Wyo. Code R. 048-0037-28
Medicaid
Chapter 28: Swingbed Services
Effective Date: 07/19/1994 to 11/10/1994
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.28.07191994
Date Filed 07/19/94
Expr Date 11/16/94
Supr Date
Repeal Date
Document Type EMRGRULE
This rule is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. 424-101 et seq and the Wyoming Administrative Procedures Act at W. S. 16-3-101 et seq.
(a) This rule shall apply to and govern the provision of and reimbursement of services provided to recipients in swingbeds and shall apply to all recipients and providers.
(b) The Department may issue Manuals or Bulletins to providers and/or other affected parties to interpret the provisions of this Chapter. Such Manuals shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in Manuals or Bulletins shall be subordinate to the provisions of this Chapter.
(c) This Chapter is effective for swingbed services, services provided to heavy care patients and services provided to extraordinary patients in cost reporting periods beginning on or after July 1, 1994.
(a) Except as otherwise specified, the terminology used in this rule is the standard terminology and has the standard meaning used in accounting, health care, Medicaid and Medicare.
(b) Medicaid reimbursement for swingbed services, services provided to extraordinary patients and services provided to heavy care patients is limited to services furnished to individuals that are nursing facility eligible.
(a) 'Admitted.' Admitted as defined by Chapter XXX, which definition is incorporated by this reference.
(b) 'Appropriate bed.' A certified bed in a nursing facility that is:
(i) Available; and
(ii) In a room where the other bed, if any, is occupied by a member of the same sex or the spouse of the Proposed Rule (May 1994) recipient
(c) 'Attachment A.' Attachment A to Chapter VII, which is incorporated by this reference.
(d) 'Availability date.' 'Availability date' as defined in 42 C.F.R. 413.114(b), which is incorporated by reference.
(e) 'Available.' A certified bed in a nursing facility that is:
(i) Not occupied by an individual;
(ii) Not a reserved bed for which the facility has received or will receive reimbursement; and
(iii) In a nursing facility willing and able to provide the services required by the recipient.
(f) 'Certified.' Approved by the survey agency.
(g) 'Chapter I.' Chapter I, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
(h) 'Chapter III.' Chapter III, Provider Participation, of the Wyoming Medicaid Rules.
(i) 'Chapter VII.' Chapter VII, Wyoming Nursing Home Reimbursement System of the Wyoming Medicaid rules.
(j) 'Chapter X.' Chapter X, Pharmaceutical Services, of the Wyoming Medicaid Rules.
(k) 'Chapter XIX.' Chapter XIX, Nursing Facility Preadmission Screening, of the Wyoming Medicaid rules.
(l) 'Chapter XXII.' Chapter XXII, Nursing Facility Evaluation of Medical Necessity, of the Wyoming Medicaid rules.
(m) 'Chapter XXX.' Chapter XXX, Level of Care Hospital Reimbursement, of the Wyoming Medicaid Rules.
(n) 'Claim.' A request by a provider for Medicaid payment for swingbed services provided to a recipient.
(o) 'Cost reporting period.' The fiscal period used by a hospital to report its costs to Medicare.
(p) 'Covered service.' Nursing facility services, services furnished to a heavy care patient or an extraordinary recipient in a swingbed that are reimbursable pursuant to this Chapter.
(q) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(r) 'Desk review.' A review by the Department of a facility's financial records and any supporting or related documentation to determine whether: (i) claims have been submitted in accordance with this Chapter; and (ii) that the facility has not received excess payments.
(s) 'DFS.' The Wyoming Department of Family Services, its agent, designee or successor.
(t) 'Division.' The Division of Health Care Financing of the Department, its successor, agent or designee.
(u) 'Excess payments.' Medicaid funds received by a provider which exceed the Medicaid allowable payment. 'Excess payments' includes:
(i) Payments for services furnished to extraordinary recipients or heavy care patients which were both reimbursed pursuant to a negotiated rate and paid as Medicaid program services; and
(ii) Medicaid funds paid as part of a negotiated rate that exceed the actual cost of furnishing the services.
(v) 'Extraordinary recipients.' Extraordinary recipients as defined by Chapter VII, which definition is incorporated by this reference.
(w) 'Field audit.' An on-site examination, verification and review by the Department of a facility's financial records and any supporting or related documentation to determine whether: (i) claims have been submitted in accordance with this Chapter; and (ii) that the facility has not received excess payments.
