048-41 Wyo. Code R. §§ 41-7 - Covered Services, Service Requirements, and Restrictions

(a) The services listed in this section are covered services if they are functionally necessary and part of a current individual plan of care approved by the Division.

(i) Case management services.

(A) Case management is a stand alone service. A participant (or guardian, if applicable) may choose any individually-selected service coordination provider, and shall not be expected or required to receive any other service from that provider.

(B) Individually-selected service coordinators shall be required to provide a minimum of 60 minutes per calendar month of person-to-person contact with the participant or guardian.

(I) This may include face-to-face meetings and telephone conversations between the individually-selected service coordinator, the participant, and/or the guardian.

(II) Individually-selected service coordinators shall be required to complete one monthly visit to participant in his or her home.

(C) Individually-selected service coordinators shall schedule and facilitate six month review team meetings and annual individual plan of care meetings, including:

(I) Notifying all individual plan of care team members of the scheduling of the meetings at least 30 days in advance unless a shorter notification time is approved by the Division.

(II) Notifying the Division in writing of the scheduling of the meetings at least 30 days in advance unless a shorter notification time is approved by the Division.

(III) Following Division requirements for facilitating team meetings; and for documenting minutes of the team meetings in the form and manner prescribed by the Division in provider manuals and bulletins issued by the Division.

(D) Individually-selected service coordinators shall facilitate other team meetings when requested by the participant, guardian, member of the team, or the Division.

(ii) Dietician.

(A) Dietician services shall be supported by a formal assessment completed by a registered dietician.

(B) Providers of dietician services may seek Medicaid reimbursement for providing such services to a group of up to three participants at a time.

(iii) Environmental modification.

(A) Environmental modifications shall be approved pursuant to Chapter 44.

(iv) Habilitation services.

(A) Participants may receive more than one habilitation service in a given day.

(B) Participants shall be in attendance in service areas in order for providers to bill for services.

(C) Purposes of the habilitation service codes shall be met, including assisting participants in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings.

(I) Habilitation providers shall work with the participant on objectives as stipulated in the individual plan of care and document the results in the form and manner established by the individual plan of care team.

(D) Habilitation rates shall include personal care and respite services, except for in the cases listed under (E) of this section.

(E) Residential habilitation services and respite services may appear on the same individual plan of care when:

(I) The participant is transitioning into a residential setting such as a group home, or

(II) Unpaid caregivers need respite when the participant spends time at home visiting on weekends or vacations.

(III) When residential habilitation providers who are not required to obtain and maintain CARF accreditation pursuant to Chapter 45 require respite for vacations, sick days, or other emergencies. In these cases, a maximum of 1,344 units of respite shall be allowed during a plan year.

(F) In-home support services and residential habilitation services may appear on the same individual plan of care when the participant is transitioning into or out of a residential setting such as a group home.

(G) When supported employment services are provided in a work site in which persons without disabilities are employed, payment shall be made only for the adaptations, supervision, and training required by individuals receiving waiver services as a result of their disabilities, and shall not include payment for the supervisory activities rendered as a normal part of the business setting.

(H) Reimbursement for habilitation services shall not be made directly or indirectly to a parent, stepparent, spouse, or guardian of a participant.

(I) Habilitation rates for each participant shall include the cost for routine transportation by the provider regardless of the number of trips.

(J) Residential habilitation services shall not be provided in residential settings other than the home of the participant or in the community.

(K) In-home support services shall not be provided in residential settings other than the home of the participant or in the community.

(v) Occupational therapy.

(A) Reimbursement for occupational therapy services shall require both a prescription and a treatment letter or recommendation from a physician.

(B) Providers of occupational therapy services may seek Medicaid reimbursement for providing such services to a group of up to three participants at a time.

(vi) Personal care services.

(A) The participant shall be present when personal care services are provided.

(B) Personal care services may include the preparation of meals, exclusive of the cost of the meals.

(C) When specified in the individual plan of care, personal care services may also include such housekeeping chores as bed making, dusting, and vacuuming, which are incidental to the care furnished, or which are essential to the health and welfare of the participant, rather than that individual's family.

(D) Personal care providers may include members of the family of the participant, except that Medicaid shall not reimburse a parent for providing such services to an adult child, or a spouse for providing such services to the other spouse.

(E) Providers certified to provide personal care services who are family members of the participant shall meet the same standards as providers certified to provide personal care services who are unrelated to the participant.

(F) Providers of personal care services shall not seek Medicaid reimbursement for providing such services to more than one participant at a time.

(vii) Physical therapy.

(A) Reimbursement for physical therapy services shall require both a prescription and a treatment letter or recommendation from a physician.

(B) Providers of physical therapy services may seek Medicaid reimbursement for providing such services to a group of up to three participants at a time.

(viii) Respiratory therapy.

(A) Reimbursement for respiratory therapy services shall require both a prescription and a treatment letter or recommendation from a physician.

(ix) Respite services.

(A) Respite services shall be covered if provided in one of the following locations:

(I) The residence of the participant.

(II) A group home.

(III) Certified provider location, or

(IV) The community, including parks, stores, and recreation centers.

(B) A respite service provider or provider staff providing respite services:

(I) Shall serve no more than two participants at a given time unless approved by the Division.

(II) May also provide supervision to other children under the age of 12 or other individuals requiring support and supervision, and

(III) Shall limit the total combined number of persons in (I) and (II) to no more than three persons unless approved by the Division.

(C) Respite services shall not take the place of residential or day habilitation services.

(D) Respite services shall accommodate each family's living routine.

(E) Respite services shall accommodate the needs of the participant.

(F) The respite site and services shall be matched to the identified needs of each participant and family.

(G) A respite provider shall not provide respite services to adults and children at the same time except to participants who are 18 to 20 years of age who may receive respite services with adults. In exceptional cases, such as when participants are members of the same family, respite may be provided to adults and children at the same time with Division approval.

(x) Skilled nursing.

(A) Shall be prescribed by a physician.

(B) May include preventative and rehabilitative procedures.

(C) Shall be listed on a form required by the Division and identified in the individual plan of care.

(D) Shall involve direct patient care.

(xi) Specialized equipment.

(A) Shall be provided pursuant to Chapter 44.

(xii) Speech, hearing, and language services.

(A) Reimbursement for speech, hearing, and language services shall require both a prescription and a treatment letter or recommendation from a physician.

(B) Providers of speech, hearing, and language services may seek Medicaid reimbursement for providing such services to a group of up to three participants at one time.

(b) Services otherwise covered by Medicaid shall not be covered services under this Chapter.

(c) Extended state plan services shall be funded to the maximum allowable amount under the state plan before these services are paid for under the waiver.

(d) Parents, stepparents, and/or spouses shall not be reimbursed by waiver funding for any waiver services.

Notes

048-41 Wyo. Code R. §§ 41-7