Wyo. Code R. 048-0037-46
Medicaid
Chapter 46: Medicaid Supports and Comprehensive Waivers
Effective Date: 06/21/2017 to 07/26/2018
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.46.06212017
This Chapter is promulgated by the Department of Health pursuant to Wyo. Stat. Ann. § 9-2-102, the Medical Assistance and Services Act at Wyo. Stat. Ann. §§ 42-4-104 through -120, 2013 Wyo. Sess. Laws 322-25, and the Wyoming Administrative Procedure Act at Wyo. Stat. Ann. §§ 16-3-101 through -115.
(a) This Chapter shall apply to and govern Medicaid services provided under the Wyoming Medicaid Supports and Comprehensive Waivers.
(b) This Chapter, in addition to Medicaid Chapters 43, 44 and 45, shall govern services and provider requirements of the Supports and Comprehensive Waivers.
(c) The Behavioral Health Division, hereafter referred to as the 'Division', may issue manuals, bulletins, or both, to providers or other affected parties to interpret the provisions of this Chapter. Such manuals and bulletins 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.
(a) Terminology. Unless otherwise specified, the terminology used in this Chapter is standard terminology and has the standard meaning used in accounting, health care, Medicaid, and Medicare.
(b) Definitions.
(i) 'Case Manager' means an individual who provides case management services as defined in Chapter 45, Section 9.
(ii) 'Level of Service Need Score' means a participant's support needs for various parts of their everyday routine and their level of independence are tied to a Level of Service Need score ranging from 1 (least level of support) to 6 (highest level of support). The Level of Service Need scores are based on comprehensive assessments that determine an individual's level of functioning related to behavioral and health factors, and identify essential staffing and support requirements.
(iii) 'Relative' means a participant's biological or adoptive parent(s) or stepparent(s).
(c) Incorporation by reference:
(i) For any code, standard, rule or regulation incorporated by reference in these rules:
(A) 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;
(B) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (c)(ii) of this section; and
(C) The incorporated code, standard, rule, or regulation is maintained at 6101 Yellowstone Road, Suite 220, Cheyenne, Wyoming, 82002 and is available for public inspection and copying at cost at the same location.
(ii) Each code, standard, rule, or regulation incorporated by reference in these rules in further identified as follows:
(A) Center for Medicare and Medicaid Services (CMS) regulations implementing Title XIX of the Social Security Act 42 C.F.R. Part 441, Subpart G, available online at http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=ae749eaf39aabf6f20a43f0e9c4b4520&mc=true&n=sp42.4.441.g&r=SUBPART&ty=HTML.
(B) Wyoming's Medicaid State Plan, available online at http://health.wyo.gov/healthcarefin/medicaid/spa.
(C) Diagnostic and Statistical Manual of Mental Disorders (DSM-V) found at American Psychiatric Association Publishing 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209.
(D) Wyoming's CMS Comprehensive, Supports, and Acquired Brain Injury Waiver Applications, effective July 1, 2016, found at https://health.wyo.gov/behavioralhealth/dd/waivers/.
(d) This Chapter establishes a person-centered approach to determining the support needs of participants in the individualized plan of care and to assign the individual budget amount. Developing community connections, increasing independence, natural supports, self-direction, and employment opportunities are essential components of the Supports and Comprehensive Waivers.
(e) The Supports Waiver provides eligible participants supportive services so the person may remain in the place he or she currently lives, as funding is available.
(f) Objectives. In conjunction with the methodology listed in this Section, objectives of the Supports and Comprehensive Waivers include:
(i) Provide an array of services, including a continuum of support and employment offerings, to serve participants in the least restrictive and most appropriate environment;
(ii) Provide participants increased opportunities for community involvement;
(iii) Allow the opportunity to self-direct services;
(iv) Set and achieve targeted outcomes for each participant served; and
(v) Monitor and enhance continuous improvement strategies to improve service delivery for participants.
(a) All persons possess inalienable rights under the Constitutions of the United States and the State of Wyoming. Persons with developmental disabilities also possess the rights outlined in the Developmental Disabilities Assistance and Bill of Rights Act of 2000, 42 U.S.C. §15001.
(b) It is the philosophy of the Division to develop reasonable and enforceable rules for the provision of services to individuals with developmental disabilities, acquired brain injury, and related conditions in community settings in lieu of unnecessary institutionalization. This philosophy is mandated in the Supreme Court ruling on Olmstead v. L.C. ex rel. Zimring, 527 U.S. 581 (1999).
(c) This Chapter is designed not only to support the philosophy of home and community-based services, but also to protect the health, welfare, and safety of waiver participants.
(a) Eligibility under this Chapter is limited to persons who complete the application process and who meet the following requirements for clinical eligibility and financial eligibility. In order to be eligible for the Wyoming Medicaid Supports Waiver or Wyoming Medicaid Comprehensive Waiver, an individual must:
(i) Meet all citizenship, residency, and financial eligibility requirements established in Chapter 18 of Wyoming Medicaid Rules;
(ii) Meet ICF/ID level of care, as measured by the LT-104; and
(iii) Meet one of the following clinical eligibility diagnoses:
(A) A diagnosis of an intellectual disability, as defined by the DSM V. The diagnosis must:
(I) Be as determined by Medicaid enrolled clinical psychologist who is independent from the provider of waiver services, and currently licensed in Wyoming and (II) Be verified in a written psychological evaluation.
(B) A developmental disability or a related condition determined by a physician or independent psychologist currently licensed in Wyoming with verification in medical records or a written psychological evaluation which includes assessment scores. The evaluation or records must identify a severe, chronic disability, which:
(I) Manifested before the person turned age twenty-two;
(II) Reflects the need for a combination and sequence of special services which are lifelong or of extended duration;
(III) Is attributable to a mental or physical impairment, other than mental illness;
(IV) Is likely to continue indefinitely;
(V) Results in substantial functional limitations in three (3) or more major life activity areas: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency; and
(VI) Has qualifying adaptive behavior scores as determined through standard measurement of adaptive behavior, using the most current forms of the Vineland Adaptive Behavior Scales or Adaptive Behavior Assessment System. For those with a diagnosis along the Autism Spectrum Disorder, a current autism evaluation must be completed.
(C) Has an Acquired Brain Injury (ABI), as defined by Chapter 1 of the Wyoming Medicaid Rules and meets the following criteria:
(I) Is between the ages of twenty-one (21) and sixty-four (64);
(II) Meets at least one of the following evaluations to confirm the diagnosis:
(1.) A score of 42 or more on the Mayo Portland Adaptability Inventory (MPAI), or
(2.) A score of 40 or less on the California Verbal Learning Test II Trials 1-5 T, or
(3.) A score of 4 or more on the Supervision Rating Scale.
(III) A completed LT 104 verifies that the individual meets ICF/MR level of care.
(D) A child applicant who is old enough to take an Intelligence Quotient test shall meet a qualifying clinical diagnosis like an adult. A child too young to complete an
Intelligence Quotient test may meet the criteria of a developmental disability as defined in subsection (B) through medical records of a related condition using a standardized test of development, such as the Bayley Scales of Infant and Toddler Development or other similar instrument.
(iv) Qualify on the Inventory for Client and Agency Planning (ICAP) assessment, as administered by the Division’s designee, with one of the following:
(A) If age twenty-one (21) or older,
(I) A service score of 70 or less; or
(II) At least three (3) significant functional limitations listed in the following sections of the ICAP: Personal Living domain, Social/Communication domain, Community Living Domain, a diagnosis of an intellectual disability, or is non-ambulatory without assistance.
(B) If age two (2) through seventeen (17) with an ICAP service score between 30 and 70, respectively depending on age.
(C) If age twenty (20) or below, the age adjusted ICAP service score must be higher than the ICAP service score for his or her actual age and meet eligibility based on their Adaptive Behavior Quotient (ABQ):
(I) For ages zero (0) through five (5), an adaptive behavior quotient of .50 or below;
(II) For individuals age six (6) through twenty (20), an adaptive behavior quotient of .70 or below.
(b) Diagnoses and assessments used to meet initial clinical eligibility must be accurate and no more than five (5) years old. Any assessments or reassessment for eligibility are subject to review by the Division before acceptance and may require additional evidence or verification.
(c) Case managers shall complete all eligibility paperwork within 30 calendar days. Submitted paperwork shall be reviewed by the Division within 30 calendar days.
(d) For participation in the Comprehensive Waiver, an individual shall meet the clinical eligibility specified in this section and have assessed service needs in excess of the established cost limit on the Supports Waiver and meet the emergency criteria as approved by the Extraordinary Care Committee (ECC), or meet the criteria for reserved capacity as specified in 11(g) of this Chapter.
(e) Loss of eligibility.
(i) A participant shall be determined to have lost eligibility when the participant:
(A) Does not meet clinical eligibility when re-assessed; or (B) Does not meet financial eligibility; or (C) Changes residence to another state.
