Wyo. Code R. 048-0037-26
Medicaid
Chapter 26: Covered Services
Effective Date: 04/09/2019 to 05/07/2020
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.26.04092019
This Chapter is promulgated by the Department of Health pursuant to the Wyoming Medical Assistance and Services Act at Wyoming Statutes §§ 42-4-101 through -122.
This Chapter has been adopted to establish the scope of covered services, except as otherwise specified in the rules of the Department, and shall apply to all clients and providers for all services furnished on or after the Chapter's effective date.
Except as otherwise specified in Chapter 1, or as specified herein, the terminology used in this Chapter is the standard terminology and has the standard meaning as used in health care, Medicaid and Medicare.
(a) 'Applied Behavior Analysis (ABA) Treatment.' Services provided to children between the ages of 0-20 years of age with a diagnosis of Autism Spectrum Disorder.
(b) 'Ambulatory Surgical Center (ASC) Facility.' A health care facility that specializes in providing surgery, pain management, and certain diagnostic services in an outpatient setting. ASC-qualified procedures are typically more complex than those done in a doctor's office but not so complex as to require an overnight stay.
(c) 'Ambulatory Surgical Center (ASC) Services.' Surgical procedures or other services offered by an ASC facility that do not require overnight inpatient hospital care.
(d) '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.
(e) 'Audiology Services.' A hearing aid evaluation (HAE) and basic audio assessment (BAA) provided by a licensed audiologist, upon a licensed practitioner referral, to individuals with hearing disorders.
(f) 'Chiropractic Services.' Manual manipulation services provided by a licensed chiropractor.
(g) 'Chiropractor' An individual licensed as a chiropractor by the Wyoming Board of Chiropractic Examiners or by a similar agency in another state.
(h) 'Dental Services.' Professional services and dental appliances furnished by a dentist within the scope of his practice.
and functioning for daily living. Examples would include therapy for a child who isn't walking or talking at the expected age.
(q) 'Hospice Services.' 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.
(r) 'Independent Occupational Therapist.' An individual licensed as an independent occupational therapist by the Wyoming State Board of Occupational Therapy or a similar agency in another state. 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.
(s) 'Independent Physical Therapist.' An individual licensed as an independent physical therapist by the Wyoming State Board of Physical Therapy or a similar agency in another state. 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.
(t) 'Interpretation Services.' Services that assist clients with oral or sign language interpretation.
(u) 'Nurse Midwife Services' Nurse midwife services as defined by 42 C.F.R. § 440.165
(v) '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.
(w) 'Optometrist.' A person licensed to practice optometry by the Wyoming State Board of Examiners of Optometry or a similar agency in another state.
(x) 'Physician Assistant.' A person certified as a physician assistant by the Wyoming State Board of Medical Examiners or a similar agency in another state.
(y) 'Physician Services.' Professional services furnished by or under the supervision of a licensed physician.
(z) 'Preventive Services/Visits.' Any routine service or examination which is performed in the absence of a diagnosed illness, injury, or complaint.
(aa) 'Public Institution.' Public institution, as defined by 42 C.F.R. § 435.1010.
(bb) 'Radiology Services.' Professional or technical services in which X-rays or scans are used for diagnostic or therapeutic purposes.
(cc) “Rehabilitative Services.” Services that help patients keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the client was sick, hurt, or suddenly disabled.
(dd) “Speech Therapy Services.” Outpatient services provided by or under the direct supervision of a licensed speech therapist pursuant to written orders of a physician.
(ee) “Vision Services.” Professional services and corrective lenses furnished by an Optometrist, optician, or Ophthalmologist within the scope of his practice.
(a) The services and supplies specified in subsection (b) are covered services if medically necessary, subject to any exclusions or limitations contained in this Chapter and the rules of the Department.
