Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 2 - STATE LICENSED SHELTER CARE ELIGIBILITY AND SERVICES
Section 2-4 - Definitions

Universal Citation: WY Code of Rules 2-4

Current through September 21, 2024

Except as otherwise specified, the definitions of Chapter II, Section 3, are incorporated by this reference. The following definitions apply only to state licensed shelter care services.

(a) "Applicant." An individual that has submitted an application for state licensed shelter care services.

(b) "Attachment A." Attachment A to Chapter VII, which is incorporated by this reference.

(c) "Appropriate bed." A certified bed in a nursing facility that is:

(i) Available; and

(ii) In a room where the other bed, if any, is occupied by a member of the same sex or the spouse of the recipient.

(d) "Available." A certified bed in a nursing facility that is:

(i) Not occupied by an individual; and

(ii) Not a reserved bed for which the facility has received or will receive reimbursement.

(e) "Certified." Approved by The Health Facilities Survey, Certification and Licensure Office of WDH, its agent, designee or successor.

(f) "Chapter II." Chapter II, Rules Pertaining to General Medicaid Eligibility, of the Department of Family Services Medicaid Rules.

(g) "Chapter II.II." Chapter II.II, Rules Pertaining to Medical Institutional Care Program, of the Department of Family Services Medicaid Rules.

(h)" Chapter II.V." Chapter II.V, Rules Pertaining to SSI Related Medicaid Program, of the Wyoming Department of Family Services rules.

(i) "Chapter 2.7." Chapter 2.7, Treatment of Certain Trusts, of the Department of Family Services, Medical Programs Rules.

(j) "Chapter IV." Chapter IV, Third Party Liability, of the Wyoming Medicaid Rules.

(k) "Chapter VII." Chapter VII, Wyoming Nursing Home Reimbursement System, of the Wyoming Medicaid Rules.

(l) "Chapter XVII." Chapter XVII, Nursing Facility Resident Trust Accounts, of the Wyoming Medicaid Rules.

(m) "Chapter XIX." Chapter XIX, Nursing Facility Preadmission Screenings, of the Wyoming Medicaid Rules.

(n) "Chapter XXII." Chapter XXII, Nursing Facility Evaluation of Medical Necessity, of the Wyoming Medicaid Rules.

(o) "Claim." A request by a provider for payment for state licensed shelter care services furnished to a recipient.

(p) "County of residence." The county in which an applicant or resident lives with the intention of remaining.

(q) "Covered services." Nursing facility services.

(r) "Department (DFS)." The Wyoming Department of Family Services, its agent, designee or successor.

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

(t) "Desk review." A review by WDH of a facility's financial records and any supporting or related documentation to determine whether:

(i) claims have been submitted in accordance with this Chapter; and

(ii) that the provider has not received excess payments.

(u) "Disabled." Disabled for purposes of Medicaid eligibility.

(v) "Division." The Division of Self-Sufficiency of DFS, its agent, designee or successor, including DFS Field Offices.

(w) "Elderly." An individual that is fifty-five years of age or older, or an individual that is disabled.

(x) "Excess payments." State licensed shelter care program funds received by a provider in excess of the provider's per diem rate. "Excess funds" include funds received pursuant to a Medicaid per diem rate which is subsequently adjusted, for any reason, pursuant to Chapter VII.

(y) "Field audit." An on-site examination, verification and review by WDH of a provider's financial records and any supporting or related documentation to determine whether:

(i) claims have been submitted in accordance with this Chapter; and

(ii) that the provider has not received excess payments.

(z) "HCF." The WDH Division of Health Care Financing.

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

(bb) "Income trust." Income trust as defined by Chapter 2.7, which definition is incorporated by this reference.

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

(dd) "Medicaid per diem rate." The per diem rate established pursuant to Chapter VII.

(ee) "Medically necessary." "Medically necessary" as defined by Chapter VII, which definition is incorporated by this reference.

(ff) "Nursing facility." "Nursing facility" as defined by Chapter VII, which definition is incorporated by this reference.

(gg) "Nursing facility services." "Nursing facility services" as defined in 42 U.S.C. 1396 d(f), which is incorporated by this reference.

(hh) "Partial month care." Nursing facility services furnished to an individual that is eligible for state licensed shelter care services pursuant to Section 15, except that the individual dies before residing in the nursing facility for thirty (30) days.

(ii) "PASARR." Preadmission screening and annual resident review pursuant to Chapter XIX.

(jj) "Per diem rate." The allowable payment, as determined pursuant to this Chapter, for covered services. The per diem rate is an all-inclusive rate which includes reimbursement for all services and supplies included in the per diem rate.

(kk) "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) of Chapter VII, which is hereby incorporated by reference.

(ll) "Provider." A nursing facility located in Wyoming that meets the standards for participation as a Medicaid provider.

(mm) "Recipient." A person who has been determined eligible for and is receiving state licensed shelter care services.

(nn) "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.

(oo) "State licensed shelter care services." Nursing facility services.

(pp) "Supplemental Security Income (SSI)." The program enacted as Title XVI of the Social Security Act.

(qq) "Third party liability." Third party liability as defined by Chapter I V, which definition is incorporated by this reference.

(rr) "Undue hardship."

(i) With respect to the termination of state licensed shelter care services pursuant to subsection 18(b), an undue hardship exists if an individual would be forced to go without life sustaining services altogether or as otherwise determined on the basis of criteria established by HHS. An undue hardship may include the absence of a necessary guardianship or the lack of an income trust despite good faith efforts to develop such a trust.

(ii) With respect to the designation of a nursing facility pursuant to subsection 15(b), an undue hardship exists if:
(A) A physician certifies in writing that moving a recipient from the community of residence to a designated facility would be harmful to the recipient's health; or

(B) The individual's spouse resides in the community.

(ss) "Waiting list." A written list maintained by WDH pursuant to Section 28, which contains the names of applicants, in order of the date of application.

(tt) "Working days." 8:00 a.m. through 5:00 p.m., Mountain Time, Monday through Friday, exclusive of State holidays.

Disclaimer: These regulations may not be the most recent version. Wyoming may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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