(ii) Services to a participant determined not to meet eligibility requirements shall be terminated no more than forty-five (45) calendar days after the determination is made. If an applicant is determined not to meet eligibility criteria, the applicant or the applicant's legal representative shall be notified in writing within twenty (20) calendar days.
(iii) The Division may terminate a participant's eligibility when the participant:
(A) Voluntarily does not receive any waiver services for three (3) consecutive months;
(B) Is in a nursing home, hospital, or residential treatment facility, institution, or ICF/ID for thirty (30) calendar days; or
(C) Is in an out-of-state placement or residence for six (6) consecutive months or resides out of state for six (6) consecutive months.
(iv) If the participant is determined not to be eligible for services due to one of the criteria in (iii) of this Section, the participant or the participant's legally authorized representative shall be notified in writing within twenty (20) calendar days.
(v) A participant whose eligibility is terminated under this section may reapply at any time.
(f) Reassessments.
(i) A participant shall be reassessed for clinical eligibility at least annually or more frequently should a change in circumstances occur which requires a participant to receive a higher level of services or support to ensure the health, safety, and welfare.
(ii) The psychological evaluation shall be completed before waiver eligibility is determined, then as necessary by the participant's change in condition with prior approval by the Division.
(iii) The ICAP assessment shall be completed every five (5) years, or more frequently at the option of the Division, to provide continued verification that the participant meets waiver clinical eligibility.
(iv) The Division may require other assessments to determine budget amounts or service authorization.
(v) Psychological reassessments must be conducted by an entity without a conflict of interest to the providers chosen by the participant or legally authorized representative.
(i) The Division shall notify the participant or legally authorized representative, in writing, of the termination of eligibility within fifteen (15) calendar days.
(A) The participant, applicant, or legally authorized representative may submit, in writing, a request for reconsideration within thirty (30) calendar days of the notice of loss of eligibility, which shall include the reasons why the participant should still be considered eligible for the services.
(B) If the participant requests reconsideration, the Division Administrator or Designee shall review this written request and make a final determination in writing within thirty (30) calendar days of the request. A participant who is aggrieved or adversely affected by a reconsideration decision may also request a hearing within thirty (30) calendar days following the adverse reconsideration decision.
(C) Requests for an administrative hearing will be administered pursuant to Chapter 4.
(i) Upon notification from Wyoming Medicaid, the Division shall notify the participant or legally authorized representative in writing of termination of financial eligibility within fifteen (15) calendar days.
(A) The participant, applicant, or legally authorized representative may submit, in writing, a request for reconsideration within thirty (30) calendar days of the notice of loss of eligibility, which shall include the reasons why the participant should still be considered eligible for the services.
(B) If the participant requests reconsideration, the Division Administrator or Designee shall review this written request and make a final determination in writing within thirty (30) calendar days of the request. A participant who is aggrieved or adversely affected by a reconsideration decision may also request a hearing within thirty (30) calendar days following the adverse reconsideration decision.
(C) Requests for an administrative hearing will be administered pursuant to Chapter 4.
All individuals who have been determined eligible for waiver services shall be included in the statewide data registry used by the Division for planning, monitoring, and analysis for the waiver system. Information in the registry is considered confidential and will not be released without proper authorization, or otherwise as required by law. Providers shall provide data on programs, participant outcomes, costs, and other information as required by the Division.
(a) All waiver services specified in the plan of care must be based on the participant's assessed needs; meet the service definition(s); be considered medically or functionally necessary; align with the participant's preferences for services, supports, and providers; and be prioritized based on the availability of funding in the participant's budget.
(b) Services must have prior authorization before they may be provided to a participant.
(c) Pursuant to Chapter 45, Section 10, the individualized plan of care must be developed using person-centered practices and planning, including the preferences and outcomes desired by the participant, and address the assessed needs, potential risks and plans to mitigate risks. The plan must describe the type, scope, frequency, amount and duration of services to be provided to the participant. The plan must also identify the provider, or provider types, that furnish the described services, regardless of the funding source.
(d) Waiver services must be intended to assist the participant in acquiring, retaining, and improving the skills necessary so the individual can function with as much independence as possible, exercise choice and self-management, and participate in the rights and responsibilities of community membership.
(e) The approved plan of care shall reflect the services, and actual units that providers agree to provide over the plan year. The approved plan of care shall also include details regarding the specific support to be provided in various settings, times of day, and for specific activities that require more support than others.
(f) Providers cannot serve children under age 18 and adults at the same time unless prior authorized in writing by the Division.
(g) Waiver services shall not be used to duplicate a same service or a similar service that is available to the participant through one of the following programs:
(h) Participants may request an exemption from subsection (h) by submitting a third payer liability form as part of the participant's annual plan of care. This form must document that the service is not available through another program or agency to meet the individual participant's assessed needs. Exemptions may be granted at the direction of the Division.
(i) Routine transportation for activities provided during the service are included in the reimbursement rate for the service regardless of the number of trips. The provider may not charge a participant separately for transportation during these waiver activities unless the special activity is outside of the participant's community or normal routine.
(j) Participants receiving residential habilitation services may receive up to an average of thirty-five (35) hours of day services per week of day service which includes: Adult Day, Community Integration, Companion, and Prevocational services.
(k) Waiver services include:
(i) Adult Day Services:
(A) Adult Day Services are structured services, for participants' ages twenty-one (21) and over, which are meant to supplement community based activities. The services should consist of meaningful day activities that maximize or maintain skills and abilities; keep participants engaged in their environment and community through optimal care and support; actively stimulate, encourage, develop, and maintain, personal skills; introduce new leisure pursuits; establish new relationships; improve or maintain flexibility, mobility, and strength; or build on previously learned skills.
(B) Adult Day Services must provide active supports which foster independence, and be person-centered to the maximum extent possible, as identified in the participant's plan of care. Adult Day Services also include personal care, protective oversight, and health maintenance activities such as medication assistance and routine activities that may be provided by direct support professionals identified in the plan of care.
(C) Transportation into the community to shop, attend recreational and civic events, and to access community activities and resources, is a component of Adult Day Services. Transportation is included in the Adult Day Services rate.
(D) Adult Day Services may be provided in the participant's home if the team decides the home is a more appropriate place to receive the service and the approved plan of care supports the medical, behavioral, or other reason for the service to be provided in the person's home. If this option will be utilized during the provision of this service, the case manager must document it in the 'objective' portion in the IPC for this service.
(E) Adult Day Service providers shall be reimbursed using a tiered service rate, which is based on the individual participant's level of service need. Budgets for participants who also receive residential habilitation services shall be based on an estimate of the participant specific day service need, and multiplied by the 15 minute Community Integration rate for each Level.
(I) Basic Level of Care: Levels 1 and 2 on the Level of Service Need score. Providers serving participants at this level must provide intermittent staff support and personal attention to provide assistance as needed due to the participant’s moderately high levels of independence and functioning. Behavioral needs, if any, may be met with medication or informal direction by staff. The participant may have periods of time with indirect staff supervision where staff are onsite and available through hearing distance of a request.
(II) Intermediate Level of Care: Levels 3 and 4 on the Level of Service Need score. Providers serving participants at this level must provide full-time supervision for the participant with staff available on-site, within line of sight, to meet the participant’s functional limitations, medical, or behavioral needs. Behavioral and medical supports are not generally intense and may be provided in a shared staffing setting. Regular personal attention must be provided throughout the day for personal care, reinforcement, community or social activities.
(III) High Level of Care: Levels 5 and 6 on the Level of Service Need score. Providers serving participants at this level must provide full-time supervision with staff available on-site within absolute line of sight and frequent staff interaction and personal attention to these participants due to significant functional limitations, medical, or behavioral needs. Support and supervision needs are moderately intense, but can still generally be provided in a shared setting unless otherwise specified in the plan of care. Frequent personal attention must be given to the participant throughout the day for reinforcement, positive behavior support, personal care, community or social activities.
(A) Behavioral Support Services include training, supervision, or assistance in appropriate expression of emotions and desires, cooperation, assertiveness, acquisition of socially appropriate behaviors, and the reduction of inappropriate behaviors through the implementation of positive behavior support and interventions. Behavioral Support services may be accessed for the purpose of reducing the use of restrictions and restraints within a participant’s current plan of care or service environment.
(B) Behavioral Support services provided must not be covered under any billable service through the Medicaid State Plan.
(C) Activities conducted through this service may not include restrictive interventions described in Chapter 45, section 18, of the Wyoming Medicaid Rules.
(A) Case management is a required service for all waiver participants.
(B) Case managers may bill twelve (12) monthly units or up to two-hundred ninety-six (296) fifteen minute units per year. The number of 15 minute units used must be based upon the needs of the participant or guardian up to the approved amount authorized on the plan of care.
(C) Case managers must assist participants in gaining access to needed waiver and other Medicaid State Plan services. Case managers must also identify and assist participants with accessing additional medical, social, educational and other services, regardless of the funding source for the additional services.