(b) Covered services:
(i) Administrative Transportation;
(ii) Advanced Practitioner of Nursing (APN) services in accordance with Section 6;
(iii) Ambulance services;
(iv) Ambulatory Surgical Center (ASC) services in accordance with Section 7;
(v) Audiology Services and hearing aids in accordance with Section 8;
(vi) Certified Registered Nurse Anesthetist (CRNA) services in accordance with Section 9;
(vii) Certified Community Mental Health Center services (CMHC) as defined by Chapter 13;
(viii) Chiropractic Services in accordance with Section 10;
(ix) Comprehensive Outpatient Rehabilitation Facility (CORF) services in accordance with Section 11;
(x) Dental Services in accordance with Section 12;
(xi) Dietician Services in accordance with Section 13;
(xii) Developmental Center Services in accordance with Section 14;
(xxxiii) Physician Services in accordance with Section 25; (xxxiv) Psychiatric Residential Treatment Facility (PRTF) Services; (xxxv) Psychological Services; (xxxvi) Radiology Services in accordance with Section 26; (xxxvii) Rural Health Clinic (RHC) Services; (xxxviii) Solid organ transplants and bone marrow transplants
(A) For clients over the age of 21, transplants are limited to bone marrow, kidney, and liver;
(xxxix) Speech Therapy Services in accordance with Section 27; (xl) Swing bed Services; (xli) Targeted case management in accordance with Section 28; (xlii) Vision Services in accordance with Section 29; and
(xliii) Weight reduction treatment, including intestinal bypass surgery, gastric bypass surgery, and gastric stapling.
Section 5. Services Not Covered. The following services and supplies specified in this Section are not covered by the Department:
(a) Except in an emergency, services furnished without the consent of the client or the client's legal guardian; (b) Experimental procedures 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 during the first seventy-two (72) hours of emergency detention;
(g) Services provided to clients age 22 - 64 in an IMD, including Medicare secondary claims (cross over claims);
(h) Unless pre-approved, services which exceed the service limitations (cap limits) established by the rules of the Department;
(i) 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;
(iv) Have not received prior authorization, if applicable; or
(v) Have not received admission certification, if applicable.
(j) Abortions, except to the extent required by 42 C.F.R. § 441.200 – 441.208;
(k) Acupuncture;
(l) Alcohol and chemical rehabilitation furnished to an inpatient, except for purposes of detoxification or stabilization of acute conditions;
(m) Autopsies;
(n) Biofeedback therapies and equipment;
(o) Chronic pain rehabilitation;
(p) Community mental health services furnished outside Wyoming;
(q) Cosmetic procedures, except as specified in Section 25 of this Chapter;
(r) Custodial care such as non-skilled, personal care. Personal care would include help with activities of daily living, such as bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom;
(s) Infertility services, including counseling, reverse sterilization and artificial insemination;
(t) Missed or canceled appointments;
(u) Personal comfort items;
(v) Private-duty nursing services; (w) Sterilizations, unless the requirements of 42 C.F.R. § 441.250 – 441.259 are satisfied; and (x) Gender reassignment surgery.
(a) Eligible providers. Advanced Nurse Practitioners (APN), independently or in collaboration with a physician. (b) Covered services. (i) Professional services furnished by an APN, which are within the scope of the nurse practitioner's practice, as permitted by the Wyoming Nurse Practice Act.
(a) Eligible providers. A facility or distinct portion of a facility certified under Medicare to provide ASC services. (b) Covered services. (i) All surgical procedures covered by Medicare; and (ii) Additional surgical procedures pre-authorized and which may be provided as outpatient hospital services.
(a) Eligible providers. Physicians, independently practicing licensed Audiologists, and hearing aid equipment providers. (b) Covered services. (i) Audiological function tests; (ii) Hearing aid examinations; and (iii) Hearing aid equipment.
(a) Eligible providers. Hospitals and physicians that employ a CRNA or independently practicing CRNAs.
(b) Covered services. Anesthesia services, except as otherwise specified by the rules of the Department.
(c) Excluded services. Anesthesia services when performed in conjunction with a surgical procedure that:
(a) Eligible providers. Licensed Chiropractors.
(b) Covered services.
(i) Rehabilitative Services furnished in response to physical debilitation caused by acute physical trauma or physical illness; and
(ii) Medically necessary professional services furnished by a Chiropractor.
