Wyo. Code R. 048-0037-7
Medicaid
Chapter 7: Nursing Home Reimbursement System
Effective Date: 06/09/1995 to 05/01/1996
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.7.06091995
Section 1. Authority
These rules are promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. 42-4-101 et seq. and the Wyoming Administrative Procedures Act at W.S. 16-3-101 et seq.
Section 2. Purpose and applicability.
This rule establishes methods and standards to establish Medicaid reimbursement rates for nursing facilities which provide services to recipients. It shall apply to and govern all payments of Medicaid funds to facilities with rate effective dates on or after July 1, 1995. Per diem rates in effect as of the effective date of this rule shall remain in effect until redetermined pursuant to this rule.
Section 3. General provisions.
(a) Terminology. Except as otherwise specified, the terminology used in this rule is the standard terminology and has the standard meaning used in accounting, health care and Medicaid.
(b) Cost terms and hierarchy. This rule includes the following cost terms, even though such cost may not be reimbursable because of other provisions of this rule, in the following hierarchy:
(i) General ledger cost; (ii) Reported cost; (iii) Non-allowable cost; (iv) Allowable cost; (v) Reimbursable cost; and (vi) Cost that must be incurred.
(c) General methodology.
(i) Costs related to direct patient care are more likely to benefit quality of patient care than indirect costs.
(ii) Costs incurred in the actual delivery of patient care are more likely to contribute to the quality of care offered by a facility than costs incurred at a distance from the delivery of services.
(iii) If not otherwise specified in this Chapter, the Department shall determine per diem rates using the methodology set forth in the Medicare Provider Reimbursement Manual ('PRM') and HCFA instructions for administering the PRM, both of which are incorporated by this reference. The PRM and the HCFA instructions are published by HCFA and are available from that agency. The PRM is also published in the CCH Medicare and Medicaid Guide, and is available from Commerce Clearing House, 4025 West Peterson Avenue, Chicago, Illinois 60646.
(d) The Department may issue Manuals, Provider Bulletins, or both, to providers and/or other affected parties to interpret the provisions of this Chapter. Such Manuals and Provider Bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in Manuals or Provider Bulletins shall be subordinate to the provisions of this Chapter.
(a) 'Allowable cost.' Cost properly included as patient-related costs on the cost report. The cost must contribute directly or indirectly to patient care.
(b) 'Annualized eight quarter average rate of change in the inflation factor.' The eight quarter average rate of change in the inflation factor is computed by adding together the annualized rate of change in the inflation factor for each of the most recent eight quarters and dividing that sum by eight, with the product rounded to three places to the right of the decimal.
(c) 'Average level of care.' The average score received by recipients of a facility on the evaluations of medical necessity performed pursuant to Chapter 22. The average level of care shall be computed for each facility using the scores on initial evaluations of medical necessity performed during the twelve months ending on October 1, 1993. The average shall be redetermined using the scores on initial evaluations performed during the twelve months ending on July 1, 1993, and annually thereafter.
(d) 'Capital costs.' Costs incurred by a facility for construction, depreciation, interest, rent and leases.
(e) 'Change of ownership.' A change in a provider's ownership, control, operation or leasehold interest.
(f) 'Chapter I.' Chapter I, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
(g) 'Chapter 22.' Chapter 22, Nursing Facility Evaluation of Medical Necessity, of the Wyoming Medicaid Rules.
(h) 'Common ownership.' Common ownership exists if an individual or entity possesses significant ownership or equity in the provider and the entity providing services, supplies or property to the provider.
(i) 'Consumer price index.' The consumer price index for All Urban Consumers (CPI-U) (United States city average), as determined by the United States Department of Labor and Statistics.
(j) 'Control.' An individual or entity that has the power, directly or indirectly, to significantly influence or direct the actions or policies of another individual or entity.
(k) 'Cost report.' An itemized statement of a facility's historical costs for the most recently completed fiscal period, prepared in accordance with GAAP, these regulations and the cost report instructions, and submitted on the most recent version of the Wyoming Financial and Statistical Report for Nursing Facilities. 'Cost report' includes any supplemental requests by the Department for additional information.
(l) 'Cost that must be incurred.' A cost that must be incurred by an efficiently and economically operated facility.
(m) 'Credit balance.' Medicaid funds received by a provider that are owed to the Department for any reason.
(n) 'Department.' The Wyoming Department of Health, the single state agency appointed pursuant to 42 U.S.C. § 1396a(a) (5), its agent, designee or successor.
(o) 'Desk review.' A review by the Department of a facility's cost report to determine: (1) if the cost report has been prepared and submitted in compliance with this rule; (2) that costs have been properly allocated; (3) that costs are allowable; (4) that income is shown to reduce applicable costs; and (5) that all costs are reasonable and ordinary. A facility may not request that the Department perform a desk review.
(p) 'Dodge Construction Index.' The Dodge Construction Index for Nursing Homes.
(q) 'Excess payments.' Medicaid funds received by a provider in excess of the provider's per diem rate, or which were received pursuant to a per diem rate which is subsequently determined to be erroneous or based on erroneous information.
(r) 'Extraordinary recipients.' Recipients that require ventilator care.
(s) 'Facility.' A nursing facility (NF) that meets all of the requirements of state licensure and certification for participation in the Medicaid program. 'Facility' may include a distinct part of a hospital or institution which is designated to provide NF services.
(t) 'Fair market value.' The price a prudent buyer would pay a seller in an arms-length transaction.
(u) 'Field audit.' An examination, verification and review of a facility's financial records and any supporting or related documentation conducted by employees, agents or representatives of the Department or HCFA. A facility may not request that the Department perform a field audit.
(v) 'Financial records.' All records, in whatever form, used or maintained by a facility in the conduct of its business affairs and which are necessary to substantiate or understand the information contained in the facility's cost reports, including all such information regarding home office expenses.
(w) 'General ledger cost.' A cost properly recorded on a facility's general ledger in accordance with GAAP. This includes cost incurred at an individual facility as well as central office or pooled cost reasonably allocated to an individual facility.
(x) 'Generally accepted accounting principles (GAAP).' Accounting concepts, standards and procedures established by the American Institute of Certified Public Accountants.
(y) 'Generally accepted auditing standards (GAAS).' Auditing standards, practices, and procedures established by the American Institute of Certified Public Accountants.
(z) 'HCFA.' The Health Care Financing Administration of the United States Department of Health and Human Services, or its designee.
(aa) 'Historical cost.' The general ledger costs properly reported on the cost report by a facility during the fiscal period immediately preceding the rate period for which the per diem rate is effective.
(bb) 'Incentive allowance.' A component of the per diem rate paid to those providers that meet the criteria of Section 21.
(cc) 'Inflation factor.' The SNF Market Basket as published quarterly by DRI/McGraw-Hill.