(D) Billable case management activities include: plan of care development, service coordination, monitoring of the plan of care, second-line medication monitoring, following up on concerns, service observation, team meetings, conducting participant specific training, service documentation review, face to face meeting with participants, guardians or family member relating to the plan of care or service delivery, advocacy and referral activities, crisis intervention coordination, coordination of natural supports and non-waiver resources, and home visits.
(E) To bill for a monthly unit of case management, a case manager shall:
(I) Document all billable activities provided during the month; and
(II) Provide at least two hours minimum of documented service, with at least one hour of person-to-person contact with the participant or guardian per calendar month and a home visit.
(III) The person to person contact must include either face-to-face meetings or phone conversations with the participant and guardian.
(IV) The direct monthly contact shall be used to discuss waiver services, health, and safety topics with the participant to ensure the participant is satisfied with services and has no unmet needs.
(F) To bill using fifteen (15) minute units, a case manager shall:
(I) Provide at least one (1) unit of service per month for each waiver participant on his or her caseload;
(II) Complete monthly in-home visits, with the participant present, for participants receiving residential habilitation, special family habilitation, and supported living services.
(III) Complete quarterly in-home visits, with the participant present, for participants residing in any other residential setting.
(IV) Complete additional in-home visits during times of crisis, when requested by the participant, or when otherwise required by these rules.
(G) The case manager shall schedule and facilitate annual and semi-annual individual plan of care team meetings, and other team meetings when requested by the participant, guardian, a member of the team, or the Division, and when concerns arise with incidents, restrictive interventions, or when service over- or under-utilization occurs.
(H) The case manager shall give at least thirty (30) calendar days advance written notice to team members and the Division for a plan of care meeting unless a shorter notification time is approved by the Division.
(I) The case manager shall monitor the plan of care in accordance with Chapter 45 of the Wyoming Medicaid Rules.
(A) Child Habilitation Services provide participants ages zero (0) through seventeen (17) with regularly scheduled activities and supervision for part of a day, where services include formal and informal training, the coordination and intervention directed at skill development and maintenance, physical health promotion and maintenance, language development, cognitive development, socialization, social and community integration, and domestic and economic management.
(B) Services may provide supplementary staffing necessary to meet the child's exceptional care needs in a daycare setting, and do not include the basic cost of child care for ages birth through age twelve (12). Basic cost of child care means the rate charged by and paid to a childcare center or worker for children who do not have special needs.
(C) Services are billed by fifteen (15) minute units. Services may not be approved on the Comprehensive waiver in excess of 9400 units per year. Services approved must be based on assessed need and fit within the person's assigned budget.
(D) A provider may receive reimbursement for up to two (2) participants at one time. A Child Habilitation provider employee may not supervise more than three (3) persons regardless of funding source during the provision of this service.
(v) Cognitive Retraining Services: provide training to the person served or family members that will assist in compensating for the loss of or restoring cognitive function (e.g. ability/skills for learning, analysis, memory, attention, concentration, orientation, and information processing) in accordance with the Plan of Care. They are billed as a 15 (fifteen) minute unit.
(A) Community Integration Services offer assistance with acquisition, retention, or improvement in self-help, socialization and adaptive skills that takes place in a non-residential setting, separate from the participant's private residence or other residential living arrangement.
(B) Services must be furnished in any of a variety of settings in the community and may not be limited to fixed-site facilities. Activities and environments must be designed to foster the acquisition of skills, appropriate behavior, greater independence, community networking, and personal choice. Making connections with community members is a strong component of this service provision.
(C) Community Integration services must focus on enabling the participant to attain or maintain his or her maximum functional level and shall be coordinated with any physical, occupational, or speech therapies in the service plan. Services may serve to reinforce skills or lessons taught in other settings.
(D) Community Integration Services are habilitative services that provide assistance and training with the acquisition and retention of skills. Community integration services should be meaningful to the participant and minimize time spent in a congregate facility.
(E) Tiered service rates must be provided based upon level of service need, according to the following tier descriptions:
(I) Basic Level of Care: Levels 1 and 2 on the Level of Service Need score. Providers serving participants at this level must provide intermittent staff supports and personal attention to the participant daily to provide assistance as needed due to the participant's moderately high level of independence and functioning. Behavioral needs, if any, may be met with medication or informal direction by staff. The participant may have periods of time with indirect staff supervision where staff are onsite and available within hearing distance to assist with a participant's request.
(II) Intermediate Level of Care: Levels 3 and 4 on the Level of Service Need score. Service tier requires full-time supervision for the participant with staff available on-site within line of sight to meet the participant's functional limitations, medical, or behavioral needs. Behavioral and medical supports are not generally intense and can be provided in a shared staffing setting. Regular personal attention must be provided throughout the day for personal care, reinforcement, community, or social activities.
(III) High Level of Care: Levels 5 and 6 on the Level of Service Need score. Providers serving participants at this level must provide full-time supervision with staff available on-site within absolute line of sight, and frequent staff interaction and personal attention to meet the participant's functional limitations, medical, or behavioral needs. Support and supervision needs are moderately intense, but can still generally be provided in a shared setting unless otherwise specified in the plan of care. Frequent personal attention must be given to the participant throughout the day for reinforcement, positive behavior support, personal care, community, or social activities.
(A) Companion services include non-medical care, supervision, socialization and assisting a waiver participant in maintaining safety in the home and community and enhancing independence. Companions may assist or supervise the individual with such tasks as meal preparation, laundry, and shopping, but do not perform these activities as discrete services. Companions may also perform light housekeeping tasks that are incidental to the care and supervision of the participant. The provision of companion services does not entail hands-on nursing care, but does include personal care assistance with activities of daily living as needed during the provision of services.
(B) Companion services units are available for individual services or in groups serving no more than three (3) participants total.
(C) Service may exceed a nine (9) hour cap only for special events or out of town trips.
(A) Crisis intervention services may be provided for the purpose of supporting a participant when the need arises. Crisis intervention services may include positive behavior supports or other non-violent, non-physical crisis intervention services to deescalate a situation, teach appropriate behaviors, and keep the participant safe until the participant is stable. Crisis intervention services may not be used to watch a participant in case a behavior occurs.
(B) Crisis intervention services are available to a participant age eighteen (18) years or older in Residential Habilitation, Community Integration services, Prevocational, or Supported Employment Services.
(C) Crisis intervention services may be added to a plan for situations where a participant’s tier level of habilitation services may not provide sufficient support for specific activities, medical conditions, or occurrences of behaviors or crisis, but the extensive supervision is not needed at all times. Intervention for behavioral purposes is not intended for watching the person should the behavior occur, but for the purpose of supporting the participant when the need arises, using positive behavior supports and non-violent, non-physical crisis intervention services to de-escalate a situation, teach appropriate behaviors and keep the participant safe until the participant is stable.
(D) The quantity of service must be approved by the Extraordinary Care Committee and be based on verified need, evidence of the diagnosis, or condition requiring this service.
(E) Documentation of progress and data on behaviors and the outcome of the intervention services must be submitted to the case manager and Division every six months or at the frequency specified in the approved plan of care.
(A) Dietician services shall be supported by a formal assessment completed by a registered dietician and must be prescribed by a physician.
(B) Providers must provide at least thirty (30) minutes of service to bill for Dietician services. This service is billed at a per session rate.
(C) The Dietician services must be for participants who show a pattern of chronic and unusual need requiring Dietician services. Chronic needs encompass conditions, such as severe obesity, poor food choices that compromise health, special diets approved by a physician for specific diagnoses, or severe allergies.
(x) Environmental modification. Environmental modifications shall be provided pursuant to Chapter 44.
(A) Employment Discovery and Customization services are available to a participant age eighteen (18) or older to determine the strengths, needs, and interests of the participant relating to employment. Services include developing an employment opportunity through job carving, self-employment or entrepreneurial initiative, or other job development or restructuring strategies that result in job responsibilities being customized and individually negotiated to fit the needs of participants.
(B) Employment Discovery and Customization services may not duplicate reasonable accommodations and supports that may be necessary and expected of an employer for a participant to perform functions of a job that is individually negotiated and developed.
(C) Employment discovery and customization is a 1:1 support service and has a limited time frame of 12 months. This service is reimbursed at a fifteen (15) minute unit rate. An additional twelve (12) months may be approved by the Division upon review of the progress made the prior year.
(D) Employment Discovery and Customization services are capped at 400 units annually. When the service is approved, participants will receive 100 units to develop a strengths, needs, and interest assessment, and an employment plan. Once the employment plan is submitted to the Division, an additional 300 units may be approved to explore various types of job customization, self-employment, or entrepreneurial opportunities.
(A) Homemaker services may consist of general household activities such as meal preparation and routine household care, and may be provided by a trained homemaker when the individual regularly responsible for these activities is unable to manage the home and care for oneself or others in the home, or when the person who usually does these things is temporarily unavailable or unable to perform the tasks.