(x) 'Geographic region.' 'Geographic region' as defined in 42 C.F.R. 413.114(b), which is incorporated by reference.
(y) 'HCFA.' The Health Care Financing Administration of the United States Department of Health and Human Services, or its designee.
(z) 'Heavy care patients.' Recipients:
(i) For whom care and services in addition to nursing facility services, but less than inpatient hospital services, are medically necessary; and
(ii) That have not been admitted as a resident by a nursing facility.
(aa) '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; (v) meets the requirements of 42 C.F.R. 482.66, which are incorporated by this reference; and (vi) 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.
(bb) "Inpatient." An "inpatient" as defined by 42 C.F.R. 440.10, which is incorporated by this reference.
(cc) "Inpatient hospital service." "Inpatient hospital services" as defined by 42 C.F.R. 440.10, which is incorporated by this reference.
(dd) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(ee) "Medicaid program services." Services, other than swingbed services, which are Medicaid reimbursable pursuant to the rules and policies of the Department. "Medicaid program services" excludes services and supplies included in the per diem rate.
(ff) "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 live. The service must be:
(i) Consistent with the diagnosis and treatment of the recipient's condition;
(ii) Recognized as the prevailing standard or current practice among the provider's peer group;
(iii) Required to meet the medical needs of the recipient and undertaken for reasons other than the convenience of the recipient and the provider; and
(iv) Provided in the most efficient manner and/or setting consistent with appropriate care required by the recipient's condition.
(gg) "Medical necessity review." A review by the Department to determine whether the services a patient is receiving are medically necessary. The review may be conducted on-site or by reviewing medical records.
(hh) "Medicare." The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(ii) "Minimum data set (MDS)." The resident assessment required by 42 C.F.R. 483.20, which is incorporated by this reference, and in the form and containing the information specified by the Department.
(jj) "Negotiated rate." A daily reimbursement rate agreed upon by the Division and a provider for services furnished to a heavy care patient or an extraordinary recipient. A negotiated rate shall not be effective for services furnished before there is a written agreement between the Division and the provider.
(kk) "Nursing facility." Nursing facility is defined in Chapter VII, which definition is incorporated by this reference.
(ll) "Nursing facility eligible." Recipients that have been determined to be:
(i) Medically eligible for nursing facility services pursuant to Section 10; and
(ii) Financially eligible for nursing facility services by DFS.
(mm) 'Nursing facility services.' 'Nursing facility services' as defined in 42 U.S.C. 1396d(f), which is incorporated by this reference.
(nn) 'Patient.' An individual admitted to a hospital that is receiving swingbed services.
(oo) 'Patient-related services.' Patient-related services as defined in Chapter VII, which is incorporated by this reference.
(pp) 'Per diem rate.' The Medicaid allowable payment, as determined pursuant to this Chapter. The per diem rate includes reimbursement for all services and supplies included in the per diem rate.
(qq) 'Physician.' A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a comparable agency in another state, or a person licensed to practice dentistry by the Wyoming Board of Dental Examiners or a comparable agency in another state.
(rr) 'Provider.' A provider as defined by Chapter III, which definition is incorporated by this reference.
(ss) 'Recipient.' A person who has been determined eligible for Medicaid.
(tt) 'Reserved bed.' 'Reserved bed' as defined by Chapter VII, which definition is incorporated by this reference.
(uu) 'Services.' Health services, medical supplies or medical equipment.
(vv) 'Services and supplies included in the per diem rate.' Services and supplies used in providing patient-related services, including, but not limited to those specified in Attachment A.
(ww) 'Survey agency.' The Health Facilities Survey, Certification and Licensure Office of the Department, its agent, designee or successor.
(xx) 'Swingbed.' A bed in a hospital which is certified for either inpatient services or nursing facility services.
(yy) 'Swingbed services.' Nursing facility services provided to a recipient in a swingbed, except that services provided to a heavy care patient or an extraordinary recipient in addition to nursing facility services are not swing-bed services.
(zz) 'Transfer period.' The period within which a patient in a swingbed must be transferred as specified in Section 12.
(aaa) 'Treatment plan.' A written document furnished by a provider to the Division which:
(i) Identifies a recipient's diagnosis;
(ii) Contains a short-term and a long-term prognosis;
(iii) Treatment goals;
(iv) Itemizes the services to be furnished to the recipient, the charges for the services and the outcome expected from the services; and
(v) Is signed by a physician, who certifies the medical necessity of the services identified in (iv).
