The following definitions shall apply in the interpretation
and enforcement of these rules. Where the context in which words are used in
these rules indicates that such is the intent, words in the singular number
shall include the plural and vice versa. Throughout these rules gender pronouns
are used interchangeably. The drafters have attempted to utilize each gender
pronoun in equal numbers, in random distribution. Words in each gender include
individuals of the other gender.
(a)
"Advocate." A person, chosen by the participant or legal guardian, who supports
and represents the rights and interests of the participant in order to ensure
the participant's full legal rights and access to services. The advocate can be
a friend, a relative, or any other interested person. An advocate has no legal
authority to make decisions on behalf of a participant.
(b) "Adult." A person twenty-one years of age
or older for purposes of the Adult Developmental Disabilities Home and
Community Based Waiver.
(c) "Adult
Developmental Disabilities Home and Community Based Waiver." The Adult
Developmental Disabilities Home and Community Based Waiver submitted to and
approved by the Centers for Medicare and Medicaid Services pursuant to Section
1915(c) of the Social Security Act.
(d) "Applicant." An individual who is
requesting services.
(e)
"Application." A written statement, in the form specified by the Division,
which is submitted to the Division, in which an individual indicates that he or
she is interested in receiving covered services. An application may be
submitted by one person on behalf of another but shall have the legal
guardian's signature if applicable.
(f) "Assessment." A determination, pursuant
to Section
6 of
this Chapter, of an individual's functional capacity and needs.
(g) "Behavior support plan." A written plan
that is developed based on a functional assessment of behaviors that negatively
impact a person's ability to acquire, retain, and/or improve the self-help,
socialization, and adaptive skills necessary to reside successfully in home and
community-based settings, and that contains multiple intervention strategies
designed to modify the environment and teach new skills.
(h) "Caregiver." A person who provides
services to a participant.
(i)
"Case management." Services that assist participants in gaining access to
needed waiver and other Wyoming Medicaid state plan services, as well as needed
medical, social, educational, and other services, regardless of the funding
source for the services to which access is gained. Case management services are
provided by individually-selected service coordinators, whose responsibilities
include ongoing monitoring of the provision of services included in the
individual plan of care, and initiating and overseeing the process of
assessment and reassessment of the participant's level of care and review of
the individual plan of care.
(j)
"Centers for Medicare and Medicaid Services (CMS)." The Centers for Medicare
and Medicaid Services of the United States Department of Health and Human
Services, its agent, designee, or successor.
(k) "Chapter 1." Chapter 1, Rules for
Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
(l) "Chapter 3." Chapter 3, Provider
Participation, of the Wyoming Medicaid Rules.
(m) "Chapter 16." Chapter 16, Medicaid
Program Integrity, of the Wyoming Medicaid Rules.
(n) "Chapter 26." Chapter 26, Medicaid
Covered Services, of the Wyoming Medicaid Rules.
(o) "Chapter 35." Chapter 35, Medicaid
Benefit Recovery, of the Wyoming Medicaid Rules.
(p) "Chapter 39." Chapter 39, Recovery of
Excess Payments, of the Wyoming Medicaid Rules.
(q) "Chapter 42." Chapter 42, DD Child Waiver
Services, of the Wyoming Medicaid Rules.
(r) "Chapter 43." Chapter 43, Acquired Brain
Injury Waiver Services, of the Wyoming Medicaid Rules.
(s) "Chapter 44." Chapter 44, Environmental
Modifications and Specialized Equipment, of the Wyoming Medicaid
Rules.
(t) "Chapter 45." Chapter
45, Waiver Provider Certification and Sanctions, of the Wyoming Medicaid
Rules.
(u) "Claim." A request by a
provider for Medicaid payment for covered services provided to a
participant.
(v) "Clinically
eligible." Determination that a person has met the requirements set forth in
Section
6(b) of this
Chapter.
(w) "Conservator." A
person appointed by the court to manage the estate for an individual incapable
of managing his or her financial affairs.
(x) "Covered services." Those services that
are Medicaid reimbursable pursuant to Section
7 of
this Chapter.
(y) "Department." The
Wyoming Department of Health, its agent, designee, or successor.
(z) "Department of Family Services (DFS)."
The Wyoming Department of Family Services, its agent, designee, or
successor.
