CHAPTER 12

 

HOME HEALTH SERVICES

 

 Section 1. Authority.

 

 The Wyoming Department of Health promulgates this chapter under the Medical Assistance and Services Act, Wyoming Statutes §§ 42-4-101 through -124.

 

 Section 2. Purposes and Applicability. 

 

 (a) This Chapter governs home health services covered by Medicaid. 

 

 (b) The Department may issue Provider Manuals and Provider Bulletins to interpret the provisions of this Chapter. The contents of manuals and bulletins are subordinate to the provisions of this Chapter. 

 

 (c)  Title XIX of the Social Security Act, 42 U.S.C.A. §§ 1396a, et seq., and 42 C.F.R. § 440.70 apply to this Chapter. 

 

 Section 3. Definitions. Except as defined in this Section or as defined in Chapter 1, the terminology used in this Chapter is the standard terminology and has the standard meaning used in accounting, health care, Medicaid, and Medicare. 

 

 (a) "Attending physician" m e a n s t he physician who prescribes home health services or reviews and certifies the plan of treatment. 

 

 (b) "Encounter" refers to a documented interaction between a patient and a healthcare provider on a specific date of service, where all services are provided, regardless of the duration or number of interactions throughout that day. An exception to billing one encounter per day applies to services that cannot be provided at a single time due to medical necessity or specific practitioner orders regarding frequency or scheduling.  

 

 (c) "Home health agency" an agency primarily engaged in arranging and directly providing nursing or other healthcare services to persons at their residence.

 

 (d) "Home health aide" means a person who is certified as a nursing assistant/nurse aide by the Wyoming State Board of Nursing, and employed by a home health agency. 

 

 (e) "Home health aide service" m e a n s a covered service provided pursuant to a plan of treatment by a home health aide under the supervision of a registered nurse. 

 

 (f) "Intermittent" m e a n s three or fewer encounters per day for home health aide services and skilled nursing services combined. 

 

 (g) "Long-term custodial care" means care that has moved beyond the acute phase (has become clinically stable) and is expected to be needed for the rest of the client's life.

 (h) "Plan of treatment" m e a n s a plan prepared on CMS Form 485 or other form designated by the Department which is signed and dated by the client's practitioner, and which specifies the:

 

  (i) Client's diagnosis;

 

  (ii) Objectives of the plan;

 

  (iii) Client's prognosis;

 

  (iv) Covered services which are medically necessary for the implementation of the plan; and

 

  (v) Person or persons to provide such services or supplies.

 

 (i) "Practitioner" means attending physician, advanced practice registered nurse, physician's assistant or other licensed practitioner of the healing arts within the scope of their practice.

 

 (j) "Supplies" means medical supplies authorized for Medicaid payments under Wyo. Stat. § 42-4-103 and the Rules and Regulations for Medicaid.

 

 Section 4. Covered Services and Supplies.

 

 (a) The services and supplies specified in subsection (b) are covered services if the services are:

 

  (i) Intermittent;

 

  (ii) Medically necessary;

 

  (iii) Ordered by a practitioner;

 

  (iv) Documented in a plan of treatment; and

 

  (v) Expected to last six months or less.

 

 (b) Covered services. The following are covered services:

 

  (i) Skilled nursing services provided by a registered nurse for a client's condition while in the acute phase;

 

  (ii) Home health aide and LPN services supervised by a registered nurse, which must include the following:

 

   (A) A registered nurse shall be available for consultation in person or by telephone;

   (B) In-person home visits by a registered nurse:

 

    (1.) At least once every two weeks if the client is receiving skilled nursing care; or

 

    (2.) At least every sixty days if the client only receives home health aide services. The supervisory visits must occur while the aide is furnishing services. Supervisory visits are not a covered service;

 

   (C) Each home health aide encounter must include at least one of the following personal care services in addition to all ordered services that can be provided in one encounter unless medically indicated otherwise:

 

    (1.) Bath (bed, sponge, tub, shower, or shampooing hair);

 

    (2.) Nail or skin care (applying lotion to a client does not constitute personal care);

 

    (3.) Oral hygiene;

 

    (4.) Toileting and elimination;

 

    (5.) Safe transfers and assisted ambulation;

 

    (6.) Assisted dressing;

 

    (7.) Assisted range of motion and positioning; or

 

    (8.) Assisted nutrition or fluid intake (such as meal set-up, meal preparation, feeding assistance, and meal supervision);

 

   (D)  Each LPN encounter must include at least one of the following:

 

    (1.) direct patient care;

 

    (2.) monitoring;

 

    (3.) some assessments focus or patient history;

 

    (4.) medication management;

 

    (5.) wound care;

 

    (6.) patient and family education; or

 

    (7.) supervision of home health aides;

 

  (iii) Physical therapy services provided by a licensed physical therapist;

 

  (iv) Speech, hearing, and language services provided by a licensed speech therapist;

 

  (v) Occupational therapy services provided by a licensed occupational therapist;

 

  (vi) Medical social services provided by a licensed social worker; and

 

  (vii) Disposable medical supplies provided by a provider in accordance with a plan of treatment.

 

 Section 5. Excluded Services.

 

 (a) The following are not covered services:

 

  (i) Long-term custodial care;

 

  (ii) Homemaker services;

 

  (iii) Respite care;

 

  (iv) Home delivered meals;

 

  (v) Services for clients that are in a hospital or a nursing facility;

 

(vi) Services that are not cost effective;

 

  (vii) Services where the desired outcome could be better and faster accomplished in another setting; and

 

  (viii) Any other service not included in Section 4 of this Chapter.

 

  (ix) Initial assessment or supervisory visits required at least every sixty days performed by an LPN.

 

 (b) If a service requires a client to comply to achieve measured success and the client does not comply, that service will not be a covered services for that client.

 

 (c) Breaking up personal care into multiple encounters for the convenience of the home health agency staff or due to scheduling issues with home health staff is prohibited and the services provided in that manner will not be covered services.

 

 

 

 Section 6. Prior Authorization.

 

 (a) All home health services require prior authorization.

 

 (b) To request prior authorization, a provider must submit completed prior authorization forms specified by the Department, including a plan of treatment that includes a statement by a practitioner that the requested home health services are appropriate and medically necessary.

 

  (i) At least once every sixty days, a practitioner must review the plan of treatment to determine if it is still appropriate and medically necessary, and, if it is, sign and date the plan again and resubmit it to the Department.

 

  (ii) All new home health orders must be accompanied by documentation of a face-to-face visit between the client and the ordering practitioner within the ninety days prior to the start of home health services.

 

  (iii) If a client is eligible for both Medicare and Wyoming Medicaid, the client's ordering practitioner must provide documentation that shows the client is not home-bound and would not qualify for home health services under the client's Medicare benefits.