(c) Service limitations.
(i) Unless pre-approved, Medicaid reimbursement for Chiropractic services shall be limited to a total of twenty (20) visits per calendar year;
(ii) Medicaid reimbursement for Evaluation and Management shall be limited to a total of twelve (12) visits per calendar year and is inclusive of all outpatient medical services provided by a Chiropractor, Physician, Nurse Practitioner, Ophthalmologist, Physician Assistant, and Optometrist and to the outpatient department of a hospital. The limitations of this subsection shall not apply to:
(a) Eligible providers. Facilities certified by Medicare as a CORF.
(b) CORF services are limited to: (i) Drugs and biologicals that cannot be self-administered; (ii) Medical supplies and equipment; (iii) Nursing services; (iv) Occupational therapy; (v) Orthotics and prosthetics; (vi) Physician Services; (vii) Physical therapy; (viii) Respiratory therapy; (ix) Social or psychological services; and (x) Speech therapy. (c) Excluded services. (i) Services directed at general conditioning or maintenance; and (ii) Services that exceed the limitations imposed by this and the other rules of the Department.
(a) Covered services for clients under the age of twenty-one (21): (i) Preventive visits; (ii) Restorative fillings, crowns, and tooth replacement; (iii) Extractions; (iv) Partial or complete dentures; (v) Root canal therapy; (vi) Periodontal treatment;
(vii) Oral and maxillofacial surgery; (viii) Orthodontic treatment for severe malocclusions; and (ix) Palliative treatment. (b) Covered services for clients age twenty-one (21) and older: (i) Preventive visits; (ii) Extractions; (iii) Palliative treatment; and (iv) Oral and maxillofacial surgery.
(a) Eligible providers. Dietitians. (b) Covered services. (i) Medically necessary professional services furnished by a dietitian, as prescribed by a physician. (c) Service limitations. (i) Medicaid reimbursement for Dietitian service(s) shall be limited to a total of twenty (20) visits per calendar year, unless pre-approved. (ii) The limitations of this subsection shall not apply to: (A) A client who is under age twenty-one (21); or (B) A pregnant woman.
(a) Eligible providers. Developmental Centers certified by the Developmental Disabilities Division and under contract with that Division to provide such services. (b) Covered services. Diagnostic assessment and evaluation, behavioral health, speech, physical therapy services, occupational therapy services, and case management services.
Section 15. Emergency Hospital Services. Emergency Hospital Services are covered at the most accessible enrolled hospital available that is equipped to furnish appropriate Emergency
Hospital Services.
(a) Eligible Providers. Free-standing or hospital-based facilities certified by Medicare to provide ESRD services.
(b) Covered services. ESRD services for outpatient dialysis and other treatment for persons with end-stage renal disease.
(a) Eligible Providers. A clinic, which is neither located on the premises of a hospital nor owned by a hospital and meets the minimum requirements for routine contraceptive management as specified by the state Public Health Division. A laboratory in a clinic shall be licensed by the State of Wyoming.
(b) Covered Services. The following services are covered 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 following care furnished to the clinic's patients:
(a) Eligible providers. Hospice providers certified by Medicare and located within the State of Wyoming. Services provided by a hospice provider located outside the State of Wyoming shall not be eligible for Medicaid reimbursement unless the services are pre-approved.
(b) Covered services. The following services shall be covered if provided pursuant to a written plan of care established by the hospice provider and approved by the client's attending physician:
(iv) General inpatient care;
(v) Hospice, nursing facility room and board; and
(vi) Hospice, inpatient hospice facility room and board.
(c) Limitations. During the time a client elects to receive Hospice Services, the client shall waive all rights to Medicaid payments for the following services:
(i) Hospice Services provided by a provider other than the hospice provider designated by the client (unless provided under arrangements by the designated hospice); and
(ii) Any Medicaid services that are related to the treatment of the terminal illness (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 client's attending physician if that physician is neither an employee of the designated hospice nor receiving compensation from the hospice for furnishing such services;
(C) Provided as room and board by a nursing facility if the client is a resident of a nursing facility;
(D) Provided by a Home and Community Based Waiver; or
(E) Delivered to a client under the age of twenty-one (21) years. Clients under the age of twenty-one (21) shall be eligible for curative services as well as terminal illness hospice care.