(B) Homemaker services do not include any direct care or supervision of the waiver participant.
(C) Units of homemaker service must not exceed three (3) hours per week per household or 624 units annually. Homemaker services are not available to participants who receive residential habilitation or special family habilitation home services on the waiver. This service is billed at a fifteen (15) minute unit rate.
(A) Independent Support Brokerage must include services to assist the participant or the legally authorized representative in arranging for, directing, and managing services that are being self-directed. The support broker shall assist in identifying immediate and long-term needs, budgeting, developing options to meet needs, teaching self-advocacy, assisting with employee grievances and complaints, and accessing identified supports and services. The Support Broker shall conduct practical skills training to enable participants and their legal representatives to independently direct and manage waiver services by providing information on how to recruit and hire direct care workers, manage workers, effectively communicate, and problem-solve.
(B) This service may not duplicate other waiver services, including case management.
(C) The service has a cap of 320 units annually based on a fifteen (15) minute unit rate.
(D) A Support Broker, when on a participant's plan of care, has the responsibility for training all of the participant's employees on the policy for reportable incidents and ensuring that all incidents meeting the criteria of the Division's Notification of Incident Process are reported.
(E) A Support Broker must review employee time sheets and the monthly Fiscal Management Service reports to ensure that the individual budget amount is being spent in accordance with the approved plan of care, and coordinate follow-up on concerns with the participant's case manager.
(F) Support Brokerage is an optional service for a participant or legally authorized representative who self-directs services.
(G) A Support Broker shall be free of any conflict of interest including employment with a certified waiver provider or provision of any other waiver service to the same participant.
(H) A Support Broker hired by the participant through self-direction shall only serve one (1) participant or two (2) participants who are siblings residing in the same household.
(I) If a participant hires a parent or stepparent as an employee of a direct care service, then the participant must have an actively involved, unrelated support broker to ensure there is a responsible person in addition to the participant to assume employer responsibilities.
(A) Individual Habilitation Training is a specialized 1:1 intensive training service for a participant under age twenty-two (22) to assist with the acquisition or improvement in skills not yet mastered that will lead to more independence and a higher level of functioning. Individual Habilitation Training services are for participants who live with unpaid caregivers or who need less than twenty-four (24) hour paid supervision and support.
(B) Supports and training objectives must be part of the plan of care and may include: adaptive skill development; assistance and training on activities of daily living; transportation safety; navigation; building social capital and connections; and hobby skill development for work on fine or gross motor skills.
(C) Objectives must be specific and measureable, and data must be tracked and analyzed for trends. Summary reports on progress or lack of progress must be given to the case manager and participant or guardian monthly. Objectives shall be re-written as needed when skills are learned or training is not yielding progress.
(D) Supports may include facilitation of inclusion of the individual within a community group or volunteer organization; opportunities for the participant to join associations or community groups; opportunities for inclusion in a broad range of community settings including opportunities to pursue social and cultural interests; choice making; and volunteer time.
(E) Individual Habilitation Training is an hourly unit, which can be provided in different increments throughout the calendar day, as long as the total units billed equals at least 60 minutes. Only hourly billing units are accepted.
(F) Individual Habilitation Training has a four (4) hour a day limit and units shall be approved based upon the participant's need and budget limit.
(A) Reimbursement for occupational therapy services shall require both a prescription and a treatment letter or recommendation from a physician.
(B) Occupational therapy services cover only habilitative therapy services that are not covered on the Medicaid State Plan.
(C) Providers of occupational therapy group services may serve up to three (3) participants at a time.
(D) Occupational Therapy services consist of the full range of activities provided by a licensed occupational therapist and services may be used for maintenance and the prevention or regression of skills.
(E) Services are available for a participant age twenty-one (21) and older.
(F) Service is available as a fifteen (15) minute unit for an individual session or as a group session unit, which requires a minimum of thirty (30) minutes in service in order to bill.
(A) Personal care services shall be provided on a 1:1 basis and include assistance to a participant to accomplish tasks ranging from hands-on assistance and performing a task for the participant to cuing the participant to perform a personal care task.
(B) Health-related personal care services may be provided for care relating to medical or health protocols, medication assistance or administration, and range of motion exercises. Health related services may be provided after staff are trained by the appropriate trainer or medical professional, and the provider must maintain documentation of training.
(C) Services may include: (I) assistance in performing activities of daily living, such as: bathing, dressing, toileting, transferring, or maintaining continence, and (II) instrumental activities of daily living on the person's property, such as: personal hygiene, light housework, laundry, meal preparation (exclusive of the cost of the meal), using the telephone, medication, or money management. Personal Care Services must be essential to the health and welfare of the participant, rather than that participant's family.
(D) A participant living in a non-residential service setting may receive up to 6000 units per year based upon the participant's assessed need and availability of funds within the participant's assigned budget. This service is billed as a fifteen (15) minute unit.
(E) A participant living in a residential service setting on the Comprehensive Waiver, who needs ongoing supervision and cannot attend a day service due to medical or health conditions limit attendance in these programs, may receive up to 7280 units of personal care services per year based upon the participant's need and availability of funds within the participant's assigned budget.
(F) The amount of personal care services for a minor child provided by the child's legally authorized representative, parent or stepparent must be based upon individual extraordinary care needs as specified in the approved individualized plan of care and other assessments.
(G) For relative providers residing in the same household as the waiver participant, personal care provided by the relative provider in the home shall be for extraordinary care only and cannot exceed four (4) hours per day per participant unless approved by the Division's Extraordinary Care Committee.
(A) Reimbursement for physical therapy services shall require both a prescription and a treatment letter or recommendation from a physician.
(B) Physical therapy services cover only habilitative therapy services that are not covered on the Medicaid State Plan.
(C) Providers of physical therapy group services may serve up to three (3) participants at a time.
(D) Physical Therapy services may be used for maintenance and the prevention or regression of skills and assist participants to preserve and improve their abilities for independent functioning, such as range of motion, strength, tolerance, and coordination.
(E) Physical Therapy services are available for a participant age twenty-one (21) and older.
(F) Physical Therapy services are available as a fifteen (15) minute unit for an individual session or thirty (30) minute unit as a group session.
(A) Prevocational services are available to a participant age twenty-one (21) or older and must be designed to create a path to integrated community-based employment in a job matched to the individual’s interests, strengths, priorities, abilities, and capabilities.
(B) Services must provide learning and work experiences, including volunteer work, where the individual can develop general, non-job-task-specific strengths and skills that contribute to employability in paid employment in integrated community settings. Services may include teaching concepts such as compliance, attendance, task completion, problem solving, interpersonal relationships, and safety.
(C) Services may be furnished in a variety of locations in the community and are not limited to provider facilities. Prevocational services may be provided at a volunteer worksite or mentorship locations for the purpose of teaching job preparedness for a specific type of work.
(D) Participation in prevocational services may not be required as a pre-requisite for individual or small group supported employment services furnished under the waiver.
(E) Participants receiving paychecks in prevocational services must be compensated by the participant’s employer in accordance with applicable state and federal laws.
(F) Waiver reimbursement is not available for the provision of vocational services delivered in facility-based or sheltered work settings, where individuals are supervised for the primary purpose of producing goods or performing services.
(G) Prevocational services are time-limited and should not exceed twelve (12) consecutive months. Units cannot exceed 7280 units per plan year either as a stand- alone service or in combination with Companion and Adult Day Services when a person is living in a residential habilitation setting.
(H) An additional twelve (12) months may be approved by the Division in subsequent years with submission of an approved employment plan (through vocational rehabilitation, school district, or the waiver) and upon review of active progress made the prior year on finding employment opportunities, increasing work skills, time on tasks, or other job preparedness objectives.
(I) A monthly objective must be included in the provision of services relating to work readiness skills. These skills and objectives may include volunteering, mentoring, increasing involvement with community members, improving communication with community members, and accessing other resources to further employment development and potentially prepare the participant for work in the community. Progress on objectives must be reported annually, or as requested, to the case manager, participant, and legally authorized representative.
(J) If there is no progress on prevocational training objectives or the employment pathway planning, a participant may not receive prevocational services in subsequent years and other waiver services may be accessed to meet the supervision and support needs of the participant.
(K) Tiered service rates must be based upon level of service need:
(I) Basic Level of Care. Levels 1 and 2 on the Level of Service Need score. Participants require limited staff supports and personal attention to a participant daily due to a moderately high level of independence and functioning. Behavioral needs, if any, can be met with medication or informal direction by staff. The participant may have periods of time with indirect staff supervision where staff are onsite and available through hearing distance of a request.
(II) Intermediate Level of Care. Levels 3 and 4 on the Level of Service Need score. Participants require full-time supervision with staff available on-site within line of sight due to significant functional limitations, medical or behavioral needs. Behavioral and medical supports are not generally intense and can be provided in a shared staffing setting. Regular personal attention is given throughout the day for personal care, reinforcement, community or social activities.
