 'HCFA.' The Health Care Financing Administration of the United States Department of Health and Human Services.
(ff) '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.
(gg) 'Independent physical therapist.' An independent physical therapist certified by Medicare. An 'independent physical therapist' is neither employed by, directly affiliated with nor working under the supervision of a hospital, nursing facility, physician or other provider of health services.
(hh) 'Inpatient.' An 'inpatient' as defined by 42 C.F.R. 440.2(a), which is incorporated by this reference.
(ii) 'Inpatient hospital service.' 'Inpatient hospital services' as defined in 42 C.F.R. 440.10, which is incorporated by this reference.
(jj) '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.
(kk) 'Local agency.' The County office of the Wyoming Department of Family Services, its agent, designee or successor.
(ll) 'Local trade area.' The geographic area surrounding thee recipient's residence, including portions of states other than Wyoming, commonly used by other persons in the same area to obtain similar services.
(mm) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(nn) 'Medicaid allowable payment.' The maximum Medicaid reimbursement as determined pursuant to the rules of the Department.
(oo) '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 or reasons other than the convenience of the recipient and the provider; and
(iv) Performed in the least costly setting required by the recipient's condition.
(pp) 'Medical supplies.' Disposable, semi-disposable or expendable supplies ordered by a physician for the treatment of an illness or Injury.
(qq) 'Medicare.' The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.
(rr) 'Nurse midwife.' A registered nurse who is certified as a nurse midwife by the American College of Nurse-Midwives.
(ss) 'Nurse practitioner.' An 'advanced practitioner of nursing' as defined by W.S. 33-21-120(a)(i), which is incorporated by this reference, or a registered nurse that is certified or licensed as a nurse practitioner pursuant to the laws of another state.
(tt) 'Nursing facility.' A skilled nursing facility, and intermediate care facility or a nursing facility as defined by applicable federal law. 'Nursing facility' may include a distinct part of a hospital or institution which is designated to provide nursing facility services.
(uu) 'Ophthalmologist.' A physician who has successfully completed postgraduate ophthalmology program of at least three years duration that is accredited by the American Board of Ophthalmology.
(vv) 'Optometrist.' A person licensed to practice optometry by the Wyoming State Board of Examiners of Optometry or a similar agency in another state.
(ww) 'Outpatient.' An 'outpatient' as defined in 42 C.F.R. 440.20(a), which is incorporated by this reference.
(xx) 'Physician.' A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a comparable agency in another state.
(yy) 'Physical therapist.' A person licensed to practice as a physical therapist by the Wyoming State Board of Physical Therapy or a similar agency in another state.
(zz) 'Preventive services.' Any routine service or examination which is performed in the absence of a diagnosed illness, injury or complaint.
(aaa) 'Prior authorization or prior authorized.' Approval by the Division, pursuant to the rules and procedures of the Department, before covered services are provided.
(bbb) 'Provider.' Any individual or entity that has qualified as a provider pursuant to the rules of the Department.
(ccc) 'Psychologist.' A person licensed to practice psychology by the Wyoming Board of Psychologist Examiners or a similar agency in another state.
(ddd) 'Recipient.' A person who has been determined eligible for Medicaid.
(eee) 'Recipient under age twenty-one.' A recipient before or during the month in which he or she turns twenty-one years of age.
(fff) 'Regional 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 developmentally disabled children by the Division of Developmental Disabilities.
(ggg) 'Registered nurse.' A person licensed to practice nursing by the Wyoming Board of Nursing or a similar agency in another state.
(hhh) 'Rural health clinic.' A 'rural health clinic' as defined by 42 C.F.R. 491.2(f), which is incorporated by this reference.
(iii) 'Rural health clinic services.' 'Rural health clinic services as defined by 42 C.F.R. 440.20(b), which is incorporated by this reference.
(jjj) 'Service limitations.' Limits on the quantity of covered services which are Medicaid reimbursable as set forth in the rules of the Department.
(kkk) 'Services.' Health services, medical supplies or equipment.
(lll) 'Standing orders.' Orders from a provider that a certain service or services be provided to every patient, regardless of diagnosis.
(mmm) "Supervisor" An individual licensed to provide services who takes professional responsibility for such services, even when even when provided by another individual or individuals.
(nnn) "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.
(ooo) "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.
Section 4. Covered services.