(dd) 'Interim payments.' Payments to a new facility during the time between the effective date of the new facility's provider agreement and the determination of a per diem rate pursuant to this rule.
(ee) 'Licensed bed.' A bed in a facility for which the facility has been licensed by the Medical Facilities Office of the Department.
(ff) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act, as amended, and the Wyoming Medical Assistance and Services Act, as amended.
(gg) 'Medicaid program services.' Services, other than nursing facility services, which are Medicaid reimbursable pursuant to the rules and policies of the Department. 'Medicaid program services' excludes services and supplies included in the per diem rate, or services and supplies included in a negotiated rate.
(hh) 'Medicare.' The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(ii) 'Negotiated rate.' The rate, not to exceed actual costs to the facility, which the Department agrees to pay for services provided to an extraordinary recipient in lieu of the facility's per diem rate.
(jj) 'New facility.' A newly constructed facility, a newly designated portion of a hospital which has not previously been designated as a facility, or an existing facility which has not previously been certified. An addition to a certified facility is not a 'new facility.'
(kk) 'Nonallowable cost.' Costs which are not reasonably related to services included in the Medicaid per diem rate, or which are against public policy. Contractual allowances, courtesy discounts, charity allowances, and similar adjustments or allowances are adjustments to revenue and, therefore, are not included in allowable cost. Nonallowable costs also include, but are not limited to:
(i) Advertising expense (other than help wanted ads and telephone directory expense);
(ii) Attorney fees and other costs associated with negotiations, administrative proceedings or litigation involving the Department, except as specified in settlement;
(iii) Bad debts;
(iv) Cost arising from joint use of resources (including central office and pooled cost) not reasonably related to patient care;
(v) Capital costs due solely to changes in ownership;
(vi) Costs incurred in transactions with organizations related to the provider by common ownership or control, to the extent that such costs exceed the limits established under 42 C.F.R. 413.17, which limits are hereby incorporated by reference;
(vii) Costs not reasonably related to patient care;
(viii) Costs of ancillary services covered by Medicare Part B as specified in the following sentence. The cost to be offset shall be determined by calculating the ratio of Medicaid patient days to total patient days reduced by Medicare patient days, and multiplying the ratio by the cost of Medicare Part B costs reported on the Medicare cost report;
(ix) Costs related to the acquisition, establishment or operation of an in-house pharmacy, other than the reasonable costs of a pharmacy consultant;
(x) Costs related to extraordinary recipients that exceed the per diem rate;
(xi) Costs related to hospice services;
(xii) Costs (such as legal fees, accounting and administration costs, travel costs, and the costs of feasibility studies) which are attributable to the negotiation or settlement of the sale or purchase of any capital asset by acquisition or merger after July 17, 1984, for which any Medicaid payment has been previously made;
(xiii) Costs which exceed the costs which must be incurred by an efficiently and economically operated facility, except as otherwise allowed by this Chapter.
(xiv) Federal income and excess profit taxes;
(xv) Fees paid to directors and salaries, wages or fees paid to nonworking officers, employees or consultants;
(xvi) Fund-raising expenses;
(xvii) Interest or penalties on federal or state taxes;
(xviii) Life insurance premiums for officers and owners and related parties except the amount relating to a bona fide nondiscriminatory employee benefits plan;
(xix) Meals and lodging provided to guests and employees. If the cost cannot be ascertained, the revenue from meals and lodging furnished to guests and employees shall be offset against the appropriate cost;
(xx) Prescription drugs;
(xxi) Public relations expenses;
(xxii) Resident personal purchases;
(xxiii) Return on equity;
(xxiv) Self-employment taxes;
(xxv) Stockholder relations or stock proxy expenses;
(xxvi) Taxes or assessments for which exemptions are available;
(xxvii) Telephone, television and radio which are located in patient accommodations and which are furnished solely for the personal comfort of patients;
(xxviii) Value of services (imputed or actual) rendered by nonpaid workers or volunteers; and
(xxix) Vending machine and related supplies.
(ll) 'Nursing facility.' A nursing facility as defined by 42 U.S.C. § 1396r(a), which is incorporated by this reference.
(mm) Nursing facility services.' Nursing facility services' as defined in 42 U.S.C. § 1396d(f), which is incorporated by this reference.
(nn) 'Occupancy.' As used in minimum occupancy calculations means the ratio of patient days for a cost report time period to total licensed bed days available for the same time period. Both patient days and total licensed bed days available shall apply to the same facility beds, either the entire licensed facility or only to the certified portion of a facility, depending on a facility's cost finding methodology.
(oo) 'OSCAR report.' The online Survey, Certification and Reporting (OSCAR) summary report of survey findings.
(pp) 'Patient.' A resident of a facility.
(qq) 'Patient day.' That period of service rendered to a patient between the census-taking hours on two successive days. 'Patient day' does not include any day that a patient was temporarily absent.
(rr) 'Patient-related costs.' Reasonable and ordinary costs which contribute directly or indirectly to patient care. Restricted grants and gifts must be offset against related expense for purposes of determining patient-related costs.
(ss) 'Patient-related services.' Services provided directly or indirectly to patients.
(tt) 'Per diem cost.' Cost component cost divided by patient days. Cost component costs, patient days and licensed beds shall be for the same time period.
(uu) 'Per diem rate.' The Medicaid allowable payment, as determined pursuant to this Chapter, for services furnished by a facility to a recipient, including the inflation adjustment and the incentive allowance, if any.
(vv) 'Permanent financing.' Financing attendant to the acquisition of patient-related tangible assets.
(ww) 'Pooled costs.' Costs incurred outside the facility by a provider that owns more than one facility or by a person or entity that owns, manages or controls a facility.
(xx) 'Private pay rate.' The patient day weighted average of the daily rates a facility charges to non-recipients, other than Medicare recipients, after all discounts, allowances and subsidies are subtracted, for the same or similar services, as of the ninetieth (90th) day after the end of the facility's fiscal period, as defined by paragraph 5(c)(vi).
(yy) 'Provider.' A facility which has or had a provider agreement with the Department.
(zz) 'Provider agreement.' A formal written agreement between the Department and a facility certified to provide services to recipients.
(aaa) 'Reimbursement standard.' The standard established pursuant to Section 17 of this Chapter.
(bbb) 'Quality of care.' The quality of care provided by a facility as measured by the number of Level A deficiency citations, or their equivalent or successor as determined by the Department in conformance with applicable Federal statutes and regulations, received by the facility on the latest survey and taking into consideration the number of validated complaints involving the facility. The quality of care shall be determined effective October 1, 1993, and shall be redetermined effective each July 1 thereafter using the results of the latest completed survey as summarized on the OSCAR report and the number of validated complaints regarding the previous twelve months. For purposes of this definition, 'validated complaints' means written complaints which are validated by the survey agency.