(III) High Level of Care. Levels 5 to 6 on the Level of Service Need score. Participants require full-time supervision with staff available on-site within absolute line of sight and frequent staff interaction and personal attention for significant functional limitations, medical or behavioral needs. Support and supervision needs are moderately intense, but can still generally be provided in a shared setting unless otherwise specified in the plan of care. Frequent personal attention given throughout the day for reinforcement, positive behavior support, personal care, community or social activities.
(L) For each participant receiving this service, documentation must be maintained in the provider and case manager's file that demonstrates prevocational services or a similar service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.).
(A) Residential habilitation services shall consist of individually-tailored supports for a waiver participant age eighteen (18) or older on the Comprehensive Waiver to assist with the acquisition, retention, or improvement in skills related to living in the community. Services shall be provided appropriate to the level of supervision identified in the plan of care and include regular adaptive skill development, assistance with activities of daily living, community inclusion, transportation, adult educational supports, social and leisure skill development. Services must assist the participant to be as independent as possible and reside in the most integrated setting appropriate to his or her needs.
(B) Participants receiving residential habilitation shall have one primary residence. A participant’s bedroom shall be uniquely assigned to him or her unless an exception as outlined in Chapter 45 Section 13 (f)(xiv)(D) is requested. The primary residence shall be stipulated in a lease or residency agreement, be homelike in nature, and decorated according to the participant’s preferences.
(C) The participant must have immediate, on-site access to the provider of services on a twenty-four (24) hour basis, as defined by the Level of Service.
(D) Services shall not include payments for the cost of room and board, including the cost of building maintenance, upkeep and improvement.
(E) Residential Habilitation services are reimbursed using a daily unit based upon the level of service need of the participant, where the participant needs some level of ongoing twenty-four (24) hour support by a provider on site.
(F) Residential Habilitation may be delivered through self-direction as Shared Living, where the participant and other housemates own or lease the residence from an entity that is not a certified waiver provider. The employee hired through self-direction may serve up to three (3) people in shared living, but can serve no other participants in a residential habilitation service.
(G) For a participant receiving this service, the participant will be assigned a tiered level of reimbursement as specified in an approved plan of care. Tier levels for this service align with the assessed Level of Service Need for the participant and the expectations of the service as specified in the definition. All supervision and supports delivered must align with the participant’s plan of care.
(H) Tiered Level descriptions. Residential Habilitation participants must receive services in accordance with the written plan of care, and the following tiers descriptions.
(I) Level 1-Level 1 participants exhibit a high level of independence and functioning without significant behavioral or medical issues. Provider staff serving Level 1 participants shall meet with participants on a periodic basis each day for the purpose of providing general supervision, support, monitoring, and training. Staff shall be available on-call for twenty-four (24) hour support.
(II) Level 2- Level 2 participants exhibit a moderately high level of independence and functioning with few or no behavioral or medical issues. Level 2 participants may require minimal staff support, monitoring, or personal care. Provider staff serving Level 2 participants shall meet periodically with the participant during awake hours on each day billed to provide general supervision, support, monitoring, training, and personal care. Staff shall be available on-call for twenty-four (24) hour support.
(III) Level 3- Due to moderate functional limitations in activities of daily living and possible behavioral support needs, this tier requires staff available to meet periodically with the participant on each day billed for general supervision, support, personal care, positive behavior support, monitoring, training and staff support through the night in the residence or in a nearby office.
(IV) Level 4- Level 4 participants exhibit significant functional limitations, and medical or behavioral support needs that can be met in a shared staff setting. Provider staff serving Level 4 participants shall be on-site, full-time, and regularly provide personal attention throughout the day for training, personal care, reinforcement, positive behavior support, community, and social activities. Staff shall be available for support in the residence through the night.
(V) Level 5- Level 5 participant's exhibit significant and somewhat intensive functional limitations, as well as medical or behavioral support needs that require a limited shared staff setting. Provider staff serving participants serving Level 5 participants shall be on-site and in line-of-sight during most awake hours when the participant is in this service, with frequent personal attention given throughout the day for training, personal care, reinforcement, community or social activities. Staff shall be available for support in the residence through the night, with additional expectations stipulated in the plan of care.
(VI) Level 6- Level 6 participants exhibit high medical, behavioral or personal care needs, which require frequent personal support and supervision. Level 6 participants shall be served by one (1) staff person who is on-site and in line-of-sight during all awake hours, while the participant is in this service. The expectation is that the participant shall receive the attention of at least one to two caregiver(s) as specified in the plan of care. Staffing ratios during the day and night must be kept as approved by BHD in the plan of care.
(I) Residential habilitation services and respite services may not appear on the same individual plan of care except when:
(I) The participant is transitioning into a residential setting such as a group home; or (II) Unpaid caregivers need respite when the participant spends time at home visiting on weekends or vacations.
(III) The residential provider provides a host-home environment and the provider is not accredited by a national organization
(J) The provider shall provide residential habilitation services directly to the participant in the community or in the residence during both awake and sleeping time for a minimum of eight (8) hours in a twenty-four (24) hour period (from 12:00am-11:59pm) for the provider to be reimbursed.
(K) Participants shall be free to voluntarily leave their residential habilitation home, with the intent to return, for events such as vacations, family visits, or sleepovers. Providers shall not receive reimbursement while the participant is outside the residential habilitation home for these or other similar purposes, except that the provider may receive full reimbursement for the day that the participant returns to the residential habilitation provider home.
(L) A participant not yet receiving twenty-four (24) hour residential services who may be at significant risk due to extraordinary needs that cannot be met in their current living arrangement and require twenty-four (24) hour care may request Residential Habilitation services if the participant meets one of the following targeting criteria:
(I) A substantial threat to a person’s life or health due to the abrupt absence of a residence or caregivers who can provide the necessary support needed to keep the person safe. The emergency requires verification of need by Department of Family Services, the Behavioral Health Division or Protection & Advocacy System, Inc.
(II) The person’s condition poses a substantial threat to a person’s life or health, and is documented in writing by a physician.
(III) The person has caused serious physical harm to him or herself or someone else in the home, or the person’s condition presents a substantial risk of physical threat to him or herself or others in the home.
(IV) There are significant and frequently occurring behavior challenges resulting in danger to the person’s health and safety, or the health and safety of others in the home.
(V) The person’s critical medical condition requires ongoing twenty-four (24) hour support and supervision to maintain the person’s health and safety.
(VI) Loss of primary caregiver due to caregiver’s death, incapacitation, critical medical condition, or inability to provide continuous care.
(M) Any new residential habilitation placement must be approved by the Extraordinary Care Committee.
(A) Respite is a short-term service that allows an unpaid caregiver, a Residential Habilitation provider who is not nationally certified or accredited, or a Special Family Habilitation Home provider to receive limited relief from the daily care of a participant. Services may include assistance with activities of daily living, medication assistance, and general supervision provided in the caregiver’s
(B) Services must be primarily episodic in nature, and may not be used when parents or primary caregivers are working.
(C) A respite provider may serve up to two (2) unrelated participants at the same time or up to three (3) participants in the same family who live in the same household. A participant requiring 1:1 care must receive 1:1 respite services.
(D) Respite is reimbursed as a fifteen (15) minute unit or a daily rate.
(E) On the Comprehensive Waiver, the total number of fifteen (15) minute units available for respite per plan year is 5000. When respite services exceed nine (9) hours a day, the provider must bill as a daily unit. There is no unit cap on the Supports Waiver.
(F) A provider may provide supervision to other non-waiver participants requiring support and supervision, and must limit the total combined number of persons they are providing supervision to at a given time to no more three (3) persons unless approved by the Division.
(xxi) Self-Directed Goods and Services. Self-Directed Goods and Services, which include services, equipment, and supplies that provide direct benefit to the participant and support specific outcomes in the individuals plan of care, shall be provided pursuant to Chapter 44.
(A) Skilled Nursing services are medical care services delivered to individuals with complex chronic or acute medical conditions and performed within the Nurse’s scope of practice as defined by Wyoming’s Nurse Practice Act. Skilled Nursing services include the application of the nursing process including assessment, diagnosis, planning, intervention and evaluation, and the administration, teaching, counseling, supervision, delegation, and evaluation of nursing practice and the execution of the medical regimen.
(B) Services needed must be specifically prescribed by a physician on a form specified by the Division and require a level of expertise that is undeliverable by non-medical trained individuals.
(C) The delivery of Skilled Nursing services is limited to those individuals who possess an unencumbered license issued by the Wyoming State Board of Nursing.
(D) Skilled Nursing services may be used when the Medicaid State Plan Services have been exhausted, are not available in the person’s area, are not available due to services denied by the home health provider, or the hours of need for the service are not available by the home health provider. The form showing evidence of no other skilled nursing services available will be reviewed annually and may be subject to an annual update as service providers or state plan service coverage in regions becomes available.