(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:
(vii) Early and periodic screening diagnosis and treatment (EPSDT) services furnished to individuals under twenty-one years of age;
(xvi) Institution for mental disease (IMD) services furnished to individuals sixty-five years of age and older; (xvii) Laboratory services; (xviii) Medical supplies and equipment; (xix) Nurse midwife services; (xx) Nurse practitioner services; (xxi) Nursing facility services; (xxii) Outpatient hospital services; (xxiii) Pharmaceutical services; (xxiv) Physical therapy services; (xxv) Physician services; (xxvii) Radiology services; (xxviii) Rural health clinic services; (xxix) Swing-bed services; and (xxx) Vision care services.
Section 5. Services not covered by Medicaid.
(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 rule, "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 has been arrested by a state, local or federal law enforcement agency; (f) Services provided to an individual in emergency detention; (g) Services provided pursuant to the order of a court that are: (i) Not covered services; (ii) Have not received prior authorization, if so required; or (iii) In excess of service limitations.
(h) Services which exceed the service limitations established by the rules of the Department.
(i) The following medical services:
(j) The following surgical procedures:
(k) The following services:
(i) Acupuncture;
ii) Alcohol and chemical rehabilitation, except as specified in Chapter IX;
(iii) Chronic pain rehabilitation;
(iv) Infertility services, including counseling, reverse sterilization and artificial insemination;
(v) Personal comfort items;
(vi) Sleep disorder clinic services; and
(vii) Weight reduction treatment.
(l) Payment for noncovered services. Except as specified in subsection (m), a provider that provides a noncovered service to a recipient may seek payment from the recipient if the provider informed the recipient of the recipient's potential liability before providing the service, and the recipient agreed in writing to pay for such services before they were furnished.
(m) 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 (1).
Section 6. Ambulance services.
Ambulance services are subject to the requirements of Chapter XV.
Section 7. 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
(d) Medicaid allowable payment. The Medicaid allowable payment shall be pursuant to Chapter III.
Section 8. 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 pursuant to Chapter III.
Section 9. 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) And 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 pursuant to Chapter III.
Section 10. Community mental health services.
Community mental health services are subject to Chapter XIII. Section 11. Dental services.
Dental services are subject to Chapter IV.
Section 12. Emergency hospital services.
(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 XXIV.
Section 13. EPSDT services.
EPDST services are subject to Chapter VI.
Section 14. End stage renal dialysis (ESRD) services.
(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 not exceed the lower of the provider's usual and customary charge and the Medicare allowable payment for similar services.
(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 Title X of the Social Security Act, which standards are incorporated by reference. A laboratory in a clinic must be licensed by the State.
(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 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 not exceed the lower of the provider's usual and customary charge and the Medicaid fee schedule.
(a) Definition. Rural health clinic services provided in an FQHC.
(b) Eligible providers. An FQHC.
(c) Covered services. Rural health clinic services.
(d) Medicaid allowable payment. Payment for services shall be pursuant to Section 32(e).
HCBW services are subject to Chapter XXX.
Section 18. Home health services.
Home health services are subject to Chapter XII.
Section 19. Hospital services.
Hospital services are subject to Chapters VIII, IX and XXIV.
Section 20. ICF/MR Services.
ICF/MR services are subject to Chapters XX and XXVII.
Section 21. Institution for mental diseases (IMD) services. IMD services are subject to Chapter XVIII.
Section 22. Laboratory services.
(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 physician which are directly related to the recipient's diagnosis and treatment plan as specified by the ordering physician.
(d) Excluded and limited services:
(e) Medicaid allowable payment. Reimbursement for laboratory services shall be pursuant to Chapter III.
Section 23. Medical supplies and equipment.
Medical supplies and equipment are subject to Chapter XI.
Section 24. Nursing facility services.
Nursing facility services are subject to Chapters V, VII, XVII, XIX, XXII and XXIII.
(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.
(i) Services furnished in a hospital or a clinic are covered only to the extent the facility permits such services; and
(ii) Services furnished out of state require prior authorization.
(e) Medicaid allowable payment. The Medicaid allowable payment shall be pursuant to Chapter III.
(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 as 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.
(i) Services furnished in a hospital or a clinic are covered only to the extent the facility permits such services; and
(ii) Services furnished out of state require prior authorization.
(e) Medicaid allowable payment. The Medicaid allowable payment shall be pursuant to Chapter III.
Pharmaceutical services are subject to Chapter X.
(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 regional 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 provided to a recipient under age twenty-one with chronic disabilities when furnished by a regional developmental center pursuant to an:
(A) Individualized education plan developed by the school system; or
(B) Individualized family services plan developed by a regional developmental center.
