Wyo. Code R. 048-0037-26
Medicaid
Chapter 26: Covered Services
Effective Date: 05/24/2006 to 12/17/2015
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.26.05242006
This Chapter 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 Chapter defines which services are covered services, except as otherwise specified in the rules of the Department, and shall apply to all recipients and providers. It applies to all services furnished on or after the Chapter's effective date.
(b) The Department may issue Manuals or Bulletins to providers and/or other affected parties to interpret the provisions of this Chapter. 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.
(c) The incorporation by reference of any external standard is intended to be the incorporation of that standard as it is in effect on the effective date of these rules and regulations.
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.
The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indicates that such is the intent, words in the singular number shall include the plural and vice versa. Throughout these rules gender pronouns are used interchangeably. The drafters have attempted to utilize each gender pronoun in equal numbers, in random distribution. Words in each gender include individuals of the other gender.
(a) 'Administrative transportation.' Administrative transportation as defined in Chapter 36, which definition is incorporated by this reference.
(b) “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.
(c) “CFHD.” The Community and Family Health Division of the Department, its agent, designee, or successor.
(d) “Chapter 1.” Chapter 1, Medicaid Administrative Hearings of the Wyoming Medicaid Rules.
(e) “Chapter 3.” Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(f) “Chapter 5.” Chapter 5, Medicaid Long Term Care Facility Remedies/Terminations, of the Wyoming Medicaid Rules.
(g) “Chapter 6.” Chapter 6, HEALTH CHECK Services, of the Wyoming Medicaid Rules.
(h) “Chapter 7.” Chapter 7, Wyoming Nursing Home Reimbursement System, of the Wyoming Medicaid Rules.
(i) “Chapter 8.” Chapter 8, Inpatient Admission Certification, of the Wyoming Medicaid Rules.
(j) “Chapter 9.” Chapter 9, Hospital Services, of the Wyoming Medicaid Rules.
(k) “Chapter 10.” Chapter 10, Pharmaceutical Services, of the Wyoming Medicaid Rules.
(l) “Chapter 11.” Chapter 11, Medical Supplies and Equipment of the Wyoming Medicaid Rules.
(m) “Chapter 12.” Chapter 12, Home Health Services, of the Wyoming Medicaid Rules.
(n) “Chapter 13.” Chapter 13, ~~Community~~ Mental Health Services, of the Wyoming Medicaid Rules.
(o) “Chapter 15.” Chapter 15, Ambulance Services, of the Wyoming Medicaid Rules.
(p) “Chapter 16.” Chapter 16, Medicaid Program Integrity, of the Wyoming Medicaid Rules.
(q) “Chapter 17.” Chapter 17, Nursing Facility Resident Trust Accounts, of the Wyoming Medicaid Rules.
(r) “Chapter 19.” Chapter 19, PASARR, of the Wyoming Medicaid Rules.
(s) “Chapter 20.” Chapter 20, Reimbursement of Intermediate Care Facilities for the Mentally Retarded, of the Wyoming Medicaid Rules.
(t) “Chapter 22.” Chapter 22, Nursing Facility Evaluation of Medical Necessity, of the Wyoming Medicaid Rules.
(u) “Chapter 25.” Chapter 25, ICF/MR Services, of the Wyoming Medicaid Rules.
(v) “Chapter 28.” Chapter 28, Swingbed Services, of the Wyoming Medicaid Rules.
(w) “Chapter 30.” Chapter 30, Chapter 30, Level of Care Inpatient Hospital Reimbursement, of the Wyoming Medicaid Rules.
(x) “Chapter 31.” Chapter 31, Selective Contracting of Hospital Services, of the Wyoming Medicaid Rules.
(y) “Chapter 32.” Chapter 32, Disproportionate Share Hospitals, of the Wyoming Medicaid Rules.
(z) “Chapter 33.” Chapter 33, Reimbursement of Outpatient Hospital Services, of the Wyoming Medicaid Rules.
(aa) “Chapter 34.” Chapter 34, Home or Community-Based Waiver Services, of the Wyoming Medicaid Rules.
(bb) “Chapter 35.” Chapter 35, Medicaid Benefit Recovery, of the Wyoming Medicaid Rules.
(cc) “Chapter 36.” Chapter 36, Administrative Transportation, of the Wyoming Medicaid Rules.
(dd) “Chapter 37.” Chapter 37, Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs), of the Wyoming Medicaid Rules.
(ee) “Chapter 39.” Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid Rules.
(ff) “Claim.” A request by a provider for Medicaid payment for covered services provided to a recipient.
(gg) “CMS.” The Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services, its agent, designee, or successor.
