Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 26 - COVERED SERVICES
Section 26-16 - Hospice Services
Universal Citation: WY Code of Rules 26-16
Current through September 21, 2024
(a) Eligible providers. Hospice providers certified by Medicare and located within the State of Wyoming. Services provided by a hospice provider located outside the State of Wyoming shall not be eligible for Medicaid reimbursement unless the services are pre-approved.
(b) Covered services. The following services shall be covered if provided pursuant to a written plan of care established by the hospice provider and approved by the client's attending physician:
(i) Routine
home care;
(ii) Continuous home
care;
(iii) Inpatient respite
care;
(iv) General inpatient
care;
(v) Hospice, nursing facility
room and board; and
(vi) Hospice,
inpatient hospice facility room and board.
(c) Limitations. During the time a client elects to receive hospice services, the client shall waive all rights to Medicaid payments for the following services:
(i) Hospice Services provided by a provider
other than the hospice provider designated by the client (unless provided under
arrangements by the designated hospice); and
(ii) Any Medicaid services that are related
to the treatment of the terminal illness (or a related condition) for which
hospice services were elected, or services that are equivalent to hospice
services, except for services:
(A) Provided by
the designated hospice, either directly or by arrangement with another
provider;
(B) Provided by the
client"s attending physician if that physician is neither an employee of the
designated hospice nor receiving compensation from the hospice for furnishing
such services;
(C) Provided as room
and board by a nursing facility if the client is a resident of a nursing
facility;
(D) Provided by a Home
and Community Based Waiver; or
(E)
Delivered to a client under the age of twenty-one (21) years. Clients under the
age of twenty-one (21) shall be eligible for curative services as well as
terminal illness hospice care.
(d) Medicaid allowable payment. The Medicaid allowable payment shall be determined as follows:
(i) The Medicaid allowable payment to the
hospice provider for room and board furnished in a nursing facility shall be
ninety-five percent (95%) of the nursing facility's per diem rate. The hospice
provider shall be responsible for paying the nursing facility for the room and
board services furnished to a client of hospice services.
(ii) Providers providing hospice services in
an inpatient hospice facility that does not meet eligibility criteria for
inpatient hospice care billing may receive room and board payments. Payments
for room and board shall not exceed fifty percent (50%) of the average Wyoming
Medicaid nursing home room and board rate.
(iii) Total Medicaid payments to a hospice
provider for inpatient care furnished to clients of hospice services shall not
exceed twenty percent (20%) of the aggregate number of days of hospice care
provided by the hospice provider to all Medicaid clients during the applicable
twelve-month period. The limit shall be applied as follows:
(A) For each twelve-month period beginning on
November 1, the Department shall determine the aggregate number of days of
inpatient care furnished by each hospice provider to clients of hospice
services (the number of days of inpatient care shall include general inpatient
care and inpatient respite care); and
(B) If payments for inpatient services exceed
twenty percent (20%) of the total days of Medicaid services, the Medicaid
payments for such services shall be considered overpayments and shall be
recovered.
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