(d) Excluded services. Services furnished by an independent physical therapist in a nursing facility or in a hospital must be billed by the facility.
(e) Medicaid allowable payment. Medicaid reimbursement for physical therapy services provided by an independent physical therapist or a physician shall be pursuant to Chapter III.
(f) 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.
(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 rule.
(d) Excluded or limited services:
(i) Abortions are not covered unless the requirements of 42 C.F.R. 441 Subpart E are satisfied. Such requirements are incorporated by reference.
(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;
(II) Procedure requiring prior authorization for which prior authorization was not received; and
(III) Procedure requiring recipient consent if proper consent was not obtained.
(iii) Allergy and clinical immunotherapy services. The following are excluded services:
(A) Sublingual, intracutaneous and subcutaneous provocative and neutralization testing; and
(B) Neutralization therapy for food allergies.
(iv) 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 and 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.
(v) Critical care is covered only if the physician is in constant attendance with the recipient.
(vi) 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.
(vii) Diet instruction is not covered if obesity is the sole diagnosis;
(viii) Hysterectomies are not covered unless the requirements of 42 C.F.R. 441 Subpart F are satisfied. Such requirements are hereby incorporated by reference.
(ix) 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;
(x) 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.
(xi) 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;
(xii) Psychiatric services. Biofeedback services are excluded.
(xiii) Speech therapy is not covered;
(xiv) Sterilizations are not covered unless the requirements of 42 C.F.R. 441 Subpart F are satisfied. Such requirements are incorporated by reference;
(xv) 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.
(xvi) Vitamin injections are covered except vitamin B12 injections.
(e) Medicaid allowable payment. Physician's services shall be reimbursed pursuant to Chapter III.
(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; and
(v) Recipients seeking emergency 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 or 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 or optometrist and to the outpatient department of a hospital shall be limited to a total of twelve visits per calendar year. The limitations of this subsection shall not apply to:
Section 30. 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:
(d) Limited services. Routine Mammography is limited as follows:
(e) Medicaid allowable payment. Subject to paragraphs (i) and (ii), reimbursement for radiology services shall be pursuant to Chapter III.
(i) Services performed in physician's office are covered only if performed by or under the direction 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. Services provided to developmentally disabled children as part of an individualized education plan or as part of an individualized family services plan.
(b) Eligible providers. Regional developmental centers certified by the Division of Developmental Disabilities and under contract to that Division to provide such services.
(c) Covered services. Developmental services, including developmental assessment and therapy services.
(d) Medicaid allowable payment. The Medicaid allowable payment shall be pursuant to Chapter III.
(a) Definition. Health services furnished by a facility that is qualified to participate as a rural health clinic under Medicare.
(b) Eligible providers. Rural health clinics 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 a clinic:
(i) By or under the direction of a physician; and
(ii) In a face-to-face encounter between the recipient and the appropriate health professional.
(d) Physician direction.
(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 clinic; 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 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.
(e) Medicaid allowable payment. The Medicaid allowable payment for each encounter shall be the lower of the provider's usual and customary charge and the encounter rate established under Medicare.
(i) Multiple encounters. Encounters with more than one health professional and multiple encounters with the same professional that occur on the same day at the same location are a single encounter for reimbursement purposes unless the recipient, between visits, suffers an illness or injury which requires additional diagnosis or treatment.
(ii) Diagnostic tests, injections or other incidental services furnished in the absence of an encounter shall be reimbursed pursuant to Chapter III.
Swing-bed services are subject to Chapter XXVIII.
(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 who are under twenty-one years of age.
(i) Contact lenses if medically necessary;
(ii) Eyeglasses;
(iii) Photosensitive lenses if medically necessary; and (iv) Routine eye examinations.
(e) Prior authorization is required for vision therapy or training.
(g) Medicaid allowable payment. Medicaid reimbursement for vision services shall be pursuant to Chapter III.
(f) Copayment and service limitations. Office visits to an optometrist or an ophthalmologist are subject to the provisions of subsections 29(f) through (j).
(a) Medicaid reimbursement for covered services may be limited as specified in this rule 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.
(d) Exceptions. Service limitations shall not apply to:
(i) Recipients under age twenty-one; and
Section 36. Severability. If any portion of these rules 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 all such covered services to Medicaid recipients.
The Department is promulgating this rule to establish the scope of services covered by the Wyoming Medicaid program, as well as policies and methods for reimbursing the providers of such services. This rule is further being promulgated to reflect service limitations which became effective March 1, 1992.