(hh) “Consultation.” An opinion or advice rendered by one physician to another as part of the evaluation or treatment of a recipient.
(ii) “CORF.” A Comprehensive Outpatient Rehabilitation Facility as described in 42 CFR 400.200, which is incorporated by this reference.
(jj) “Corrective lenses.” Prescription eyeglasses or, if the recipient’s vision cannot be appropriately corrected using eyeglasses, contact lenses.
“Covered service.” Services which are Medicaid reimbursable pursuant to the rules of the Department.
(ll) “CRNA.” Certified registered nurse anesthetist. 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).
(mm) “Dentist.” A person licensed to practice dentistry by the Wyoming Board of Dental Examiners or a similar agency in another state.
(nn) “Department.” The Wyoming Department of Health, its agent, designee or successor.
(oo) “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.
(pp) “Developmental Disabilities Division.” The Division of Developmental Disabilities of the Department, its agent, designee, or successor.
(qq) “DFS.” The Wyoming Department of Family Services, its agent, designee or successor.
(rr) “Diagnostic evaluation/assessment.” A comprehensive, multi-disciplinary evaluation of a child five years 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 following:
(A) Physical development, including fine and gross motor skills;
(B) Cognitive development;
(C) Speech development; and
(D) Social and emotional development.
(ss) 'Direct supervision.' Supervision in which the responsible practitioner is physically present in the building where the services are being provided.
(tt) '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.
(uu) 'Emergency detention.' A Person detained or involuntarily hospitalized pursuant to W.S. § 25-10-101 et seq.
(vv) 'Emergency hospital services.' Emergency hospital services as defined in 42 C.F.R. 440.170(e), which is incorporated by this reference.
(ww) 'Enrolled.' Enrolled as defined in Chapter 3, which definition is incorporated by this reference.
(xx) 'EPSDT.' Early and periodic screening, diagnosis and treatment services for recipients under the age of 21.
(yy) 'Equipment.' Items, including durable medical equipment, that are designed for repeated use, have a medical purpose and are intended for home use.
(zz) “Excess payments.” Excess payments as defined in Chapter 39, which definition is incorporated by this reference.
(aaa) “Extended psychiatric care.” Extended psychiatric care as defined in Chapter 30, which definition is incorporated by this reference.
(bbb) “FQHC.” Federally-qualified health center. A federally-qualified health center as defined by 42 U.S.C. § 1396d(l)(2)(B), which is incorporated by this reference.
(ccc) “HCBS.” Home and community-based. Home and community-based services as defined by 42 C.F.R. § 440.180, which is incorporated by this reference.
(ddd) “Hospice program.” Hospice program as defined by 42 U.S.C. § 1395x(dd), which is incorporated by this reference.
(eee) “Hospital.” An institution that:
Is approved to participate as a hospital under Medicare;
Is maintained primarily for the treatment and care of patients with disorders other than mental diseases or tuberculosis;
Has a provider agreement;
Is enrolled in the Medicaid program; and
Is licensed to operate as a hospital by the State of Wyoming, or, if the institution is out-of-state, licensed as a hospital by the state in which the institution is located.
(fff) “ICF/MR.” Intermediate care facility services for the mentally retarded. Intermediate care facility services as defined by 42 U.S.C. § 1396d(d), which is incorporated by this reference, and applicable HHS regulations.
(ggg) “Independent occupational therapist.” An independent occupational therapist certified by Medicare. An independent occupational therapist is neither employed by, directly affiliated with, nor working under the supervision of a hospital, nursing facility, physician or other provider of health.
(hhh) “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.
(iii) “Inpatient.” An inpatient as defined by 42 C.F.R. § 440.2(a), which is incorporated by this reference.
(jjj) “Inpatient hospital service.” Inpatient hospital services as defined in 42 C.F.R. § 440.10, which is incorporated by this reference.
(kkk) “Licensed practitioner.” A health professional licensed by an agency or board of the State of Wyoming or a similar agency in another state who is acting within the scope of his or her licensure. “Practitioner” includes physicians and mid-level practitioners.
(lll) “Local agency.” The County office of DFS, its agent, designee or successor.
(mmm) “Medicaid.” Medical assistance and services provided pursuant to Title XIX of the Social Security Act and/or the Wyoming Medical Assistance and Services Act. “Medicaid” includes any successor or replacement program enacted by Congress and/or the Wyoming Legislature.
(nnn) “Medicaid allowable payment.” The maximum Medicaid reimbursement as determined pursuant to the rules of the Department.
(ooo) “Medicaid fee schedule.” The Medicaid fee schedule as established pursuant to Chapter 3.