(ccc) 'Rate effective date.' The first day of the fifth month after the end of the facility's fiscal year.
(ddd) 'Recipient.' A person that has been determined eligible for Medicaid.
(eee) 'Reimbursable cost.' Allowable cost, subject to the cost component limitations established pursuant to this Chapter. Reimbursable cost must be equal to or less than allowable cost and must be equal to or greater than cost that must be incurred.
(fff) 'Related to the provider.' The provider to a significant extent is associated or affiliated with or has control of or is controlled by an individual or entity.
(ggg) 'Reported cost.' General ledger cost properly reported on the cost report. It is composed of allowable cost and nonallowable cost.
(hhh) 'Representation statement.' A written statement, in the form specified by the Department, which specifies the persons or entities which have assumed the assets and liabilities of a facility.
(iii) 'Reserved bed.' A licensed bed in a facility reserved for a recipient who is temporarily absent.
(jjj) 'Services.' Nursing facility services' as defined in 42 U.S.C. § 1396d(f), which is incorporated by this reference.
(kkk) 'Services and supplies included in the per diem rate.' Services and supplies used in providing patient-related services, including, but not limited to those specified in Attachment A, which is incorporated by this reference.
(lll) 'Services and supplies not included in the per diem rate.' Services and supplies which are not included in the per diem rate include, but are not limited to:
(i) Audiology services;
(ii) Barber and beauty shop services other than routine personal hygiene items and services;
(iii) Cigarettes, cigars, pipes and tobacco;
(iv) Clothing;
(v) Cosmetics;
(vi) Dental services (unless under purchase for service contract);
(vii) Dry cleaning;
(viii) Eye examinations and other optical supplies and services;
(ix) Hearing aids;
(x) Hospital services;
(xi) Laboratory services;
(xii) Orthotic services;
(xiii) Physician services;
(xiv) Podiatry services;
(xv) Prosthetic devices;
(xvi) Ventilators; and
(xvii) Customized wheelchairs that are fitted or fabricated to a specific individual and cannot be used by any other person, and electric wheelchairs, including batteries.
(mmm) 'Survey.' A survey, including extended or special surveys, performed pursuant to Pub. L. No. 100-203, §4213 100 Stat. 1330-207 (codified at 42 U.S.C. § 1396r(g)).
(nnn) 'Temporary absence' or 'temporarily absent.' When a recipient is out of a facility for hospitalization, therapeutic home visits, or for any other reason, and is expected to return to the facility.
(ooo) 'Usual and customary.' The facility's private pay rate.
(ppp) 'Working capital.' Patient-related financing other than permanent financing.
(qqq) 'Working day.' A day on which the offices of the State of Wyoming are open for transacting business.
(a) Time of submission. Complete cost reports shall be submitted by the first working day of the fourth month following the end of the fiscal period, as defined in paragraph (c) (vi).
(i) Complete cost report. A cost report shall be deemed complete upon receipt of the completed and certified cost report and the information specified in subparagraphs (c) (iii) (A-F). The per diem rate shall not be computed, however, until the receipt of the information specified in subparagraphs (c) (iii) (A-J). The Department may request additional information, such request to be in writing sent by certified mail, return receipt requested. Any such information must be submitted, by certified mail, return receipt requested, within thirty days after the date of the request. A cost report may not be amended after submission.
(ii) Extension. A thirty (30) day extension of the submission date shall be granted by the Department for good cause if requested by a provider in writing prior to the due date. A cost report shall not be deemed past due while an extension term is in effect. Only one request for an extension may be granted for each cost reporting period.
(b) Failure to timely submit cost report. If a cost report, including the information specified in subparagraphs (c) (iii) (A-F) and any information requested pursuant to paragraph (a) (i), is more than ten (10) days past due, the Department shall reduce the per diem rate by twenty-five percent (25%) until all missing information is received in writing in the form specified by the Department. If the cost report, including the information specified in subparagraphs (c) (iii) (A-F), is more than sixty (60) days past due, the Department shall suspend all Medicaid payments until all missing information is received in writing in the form specified by the Department. Upon receipt of a complete cost report that has been prepared in accordance with these rules, the penalty will be refunded, without interest. This remedy does not affect the Department's right to withhold per diem payments, terminate provider participation or invoke other remedies permitted by applicable statutes and rules.
(c) Preparation of cost reports.
(i) Cost reporting must be reasonable and consistent within a facility, between Medicaid certified and noncertified parts where such distinction is utilized for cost finding, among multiple facilities under the same ownership or control, and over time.
(ii) Allocation of costs. Costs must be allocated pursuant to the cost report.
(iii) Required information. Authenticated copies of significant agreements and other documentation must be attached to the cost report. This material includes:
(A) Contracts or agreements involving the purchase of facilities or equipment during the last seven years, unless previously submitted;
(B) Contracts or agreements with owners or parties related to the provider, unless previously submitted;
(C) Leases regarding real or personal property, unless previously submitted;
(D) Management contracts, unless previously submitted;
(E) Mortgages and loan agreements, unless previously submitted;
(F) Working trial balance actually used to prepare cost report with line number tracing notations or similar identifications;
(G) Audit, review or compilation statements prepared by an independent accountant that includes facility costs or allocation of costs to the facility, including disclosure statements and management letters or SEC Forms 10-K;
(H) Home office cost statement;
(I) Medicare cost report;
(J) Any other document, requested in writing by the Department, relating to the provision of services, the submission of claims for reimbursement or a facility's cost reports;
(K) Annual corporation report; and
(L) Federal income tax returns.
(iv) If any document is not submitted with the cost report, an explanation must be attached to the cost report and subsection (b) shall apply.
(v) Changes in a facility's reporting methods are permissible only when written application is received by the Department prior to the end of the cost report period. The Department shall approve the change if it can reasonably be expected to result in more accurate reporting.
(vi) Fiscal period. A provider shall adopt the same fiscal period for completing the cost report as the facility uses for federal income tax reporting. Normally, a fiscal period will be twelve months in length. It may be less than twelve months because of tax period changes.
(d) Certification of cost reports.
(i) General requirement. The provider must certify the accuracy and validity of the cost report.
(ii) Who may certify. Certification must be made by a person authorized by the governing body of the facility to make such certification. Proof of such authorization shall be furnished upon request by the Department.
(A) If the provider is a corporation, an officer of the corporation must certify;
(B) If the provider is a general or limited partnership, a general partner must certify;
(C) If the provider is a sole proprietorship or sole owner, the owner must certify;
(D) If the provider is a public facility, the chief administrative officer of the facility must certify; or
(E) If the provider is some other entity, the person certifying must be approved in writing by the Department before the certification.