(aa) "Developmental
disability." As defined in federal law (
42
U.S.C. §
15002(8) ), a
severe, chronic disability of an individual that:
(i) Is attributable to a mental or physical
impairment or combination of mental and physical impairments.
(ii) Is manifested before the individual
attains age 22.
(iii) Is likely to
continue indefinitely, and
(iv)
Results in substantial functional limitations in 3 or more of the following
areas of major life activity:
(A)
Self-care
(B) Receptive and
expressive language
(C)
Learning
(D) Mobility
(E) Self-direction
(F) Capacity for independent living
(G) Economic self-sufficiency, and
(v) Reflects the individual's need
for a combination and sequence of special, interdisciplinary, or generic
services, individualized supports, or other forms of assistance that are of
lifelong or extended duration and are individually planned and
coordinated.
(bb)
"Dietician." A person who is registered as a dietician by the Commission on
Dietetic Registration.
(cc)
"Dietician services." Services furnished by a registered dietician, including:
(i) Menu planning.
(ii) Consultation with and training of
caregivers, and
(iii) Education of
participants.
(dd)
"Director." The Director of the Department or the Director's agent, designee,
or successor.
(ee) "Division." The
Developmental Disabilities Division of the Department, its agent, designee or
successor.
(ff) "Drug used as a
restraint." Any drug that:
(i) Is
administered to manage a participant's behavior in a way that reduces the
safety risk to the participant or others, and
(ii) Has the temporary effect of restricting
the participant's freedom of movement, and
(iii) Is not a standard treatment for the
participant's medical or psychiatric condition.
(gg) "Emergency." A circumstance or set of
circumstances or the resulting state that calls for immediate action or an
urgent need for assistance or relief as defined in Section
14
of this Chapter.
(hh) "Emergency
case." A participant currently receiving services who has an
emergency.
(ii) "Emergency
referral." A person who:
(1) is potentially
eligible for covered services; and
(2) has an emergency.
(jj) "Enrolled." Enrolled as defined in
Chapter 3.
(kk) "Environmental
modification." The physical modification of a residence of a participant
pursuant to Chapter 44.
(ll)
"Excess payments." Excess payments as defined in Chapter 16 and Chapter
39.
(mm) "Extended Wyoming Medicaid
state plan services." Services which are available to the general Medicaid
population through the Wyoming Medicaid state plan, but which may be made
available to a participant whose needs exceed state plan service limitations.
Extended services include:
(i) Occupational
therapy services.
(ii) Physical
therapy services.
(iii) Speech,
hearing, and language services.
(iv) Any other services covered by
Medicaid.
(nn)
"Extraordinary Care Committee (ECC)." A committee that has the authority to
approve or deny individual plans of care, emergency funding, and funding due to
a material change in circumstance or other condition justifying an increase in
funding as defined in Section
12
of this Chapter. Membership of the ECC shall include a representative of the
Division, a representative of the State Medicaid Program, and a representative
of the Department's Fiscal Office.
(oo) "Extraordinary care rate." Payment in
addition to the individualized budget amount, pursuant to Section
12
of this Chapter, because of an emergency, a material change in circumstances,
or other condition justifying an increase in funding.
(pp) "Financial records." All records, in
whatever form, used or maintained by a provider in the conduct of its business
affairs and which are necessary to substantiate or understand the information
contained in the provider's cost reports or a claim.
(qq) "Functionally necessary." A waiver
service that is:
(i) Required due to the
diagnosis or condition of the participant, and
(ii) Recognized as a prevailing standard or
current practice among the provider's peer group, or
(iii) Intended to make a reasonable
accommodation for functional limitations of a participant, to increase a
participant's independence, or both.
(iv) Provided in the most efficient manner
and/or setting consistent with appropriate care required by the participant's
condition.
(v) For the purposes
stated, utilization is neither experimental nor investigational and is
generally accepted by the medical community.
(rr) "Funding." That combination of federal
and state funds available to pay for covered services. Funding does not include
any other funds available to the Department that are not designated for covered
services.
(ss) "Generally Accepted
Auditing Standards (GAAS)." Current auditing standards, practices, and
procedures established by the American Institute of Certified Public
Accountants.
(tt) "Guardian." A
person lawfully appointed as guardian to act on the behalf of the participant
or applicant.