(a) Payments only to providers. No hospital that provides swingbed services to a recipient shall receive Medicaid funds unless the hospital is certified to provide such services, has signed a provider agreement and is enrolled.
(b) Compliance with HHS regulations. A hospital that wishes to receive Medicaid reimbursement for swingbed services furnished to a recipient must meet the requirements of applicable federal regulations, including 42 C.F.R. 482.66 and 483.1 et seq., which are incorporated by this reference.
(c) Compliance with Chapter III. A hospital that wishes to receive Medicaid reimbursement for swingbed services furnished to a recipient must meet the requirements of Chapter III, Sections 4 through 6, which are incorporated by this reference.
Section 6. Provider Records. A provider must comply with Chapter III, Section 7, which is incorporated by this reference.
Section 7. Verification of Recipient Data. A provider must comply with Chapter III, which is incorporated by this reference.
(a) General requirements. A patient that receives swingbed services is not subject to the requirements of Chapter XIX, except that a patient that remains in a swingbed for more than thirty consecutive days is subject to the requirements of Chapter XIX.
(b) Timely completion of PASARR. The requirements of Chapter XIX must be satisfied on or before the thirtieth consecutive day.
(c) Failure to timely complete. The failure to timely complete the requirements of Chapter XIX shall result in nonpayment for services provided after the thirtieth consecutive day and until the date the PASARR requirements are satisfied.
(a) General requirements. Upon notification by the Department through a Manual or Bulletin, each provider must complete an MDS for any recipient that receives swingbed services for more than thirty consecutive days and comply with subsections (b) and (c). Notification from the Department shall be by a Provider Bulletin or Provider Manual,
(b) Timely completion. The MDS must be completed on or before the thirtieth consecutive day.
(c) Failure to timely complete. The failure to timely provide the MDS shall result in non-payment for services provided after the thirtieth consecutive day and until the date the MDS is completed, or, if payments have already been made, the recovery of such payments.
Section 10. Determination of medical eligibility. All applicants or recipients must undergo an evaluation of medical necessity pursuant to Chapter XXII before a hospital may receive Medicaid reimbursement for services provided to an individual in a swingbed.
Section 11. Medicaid allowable payment for swingbed services.
(a) The per diem rate for swingbed services shall be the lower of:
(i) The hospital's usual and customary charges for swingbed services; and
(ii) The lowest per diem rate currently in effect for nursing facility services furnished in a nursing facility in the community where the hospital is located, as determined pursuant to Chapter VII.
(iii) The per diem rate includes reimbursement for all services and supplies furnished to the recipient, including all services and supplies included in the per diem rates established pursuant to Chapter VII (including Attachment A), except as otherwise specified in this Chapter.
(b) A hospital shall not be reimbursed for swingbed services if:
(i) The recipient was admitted to the hospital from a nursing facility which has available an appropriate bed to which the recipient could return;
(ii) There is an available bed in a nursing facility within the hospital's geographic region and the recipient has not been transferred as required by Section 14;
(iii) The hospital is located outside the State of Wyoming; or
(iv) As otherwise prohibited by 42 C.F.R. 413.114(d), which is incorporated by this reference,
(c) Costs related to swingbed services shall not be included in the facility's cost report, cost settled pursuant to Medicare principles or otherwise, and shall not be used to rebase inpatient hospital rates pursuant to Chapter XXX.
Section 12. Medicaid allowable payment for services provided to heavy care patients.
(a) Medicaid reimbursement for services provided to a heavy care patient in a swingbed shall be the per diem rate plus a negotiated rate to cover the cost of medically necessary services and supplies that are not included in the per diem rate.
(i) The Division will negotiate with providers on a case-by-case basis to determine the negotiated rate and the billing procedures for heavy care patients.
(ii) Prior to such negotiations, the provider shall submit to the Division:
(A) A treatment plan; and
(B) A proposed reimbursement rate, including all relevant financial records and all medical records which document the medical necessity for heavy care.
(iii) The Division may request, and the provider shall furnish before a negotiated rate is established, additional information to document the medical necessity of heavy care.
(iv) The negotiated rate shall be the rate agreed upon by the provider and the Division for medically necessary services.
(v) The Division shall reevaluate the condition of a heavy care patient after the first fifteen days and at least every thirty days thereafter, and shall renegotiate the negotiated rate to reflect changes in the patient's condition.
