Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 42 - CHILDREN'S DEVELOPMENTAL DISABILITIES HOME & COMMUNITY BASED WAIVER
Section 42-9 - Development and Approval of the Individual Plan of Care
Universal Citation: WY Code of Rules 42-9
Current through September 21, 2024
(a) Development of the individual plan of care.
(i) After the targeted individualized
budget amount is identified by the Division, the individual plan of care team,
coordinated by the individually-selected service coordinator, shall assist the
participant in determining the use of the targeted individualized budget amount
in developing the individual plan of care.
(ii) The individual plan of care shall be
completed in the form and manner prescribed by the Division in accordance with
Section 23 of Chapter 1, Rules for Individually-selected Service Coordinators
of the Rules of the Developmental Disabilities Division.
(iii) The individually selected service
coordinator shall develop the individual plan of care that includes:
(A) A completed pre-approval page signed by
the participant or guardian and the individually-selected service
coordinator.
(B) Freedom of Choice
Document or its successor.
(C)
LT-MR-10 4 form or its successor.
(D) Medical report signed by a physician if
the participant is eligible due to a diagnosis of a related condition. The
medical report shall discuss the diagnosis and what the recommended treatments
or services may be.
(E)
Psychological report that is no more than 5 years old and signed by a
psychologist.
(I) The psychological report
shall specify a clinical diagnosis of mental retardation or a related
condition.
(II) The psychological
report shall provide recommendations that the individual plan of care team
shall review and address through the individual plan of care.
(F) ICAP report that is no more
than 5 years old.
(G) Objective
pages as required by the Division for each habilitation service. The
individually-selected service coordinator is responsible for ensuring that
objective pages are completed. The objectives shall:
(I) Define the training activities of an
individual and the methods used to train the activity.
(II) Be measurable and meaningful to the
participant.
(III) Be reflected on
the personal schedule.
(H) Identification of rights and rights
restrictions in accordance with Appendix A of this Chapter, including the use
of restraints as defined in Section 4 of this Chapter, including:
(I) Why the restriction is imposed.
(II) How the restriction is
imposed.
(III) The plan to restore
the right being restricted.
(IV)
Signature of the participant and/or guardian.
(V) Rights restrictions shall be reviewed at
least every six months by the individual plan of care team.
(VI) Rights restrictions that occur that are
not part of the individual plan of care shall be reported to the Division on a
form designated by the Division.
(I) Skilled nursing information on the form
required by the Division that includes all areas of skilled nursing required by
the participant.
(J) Medication
administration indicating the level of medication administration or monitoring
required for the participant. Levels of support include:
(I) Medication administration.
(II) Medication management
training.
(III) Medication
monitoring.
(IV) Ability to
self-medicate with no assistance.
(K) A behavior support plan, if applicable,
that reflects and addresses maladaptive behaviors identified by the individual
plan of care team, the psychological evaluations, and the Inventory for Client
and Agency Planning, including maladaptive behaviors listed as moderate or
above pursuant to Section 30 of Chapter 45.
(L) Schedules for habilitation, personal
care, and respite services. The purpose of the schedule shall be to provide
information about the services and supports needed throughout a participant's
day and justify the rates for services. Schedules shall be personalized and
shall:
(I) Reflect the purpose of the
services.
(II) Reflect
recommendations from therapists, physicians, psychologists, and other
professionals.
(III) Reflect the
participant's desires and goals.
(IV) Include all information required by
Chapter 45.
(b) Approval of the individual plan of care.
(i) The individually-selected service
coordinator shall submit the individual plan of care to the Division with the
Division's current technical checklist.
(ii) The Division shall have 20 calendar days
to review and approve an individual plan of care contingent upon the
individually-selected service coordinator submitting all the requested
information to the Division.
(iii)
The Division shall approve or make recommendations to modify the plan. This may
result in an adjustment to the individualized budget amount.
(iv) Upon approval and prior to
implementation of the plan, the individually-selected service coordinator shall
distribute copies of the individual plan of care to the participant, the
guardian, advocates, or representatives designated by the participant or
guardian, and to habilitation, respite, personal care, and therapy providers on
the individual plan of care in accordance with applicable privacy and
confidentiality law and regulation.
(v) All other providers shall be given
information from the individual plan of care pertinent to the provision of
services.
(vi) All services shall
be provided pursuant to the individual plan of care.
(vii) Medicaid reimbursement shall be limited
to the covered services and the providers specified in the individual plan of
care on the pre-approval form signed by the Division.
(viii) The Division shall not reimburse for
services in excess of those specified in an approved individual plan of care or
to providers not so specified.
(ix)
The Division shall not approve an individual plan of care nor reimburse for
services provided to a participant before clinical eligibility has been
established pursuant to Section 6 of this Chapter.
(x) Any provider who submits a claim for
payment for services that have been approved but not yet provided to the
participant shall be subject to the requirements of Chapter 16 and Chapter 39
including any available sanctions.
(xi) The Division shall review and approve
individual plans of care at least annually or more frequently at the option of
the Division.
(c) Modification of individual plan of care requiring approval of the Division.
(i) Modifications to the pre-approval page of
the individual plan of care shall be submitted for approval to the Division
when there is a change in service rates, a change in service units, or a change
in providers.
(ii) If the change
does not require an increase in the individualized budget amount, the Division
shall approve, deny, or make recommendations to modify the plan.
(iii) If the change requires an increase in
the individualized budget amount, the modification to the plan shall be due to
an emergency, a material change in circumstance, a potential emergency, or
other condition justifying an increase in funding and the modification shall be
reviewed by the Extraordinary Care Committee in accordance with Section 12 of
this Chapter.
(iv) The Division
shall have 7 calendar days to review and approve modifications to the
pre-approval page of the individual plan of care contingent upon the
individually-selected service coordinator submitting all the requested
information to the Division.
(v)
The effective date of the modification shall be the date indicated on the
pre-approval page by the signature of a Division representative.
(vi) When the level or intensity of services
is permanently decreased, modifications to the individual plan of care shall be
submitted for approval to the Division. The rates on the modification shall
reflect the decrease in need of services. The decrease in services may include
but is not limited to decreases in staffing levels or decreases in total hours
of service provided in a day.
(d) Modifications to the individual plan of care that do not require Division approval.
(i) The individual plan of care shall be
updated by the individually-selected service coordinator whenever there are
significant changes to the participant's needs, including:
(A) Changes in health and safety
needs.
(B) Changes in employment
status.
(C) Changes in
medication.
(D) Changes in adaptive
equipment.
(E) Changes in
diagnoses.
(F) Changes in mealtime
needs.
(G) These changes do not
need to be submitted to the Division unless the changes result in a change
listed in (c) of this Section.
(e) Participant no longer receiving waiver services.
(i) The individually-selected
service coordinator shall submit a modification ending the plan within 45
calendar days of the last date of service.
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