(uu) "Habilitation."
Services designed to assist participants in acquiring, retaining, and improving
the self-help, socialization, and adaptive skills necessary to reside
successfully in home and community-based settings. Habilitation includes:
(i) Day habilitation - Assistance with
acquisition, retention, or improvement in self-help, socialization, and
adaptive skills which take place in a non-residential setting, separate from
home or facility in which the participant resides.
(ii) In-home support - The provision of
intermittent one-to-one habilitation services provided in the participant's
home or the community to participants who reside with family, guardians, or
independently. Individuals receive skills training to increase independence
related to their own health care, self-care, safety, and access and use of
community services.
(iii)
Prevocational services - Services that prepare an individual for paid or unpaid
employment, but are not job-task oriented. Services include teaching such
concepts as compliance, attendance, task completion, problem solving, and
safety. Prevocational services furnished under the waiver shall not be
available under a program funded under the Rehabilitation Act of 1973 or the
Individuals with Disabilities Education Improvement Act of 2004.
(iv) Residential habilitation - The provision
of habilitation services provided in the participant's home or community that
provide assistance with acquisition, retention, or improvement in skills
related to activities of daily living, such as personal grooming and
cleanliness, bed making and household chores, eating and preparation of food,
and the social and adaptive skills necessary to enable the individual to reside
in a non-institutional setting. Residential habilitation services shall include
access to residential habilitation services on a 24-hour basis.
(v) Supported employment services - Services
provided to assist participant in sustaining paid employment, including
supervision and training. Supported employment services furnished under the
waiver shall not be available under a program funded by either the
Rehabilitation Act of 1973 or Disabilities Education Improvement Act of
2004.
(vv) "HHS." The
United States Department of Health and Human Services, its agent, designee, or
successor.
(ww) "ICF/MR." An
intermediate care facility for people with mental retardation as defined in
42 U.S.C. §
1396 d(d), which is incorporated by this
reference.
(xx) "Individualized
Budget Amount (IBA)." The Division's allocation of Medicaid waiver funds that
may be available to a participant to meet his or her needs pursuant to Section
8 of
this Chapter.
(yy) "Individual Plan
of Care (IPC)." A written plan of care for a participant that describes the
type and frequency of services to be provided to the participant regardless of
the funding source and that identifies the provider or provider types that
furnish the described services. The IPC shall reflect the services and actual
units that providers are agreeing to provide over the plan year.
(zz) "Individual Plan of Care (IPC) team." A
group of persons who are knowledgeable about the person and are qualified,
collectively, to assist in developing an individual plan of care for that
person. Membership of the team shall include the participant, the guardian if
applicable, the individually-selected service coordinator, providers on the
person's individual plan of care, an advocate if applicable, and any other
person chosen by the participant.
(aaa) "Individually-selected Service
Coordinator (ISC)." An individual or entity that is qualified pursuant to
Chapter 1, Rules for Individually-selected Service Coordinators of the Rules of
the Developmental Disabilities Division, to act as an individually-selected
service coordinator, also known as case manager.
(bbb) "Informed choice." A decision made by a
participant or guardian if applicable that is made voluntarily, without
coercion or undue influence, and that is based on sufficient experience and
knowledge, including exposure, awareness, interactions, and/or instructional
opportunities, to ensure that the choice is made with adequate awareness of all
the available alternatives to and consequences of options available.
(ccc) "Inventory for Client and Agency
Planning (ICAP)." An instrument used by the Division to help determine
eligibility and to determine the needs of the participant, available from
Riverside Publishing, its successor, or designee.
(ddd) "Institution." An Intermediate Care
Facility for people with Mental Retardation (ICF/MR), nursing facility,
hospital, prison, or jail.
(eee)
"LT-MR-104." A document, or its successor, completed by the
individually-selected service coordinator that verifies that the participant or
applicant meets the ICF/MR level of care.
(fff) "Mechanical restraint." Any device
attached or adjacent to a participant's body that he or she cannot easily move
or remove that restricts freedom of movement or normal access to the
body.
(ggg) "Medicaid." Medical
assistance and services provided pursuant to Title XIX of the Social Security
Act and/or the Wyoming Medical Assistance and Services Act. "Medicaid" includes
any successor or replacement program enacted by Congress and/or the Wyoming
Legislature.