(d) Medicaid allowable payment. The Medicaid allowable payment shall be determined as follows:
(i) The Medicaid allowable payment to the hospice provider for room and board furnished in a nursing facility shall be ninety-five percent (95%) of the nursing facility's per diem rate as determined by Chapter 7. The hospice provider shall be responsible for paying the nursing facility for the room and board services furnished to a client of Hospice Services.
(ii) Providers providing Hospice Services in an inpatient hospice facility that does not meet eligibility criteria for inpatient hospice care billing may receive room and board payments. Payments for room and board shall not exceed fifty percent (50%) of the average Wyoming Medicaid nursing home room and board rate.
(iii) Total Medicaid payments to a hospice provider for inpatient care furnished to clients of Hospice Services shall not exceed twenty percent (20%) of the aggregate number of days of hospice care provided by the hospice provider to all Medicaid clients during the applicable twelve-month period. The limit shall be applied as follows:
(A) For each twelve-month period beginning on November 1, the Department shall determine the aggregate number of days of inpatient care furnished by each hospice provider to clients 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 (20%) of the total days of Medicaid services, the Medicaid payments for such services shall be considered overpayments; and shall be recovered pursuant to Chapter 16.
(a) Hospital Services (including ancillary services provided in a hospital) shall be covered services if provided:
(i) Pursuant to the written orders of a licensed physician; and
(ii) By or under the supervision of a licensed physician.
(b) Inpatient Hospital Psychiatric Services. Psychiatric services are limited to stabilization of acute conditions. Such services shall only be covered services when:
(i) The client is evaluated by a multidisciplinary team within forty-eight (48) hours after admission;
(ii) The multidisciplinary team prepares an individualized treatment plan; and
(iii) The medical record documents a plan of active treatment and individual, group, or family therapy directed to achieve the goals specified in the individualized treatment plan.
(c) Limitations on Hospital Services.
(i) Medicaid reimbursement for outpatient hospital services shall be limited to a total of twelve (12) visits per calendar year to a hospital clinic, a hospital emergency room (for non-emergency services), and a physician's office, unless additional visits are pre-approved.
(ii) Exceptions. The limitations of subsection (c)(i) shall not apply to:
(A) An individual seeking emergency services who is diagnosed with an emergent condition;
(B) An individual seeking family planning clinic services;
(C) A client who is under age twenty-one (21);
(D) A pregnant woman;
(E) Items and services furnished directly by the Indian Health Services, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through a referral under a purchase order contract health services (as described in 42 C.F.R., Ch. I, Subch. M, Pt. 136, Subpart C) to an American Indian or Alaskan Native who is enrolled as a member of a Federally-Recognized Tribe or otherwise meets the definition of “Indian” at Section 4 of the Indian Healthcare Improvement Act (25 U.S.C. § 1608);
(F) A resident of a nursing facility; or
(G) A client who is also eligible for Medicare and where Medicare has reimbursed the provider for the claim.
(a) Interpreters shall adhere to national standards developed by the National Council on Interpreting in Healthcare (NCIHC), to include accuracy, confidentiality, impartiality, role boundaries, professionalism, professional development, and advocacy.
(b) Covered Services. The interpretation provider shall only bill for time spent with the client.
(i) Excluded services. Interpreter services in conjunction with the following services:
(A) Inpatient and outpatient services;
(B) Services in an Intermediate Care Facility for persons with Intellectual Disabilities (ICF/ID);
(C) Nursing Facility services;
(D) Ambulance Services by public providers;
(E) Psychiatric Residential Treatment Facility (PRTF) services;
(F) Comprehensive Inpatient and Outpatient Rehabilitation Facility Services;
(G) Services provided by other agencies and organizations receiving federal funding;
(H) Interpreter services provided by a family member, volunteer, associate, or friend; and
(I) Reimbursement for interpreter travel to and from the appointment.