(iii) Certification statement. The cost report must contain the following certification statement:
Misrepresentation or falsification of any information contained in this cost report may be punishable by fine and/or imprisonment under state or federal law.
I hereby certify that I have read the above statement and I have examined the accompanying cost report and supporting schedules prepared by _____ (Provider name and number) _____ for the cost report beginning _____, 19____, and ending _____, 19____, and that to the best of my knowledge and belief, it is a true, correct, and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted.
Signature Title Date
(e) Substitute cost report forms. If a facility desires to submit its cost report on forms other than those specified by the Department, the facility must submit such substitute forms to the Department in advance of their use for prior approval. To be approved, such forms must be accompanied by a letter which represents that each page of the substitute form is the same size and has the same general appearance as the Department's cost report and that all form and data elements are present and appear in the same location and sequence on each page as on the Department's cost report. If approved, the Department shall issue an approval letter. Each use of substitute forms shall require a reference to the date of the Department's approval letter and indicate the substitute form's sponsor.
(a) Multiple business enterprises. If a provider owns, controls or manages multiple business enterprises, the revenues, expenses, statistical and financial records of each separate enterprise shall be clearly identifiable. If a field audit or desk review establishes that the provider's records do not clearly identify the information required by this rule, none of the commingled cost shall be an allowable cost for purposes of the facility's per diem rate.
(b) Control, ownership or management by third party.
(i) Separate records. When the facility is owned, controlled or managed by a person or entity that owns, controls or manages one or more other nursing facilities, records of central office and other costs incurred outside the facility shall be maintained so as to separately identify revenues and expenses of, and allocations to, individual facilities.
(ii) Allocation of pooled costs shall be reasonable and conform to GAAP, the provisions of this rule, and the instructions of the Department. Pooled cost is allowable only to the extent that the pooled cost is incurred in providing patient-related services and the provider can demonstrate that pooled cost improves efficiency, economy, or quality of care. All patient-related pooled costs allocated to a facility that meets these requirements shall be reported in the operating cost component.
(iii) Direct patient service costs. Direct patient service costs incurred by multiple facility organizations may be reported in the health care component if the service was rendered to the recipient at the facility and is separately identified, rather than allocated, in the provider's accounting records. Patient service costs which do not meet these criteria must be reported in the operating cost component.
(a) New facilities.
(i) A new facility shall receive an interim rate determined pursuant to subsection 18(b).
(ii) A new facility's interim rate will be effective until the end of the first fiscal year ending six or more months after the certification date, at which time the Department shall establish a per diem rate pursuant to this rule.
(b) Change of ownership.
(i) A facility which has a change of ownership on or after August 1, 1992, shall receive the per diem rate in effect for that facility on the date of the change of ownership. This per diem rate shall remain in effect until the end of the first fiscal year ending six or more months after the date of the change of ownership, at which time the Department shall establish a per diem rate pursuant to this rule.
(ii) Record keeping requirements. The former owner shall be responsible for maintaining all medical and financial records for one year after the date of the change of ownership. If the facility is involved in an audit or administrative or judicial proceedings which require access to such records, the records must be maintained until the completion of all proceedings, including any applicable appeal periods.
(c) Other facilities. The per diem rate for all other facilities shall be established pursuant to the other provisions of this rule.
(d) Effective dates of per diem rates. Per diem rates are established prospectively and shall remain in effect from the rate effective date until redetermined pursuant to this rule.
(a) Per diem rate. The Department reimburses facilities providing nursing facility services to recipients using the per diem rates established pursuant to this Chapter.
(b) Reserved bed days.
(i) Facilities may receive the per diem rate for reserved bed days during temporary absences if an appropriate bed is not available during the time for which reimbursement is sought. For purposes of this section, 'appropriate bed' means a bed in an empty room or a bed in a vacant bed in a room occupied by a person of the same sex as the temporarily absent recipient.
(ii) Reimbursement for temporary absences is limited to fourteen days per calendar year.
(iii) A provider may not bill a recipient or the recipient's family for reserved bed days that are not reimbursed pursuant to this section unless the facility has informed the recipient, in writing, before the period for which reimbursement is sought of the recipient's option to make payments to hold the bed if the temporary absence exceeds the period for which Medicaid reimbursement is available.
(a) General requirement. Costs shall be allocated among the following cost components as specified in this section: (1) health care costs; (2) capital costs; and (3) operating costs. For purposes of this section, 'labor costs' includes the cost of employee benefits and taxes.
(b) Health care cost component. The health care cost component consists of the following costs provided such costs are direct costs of patient-related services actually rendered within the facility (or direct patient-related services provided outside the facility if medically necessary) and the cost of related supplies actually used in the facility:
(i) Activities, including direct labor cost;
(ii) Dietary, including direct labor cost;
(iii) Direct health care labor costs for the following:
(A) Health care education, including OBRA '87 nurse aide training requirements;
(B) Licensed practical nurses;
(C) Medical director;
(D) Nurse assistants;
(E) Nursing administrators;
(F) Nursing consultants;
(G) Registered nurses; and
(H) Rehabilitation personnel.
(iv) Services and supplies included in the per diem rate (reduced by the cost of services paid from other sources); and
(v) Social services, including direct labor cost; and
(vi) Travel cost related to the above.
(c) Capital cost component. The capital cost component consists of the following costs:
(i) Leasehold amortization;
(ii) Rent/lease expense;
(iii) Depreciation; and
(iv) Interest on real estate and personal property.
(d) Operating cost component. The operating cost component consists of:
(i) Housekeeping, including direct labor;
(ii) Laundry, including direct labor cost;
(iii) Medical records;
(iv) OBRA '87 compliance costs other than the cost of nurse aide training;
(v) Patient-related administrative costs (including home office and management fees which are not health care costs under subsection (b));
(vi) Plant operations and equipment costs;
and
(vii) Travel costs related to the above.
(a) Depreciation.
(i) The depreciation of a tangible asset used to deliver patient-related services is an allowable cost if the asset is:
(A) In use;
(B) Identifiable to patient care;
(C) Available for physical inspection; and
(D) Recorded in the provider's records.
(ii) Basis. The basis used in calculating depreciation shall be the historical cost of the asset.
(iii) Method. Depreciation must be reported on the straight line method.
(iv) Useful life. Useful life shall be determined in accordance with the most recent edition of Estimated Useful Lives of Depreciable Assets, as published by the American Hospital Association, which is hereby incorporated by reference.
(v) If a single asset or collection of like assets acquired in quantity, including permanent betterment or improvements, has at the time of acquisition an estimated useful life of at least two (2) years and historical cost of at least five-hundred dollars ($500.00), the cost shall be depreciated over the useful life of the asset.
(vi) Patient-related items that do not qualify for the above definition shall be expenses in the year acquired.