(hhh) "Medicaid
allowable payment." Medicaid reimbursement for covered services as determined
pursuant to Section
18
of this Chapter.
(iii) "Medicaid
Fraud Control Unit (MFCU)." The Medicaid Fraud Control Unit of the Wyoming
Attorney General's Office, its agent, designee, or successor.
(jjj) "Medical records." All documents, in
whatever form, in the possession of or subject to the control of a provider,
which describe the participant's diagnosis, condition, or treatment, including,
but not limited to, the individual plan of care.
(kkk) "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 services must be:
(i) Consistent with the diagnosis and
treatment of the participant's condition.
(ii) Recognized as the prevailing standard or
current practice among the provider's peer group.
(iii) Required to meet the medical needs of
the participant and undertaken for reasons other than the convenience of the
participant and the provider, and
(iv) Provided in the most efficient manner
and/or setting consistent with appropriate care required by the participant's
condition.
(lll)
"Medicare." The health insurance program for the aged and disabled established
pursuant to Title XVIII of the Social Security Act.
(mmm) "Medication administration." Medication
physically given by someone other than a participant because the participant
cannot take his or her own medications or administer treatments.
(nnn) "Medication management training."
Medication management training completed by a nurse, including instructing and
assisting the participant in setting up medications.
(ooo) "Medication monitoring." Observation
and documentation of participant's self-administration of medication by
provider or provider staff for participants who do not require medication
administration or medication management by a nurse.
(ppp) "Mental retardation." A diagnosis as
determined by a psychologist per the American Association on Mental Deficiency,
Classification in Mental Retardation (Herbert J. Grossmaned.,
8th ed. 1 983).
(qqq) "Modification to individual plan of
care." A change to an individual plan of care pursuant to Section
9 of
this Chapter. A modification may include the addition, substitution, or
deletion of providers, covered services, or both. Modifications may increase or
decrease the Medicaid waiver allowable payment.
(rrr) "Objectives." Set of meaningful and
measurable goals for the participant and the methods used to train the person
on the goals.
(sss) "Occupational
therapist." A person licensed to practice occupational therapy pursuant to W.
S. §
33-40-102(a)(iii).
(ttt) "Occupational therapy services."
Occupational therapy services that are:
(i)
Provided by or under the scope of practice of an occupational therapist,
and
(ii) Necessary to keep a
participant in his or her home or out of an institution.
(iii) Occupational therapy services may
include individual therapy and group therapy.
(uuu) "Overpayments." Overpayments as defined
in Chapter 16 and Chapter 39.
(vvv)
"Participant." An individual who has been determined eligible for covered
services on the Waiver.
(www)
"Personal care services." Services to assist a participant with the activities
of daily living, including eating, bathing, dressing, and personal hygiene, and
household activities.
(xxx)
"Personal restraint." The application of physical force or physical presence
without the use of any device, for the purposes of restraining the free
movement of the body of the participant. The term personal restraint does not
include briefly holding, without undue force, a participant in order to calm or
comfort him or her, or holding a participant's hand to safely escort him or her
from one area to another.
(yyy)
"Person-centered planning." A process, directed by a participant, that
identifies the participant's strengths, capacities, preferences, needs, the
services needed to meet the needs, and providers available to provide services.
Person-centered planning allows a participant to exercise choice and control
over the process of developing and implementing the individual plan of
care.
(zzz) "Physical therapist." A
person licensed to practice physical therapy pursuant to W. S. §
33-25-101(a)(ii).
(aaaa) "Physical therapy services."
Maintenance or restorative physical therapy services that are:
(i) Prescribed by a physician.
(ii) Provided by or under the scope of
practice of a licensed physical therapist, and
(iii) Necessary to keep a participant in his
or her home or out of an institution.
(iv) Physical therapy services may include
individual therapy and group therapy.
(bbbb) "Physician." A person licensed to
practice medicine or osteopathy by the Wyoming Board of Medical Examiners or a
similar agency in a different state.
(cccc) "Power of Attorney." An instrument in
writing whereby one person, as principal, appoints another as his agent and
confers authority to perform certain specified acts or kinds of acts on behalf
of principal (Black's Law Dictionary, Sixth Edition, 1990).
(dddd) "Prior authorization." Prior
authorization as defined in Chapter 3.