(a) Eligible providers. Independent laboratories certified by Medicare, hospitals laboratories, and physician offices with a laboratory licensed by the state in which the laboratory is located.
(b) Covered services. Professional or technical laboratory services ordered by a licensed provider under their scope of practice. Services shall be directly related to the diagnosis and treatment of the patient as specified in the ordering provider’s treatment plan.
(c) Excluded services:
(i) Handling charges where a specimen is referred by one (1) laboratory to another;
(ii) Post-mortem examinations;
(iii) Fees charged to obtain immediate results;
(iv) Technician callback fees; and
(v) Services that are not FDA approved.
(d) Limited services:
(i) Specimen collection fees shall be paid only to the provider that collects the specimen from the client.
(ii) Only one collection fee shall be allowed for each type of specimen for each client encounter, regardless of the number of specimens extracted.
(iii) Clinical laboratory services routinely performed by non-physicians shall not be entitled to a professional component.
(a) Covered services. Professional services furnished by a licensed nurse midwife that are:
(i) In collaboration with a physician;
(ii) Throughout the maternity period; and
(iii) Within the scope of the nurse midwife's practice as permitted by the Wyoming Nursing Practice Act (Wyo. Stat. § 33-21-119, 157).
(b) Excluded and limited services. Services furnished in a hospital or a clinic shall be covered only to the extent the facility permits such services.
(a) Eligible providers. Licensed Independent Occupational Therapists, Hospitals, Physicians, PRTFs, and Developmental Centers that employ licensed occupational therapists.
(b) Covered services.
(i) Prescribed rehabilitative occupational therapy services furnished in response to physical debilitation caused by acute physical trauma or physical illness;
(ii) Occupational therapy services prescribed while the client was an inpatient and continuing on an outpatient basis;
(iii) Occupational therapy services furnished in a Developmental Center or PRTF to a client pursuant to:
(A) An individualized education plan (IEP) developed by the school system or PRTF; or
(B) An individualized family services plan developed by a Developmental Center.
(c) Service limitations.
(i) Unless pre-approved, Medicaid reimbursement for client occupational therapy visits shall be limited to twenty (20) visits per calendar year.
(ii) Habilitative Services are not covered for clients 21 years of age or older.
(iii) Except as otherwise specified in this Chapter, Physical, Occupational, or Speech Therapy Services shall be prescribed by the attending physician and re-certified by the attending physician every one hundred eighty (180) days.
(a) Eligible providers. Licensed Independent Physical Therapists, physicians, hospitals, PRTFs, and Developmental Centers that employ licensed physical therapists.
(b) Covered services.
(i) Prescribed rehabilitative physical therapy services furnished in response to physical debilitation caused by acute physical trauma or physical illness as prescribed by a Physician;
(ii) Physical therapy services prescribed while the client 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 client under age twenty-one (21) with chronic disabilities when furnished by a Developmental Center or PRTF pursuant to an:
(A) Individualized education plan developed by the school system or PRTF; or
(B) Individualized family services plan developed by a Developmental Center.
(c) Service limitations.
(i) Unless pre-approved, Medicaid reimbursement for client physical therapy visits shall be limited to a total of twenty (20) visits per calendar year.
(ii) Habilitative Services are not covered for clients 21 years of age or older.
(iii) Except as otherwise specified in this Chapter, Physical, Occupational, or Speech Therapy Services shall be prescribed by the attending physician and re-certified by the attending physician every one hundred eighty (180) days.
(a) Covered services. Medically necessary professional services furnished by or under the supervision of a licensed Physician, except as otherwise specified by this Chapter.
(b) Excluded or limited services.
(i) Anesthesia services shall be limited as follows:
(A) An anesthesiologist shall not receive Medicaid reimbursement for a consultation in addition to any other anesthesia services for the same surgery.