(vii) Donated assets.
(A) Definition. An asset is donated to the extent the provider acquired the asset without paying fair market value in cash, property or services.
(B) Basis. The basis of donated assets, except for donations between providers or from a party related to the provider, is the asset's fair market value, minus the value the provider gave for the asset. If the fair market value of the asset is over $2,000.00, the basis shall be the lesser of the appraised value and the fair market value. If the donor is related to the provider, the basis shall be the lesser of the net book value of the donor and fair market value.
(C) Cash donations. Cash donations shall be treated as revenue, and not as an offset to expense accounts.
(b) Permanent Financing Interest.
(i) Allowable cost. Permanent financing interest incurred on patient-related real property, improvements to real property, buildings, building components and equipment is an allowable cost subject to the limitations of this subsection.
(ii) Maximum allowable interest rate. The allowable interest rate on permanent financing from a party related to the provider shall not exceed the Federal Home Loan Mortgage Corporation, Whole Loan Purchase, Multi-Family rate in effect on the date the loan commitment was signed by the lender and borrower.
(iii) Maximum allowable interest expense. The principal amount of permanent financing shall not exceed the allowable historical cost of the facilities and equipment.
(iv) Reporting requirements. Interest expense must be supported by a written loan agreement, showing that funds were borrowed, payment of interest and repayment of principal is required, and funds were used to purchase patient-related real property, buildings, building components and equipment. The lender, purpose, principal amount, terms and interest rate must be identifiable in the provider's financial records.
(c) Lease and rental expense.
(i) Allowable cost. Lease or rental expenses incurred on patient-related real property, buildings, building components and equipment are an allowable cost subject to the limitations of this subsection.
(ii) Maximum allowable. Leases, rental agreements, and contracts involving the use of real or personal property shall be subject to the same maximum capital component limit as owners of property.
(iii) Related parties. If a provider rents, leases or purchases patient-related real property, buildings, building components and equipment from a party related to the provider, the historical cost to the related party, not to exceed fair market value, shall be utilized in computing the allowable capital cost.
(d) Amortization of leasehold improvements.
(i) Allowable cost. Lease or rental expenses incurred on patient-related real property, buildings, building components and equipment are an allowable cost subject to the limitations of this subsection.
(ii) Amortization of leasehold improvements shall be calculated and reported in accordance with GAAP and are a capital cost.
(iii) Amortization of organizational cost shall be reported in the operating cost component.
(a) Working capital interest.
(i) Generally. Interest on working capital loans is an allowable cost only if the loans were costs that must be incurred to provide patient-related services.
(ii) Limitation. Interest on working capital loans may not exceed the actual reported interest less any investment income revenue.
(iii) Reporting. Interest on working capital loans shall be reported as an operating cost.
(b) Compensation for services from owners or parties related to the provider.
(i) Compensation for services from an owner or a party related to the provider is an allowable cost if such services were:
(A) Actually performed;
(B) Necessary to the delivery of patient related services; and
(C) The compensation paid was reasonable.
(ii) Documentation. A provider must maintain written documentation of the time and work performed, the work's relationship to patient care, whether such work was performed at the facility or outside the facility, and the compensation paid for such work.
(iii) Maximum allowable. Compensation of an owner or party related to the provider is not an allowable cost to the extent it exceeds the median range for comparable services as contained in the most recent survey of administrative salaries paid to persons other than owners of proprietary and nonproprietary providers conducted by the Bureau of Health Insurance and published in the Medicare Provider Reimbursement Manual PRM Part 1, Section 905.2, which is hereby incorporated by reference.
(A) Part-time employees. For individuals who work less than a forty (40) hour work week, the maximum allowable amount shall be reduced by the ratio of actual number of hours worked per week to forty.
(B) Full-time employees. For individuals who work more than a forty (40) hour work week, either in one or more facilities, the allowable amount shall not exceed the median range in total, nor per facility. If the total hours worked by an individual in more than one facility exceed forty (40) hours per week, the allowable amount shall be prorated between the facilities.
(a) The cost of services or supplies not included in the per diem rate shall be removed from patient-related cost.
(b) The method of removal depends on a provider's accounting and other records. If a provider has adequate segregation in accounting records, such adjustment shall be based on the cost of services or supplies not included in the per diem rate. If a provider does not maintain adequate cost segregation or if such accounts cannot reasonably be subjected to normal audit procedures, then the related revenue shall be used as an adjustment to patient expense, provided the related revenue amount is reasonably equal to or greater than cost. If these conditions are not met, the entire group of aggregated ancillary or other revenue accounts, or aggregated ancillary or other cost accounts, if greater, shall be used as an offset to patient expenses.
(a) Effective date. A provider's per diem rate shall become effective on the rate effective date.
(b) Effective period of rate. A facility shall be bound by the per diem rate until a new rate is computed pursuant to this rule, unless the rate is changed as the result of a desk review or field audit.
(c) Determination of rates. The Department shall determine a facility's per diem rate by the first day of the fourth month after the month in which the Department receives the facility's cost report and all information required by section 5(c) (iii) (A-J), with the rate to be effective pursuant to Section 18.
(d) Notice of rate. The Department shall notify providers of the per diem rate by certified mail, return receipt requested.
(a) Creation of data base. Each year the Department shall create a data base using the latest complete desk reviewed cost reports for each provider. 'Latest complete' means that the cost report was used to compute the provider's most recent per diem rate and the rate was set by October 1, 1993, or by July 1 of the applicable year thereafter.
(b) Adjustment of cost reports. Cost reports included in the data base shall be adjusted so that transactions with owners or parties related to providers are limited pursuant to this rule. Per diem cost report information for the capital cost component shall be subject to a minimum occupancy of ninety percent (90%).
(c) Each year the Department shall create a data base which reflects the quality of care and the average level of care provided in facilities.
(a) Median health care cost. Using the data base created pursuant to Section 14, the median health care cost shall be determined by arraying the inflation-adjusted allowable per-diem health care cost for each provider, from low to high and selecting the cost associated with the median licensed bed.
(b) Median operating cost. Using the data base created pursuant to Section 14, the median operating cost shall be determined by arraying the inflation-adjusted allowable per-diem operating cost for each provider, from low to high and selecting the cost associated with the median licensed bed.
(c) Median capital cost. Using the data base created pursuant to Section 14, the median capital cost shall be determined by arraying the inflation-adjusted allowable per-diem capital cost for each provider, from low to high and selecting the cost associated with the median licensed bed.
The Department shall, on or before December 1, 1993, and on or before September 1 thereafter, determine limitations for each cost component in accordance with this rule using the data base created pursuant to Section 14 and the medians determined pursuant to Section 15.
(a) Capital costs. Capital costs shall not exceed the maximum allowable as determined pursuant to Section 19.