(b) All inclusive. The negotiated rate shall be an all inclusive reimbursement rate for all services and supplies furnished by the facility, except as specified in Section 16 and/or as otherwise agreed by the Division.
(c) Maximum rate. The negotiated rate shall not exceed the actual cost of the services provided to the heavy care patient.
(d) Reimbursement for services provided to a heavy care patient, other than the per diem established pursuant to Section 11, shall not begin until a negotiated rate is agreed upon by the Division in writing.
(e) The Division's refusal to agree to pay the rate requested by a provider for a heavy care patient is not an adverse action for purposes of Chapter I.
(f) Costs related to services for heavy care patients shall not be cost settled by Medicaid and shall not be used to rebase inpatient hospital rates pursuant to Chapter XXX.
Section 13. Medicaid allowable payment for services provided to extraordinary recipients.
(a) Medicaid reimbursement for services provided to an extraordinary recipient in a swingbed shall be the per diem rate plus a negotiated rate to cover the cost of medically necessary services and supplies that are not included in the per diem rate.
(i) The Division will negotiate with providers on a case-by-case basis to determine the negotiated rate and the billing procedures for extraordinary recipients.
(ii) Prior to such negotiations, the provider shall submit to the Division:
(A) A treatment plan; and
(B) A proposed reimbursement rate, including all relevant financial records and all medical records which document the medical necessity for services provided to an extraordinary recipient.
(iii) The Division may request, and the provider shall furnish before a negotiated rate is established, additional information to document the medical necessity for services provided to an extraordinary recipient.
(iv) The negotiated rate shall be the rate agreed upon by the provider and the Division for medically necessary services.
(v) The Division shall reevaluate the condition of an extraordinary recipient after the first fifteen days and at least every thirty days thereafter, and shall renegotiate the negotiated rate to reflect changes in the recipient's condition.
(b) All inclusive. The negotiated rate shall be an all inclusive reimbursement rate for all services and supplies furnished by the facility, except as specified in Section 16 and/or as otherwise agreed by the Division.
(c) Maximum rate. The negotiated rate shall not exceed the actual cost of the services provided to the extraordinary recipient.
(d) Reimbursement for services provided to an extraordinary recipient, other than the per diem established pursuant to Section 11, shall not begin until a negotiated rate is agreed upon by the Division in writing.
(e) The Division's refusal to agree to pay the rate requested by a provider for an extraordinary recipient is not an adverse action for purposes of Chapter I.
(f) Costs related to services for extraordinary recipients shall not be cost settled by Medicaid and shall not be used to rebase inpatient hospital rates pursuant to Chapter XXX.
(a) Affected hospitals. All providers of swingbed services are subject to the requirements of this Section.
(b) Except as provided in subsection (c) an applicant or recipient receiving swingbed services must be transferred to the first available, appropriate nursing facility bed in the hospital's geographic region within five (5) days, excluding weekends and holidays, after the availability date. Medicaid reimbursement to the hospital for swingbed services shall terminate for services provided after the date of the transfer or the last day of the transfer period, whichever is earlier.
(c) The requirements of subsection (b) shall not apply if the recipient's physician certifies, in writing, within the transfer period that transfer is not medically appropriate.
(a) General requirements. Payment of claims shall be pursuant to Chapter III, Section 11, which is incorporated by this reference.
(b) Certification. Each claim must contain a certification by the provider that the service was medically necessary, that it was provided on the date specified, that third party liability has been paid or, if third party liability has been denied, documentation of that denial is attached, and that the reimbursement sought is not in excess of the provider's usual and customary charge for the service.
(a) The Medicaid allowable payment for Medicaid program services furnished to a recipient receiving swingbed services shall be determined pursuant to the rules and policies of the Department.
(b) The Medicaid allowable payment for Medicaid program services furnished to a heavy care patients or an extraordinary recipient shall be determined pursuant to the rules and policies of the Department, except:
(i) Inpatient hospital services shall not be reimbursable unless the recipient of the services is discharged from the swingbed and admitted to a hospital as an inpatient; and (ii) As otherwise agreed to by the Division and the hospital pursuant to Sections 12 or 13.
(c) Claims for Medicaid program services shall be submitted pursuant to the rules and policies of the Department.
(a) Field audits and desk reviews. The Department or HCFA may perform a field audit or a desk review of a provider at any time to determine the accuracy and reasonableness of claims submitted by the provider.