(B) Anesthesia services shall not be covered when performed in conjunction with:
(I) A non-covered surgical procedure; or
(II) A procedure requiring client consent if proper consent was not obtained.
(ii) The following allergy and clinical immunotherapy services are excluded:
(A) Sublingual, intracutaneous and subcutaneous provocative and neutralization testing; and
(B) Neutralization therapy for food allergies.
(iii) 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 excluded.
(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 shall be covered only if authorized prior to the procedure.
(iv) Dermatology. The following shall be 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.
(v) Medical supplies. Expendable medical supplies normally used in a physician's office shall be 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 client may be separately billed to Medicaid.
(vi) Prolonged care shall be limited to a total of three (3) hours per day unless there is documentation in the medical records that additional prolonged care was medically necessary.
(vii) Sterilizations shall not be covered unless the requirements of 42 C.F.R. § 441 Subpart F are satisfied.
(viii) Therapeutic injections shall not be covered unless:
(A) The drug cannot be administered orally;
(B) The drug cannot be self-administered; and
(C) The drug is reasonable and medically necessary.
(c) Service Limitations. Unless pre-approved, Medicaid reimbursement for client 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 (12) visits per calendar year. The limitations of this subsection shall not apply to:
(i) A client seeking emergency services who is diagnosed with an emergent condition;
(ii) A client seeking family planning clinic services;
(iii) A client who is under age twenty-one (21);
(iv) A pregnant woman;
(v) Items and services furnished directly by the Indian Health Services, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through a referral under a purchase order contract health services (as described in 42 C.F.R., Ch. I, Subch. M, Pt. 136, Subpart C) to an American Indian or Alaskan Native who is enrolled as a member of a Federally-Recognized Tribe or otherwise meets the definition of a “Indian” as Section 4 of the Indian Healthcare Improvement Act (25 U.S.C. § 1608);
(vi) A resident of a nursing facility; or
(vii) A client who is also eligible for Medicare and where Medicare has reimbursed the provider for the claim.
(a) Eligible providers. Licensed independent radiology practices, hospitals, Chiropractors and Physician practices.
(b) Excluded services:
(i) Unordered X-rays; and
(ii) Separate consultations procedures unless ordered by the attending physician;
(c) Limited services:
(i) Routine mammography is limited as follows: (A) One mammography between the ages of thirty-five (35) and thirty-nine (39); and (B) One mammography per year at age forty (40) and after. (ii) Services performed in a physician's office shall be covered only if performed by or under the direct supervision of the physician. (iii) Services performed in a 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) Eligible Providers. Independent licensed Speech Therapists, Physicians, Hospitals, PRTFs, and Developmental Centers that employ licensed speech therapists. (b) Covered Services. (i) Prescribed rehabilitative Speech Therapy services furnished in response to physical debilitation caused by acute physical trauma or physical illness as prescribed by a Physician; (ii) Speech Therapy Services prescribed while the client was an inpatient and continuing on an outpatient basis; (iii) Speech therapy prescribed as a direct result of outpatient surgery required as a result of an injury; and (iv) Speech Therapy Services provided to a client under age twenty-one (21) with chronic disabilities when furnished by a Developmental Center or a PRTF pursuant to an: (A) Individualized Education Plan (IEP) developed by the school system or PRTF; or (B) Individualized family services plan developed by a Developmental Center. (c) Service limitations. (i) Medicaid reimbursement for client speech therapy visits shall be limited to twenty (20) visits per calendar year, unless pre-approved. (ii) Habilitative Services are not covered for clients 21 years of age or older.
(iii) Except as otherwise specified in this Chapter, Physical, Occupational, or Speech Therapy Services shall be prescribed by the attending Physician and re-certified by the attending Physician every one hundred eighty (180) days.
(a) Eligible providers. Case managers.
(b) Covered services. Case management services provided only to the target groups defined in Supplement 1 to Attachment 3.1A of the Wyoming State Plan.
(a) Eligible providers. Optometrist, Opticians and licensed Ophthalmologists.