(b) Health care costs. Health care costs shall not exceed 125 percent of the median health care cost.
(c) Operating costs. Operating costs shall not exceed 105 percent of median operating costs.
(d) Effective period of limitations. The cost component limitations shall be effective for rate effective dates from October 1, 1993, through June 30, 1994. Thereafter, cost component limitation shall be effective for rate effective dates from July 1 through June 30 of each subsequent year. Cost component limitations shall not be redetermined to reflect changes in facilities' allowable costs that result from reconsideration, administrative appeals or judicial decisions.
(a) Average health care cost of facilities with health care costs below the median. The Department shall determine the average per diem health care cost of facilities with health care cost below the median by:
(i) Using the data base created pursuant to Section 14, arraying the allowable health care cost component of per diem rates in effect on July 1, 1995, and each July 1 thereafter;
(ii) Locating the median of the array using the methodology described in Section 15; and
(iii) Computing the bed-weighted average allowable per diem health care cost of all facilities with health care cost at or below the median.
(b) Average operating cost of facilities with operating cost below the median. The Department shall determine the average per diem operating cost of facilities with operating cost below the median by:
(i) Using the data base created pursuant to Section 14, arraying the allowable operating cost component of per diem rates in effect on July 1, 1995, and each July 1 thereafter;
(ii) Locating the median of the array using the methodology described in Section 15; and
(iii) Computing the bed-weighted average allowable per diem operating cost of all facilities with operating cost at or below the median.
(c) The reimbursement standard is the sum of:
(i) The average health care cost of facilities with health care cost below the median as determined pursuant to subsection (a);
(ii) The average operating cost of facilities with operating cost below the median as determined pursuant to subsection (b); and
(iii) The provider's capital cost, subject to Section 19.
(a) Except as otherwise provided in this Chapter, the per diem rate shall be the sum of:
(i) The provider's cost components, subject to the cost component limitations determined pursuant to Section 16;
(ii) An inflation adjustment as specified in Section 20; and
(iii) The incentive adjustment, if any, specified in Section 21.
(b) New facilities. A new facility shall receive a per diem rate equal to the reimbursement standard as determined pursuant to subsection 17(c), except that the capital component of the rate shall be the median allowable capital cost then in effect in Wyoming.
(c) Application of cost component limitations. The provider's reimbursable cost is the lesser of the provider's inflated allowable cost or the cost component limitations established pursuant to Section 16.
(d) Maximum per diem rate. A provider's per diem rate shall be the lesser of the rate determined pursuant to this Chapter or the facility's private pay rate.
(e) A provider shall receive one rate change per year on the rate effective date, unless:
(i) The rate is changed as the result of a desk review or field audit; or
(ii) Changes in federal or state statutes or regulations cause increases in health care costs, as defined in subsection 9(b), or operating costs, as defined in subsection 9(d), in which case the Department shall determine whether and how to reimburse for such costs.
(e) Reconsideration. A provider may request that the Department reconsider a per diem rate pursuant to Section 31. The reconsideration shall be limited to whether the Department has complied with the provisions of this rule.
(a) The maximum capital basis per licensed bed shall be $28,500.00 as of January 1, 1989.
(b) Increase in maximum capital basis. The maximum capital basis shall be increased effective July 1 of each year by the lesser of one-half of the percentage increase in the Dodge Construction Index, which is hereby incorporated by reference, or one-half of the increase in the consumer price index. (If either the Dodge Construction Index or the consumer price index is discontinued, the Department shall use whichever index is available.) The increase shall be rounded to the nearest $100.00.
(c) Allowable maximum capital basis shall be limited to the maximum capital basis per licensed bed at the time of construction or January 1, 1989, whichever is later, of each bed plus one-half (1/2) of the difference between that amount and the maximum capital basis per bed at the rate effective date.
(d) For facilities constructed, acquired or leased prior to January 1, 1989, and facilities constructed after January 1, 1989, the capital component limitation shall be limited to the allowable maximum capital basis for each licensed bed times the average annual Federal Home Loan Mortgage Corporation, Whole Loan Purchase, Multi-Family rate rounded to the nearest half percent (.5%) divided by 90% of a facility's total available licensed beds times 365 days. The average annual Federal Home Loan Mortgage Corporation Whole Loan Purchase, multi-family rate, shall be calculated as of January 1, 1989. This limit shall apply to all depreciation, interest, lease, rent, or other consideration paid for the use of property.
(e) For facilities acquired through purchase or a capital lease as defined by GAAP on or after January 1, 1989, the buyer/lessee's allowable historical cost of property shall be limited to the seller/lessor's acquisition cost increased by the lesser of one-half (1/2) of the percentage increase in the Dodge Construction Index, or one-half of the increase in the consumer price index. (If either the Dodge Construction Index or the consumer price index is discontinued, the Department shall use whichever index is available.) The maximum capital basis buyer/lessee shall be limited to the seller/lessor's maximum capital basis at the date of transaction. Any additional allowable capital expenditures incurred by the buyer/lessee shall be treated in the same manner as if the seller/lessor had acquired the additional capital expenditure. For facilities leased through a lease determined not to be a capital lease in accordance with GAAP on or after January 1, 1989, the lessee's allowable capital component shall be limited to the lessor's capital component at the date of transaction. The maximum capital basis of the lessee shall be limited to the lessor's maximum capital basis at the date of transaction.
A facility's allowable operating and allowable health care costs shall be inflated effective October 1, 1993, and each July 1 thereafter, using the annualized eight quarter average rate of change in the inflation factor. Cost components shall be inflated from the midpoint of the cost reporting period to the midpoint of the rate period as defined in Section 13.
(a) Eligibility for incentive adjustment. A facility with allowable operating cost below the operating cost component limitations established pursuant to this Chapter shall be eligible for an incentive adjustment.
(b) Computation of incentive adjustment. The incentive adjustment shall be twenty-five percent of the difference between the facility's allowable operating cost and the operating cost component limitations. That amount shall be calculated on a per diem basis and added to the facility's inflation adjusted operating costs. The adjustment may not exceed $2.00 per day.
(a) Medicaid reimbursement for services provided to an extraordinary recipient shall be the per diem rate plus a negotiated rate to cover the cost of medically necessary services and supplies that are not included in the per diem rate.
(i) The Division will negotiate with providers on a case-by-case basis to determine the negotiated rate and the billing procedures for extraordinary recipients.
(ii) Prior to such negotiations, the provider shall submit to the Division:
(A) A treatment plan; and
(B) A proposed reimbursement rate, including all relevant financial records and all medical records which document the medical necessity for services provided to an extraordinary recipient.
(iii) The Division may request, and the provider shall furnish before a negotiated rate is established, additional information to document the medical necessity for services provided to an extraordinary recipient.