(b) Excess payments. If an audit discloses that a provider has received excess payments, the Department shall recover the excess payments pursuant to Section 19.
(c) Financial or medical records which are not made available at the time of an audit shall not be admissible at an administrative hearing held pursuant to Section 20 unless the facility shows good cause for not making the records available at the time of the audit.
(a) The Department may review medical records or conduct on-site medical necessity reviews to determine whether the services a patient is receiving are medically necessary..
(b) Unnecessary services. If a medical necessity review discloses that a provider has been furnishing services that are not medically necessary and has received Medicaid payments for those services, the Department shall recover the excess payments pursuant to Section 19.
Section 19. Recovery of excess payments.
(a) Notice of excess payments. After determining that a provider has received excess payments, the Department shall send written notice to the provider by certified mail, return receipt requested, stating:
(i) The amount of the excess payments;
(ii) The basis for the Department's determination of excess payments; and
(iii) The provider's right to request reconsideration of the determination pursuant to Section 20.
(b) Reimbursement of excess payments. A provider must reimburse the Department for excess payments within thirty (30) days after the provider receives written notice from the Department pursuant to (a), even if the provider has requested reconsideration or an administrative hearing regarding the determination of excess payments.
(c) Methods of recovery of excess payments. If a provider does not timely reimburse the Department, the Department may recover the excess payments, even if the provider has requested reconsideration or an administrative hearing regarding the determination of excess payments, by:
(i) Withholding all or part of Medicaid payments until the excess payments are recovered;
(ii) Initiating a civil lawsuit against the provider; or
(iii) Any other method of collecting a debt or obligation permitted by law.
Section 20. Reconsideration.
(a) Request for reconsideration. A provider may request reconsideration of the matters specified in subsection (d). Such a request must be mailed to the Department, by certified mail, return receipt requested, within twenty (20) days after the date the provider receives notice of the action. The request must state with specificity the reasons for the request. Failure to provide such a statement shall result in the dismissal of the request with prejudice.
(b) Reconsideration. The Department shall review the matter and send written notice by certified mail, return receipt requested, to the provider of its final decision within fortyfive (45) days after receipt of the request for reconsideration or the receipt of any additional information requested pursuant to (c), whichever is later.
(c) Request for additional information. The Department may request additional information from the provider as part of the reconsideration process. Such a request shall be made in writing by certified mail, return receipt requested. The provider must provide the requested information within the time specified in the request. Failure to provide the requested information shall result in the dismissal of the request with prejudice.
(d) Matters subject to reconsideration. A provider may request reconsideration of a decision to recover excess payments.
(e) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.
(f) Administrative hearing. A provider may request an administrative hearing regarding the final agency decision pursuant to Chapter I of these rules by mailing by certified mail, return receipt requested or personally delivering a request for hearing to the Department within twenty (20) days after the date the provider receives notice of the final agency decision. At the hearing, the burden shall be on the provider to show that the agency's final decision does not comply with this Chapter.
(g) Failure to request reconsideration. A provider which fails to request reconsideration pursuant to this Section may not subsequently request an administrative hearing pursuant to Chapter I.
(h) Matters not subject to reconsideration.
(i) The use or reasonableness of the reimbursement methodologies set forth in this Chapter;
(ii) A change in a payment rate caused by a change in the reimbursement methodology as the result of a change in state or federal law, including an amendment to this Chapter or other rules of the Department; or
(iii) The Department's refusal to agree to a negotiated rate requested by a provider.
Section 21. Superseding effect. When promulgated, this rule supersedes all prior rules or policy statements issued by the Department, including provider manuals and provider bulletins, which are inconsistent with this rule.
Section 22. 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 Health Care Financing Administration of the United States Department of Health and Human Services (HCFA) is the federal agency responsible for administering the Medicaid program. The Act and HCFA regulations permit states to cover nursing facility services provided to recipients who occupy swingbeds in hospitals (swingbed services). The Wyoming Act authorizes the Department to pay for swingbed services.
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 Department is promulgating this rule to define swingbed services covered by the Wyoming Medicaid program. This rule also establishes the methods and standards for determining the reimbursement rates for hospitals which provide swingbed services. This rule is being promulgated as an emergency rule since the Department is without a rule which defines the scope of swingbed services and/or establishes the standards and methods for reimbursing hospitals for providing such services. It is to be effective for swingbed services provided on or after July 1, 1994. Proposed Rule (May 1994)