(ppp) “Medical Supplies and Equipment.” Medical Supplies and Equipment as defined in Chapter 11, which definition is incorporated by this reference.
(qqq) “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:
(rrr) “Medical supplies.” Disposable, semi-disposable or expendable supplies ordered by a physician or other licensed practitioner for the treatment of an illness or injury.
(sss) “Medicare.” The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.
(ttt) “MHD.” The Mental Health Division of the Department, its agent, designee, or successor.
(uuu) “Nurse midwife.” A registered nurse who is certified as a nurse midwife by the American College of Nurse-Midwives.
(vvv) “Nurse practitioner.” A registered nurse who is certified or licensed as a nurse practitioner by the Wyoming State Board of Nursing or a similar agency in another state.
(www) “Nursing facility.” Nursing facility as defined by 42 U.S.C. § 1396(r)(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.
(xxx) “Occupational therapist.” A person licensed as an occupational therapist by the Wyoming State Board of Occupational Therapy or a similar agency in another state.
(yyy) “OHCF.” The Office of Health Care Financing of the Department, its agent, designee, or successor.
(zzz) “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.
(aaaa) “Optometrist.” A person licensed to practice optometry by the Wyoming State Board of Examiners of Optometry or a similar agency in another state.
(bbbb) “Outpatient.” An outpatient as defined in 42 C.F.R. § 440.20(a), which is incorporated by this reference.
(cccc) “Overpayment.” Overpayment as defined in Chapter 39, which definition is incorporated by this reference.
(dddd) “Physician.” A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a similar agency in another state.
(eeee) “Physician assistant.” A person certified as a physician assistant by the Wyoming State Board of Medical Examiners or a similar agency in another state.
(ffff) “Physical therapist.” A person licensed as a physical therapist by the Wyoming State Board of Physical Therapy or a similar agency in another state.
(gggg) “Preventive services.” Any routine service or examination which is performed in the absence of a diagnosed illness, injury or complaint.
(hhhh) “Prior authorization or prior authorized.” Approval by the Office of Health Care Financing (OHCF) pursuant to Section 46 of this Chapter.
(iiii) “Provider.” Any individual or entity that has qualified as a provider pursuant to the rules of the Department.
(jjjj) “Psychologist.” A person licensed to practice psychology by the Wyoming Board of Psychologist Examiners or a similar agency in another state.
(kkkk) “Psychiatric services.” Level of care psychiatric services as defined in Chapter 30, which definition is incorporated by this reference.
(llll) “Public institution.” Public institution as defined in 42 C.F.R. § 435.1009, which definition is incorporated by this reference.
(mmmm) “Recipient.” A person who has been determined eligible for Medicaid.
(nnnn) “Recipient under age twenty-one.” A recipient before or during the month in which he or she turns twenty-one years of age.
(oooo) “Registered nurse.” A person licensed to practice nursing by the Wyoming Board of Nursing or a similar agency in another state.
(pppp) “RHC.” Rural health clinic. A rural health clinic as defined by 42 U.S.C. § 1396D(l)(1), which is incorporated by this reference.
(qqqq) “Rural health clinic services.” Rural health clinic services as defined by 42 C.F.R. § 440.20(b), which is incorporated by this reference.
(rrrr) “RTC.” Residential treatment center. A facility or program accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) or Council on Accreditation for Children and Family Services (COA) or Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and operated for the primary purpose of providing residential psychiatric care to persons under age twenty-one, except as otherwise specified in this Chapter.
(ssss) “SAD.” Substance Abuse Division. The Substance Abuse Division of the Department, its agent, designee, or successor.
(tttt) “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.
(uuuu) “Services.” Health services, medical supplies or equipment which are demonstrated to be effective in the treatment or prevention of illness or injury.
(vvvv) “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.
(wwww) “Supervisor.” An individual licensed to provide services who takes professional responsibility for such services, even when provided by another individual or individuals.
(xxxx) “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.
(yyyy) “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.
(zzzz) “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:
(x) Emergency hospital services;
(xi) EPSDT services furnished to recipients under twenty-one years of age;
(xxxii) Radiology services;
RHC services;
(xxxiv) Solid organ transplants and bone marrow transplants. Transplants limited to bone marrow, kidney, and liver for recipients over 21 years of age;
(xxxv) Swing-bed services;
(xxxvi) Vision care services; and
(xxxvii) Weight reduction treatment, including intestinal bypass surgery, gastric bypass surgery, and gastric stapling.
(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.