(eeee) "Provider." A person or entity that is
certified by the Division to furnish covered services and is currently enrolled
as a Medicaid waiver provider.
(ffff) "Psychologist." A person licensed to
practice psychology pursuant to W.S. §
33-27-113(a)(v).
(gggg) "Related condition." A condition that
results in a severe, chronic disability affecting an individual which manifests
before he or she reaches age twenty-two and that is attributable to cerebral
palsy, seizure disorder, or any condition other than mental illness that is
closely related to mental retardation and that requires similar services, as
determined by a licensed psychologist or physician.
(hhhh) "Representative payee." A person or
organization appointed by the Social Security Administration to manage Social
Security, Veterans' Administration, Railroad Retirement, Welfare Assistance, or
other state or federal benefits or entitlement program payments on behalf of an
individual who cannot manage or direct the management of his/her own
money.
(iiii) "Respiratory
therapist." A person licensed as a respiratory care practitioner by the Wyoming
Board for Respiratory Care, or a person certified or registered with the
American Respiratory Therapy Association.
(jjjj) "Respiratory therapy services."
Respiratory therapy services which are:
(i)
Prescribed by a physician.
(ii)
Furnished directly by a respiratory therapist to a participant, and
(iii) For habilitation purposes.
(kkkk) "Respite" or "Respite
services." Services provided:
(i) On a
short-term basis pursuant to the individual plan of care.
(ii) To a participant who is unable,
unassisted, to care for himself or herself, and
(iii) Because the participant's primary
caregiver is absent or in need of relief from furnishing such
services.
(llll)
"Restraint." A ''personal restraint,'' ''mechanical restraint,'' or ''drug used
as a restraint'' as defined in this section.
(mmmm) "Schedule." A personalized list of
tasks or activities that describe a typical week for a participant. The
schedule shall reflect the desires of the participant and shall include the
service being provided, details on training on specific goals for habilitation
services, level of supervision needed if specified in the individual plan of
care, health and safety needs, activities, date, time in and time out for
provision of services, provider signatures, and approximate number of hours in
service.
(nnnn) "Seclusion." The
involuntary confinement of a participant alone in a room or an area from which
the participant is physically prevented from leaving. Providers seeking
reimbursement for waiver services shall not use seclusion.
(oooo) "Services." Medical, habilitation, or
other services, equipment, or supplies, appropriate to meet the needs of a
participant.
(pppp) "Skilled
nursing services." Services listed in the individual plans of care that are
within the scope of the Wyoming Nurse Practice Act.
(qqqq) "Specialized equipment." New or used
devices, controls, or appliances that enable a participant to increase his or
her ability to perform the activities of daily living or to perceive, control,
or communicate with the environment in which the participant lives, pursuant to
Chapter 44.
(rrrr) "Speech, hearing
and language services." The following services, if furnished by a speech
pathologist or audiologist or under the scope of practice of a speech
pathologist or audiologist:
(i) Speech
pathology and audiology services, including articulation, pragmatic language
training, and devices used by the participant.
(ii) Assessment of participant's use of
visual cues.
(iii) Assessment of
the need for and use of amplification.
(iv) Assessment of a person's need for
alternative speech output devices.
(v) Speech, hearing and language services may
be provided as individual therapy and group therapy.
(ssss) "Speech pathologist." A person
licensed to practice speech pathology pursuant to W. S.
33-33-102(a)(iii).
(tttt) "Third-party liability." Third-party
liability pursuant to Chapter 35.
(uuuu) "Time out." The restriction of a
participant for a reasonable period of time to a designated area from which the
participant is not physically prevented from leaving, for the purpose of
providing the participant an opportunity to regain self-control.
(vvvv) "Transition process." The process of
changing from one provider of services to another, from one home and community
based service to another, or from one residential location to
another.
(wwww) "Waiting list." A
list of persons who are eligible for covered services and who have submitted a
completed application, but the services are unavailable because of limits
imposed by funding or the waiver. The waiting list is maintained by the
Division as specified in Section
13
of this Chapter.
(xxxx) "Waiver."
The Adult Developmental Disabilities Home and Community Based Waiver submitted
to and approved by the Centers for Medicare and Medicaid Services pursuant to
Section 1915(c) of the Social Security Act.