(iv) The negotiated rate shall be the rate agreed upon by the provider and the Division for medically necessary services.
(v) The Division shall reevaluate the condition of an extraordinary recipient after the first fifteen days and at least every thirty days thereafter, and shall renegotiate the negotiated rate to reflect changes in the recipient's condition.
(b) All inclusive. The negotiated rate shall be an all inclusive reimbursement rate for all services and supplies furnished by the facility, except as specified in Section 23 and/or as otherwise agreed by the Division.
(c) Maximum rate. The negotiated rate shall not exceed the actual cost of the services provided to the extraordinary recipient.
(d) Until the Department agrees, in writing, to a negotiated rate, reimbursement for services provided to an extraordinary recipient shall be limited to the facility's per diem rate.
(e) The Division's refusal to agree to pay the rate requested by a provider for an extraordinary recipient is not an adverse action for purposes of Chapter I.
(f) The facility shall maintain records of the costs it incurs in furnishing services to each extraordinary recipient. Costs related to services furnished to extraordinary recipients, other than nursing facility services, are not allowable costs for purposes of determining the facility's per diem rate.
(a) The Medicaid allowable payment for Medicaid program services furnished to a recipient in a nursing facility shall be determined pursuant to the rules and policies of the Department.
(b) The Medicaid allowable payment for Medicaid program services furnished to an extraordinary recipient shall be determined pursuant to the rules and policies of the Department, except as otherwise agreed to by the Division and the hospital pursuant to Section 22.
(c) Claims for Medicaid program services shall be submitted pursuant to the rules and policies of the Department.
(a) Submission of claims. A provider seeking Medicaid reimbursement for services provided to a recipient must submit claims on the forms and in the manner specified by the Department.
(b) Medicaid payment as payment in full. A provider which receives or requests Medicaid payment for services and supplies included in the per diem rate must accept Medicaid payment as payment in full for such services and supplies. A provider may not attempt to collect or retain payment in addition to the per diem rate except as permitted by 42 C.F.R. § 483.10(c), which is incorporated by this reference, or other applicable federal law.
(a) Termination of participation. If a provider's participation in the Medicaid program is terminated or suspended for any reason, the provider must submit a cost report for the period ending with the effective date of the termination or suspension. The cost report is due within forty-five (45) days after the date of termination or suspension, even though the provider's tax period does not end on the date of termination or suspension. The final month's payment due a provider shall be withheld until its cost report is filed and the Department has a reasonable time to perform a desk review and field audit of the cost report and patient funds account.
(b) Change of ownership.
(i) Notice of change of ownership. The parties to a transaction involving a change of ownership must notify the Department, in writing, of the proposed transaction no later than 60 days before the effective date of the change.
(ii) Representation agreement. Upon a change of ownership, all parties to the transaction shall have thirty days after the change to complete and sign a representation statement. If a representation statement is not timely submitted, both the original provider and any subsequent provider shall be jointly and severally responsible for all Medicaid liabilities which exist either before or after the change of ownership.
(a) The reimbursement rate for out-of-state facilities providing services to Wyoming recipients shall be the lesser of:
(i) The Medicaid reimbursement rate the facility receives for the same or similar services from the Medicaid program in the state where the facility is located;
(ii) The average bed-weighted Medicaid rate in effect in Wyoming as of the previous July 1; and
(iii) The facility's usual and customary rate.
(b) No cost reports. An out-of-state provider need not submit cost reports to the Department.
(c) Billing requirements. An out-of-state provider must submit with each claim a certification of the provider's reimbursement rate under the Medicaid program in the state where the provider is located and the facility's usual and customary charge.
(a) Period of retention. A facility which receives or has received Medicaid funds shall retain financial records for six (6) years following the date of submission of the applicable cost report to the Department. Such records must be maintained for three years in hard-copy. After that, records may be maintained on micro-fiche or micro-film. If there is a change of ownership, the former owner must comply with paragraph 7(b)(ii).
(b) Record keeping requirements.
(i) Financial records. A provider must keep financial records in accordance with GAAP and maintain sufficient control and documentation to satisfy the requirements of this rule, including accommodating GAAS and reasonable requests by the Department for additional information. The provider must maintain adequate documentation for all line items on the cost report.
(ii) Medical records. A provider must maintain records which fully document the treatment and services provided to a recipient.
(c) Availability of records. A provider shall make financial or medical records available upon request to representatives of the Department or the United States Department of Health and Human Services.
(d) Refusal to produce records. The refusal of a provider to make financial or medical records available and accessible shall result in the immediate suspension of all Medicaid payments made to the provider for the services under audit. All Medicaid payments made to the provider during the fiscal year for the services under audit shall be repaid to the Department within ten days after written request from the Department.
(e) Explanation of records. In the event of a field audit, the provider shall have available at the field audit location one or more knowledgeable persons who can explain the provider's financial records, the accounting and control system and cost report preparation, including attachments and allocations, to the auditors.
(f) Failure to maintain records. A provider unable to satisfy any of the requirements of this Section shall be given a written notice of deficiency and shall have sixty days after the date of the written notice to correct such deficiency. If, at the end of the sixty days, the Department determines that the deficiency has not been corrected, the Department shall withhold twenty-five percent (25%) of the provider's per diem rate for services provided on or after the sixtieth day. If, at the end of one hundred and twenty days after the mailing of the written notice of deficiency, the Department determines that the deficiency has not been corrected, the Department shall suspend all Medicaid payments for services provided after such date. Reimbursement shall not be reinstated until the Department determines that adequate records are being maintained. After the deficiency is corrected, the Department shall release any withheld payments.
(g) Out of state records. If a provider maintains financial or medical records out of state, the provider shall either transfer the records to an in-state location that is suitable for the Department to perform the field audit or reimburse the Department for reasonable costs, including travel, lodging and meals, incurred in performing the field audit in an out-of-state location.
(a) Report on cost report. A provider shall report a credit balance on the provider's cost report. A credit balance shall be repaid pursuant to (c).
(b) Annual request. The Department may request the repayment of any credit balance annually. Such request shall be made in writing and mailed by certified mail, return receipt requested. The provider shall repay the credit balance within sixty days after the date of receipt of the request for repayment.
(c) A provider shall repay any credit balance within sixty days after the date such credit balance is identified by the Department or the provider.
(d) Lump sum adjustment. If a credit balance identified pursuant to Sections (a) or (b) is not timely paid to the Department, the Department may recover the credit balance pursuant to Section 30.
(a) Field audits. The Department or HCFA may perform a field audit of a provider at any time to determine the accuracy and reasonableness of cost reports submitted by the provider and/or the validity of rate adjustment made pursuant to a desk review.