(i) The following medical services:
(i) Abortions, except as specified in Section 38 of this Chapter;
(ii) Acupuncture;
(iii) Alcohol and chemical rehabilitation furnished to an inpatient, 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 38 of this Chapter;
(x) Custodial care;
(xi) Hysterectomies, except as specified in Section 38 of this Chapter;
(xii) Infertility services, including counseling, reverse sterilization and artificial insemination;
(xiii) Missed or canceled appointments;
(xiv) Personal comfort items;
(xv) Private-duty nursing services;
(xvi) Routine physical examinations, except as specified in Section 38 of this Chapter;
(xvii) Services rendered by an independently practicing (A) Social worker; or
(B) Speech therapist.
(xviii) Sterilizations, except as specified in Section 38; and
(xix) Transsexual surgery.
(j) Payment for non-covered services. Except as specified in subsection (k), a provider that provides a non-covered 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.
(k) 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 (j).
(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. Administrative Transportation. Administrative transportation is subject to the requirements of Chapter 36.
Section 12. Ambulance Services. Ambulance services are subject to the requirements of Chapter 15.
Section 13. 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 the lower of the provider's usual and customary charge and the Medicaid fee schedule.
(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.
(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) For which the recipient has not given informed consent to the procedure;
(e) Medicaid allowable payment. Medicaid payment shall be the lower of the provider's usual and customary charge and the Medicaid fee schedule.
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 may include:
Drugs and biologicals that cannot be self-administered;
Medical supplies and equipment;
Nursing services;
Occupational therapy;
(v) Orthotics and prosthetics;
(vi) Physician services;
(vii) Physical therapy;
(viii) Respiratory therapy;
(ix) Social or psychological services; and
(x) Speech therapy.
(b) Eligible providers. Facilities certified by Medicare as comprehensive outpatient rehabilitation facilities.
(c) 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.
(d) Medicaid allowable payment. The lower of the provider's usual and customary charge and the Medicare rate for CORF services.
(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 Developmental Disabilities Division 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 as defined in 42 C.F.R. 440.170(e).
(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.
Section 19. EPSDT services. 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.
Section 21. Family Planning Clinic 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 the Maternal and Child Health Section of CFHD, 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.
Section 22. FQHC services. FQHC services are subject to Chapter 37.
Section 23. Freestanding substance Abuse Center Services. Freestanding substance abuse center services are subject to Chapter 13.
Section 24. HCBS services. HCBS services are subject to Chapter 34.
Section 25. Home Health Services. Home health services are subject to Chapter 12.
Section 26. Hospice Services.
(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:
(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 47.
(C) The limitations of this subsection shall not apply to inpatient services furnished to recipients diagnosed with HIV and/or AIDS.
Section 27. Hospital services. Hospital services are subject to Chapters 8, 9, 24, 30, 31, 32 and 33.
Section 28. ICF/MR Services. ICF/MR services are subject to Chapters 20 and 25.
Section 29. 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 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) Specimen collection fees will be paid only to the provider that collects the specimen from the recipient;
(iv) Fees charged to obtain immediate results are not covered; and
(v) 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.
Section 30. Medical Supplies and Equipment. Medical supplies and equipment are subject to Chapter 11.
Section 31. Mental Health Services. Mental health services provided by community mental health centers and independently practicing clinical psychologists are subject to Chapter 13.
Section 32. Nurse Midwife Services.
(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, in collaboration with a physician, throughout the maternity period, which are within the scope of the nurse midwife's practice as permitted by the Wyoming Nursing Practice Act (W.S. § 33-21-119, et seq.).
(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.
Section 33. Nurse Practitioner Services.
(a) Definition. 'Advanced nursing acts' and 'medical acts' performed by a nurse practitioner as permitted by the Wyoming Nursing Practice Act (W.S. § 33-21-119, et seq.).
(b) Eligible providers: Nurse practitioners.
(c) Covered services. Professional services furnished by a nurse practitioner, in collaboration with a physician, which are within the scope of the nurse practitioner's practice as permitted by the Wyoming Nursing Practice Act (W.S. § 33-22-119, et seq.).
(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.
Section 34. Nursing Facility services. Nursing facility services are subject to Chapters 5, 7, 17, 19 and 22.
Section 35. Occupational therapy services.
(a) Definition. Outpatient services provided by or under the direct supervision of an occupational therapist pursuant to the written orders of a physician.
(b) Eligible providers. Independent occupational therapists, hospitals, physicians, RTCs, and developmental centers that employ occupational therapists. Occupational therapy services provided by a home health agency or a nursing facility are covered by Chapters 12 and 7, respectively.
(c) Covered services.
(i) Restorative occupational therapy services furnished in response to physical debilitation caused by acute physical trauma or physical illness; or
(ii) Outpatient occupational therapy services prescribed while a person was an inpatient; or
(iii) Occupational therapy services furnished in a developmental center or an RTC to a recipient.