(E) A billable skilled nursing service unit is considered to be a service that is provided up to fifteen (15) minutes and that involves one-on-one direct patient care. Skilled nursing units may be rounded up to the nearest fifteen (15) minute unit. Units billed for rounded up services may not exceed eight (8) units within a one hour timeframe for multiple participants in a single location by one provider nurse.
(F) Skilled nursing services must address the ongoing chronic or acute medical issues for which the service is needed and must include direct patient care or services. Skilled Nursing providers cannot be reimbursed for watching television with a participant, transportation to and from doctor appointments, time spent charting, time spent in waiting room with participant, or time spent completing paperwork, or similar non-nursing activities.
(A) Special Family Habilitation Home services must include participant specific, individually-designed and coordinated training within a family host home environment that does not include the participant’s biological, step, or adoptive parents.
(B) This service is only available to participants under the age of twenty (20) years old on the Comprehensive waiver who are receiving this service before the effective date of this rule. The service is not open to newly enrolled participants.
(C) The Special Family Habilitation Home provider shall be the primary caregiver and assume twenty-four (24) hour care of the individual.
(D) This service may not be used in conjunction with Individual Habilitation Training services.
(E) The provision of Special Family Habilitation Home services includes personal care needs. Plans of care may not include the personal care service.
(F) This service pays for support to an individual who needs support twenty-four (24) hours a day. The provider shall be in the residence of the participant providing service during both awake and sleeping time for a minimum of (8) hours in a twenty-four (24) hour period (from 12:00am-11:59pm) for the provider to be reimbursed.
(G) Family visits and trips are encouraged. The provider shall not be reimbursed for days that the participant is absent, but may request reimbursement for the day the participant returns home from a trip.
(H) The Special Family Habilitation Home provider shall provide both formal and informal training opportunities to participants served. The schedule must be individualized and the training objective must be meaningful. Progress on objectives shall be reported to the case manager monthly.
(xxiv) Specialized equipment. Specialized equipment shall be provided pursuant to Chapter 44.
(xxv) Speech, hearing, and language services:
(A) Reimbursement for speech, hearing, and language services requires both a prescription and a treatment letter or recommendation from a physician.
(B) Speech, hearing, and language services cover only habilitative therapy services that are not covered on the Medicaid State Plan.
(C) Speech, hearing, and language services are available for a participant age twenty-one (21) and older and must consist of the full range of activities provided by a licensed speech therapist. Services may include screening and evaluation of participants with respect to speech function; development of therapeutic treatment plans; direct therapeutic intervention; selection, assistance, or training with augmentative communication devices; and the provision of ongoing therapy.
(D) Services through the waiver can be used for maintenance and the prevention of regression of skills.
(E) A minimum of forty-five (45) minutes of service per session must be provided in order to bill for one session
(F) Providers of speech, hearing, and language group services may seek reimbursement for providing such services to a group of up to three (3) participants at one time.
(xxvi) Subsequent Assessment:
(A) Subsequent assessments may be provided as part of ongoing case management and will include the necessary collaboration of professionals to assess the needs, characteristics, preferences and desires of the waiver participant.
(B) Case managers shall initiate and oversee subsequent assessments, regardless of payment source, including the psychological assessment or neuropsychological assessment needed for continued eligibility, and any other approved assessments necessary to determine the participant's needs and not available through the Medicaid State plan.
(C) A subsequent assessment must be prior authorized by the Division.
(A) Supported employment services must provide support and assistance to a participant age eighteen (18) or older who needs intensive support to find and maintain a job in a competitive, integrated work setting because of his or her disability. Services must assist the participant with sustaining paid work. Services may include supervision and training. Services are billed as a fifteen (15) minute unit.
(B) Supported employment services must be provided at a work site where persons without disabilities are employed. Services may provide reimbursement for the adaptations, supervision and training required to assist a participant with sustaining paid work. Reimbursement shall not include payment for supervisory activities rendered in the normal course of business.
(C) Objectives must be identified in the participant's plan that support the need for job coaching and a plan to lessen the job coaching over time, if possible. The job coach must be in the immediate vicinity of the participant during services and available for immediate intervention and support.
(D) Documentation shall be maintained in the file of each participant receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.).
(E) Services shall be provided as either in an individual 1:1 setting or as part of a group.
(I) Group supported employment services may be provided to a group ranging from two (2) to nine (9) persons. Group employment for groups larger than nine (9) people will not be reimbursed by the waiver. Group Supported Employment services consist of intensive, ongoing support that enables a participant to perform in a regular work setting, including mobile work crews or enclaves.
(II) Individual Supported Employment services are 1:1 supports provided to a participant to obtain and maintain employment.
(1.) Services may assist a participant to work in a competitive or customized job, be self-employed, or work in an integrated work setting in the general workforce where the participant is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by an individual without a disability.
(2.) Individual Supported Employment must be provided in a community-integrated employment setting, unless the support is to develop customized employment, self-employment, or home-based employment, subject to prior approval of the Division.
(A) Supported Employment Follow Along services enable a participant, who is paid at or above the federal minimum wage, to maintain employment in an integrated community employment setting.
(B) Service is provided for or on behalf of a participant through intermittent and occasional job support, communicating with the participant’s supervisor or manager, whether in the presence of the participant or not. A provider may use this service for regular contact and follow-up with the employer and participant in order to reinforce and stabilize the job placement, facilitate natural supports at the work site, provide individual program development, write tasks analyses, or conduct monthly reviews, termination reviews, and behavioral intervention.
(C) This service may cover support through phone calls between support staff and the participant’s managerial staff.
(D) A provider shall be reimbursed at a fifteen (15) minute rate for up to 100 units annually based upon individual need in order to maintain employment.
(E) This service does not reimburse for transportation, work crews, public relations, community education, in service meetings, or individual staff development.
(A) Supported Living Services assist participants who do not require ongoing twenty-four (24) hour supervision but do require a range of community-based supports and habilitation training to be able to live in their own home, family home, or rental unit.
(B) Services must be based upon need and may include assisting with activities of daily living, performing routine household activities to maintain a clean and safe home, assistance with health issues, medications and medical services, teaching the participant to access the community, and building personal relationships with others. In some cases, the service may require twenty-four (24) hour emergency assistance if specified in the plan of care.
(C) The supported living service daily rate is based on seven (7) hours of service a day and a provider shall provide a minimum of four (4) hours of documented service per calendar day for reimbursement. One (1) staff or provider can be reimbursed for up to three (3) participants during a daily unit of service provided.
(D) Supported living services can be billed at a fifteen (15) minute unit rate.
(E) Supported living is a habilitation service, which means training on objectives is required as part of the provision of services and objective progress must be reported to the participant, guardian, and case manager monthly.
(F) Supported living may not be provided on the same day as residential habilitation.
(G) The plan of care must identify either the daily unit or the individual or group 15-minute unit, based on the participant's need. Both the daily unit and the fifteen (15) minute unit may be on the participant's plan of care but cannot be used on the same day.
(xxx) Transportation:
(A) Transportation service on the waiver is a gap service to enable participants to gain access to an employment location, community services, activities, and resources as specified by the plan of care when a service provider is not needed at the event.
(B) Transportation services are not intended to replace formal or informal transportation options, like the use of natural supports, city transportation services, and travel vouchers. Whenever possible, family, neighbors, friends, or community agencies, that can provide this service without charge or with other resources, must be utilized.
(C) This service does not include transportation to medical appointments required under 42 CFR 431.53 or other transportation services available under the Medicaid state plan.
(D) Transportation services will be reimbursed based on mileage used. This service is capped at $2,000 per year.
(E) Transportation services cannot be utilized in conjunction with or to access other waiver services that specify in the service scope that transportation is covered in the rate for that service.
(a) The allocation of Medicaid waiver funds that may be available to a participant to purchase services is based on his or her assessed needs.
(b) Eligible individuals will be assigned a Level of Service Need score.
(c) The Supports Waiver.
(i) The purpose of the Supports Waiver is to assist individuals and their families in obtaining person-centered services and utilizing both natural supports and paid providers to support individuals in the home they own, lease, or share with family. This waiver allows for more flexibility for waiver participants to develop and change their service plans, provides resources and training to assist participants in learning the services system, offers new service options, gives participants an opportunity to self-direct services and hire and fire staff, and provides ongoing resources and training.
(ii) Participants enrolled in the Supports Waiver shall be assigned an individual budget amount based on:
(A) The participant’s age group, whether or not the participant has reached the age of 21;
(B) An average cost for the assessed service needs for individuals in the participant’s age group;
(C) The participant’s access to services available to the participant through programs funded under Section 110 or 504 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.);
(D) An amount for annual case management services;
(iii) The Level of Service Need score will be used in order to determine eligibility and priority order for Comprehensive Waiver funding.
(iv) Transition to the Comprehensive Waiver shall only occur as funding and a slot on the Comprehensive Waiver becomes available.