(b) Covered services. Medical treatment for clients:
(i) At risk of eye diseases, including eye disease secondary to chronic illness;
(ii) With eye injuries.
(c) Additional covered services for clients under twenty-one (21) years of age:
(i) Medically necessary contact lenses;
(ii) Eyeglasses;
(iii) Medically necessary photosensitive lenses;
(iv) Routine eye examinations; and
(v) Vision therapy.
(a) Except as specified in subsection (c), clients who receive the following services shall make a co-payment:
(i) Chiropractor evaluation and management services;
(ii) Eye examinations;
(iii) FQHC services;
(iv) Physician office visits; (v) Physician home visits; (vi) Psychiatric services; (vii) RHC services; (viii) Non-Emergent hospital emergency services; and (ix) Pharmaceutical products.
(b) Co-payment amounts. Co-payment amounts shall be made as specified in State Plan Amendment 4.18-A.
(c) Exceptions. Co-payment requirements of this Section shall not apply to:
(i) Emergency services; (ii) Family planning clinic services; (iii) Clients under the age of twenty-one (21); (iv) Pregnant women; (v) Residents of a nursing facility;
(vi) A client who is also eligible for Medicare and where Medicare has reimbursed the provider for the claim;
(vii) Items and services furnished directly to an American Indian or Alaska Native who is enrolled as a member of a Federally-Recognized Tribe or otherwise meets the definition of an “Indian” at Section 4 of the Indian HealthCare Improvement Act (25 U.S.C. § 1608);
(viii) Hospice Services; and (ix) Inpatient hospital stays.
(d) Collection of co-payment. Providers shall be responsible for collecting the co-payment. The amount of the co-payment shall be automatically deducted by the Department from the Medicaid allowable payment, regardless of whether the co-payment is actually paid. For purposes of this section, a provider shall not deny service to a client due to a client’s inability to make the co-payment, unless a client regularly refuses to make co-payments.
Section 31. Recovery of Overpayments. The Department shall recover overpayments pursuant to Chapter 16.
(a) The order in which the provisions of this Chapter appear shall not 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.
If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in full force.
(a) For any code, standard, rule, or regulation incorporated by reference in these rules:
(i) The Department of Health has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules.
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of this section; and
(iii) The incorporated code, standard, rule, or regulation is maintained at the Department of Health and is available for public inspection and copying at cost at the same location.
(b) Each rule incorporated by reference is further identified as follows:
(i) Referenced in Section 5 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. C, Pt. 441, Subpart E, incorporated as of the effective date of this Chapter and found at http://www.ecfr.gov.
(ii) Referenced in Section 3 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. C, Pt. 441, Subpart B, incorporated as of the effective date of this Chapter and found at http://www.ecfr.gov.
(iii) Referenced in Section 3 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. C, Pt. 440.170(e), incorporated as of the effective date of this Chapter and found at http://www.ecfr.gov.
(iv) Referenced in Section 3 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. G, Pt. 482.55, incorporated as of the effective date of this Chapter and found at http://www.ecfr.gov.
(v) Referenced in Section 3 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. C, Pt. 440.165, incorporated as of the effective date of this Chapter and found at http://www.ecfr.gov.
(vi) Referenced in Section 3 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. C, Pt. 435.1010, incorporated as of the effective date of this Chapter and found at http://www.ecfr.gov.
(vii) Referenced in Sections 5 and 25 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. C, Pt. 441, Subpart F, incorporated as of the effective date of this Chapter and found at http://www.ecfr.gov.
(viii) Referenced in Sections 28 and 30 of this Chapter is Wyoming’s Medicaid State Plan, incorporated as of the effective date of this Chapter and found at http://www.health.wyo.gov/healthcarefin/medicaid/spa.html.
(ix) Referenced in Sections 19 and 25 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. I, Subch. M, Pt. 136, Subpart C, incorporated as of the effective date of this Chapter and found at http://www.ecfr.gov.
(x) Referenced in Sections 19 and 25 of this Chapter is 25 U.S.C. § 1608, incorporated as of the effective date of this Chapter and found at http://uscode.house.gov.