048-25 Wyo. Code R. §§ 25-4 - Definitions

(a) "Admission." The act that allows an individual to officially enter a facility to receive services.

(b) "Applicant." A person, including a patient, who has applied for Medicaid benefits and is a resident or is seeking admission to a facility.

(c) "Certified." A facility that is certified pursuant to 42 C.F.R. 442 Subpart C, which is incorporated by this reference, to provide ICF/MR services.

(d) "Chapter III." Chapter III, Provider Participation, of the Wyoming Medicaid Rules.

(e) "Chapter XX." Reimbursement of Intermediate Care Facilities for the Mentally Retarded, of the Wyoming Medicaid rules.

(f) "Classification in Mental Retardation." The Classification in Mental Retardation (19 83 ed.) of the American Association on Mental Deficiency, which is hereby incorporated by reference. The book is published by the American Association on Mental Deficiency in Washington, D.C., and is available from the publisher.

(g) "Covered service." ICF/MR services.

(h) "Date of Admission." The date an individual enters a facility and begins receiving services.

(i) "Department." The Wyoming Department of Health, its agent, designee or successor.

(j) "Discharge." The act by which an individual who has been a patient in a facility ceases to be a patient and the facility ceases to be legally responsible for providing care for such individual. Discharge does not include an individuals temporary absence.

(k) "Division." The Division of Health Care Financing of the Department, its agent, designee or successor.

(l) "Evaluation of need for ICF/MR services." A review, pursuant to Section 8, by an IDT or such other person or entity specified by the Department, of an applicants or recipients physical and mental condition for the purpose of determining whether ICF/MR services are medically necessary.

(m) "Facility." An ICF/MR.

(n) "HCFA." The Health Care Financing Administration of the United States Department of Health and Human Services.

(o) "Interdisciplinary team (IDT)." A team of professionals which includes a QMRP, a social worker and a registered nurse.

(p) "Individual educational plan (IEP)." A written plan for children under the age of twenty-one developed by the IDT, in consultation with the child's school district, using standard assessments and standard evaluative measures to determine the strengths and needs of an individual. The IEP shall include short term and long term goals, and the training and treatment programs to achieve those goals.

(q) "Individual program plan (IPP)." A written plan developed by the IDT using standard assessments and standard evaluative measures to determine the strengths and needs of an individual. The IPP shall include short term and long term goals, and the training and treatment programs to achieve those goals.

(r) "Infirmary services." Sub-acute hospital services provided on the premises of a facility.

(s) "Intermediate care facility for the mentally retarded (ICF/MR)." An intermediate care facility as defined by 42 U.S.C. 1396 d(c) that has at least fifteen certified beds. "ICF/MR" includes that portion of the Wyoming State Training School which is certified to provide ICF/MR services.

(t) "Intermediate care facility for the mentally retarded (ICF/MR) services." Intermediate care facility services for the mentally retarded as defined in 42 U.S.C. 1396 d(d) and the regulations promulgated by HCFA, and which are provided in an ICF/MR.

(u) "Local agency." The County field office of the Wyoming Department of Family Services.

(v) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.

(w) "Medicaid allowable payment." The maximum Medicaid reimbursement as determined pursuant to Chapter XX and the other rules of the Department.

(x) "Medical necessity" or "medically necessary." A health service that is required to diagnose, treat, cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected; to relieve pain; or to improve and preserve health and be essential to life. The service must be:

(i) Consistent with the diagnosis and treatment of the recipient's condition;

(ii) In accordance with the standards of good medical practice among the provider's peer group;

(iii) Required to meet the medical needs of the recipient and undertaken for reasons other than the convenience of the recipient or the provider; and

(iv) Provided in the least costly setting required by the recipient's condition.

(y) "Medicare." The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.

(z) "Mentally retarded or mental retardation." An individual with mild, moderate, severe or profound retardation as defined by the Classification in Mental Retardation, or a person with a related condition.

(aa) "Patient." A resident in a facility.

(bb) "Person with a related condition." An individual that has a severe, chronic disability that meets all of the following conditions:

(i) It is attributable to:

(A) Cerebral palsy or epilepsy; or

(B) Any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with mental retardation, and requires treatment or services similar to those required for these persons;

(ii) It is manifested before the person reaches age twenty-two;

(iii) It is likely to continue indefinitely; and

(iv) It results in substantial functional limitations in three or more of the following areas of major life activity;

(A) Self care;

(B) Understanding the use of language;

(C) Learning;

(D) Mobility:

(E) Self-direction; and

(F) Capacity for independent living.

(cc) "Physician." A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a comparable agency in another state.

(dd) "Provider." An ICF/MR that has a provider agreement with the Department and that is certified to provide services to recipients.

(ee) "Qualified mental retardation professional (QMRP)." A qualified mental retardation professional as defined by 42 C.F.R. 483.430, which is incorporated by this reference.

(ff) "Recipient." A person who has been determined eligible for Medicaid.

(gg) "Registered nurse." An person licensed to practice professional nursing by the Wyoming Board of Nursing.

(hh) "Specialized services." A continuous program for a patient which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services that are directed toward the objective specified in paragraphs (i) and (ii). Such a program excludes services to maintain generally independent patients who are able to function with little supervision or the absence of continuous specialized treatment program.

(i) Acquisition of the behaviors necessary for the patient to function with as much self determination and independence as possible; and

(ii) Prevention or deceleration of regression or loss of current optimal functional status.

(ii) "Survey agency." The Health Facilities Survey, Certification and Licensure Office of the Department, its designee or successor.

(jj) "Temporary absence." When a recipient is out of a facility for hospitalization or therapeutic home visits. A recipient receiving infirmary services is not absent from the facility.

(kk) "Working days." Monday through Friday, exclusive of State holidays.

(ll) "Wyoming state training school." The Wyoming state training school as established pursuant to W.S. 25-5-101 et seq.

Notes

048-25 Wyo. Code R. §§ 25-4