(d) The Comprehensive Waiver.
(i) For participation in the Comprehensive Waiver, an individual shall meet the clinical eligibility specified in this section and have assessed service needs in excess of the established cost limit on the Supports Waiver and meet the emergency criteria as approved by the Extraordinary Care Committee (ECC), or meet the criteria for reserved capacity as specified in 11(g) of this Chapter.
(ii) Participants enrolled on the Comprehensive Waiver shall be assigned an individual budget amount based on the following factors:
(A) Functional and medical assessments, including the ICAP assessment, and past approved plans of care;
(B) The participant’s age group, whether or not the participant has reached the age of 21;
(C) The participant’s living situation;
(D) The participant’s need for a higher level of services;
(E) An amount for annual case management services.
(F) A temporary or permanent increase or decrease as determined by the Extraordinary Care Committee.
(iii) The factors in subsection (d) (iii) determine the participant’s Level of Service Need score in order to plan for appropriate services and supports.
(iv) Supports to the participant through waiver services must align with the Level of Service need scoring rubric associated with the person’s Level of Service score. Standards of care for each level include:
(A) Level 1, which means the participant requires few supports weekly due to a high level of independence and functioning compared to one’s peers. This participant is independent with ADLs but may follow checklists as reminders. No significant behavioral or medical issues that cannot be controlled with medication and routine medical care. Participant requires minimal support services that can be provided within a few hours per week, and can be left alone in the home or community for extended periods of time.
(B) Level 2, which means the participant requires infrequent care and limited supports daily due to a moderately high level of independence and functioning. Some days may not require any support. Behavioral needs, if any, can be met with medication or informal or infrequent verbal redirection by caregivers, which may or may not require a PBSP. There may be a need for day services and intermittent residential support services to assist with certain tasks, and the participant can be unsupervised for several hours at time during the day and night.
(C) Level 3, which means the participant requires limited personal care or regular supervision due to a moderate level of functional limitations in activities of daily living, requiring staff presence and some physical assistance. Behavioral needs, if any, are met through medication, informal direction by caregivers, or occasional therapy (every one to two weeks). Participant does not require 24-hour supervision – generally able to sleep unsupervised – but needs structure and routine throughout the day. Intermittent personal attention should be given daily for training, personal care, community or social activities.
(D) Level 4, which means the participant requires regular personal care or close supervision due to significant functional limitations, medical or behavioral conditions. Therapy and medical care may be needed monthly in addition to support from staff. Behavioral and medical supports are not generally staff-intensive and may be provided in a shared staffing setting. Regular attention is needed throughout the day for training, personal care, reinforcement, community or social activities.
(E) Level 5, which means the participant requires extensive personal care or constant supervision due to behavioral or medical concerns or due to significant functional limitations concerns, including frequent and regular on-site staff interaction and support. Therapy and medical care may be needed bi-monthly in addition to support from staff. Behavioral and medical concerns must be addressed with written behavioral or medical plans and protocols. Support needs are highly intense, but can still generally be provided in a shared staff setting. Staff must provide line of sight supervision and frequent personal attention must be given throughout the day for training, reinforcement, positive behavior support, personal care, community or social activities.
(F) Level 6, which means the participant needs total personal care or intense supervision throughout the day and night. Supervision by a sole staff on-site (not shared) must be conducted by at least one of the staff's time within close proximity providing direct support during all waking hours. At times, the participant may require the full attention of two staff for certain activities of daily living and in response to certain behavioral events. Therapy and medical care may be needed weekly in addition to support from staff. Typically, this level of service is only needed by someone with intense behaviors, not just medical needs alone. There is no ratio flexibility from the amount approved in the plan of care. Behavioral and medical supports require written plans or protocols to address support needs.
(v) A participant's individual budget amount on the Comprehensive Waiver may not exceed the current annual average cost of a resident at the Wyoming Life Resource Center. A participant who needs services in excess of this amount must have the plan of care and budget approved by the Division's Extraordinary Care Committee, who shall work with the participant's providers and plan of care team to evaluate the provision of services, monitor service delivery and participant outcomes, improve services and supports, and make plans to improve outcomes for the participant.
(a) The services that may be self-directed include Child Habilitation, Companion, Homemaker, Individual Supported Employment, Independent Support Brokerage, Individual Habilitation Training, Personal Care, Residential Habilitation Shared Living, Respite, Self-Directed Goods and Services, and Supported Living.
(b) Each participant's case manager shall provide the participant or guardian information regarding the option to self-direct waiver services at least once a year.
(c) Self-Direction opportunities are available to participants who:
(i) Live in his or her own private residence or the home of a family member; or
(ii) Reside in other living arrangements where services (regardless of funding source) are furnished to three (3) or fewer persons unrelated to the proprietor.
(d) To self-direct waiver services, the participant or legally authorized representative or other designee, shall act as the Employer of Record and use a Financial Management Service on contract with the Division.
(e) A participant may only self-direct services if the Financial Management Service contractor has open slots for new people to enroll, based upon the contracted capacity.
(f) The Financial Management Service shall assist the participant in being the Employer of Record.
(g) The Division shall provide the recommended wage ranges for all self-directed services.
(h) The Employer of Record shall be responsible to recruit, hire, schedule, evaluate and supervise self-directed employees. The Employer of Record shall have the budgetary authority to negotiate and set wages and payment terms for all services received.
(i) The Employer of Record shall hire employees to provide waiver services and work with the Financial Management Service to determine that the potential employee meets the general and specific provider standards for the service being provided.
(j) Consistent with the service definitions in this Chapter, the Employer of Record shall work with the employee hired through self-direction to determine the specific tasks to be completed during the provision of services, the employee’s schedule, and how to document services and report documentation and timesheets to the Employer and Financial Management Service. The Employer of Record shall ensure documentation is available to the case manager by the tenth (10th) business day of the month following the month in which services were provided.
(k) When the Employer of Record and the employee have reached agreement on the services to be provided, schedule, and rate, the Financial Management Service shall track the rate and services authorized and ensure the employee wages are paid in accordance with state and federal laws.
(l) Employees hired through self-direction shall document services provided in accordance with Chapter 45 and the agreed upon manner between the Financial Management Service and the Employer of Record. The Employer of Record must maintain documentation in accordance with the Wyoming Medicaid Rules.
(m) The Employer of Record, with assistance from the case manager as needed, is responsible for reviewing employee documentation of the services provided and the employee timesheets to ensure accuracy with the type, scope, amount, frequency, and duration of services agreed upon in the plan of care.
(n) A participant may choose to voluntarily terminate self-direction at any time during the plan year and shall work with the case manager to transition to other services or providers. The case manager must disenroll the participant from the Financial Management Service within thirty (30) calendar days.
(o) A participant may be involuntarily terminated from the use of self-direction if:
(i) The participant or Employer of Record is found to misuse waiver funds, (ii) The participant’s health and welfare needs are not adequately being met,
(iii) The Division, the Division of Healthcare Financing, or the Medicaid Fraud Control Unit identifies situations involving the commission of fraudulent or criminal activity associated with the self-direction of services; or
(iv) The participant chooses not to receive self-directed services for ninety (90) calendar days after active enrollment begins.
(p) A participant who is involuntarily terminated from this service under subsection (o) shall receive notice and may request an administrative hearing as provided in Chapter 4 of these Rules.
(a) The Division shall maintain a wait list for each waiver when there is insufficient funding to add additional participants to that waiver or no open slots in the waiver as approved by the Centers for Medicare and Medicaid Services.
(b) The Division shall prioritize eligible individuals on the wait lists on a first come, first serve basis. Funding opportunities will be given to the person who spent the longest time waiting for services starting from the date that the individual was determined eligible.
(c) Before being added to a Waiver wait list, the individual must be determined eligible as specified in Section 5 of this Chapter.
(d) For people with the same date of eligibility on the wait list, the Division will use the date that the “Selection of Case Manager” form was received by the Division to determine which individual’s name goes first.
(e) The level of service need score and individual budget amount shall be determined for each individual on the wait lists. An eligible individual who needs services in excess of the Supports Waiver and has a level of service need score of 4 or higher may apply for the Comprehensive Waiver and may also be placed on the Comprehensive Waiver wait list, if funding or slots are not available.
(f) The Comprehensive Waiver shall reserve capacity each year for individuals who have resided in a Wyoming institution, such as an ICF/ID, nursing home, Psychiatric Residential Treatment Facility, BOCES, prison, jail, or an inpatient psychiatric hospital and who have been:
(i) In residence at the institution for at least two (2) years;
(ii) On a BHD wait list for at least two (2) years; or
(iii) Previously on a BHD waiver a minimum of two (2) years prior to being institutionalized.
(iv) Other individuals transitioning out of institutional services may request access to reserve capacity slots based on availability.