(A) Individualized education plan (IEP) developed by the school system or an RTC; or
(B) Individualized family services plan developed by a developmental center.
(d) Medicaid allowable payment.
(i) Covered services furnished by an individual outside a facility. The Medicaid allowable payment for occupational therapy services furnished outside a facility by an independent occupational therapist or a physician shall be the lower of the provider's usual and customary charge and the Medicaid Fee Schedule.
(ii) Covered services furnished in a facility. The Medicaid allowable payment for occupational therapy services provided by an independent occupational therapist in a nursing facility, a hospital, or an RTC which is a Medicaid provider must be billed to the facility.
(e) Service limitations. Medicaid reimbursement is limited to twenty encounters per calendar year, unless prior authorized.
Section 36. Pharmaceutical services. Pharmaceutical services are subject to Chapter 10.
Section 37. Physical therapy services.
(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, RTCs, 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 or an RTC pursuant to an:
(A) Individualized education plan developed by the school system or RTC; 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, in an RTC, or in a hospital that is a separately enrolled Medicaid provider must be billed by the facility.
(e) Service limitations. Medicaid reimbursement for recipient 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 licensed 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) 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) Hysterectomies are not covered unless the requirements of 42 C.F.R. 441 Subpart F are satisfied. Such requirements are incorporated by reference;
(viii) 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;
(ix) 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;
(x) Sterilizations are not covered unless the requirements of 42 C.F.R. § 441 Subpart F are satisfied. Such requirements are incorporated by reference;
(xi) 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.
(xii) 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) Service Limitations. Medicaid reimbursement for recipient visits to a physician, ophthalmologist, physician assistant, nurse practitioner, 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; or (iii) Recipients under age twenty-one.
(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; and
(v) 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.
Section 40. RHC services. RHC services are subject to Chapter 37.
Section 41. Swing-bed services. Swing-bed services are subject to Chapter 28.
Section 42. Vision services.
(a) Definition. Professional services and corrective lenses furnished by an optometrist or ophthalmologist within the scope of his/her practice.
(b) Eligible providers. Optometrist, opticians and ophthalmologists.
(c) Covered services. Medical treatment for recipients:
(i) At risk of eye diseases, including eye disease secondary to chronic illness or (ii) With 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.
Section 43. Recipient co-payments.
(a) The recipient co-payment requirements established by this Section supersede the recipient co-payment requirements established by the other Medicaid rules, except Chapters 9 and 10, to the extent they are inconsistent with this Section.
(b) Except as specified in (c), recipients who receive the following services must make a co-payment as specified.
(i) Eye examinations. Two dollars per visit. (ii) FQHC services. Two dollars per visit. (iii) Physician services. Two dollars per non-emergency visit for each of the following: (A) Physician office visit;
(B) Physician home visit; and
(C) Psychiatric services.
(iv) RHC services. Two dollars per visit.
(v) Hospital emergency room (non-emergent). Six dollars per visit.
(c) Exceptions. The following recipients are exempt from the co-payment requirements of this Section:
(i) An individual seeking emergency services who is diagnosed with an emergent condition;
(ii) An individual seeking family planning services;
(iii) A recipient under age twenty-one;
(iv) A pregnant woman;
(v) A resident of a nursing facility; and
(vi) A recipient who is also eligible for Medicare.
(d) Collection of co-payment. Providers are responsible for collecting the co-payment. The amount of the co-payment shall be automatically deducted by the OHCF from the Medicaid allowable payment, regardless of whether the co-payment is actually paid.
(i) Prohibition on denial of services. A provider may not deny services to a recipient under a recipient's inability to make the co-payment.
(ii) Regular refusal to make co-payment. A provider may refuse services to a recipient who regularly refuses to make co-payments.
(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 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 OHCF may designate additional services that require prior authorization. In so designating additional services, the OHCF 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 OHCF may 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 46. Payment of claims. Payment of claims shall be pursuant to the payment of claims provisions of Chapter 3, which are incorporated by this reference.
(a) The Department may recover excess payments pursuant to Chapter 39, which is incorporated by this reference.
(b) The Department may recover overpayments pursuant to Chapter 16, which is incorporated by this reference.
(a) A provider may request that the Department reconsider a decision to recover excess payments or overpayments. The request for reconsideration, the reconsideration, and any administrative hearing shall be pursuant to the reconsideration provisions of Chapter 3, which are incorporated by this reference.
(b) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.
Section 49. Disposition of Recovered Funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16, which provisions are incorporated by this reference.
(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.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of various provisions.
Section 52. 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 53. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in effect.