(b) Desk review. The Department or HCFA may perform a desk review of a provider at any time to determine the accuracy and reasonableness of cost reports submitted by the provider.
(c) The Department or HCFA may perform field audits or desk reviews through employees, agents, or through a third party. Audits shall be performed in accordance with GAAS.
(d) Disallowances.
(i) Nonallowable costs. If a field audit or desk review discloses nonallowable costs or costs for services and supplies not included in the per diem rate, the Department shall adjust the per diem rate retroactively to the beginning of the rate period in question, recover any excess payments pursuant to Section 30, and adjust the per diem rate for the remainder of the rate period.
(ii) Unsubstantiated cost.
(A) Upon written request by the Department, a provider must substantiate cost or other information reported on the provider's cost report. Substantiation must be provided, in writing, within thirty days after the date of the request.
(B) Any cost which a provider cannot substantiate shall be disallowed.
(C) Substantiation may include, but is not limited to, home office cost statement, resident census, statistical and related information, cost allocations, account analyses, invoices, stock ownership information, related parties' financial information, or subcontractor's financial information.
(iii) Financial or medical records which are not made available at the time of an audit shall not be admissible at an administrative hearing held pursuant to Section 31(c) unless the facility shows good cause for not making the records available at the time of the audit.
(a) Notice of excess payments. After determining that a provider has received excess payments, the Department shall send written notice to the provider, by certified mail, return receipt requested, stating the amount of the excess payments, the basis for the determination of excess payments and the provider's right to request reconsideration of that determination pursuant to Section 31.
(b) Reimbursement of excess payments. A provider must reimburse the Department for excess payments within 30 days after the provider receives written notice from the Department of the excess payments, even if the provider has requested reconsideration or requested an administrative hearing regarding the determination of excess payments.
(c) Methods of recovery of excess payments. If a provider does not timely reimburse the Department, the Department may recover the excess payments by:
(i) Adjusting the provider's current per diem rate such that full recovery is completed within 120 days after the facility receives written notice from the Department of the excess payments, even if the provider has appealed the determination of excess payments;
(ii) Withholding all or part of Medicaid payments until the excess payments are recovered;
(iii) Initiating a civil lawsuit against the provider; or
(iv) Any other method of collecting a debt or obligation permitted by law.
(a) Request for reconsideration. A provider may request that the Department reconsider a decision to recover excess payments or the determination of the provider's per diem rate. Such request must be mailed to the Department by certified mail, return receipt requested within twenty days of the date the facility receives notice pursuant to subsection 13(d) or subsection 30(a). The request must state with specificity the reasons for the request. Failure to provide such a statement shall result in the dismissal of the request with prejudice.
(b) Reconsideration. The Department shall review the decision or rate and send written notice by certified mail, return receipt requested, to the provider of its final decision within forty-five days after receipt of the request for reconsideration or the receipt of any additional information requested pursuant to (c), whichever is later.
(c) Request for additional information. The Department may request additional information from the provider as part of the reconsideration process. Such a request shall be made in writing by certified mail, return receipt requested. The provider must provide the requested information within thirty days after the date of the request. Failure to provide the requested information shall result in the dismissal of the request with prejudice.
(d) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.
(e) Informal resolution. The provider or the Department may request an informal meeting before the final decision on reconsideration to determine whether the matter may be resolved. The substance of the discussions and/or settlement offers made pursuant to an attempt at informal resolution shall not be admissible as part a subsequent administrative hearing or judicial proceeding.
(f) Administrative hearing. A provider may request an administrative hearing regarding the final decision pursuant to Chapter I of these rules by mailing by certified mail, return receipt requested or personally delivering a request for hearing to the Department within twenty days of the date the provider receives notice of the final decision.
(g) Failure to request reconsideration. A provider which fails to request reconsideration pursuant to this section may not subsequently request an administrative hearing regarding the decision to recover excess funds or the per diem rate pursuant to Chapter I.
(h) Matters not subject to reconsideration.
(i) The use or reasonableness of the reimbursement methodologies set forth in this Chapter;
(ii) A change in a payment rate caused by a change in the reimbursement methodology as the result of a change in state or federal law, including an amendment to this Chapter or other rules of the Department; or
(iii) The Department's refusal to agree to a negotiated rate requested by a provider.
Section 32. Superseding effect. When promulgated, this Chapter supersedes all prior rules or policy statements issued by the Department, including Manuals or Bulletins, which are inconsistent with this Chapter.
Section 33. Severability.
If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.
Deodorants
Diapers
I.V. Trays
Jelly, Lubricating
Side Rails Soap Special Diets Specimen Cups Sponges Steam Vaporizers Sterile Pads Sterile Saline for Irrigation Sterile Water for Irrigation Stomach Tubes Suction Catheter Suction Machines Suction Tube Surgical Dressings (including sterile sponges) Surgical Pads Surgical Tapes Suture Removal Kit Suture Trays Syringes, all sizes Syringes, Disposable Tape, (for laboratory tests) Tape, Non-allergic or Butterfly Testing Sets and Refills (S & A) Therapy Services, including specialized rehabilitative services as set forth in 42 C.F.R. §483.45 Toenail Clipping and Cleaning Tongue Depressors Toothbrushes Toothpaste Tracheostomy Sponges Trapeze Bars Tray Service Underpads Urinals, male and female Urinary Drainage Tube Urinary Tube and Bottle Urological Solutions Walkers, all types Walter Circulating Pads Water Pitchers Wheelchairs: Amputee, Geriatric, Heavy Duty, Hemi, Lightweight, One Arm Drive, Reclining, Rollabout, Semi-Reclining, Standard
The Wyoming Department of Health (the Department) is the single state agency appointed pursuant to the Social Security Act (the Act) to administer the Medicaid program in Wyoming. The Wyoming Medical Assistance and Services Act of 1967 (the Wyoming Act) requires the Department to administer the Medicaid program in conformance with federal standards.
The Wyoming Act authorizes the Department to promulgate necessary rules. The Wyoming Administrative Procedure Act requires all agency statements of general applicability that implement, interpret or prescribe law or policy be promulgated as rules.
The Act requires the Department to reimburse long term care facilities providing nursing facility services using rates which the Department finds and represents to the United States Department of Health and Human Services are reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities providing care and services in conformity with applicable State and Federal requirements. Chapter 7 of the Department's Medicaid rules establishes the methodology for setting per diem reimbursement rates for long term care facilities in Wyoming in conformance with Federal requirements.
Chapter 7 is being amended to: clarify various definitions; establish the reimbursement standard; provide the full inflation adjustment to all facilities; clarify the procedures for reimbursing facilities for furnishing services to extraordinary recipients; and bring the reconsideration procedures into conformance with other Medicaid rules.
The rule, as amended, is to become effective for rate effective dates on or after July 1, 1995.