(a) An emergency case involves an eligible person who calls for immediate action or an urgent need for waiver services, including physical care and supervision in the least restrictive and most appropriate environment necessary to maintain the person's vital functions because of one of the following criteria:
(i) An immediate threat, or a high probability of immediate danger to the life, health, property, or environment of the eligible person or another individual because of the eligible person's medical, mental health, or behavioral condition.
(ii) A loss of the person's primary caregiver due to death, incapacitation, critical medical condition, or inability to provide continuous care. A caregiver is defined as any person, agency, or other entity responsible for the care, both physical and supervisory, of a person because of:
(iii) Homelessness, which means a situation where a person lacks access to an adequate residence with appropriate resources to meet his or her support and supervision needs, and without such support, there is evidence of serious harm to the person's life or health.
(iv) A case involving a person removed from the home due to abuse, neglect, abandonment, exploitation, or self-neglect substantiated by the Department of Family Services (DFS), Protection & Advocacy Systems, Inc., or law enforcement.
(v) A residential service request for a waiver participant or a person on the wait list not receiving 24-hour residential services, whose health or safety is at significant risk due to extraordinary needs that cannot be met in the current living arrangement because of one of following criteria:
(A) A substantial threat to a person’s life or health caused by a situation listed in (c)(i)(D) of this section that is either corroborated by the Department of Family Services, Protection & Advocacy Systems, Inc., or law enforcement;
(B) A situation where the person’s health condition or significant and frequently occurring behavioral challenges poses a substantial threat to the person’s own life or health, or to others in the home;
(C) A situation where the person’s critical medical condition requires ongoing twenty-four (24) hour support and supervision to maintain the person’s health and safety that cannot be met in the current living situation;
(D) The loss of the eligible person’s primary caregiver due to death, incapacitation, critical medical condition, or inability to provide continuous care.
(vi) Any person who requests that the Division consider an emergency case shall be directed to work with the person’s chosen case manager. The Division shall assist the person in reviewing options to choose a case manager and complete eligibility determination requirements as quickly as possible.
(vii) Emergency cases shall be referred to the Division’s Extraordinary Care Committee pursuant to section 13 of this chapter.
(viii) An individual who has not been deemed eligible for waiver services may complete the eligibility process and request emergency services. No emergency services may be provided to ineligible persons.
(a) The Extraordinary Care Committee (ECC) shall be composed of a Division waiver manager, a Medicaid manager, the Participant Support Specialist presenting the case, and a representative from the Department’s fiscal unit. When appropriate, the ECC may also include the Division’s licensed Psychologist or licensed Psychiatrist, the Medicaid Medical Director, Division’s Registered Nurse, or a behavioral specialist. Members may also consult other specialists in the field as appropriate.
(b) The ECC may only approve additional funds for participant cases if funding is available in the Division’s waiver budget appropriation.
(c) The ECC shall review:
(i) Emergency cases as defined by Section 12 of this Chapter;
(ii) Extraordinary cases that include a significant change in service need due to the onset of a behavioral or medical condition or injury;
(A) A temporary change in circumstances which requires a higher level of service or support to ensure the health, safety, and welfare of the participant.
(B) Temporary funding increases under Section 8 (c) and 8 (d);
(C) Concerns about a Level of Service Need score; or
(D) Requests requiring ECC approval under these Rules.
(d) Emergency cases can arise for a person who is eligible for covered services but is on the wait list, or for participants currently receiving Comprehensive or Supports waiver services who may be determined to be in an emergency situation pursuant to (a) of Section 12.
(e) The ECC shall have the authority to approve, partially approve, or deny a submitted funding request for any person deemed eligible for a waiver operated by the Division.
(f) An ECC request or emergency services must contain verification of how the participant’s situation meets emergency criteria. Evidence should at least include, as applicable:
(i) Written statements or reports from the other state or regional agencies that support the emergency case including specific incidents, notes related to the type of condition or injury, witnesses, follow-up, treatment summaries, and any documented accounts of events by witnesses;
(ii) Documentation of other approaches or supports that have been attempted;
(iii) Written statements from a physician or licensed psychologist explaining the significant change in the participant’s functioning limitations that result in an assessed need for additional supports or services, and how the person’s life or health is in jeopardy without such supports and services;
(iv) Evidence that the person does not qualify for funding or services through any other agency that would alleviate the emergency situation; and
(v) For persons requesting services or supports due to homelessness, evidence that:
(A) Either:
(I) Other community resources, such as a victim’s shelter, or other temporary residence are not available or appropriate; or
(II) The temporary shelter is insufficient to meet the person’s immediate health and safety needs and there is evidence of immediate and serious harm to the person’s life or health if temporarily in a temporary shelter; and (B) Due to other conditions of the emergency or the person’s condition, waiver services would be the necessary and appropriate intervention.
(g) A request may be made by the participant’s Plan of Care team, if they can demonstrate that a participant’s level of service need score does not reflect the participant’s assessed need.
(h) A request must be submitted on the form provided by the Division and accompanied by additional information that the participant and the participant’s Plan of Care team does not see adequately captured in the Inventory for Client and Agency Planning (ICAP) or in the information stored electronically by the Division for the case.
(i) The ECC may request additional assessments, including a new ICAP, a Supports Intensity Scale, or another appropriate and standardized assessment targeted for a specific diagnosis or condition.
(i) The additional assessment in these cases may provide more detailed information about the person’s support needs and assist the ECC in evaluating the need for a different Level of Service Need or extraordinary service or support.
(ii) Information from the ICAP, along with information from other assessments and information submitted by the participant’s team shall be used to make the final decision on the request for Level of Service Need. These additional assessment and information reviewed by the ECC may result in a Level of Service Need increase, decrease, or no change.
(j) Decisions of the ECC shall be by majority and rendered in writing within 20 business days of the ECC review.
(k) The Division Administrator or designee shall document a review of the decisions and may approve, deny or order more action in a case. In cases of a tie vote among members, the Administrator shall issue the final vote.
(l) The Division Administrator may approve a time limited exception while the ECC is rendering a final decision.
(m) Any eligible individual denied services under this section may request administrative review of that decision pursuant to Chapter 4, Administrative Hearings.
(a) The following services are not eligible for waiver services reimbursement:
(i) The care of individuals residing in a hospital, nursing facility, ICF/ID, or other institutional placement;
(ii) A spouse of the participant, a legally appointed guardian of a participant age 18 and over, or an owner or officer of a provider organization serving their ward cannot directly or indirectly receive reimbursement for providing waiver services for that ward;
(iii) Room and board, except when provided as part of respite in a facility, other than a private residence, approved by Medicaid;
(iv) Services currently covered under the Medicaid state plan;
(v) Services to an individual if it is reasonably expected that the cost of these services would exceed the cost of services provided in an ICF/ID, calculated by using the current annual ICF/ID rate; or
(vi) Service settings reimbursed by another state agency, such as the Department of Family Services or Department of Education.
(b) No direct service that is the responsibility of the school system will be authorized as a waiver service. The Division will not authorize waiver services for the hours the child is attending school or in a vocational program. Regular school hours and days apply for a child who receives home schooling or an adjusted school day.
(c) Any individual eligible for funding for specialized services under the Developmental Disabilities Services Act must apply for and accept any federal Medicaid benefits for which they may be eligible and benefits from other funding sources within the Department; the Department of Education, specifically including the Department of Workforce Services and Division of Vocational Rehabilitation; and other agencies to the maximum extent possible.
(a) The Division may deny or revoke authorization for waiver services for any of the following reasons:
(i) The individual fails to meet waiver eligibility criteria as established in Section 5;
(ii) The eligible individual has not met emergency criteria and no other waiver funding opportunities are available;
(iii) The individual or legal representative has not consented to waiver services;
(iv) The individual or legal representative has chosen to receive ICF/ID services;
(v) The individual, his or her legally authorized representative, or other person on his or her behalf has not supplied needed information;
(vi) The participant’s needs are not being met through waiver services;
(vii) The individualized plan of care has not been implemented;
(viii) The legislature has not appropriated sufficient fiscal resources to fund all services for all persons determined eligible for waiver services;
(ix) Funding for requested waiver services is available as a similar service from other sources, such as a school district or the Division of Vocational Rehabilitation;
(x) The eligible individual or legal representative has failed to apply for, and accept any federal Medicaid benefits for which she or he may be eligible, or benefits from other funding sources within the Department of Health, the Department of Education, Department of Workforce Services, or other agencies to the maximum extent possible.
(xi) The eligible individual or legal representative has not signed documentation required by the Department;
(xii) The eligible individual or legal representative has failed to cooperate with, or refused the services funded by the Division;
(xiii) The individual, under the age of twenty-two (22), could receive educational services during a normal, regular, or adjusted school day.
(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 its various provisions.
Section 17. Superseding Effect. This Chapter supersedes all prior rules or policy statements issued by the Division, including Provider Manuals and Provider Bulletins, which are inconsistent with this Chapter.
Section 18. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in full force and effect.