Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 43 - ACQUIRED BRAIN INJURY HOME AND COMMUNITY BASED WAIVER
Section 43-4 - Definitions

Universal Citation: WY Code of Rules 43-4

Current through September 21, 2024

The following definitions shall apply in the interpretation and enforcement of these rules. Where the contexts in which words are used in these rules indicate that such is the intent, words in the singular number shall include the plural and vice versa. Throughout these rules gender pronouns are used interchangeably. The drafters have attempted to utilize each gender pronoun in equal numbers, in random distribution. Words in each gender include individuals of the other gender.

(a) "Acquired brain injury."

(i) Any combination of focal and diffuse central nervous system dysfunction, both immediate and/or delayed, at the brain stem level and above.

(ii) These dysfunctions are acquired through the interaction of any external forces and the body, oxygen deprivation, infection, toxicity, surgery, and vascular disorders not associated with aging.

(iii) It is an injury to the brain that has occurred since birth.

(iv) It may have been caused by an external physical force or by a metabolic disorder(s).

(v) It includes traumatic brain injuries such as open or closed head injuries and non-traumatic brain injuries such as those caused by strokes, tumors, infectious disease, hypoxic injuries, metabolic disorders, and toxic products taken into the body through inhalation or ingestion.

(vi) It does not include brain injuries that are congenital or brain injuries induced by birth trauma.

(vii) These dysfunctions are not developmental or degenerative.

(b) "Acquired Brain Injury Home and Community Based Waiver." The Acquired Brain Injury Home and Community Based Waiver submitted to and approved by the Centers for Medicare and Medicaid Services pursuant to Section 1915(c) of the Social Security Act.

(c) "Advocate." A person, chosen by the participant or legal guardian, who supports and represents the rights and interests of the participant in order to ensure the participant's full legal rights and access to services. The advocate can be a friend, a relative, or any other interested person. An advocate has no legal authority to make decisions on behalf of a participant.

(d) "Adult." A person twenty-one years of age or older for purposes of the Acquired Brain Injury Home and Community Based Waiver.

(e) "Applicant." An individual who is requesting services.

(f) "Application." A written statement, in the form specified by the Division, which is submitted to the Division, in which an individual indicates that he or she is interested in receiving covered services. An application may be submitted by one person on behalf of another but shall have the legal guardian's signature if applicable.

(g) "Assessment." A determination, pursuant to Section 6 of this Chapter, of an individual's functional capacity and needs.

(h) "Behavior support plan." A written plan that is developed based on a functional assessment of behaviors that negatively impact a person's ability to acquire, retain, and/or improve the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings, and that contains multiple intervention strategies designed to modify the environment and teach new skills.

(i) "Caregiver." A person who provides services to a participant.

(j) "Case Management." Services that assist participants in gaining access to needed waiver and other Wyoming Medicaid state plan services, as well as needed medical, social, educational, and other services, regardless of the funding source for the services to which access is gained. Case management services are provided by individually-selected service coordinators, whose responsibilities include ongoing monitoring of the provision of services included in the individual plan of care, and initiating and overseeing the process of assessment and reassessment of the participant's level of care and review of the individual plan of care.

(k) "Centers for Medicare and Medicaid Services (CMS)." The Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services, its agent, designee or successor.

(l) "Chapter 1." Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.

(m) "Chapter 3." Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.

(n) "Chapter 16." Chapter 16, Medicaid Program Integrity, of the Wyoming Medicaid Rules.

(o) "Chapter 26." Chapter 26, Medicaid Covered Services, of the Wyoming Medicaid Rules.

(p) "Chapter 35." Chapter 35, Medicaid Benefit Recovery, of the Wyoming Medicaid Rules.

(q) "Chapter 39." Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid Rules.

(r) "Chapter 41." Chapter 41, DD Adult Waiver Services, of the Wyoming Medicaid Rules.

(s) "Chapter 42." Chapter 42, DD Child Waiver Services, of the Wyoming Medicaid Rules.

(t) "Chapter 44." Chapter 44, Environmental Modifications and Specialized Equipment, of the Wyoming Medicaid Rules.

(u) "Chapter 45." Chapter 45, Waiver Provider Certification and Sanctions, of the Wyoming Medicaid Rules.

(v) "Claim." A request by a provider for Medicaid payment for covered services provided to a participant.

(w) "Clinically eligible." Determination that a person has met the requirements set forth in Section 6(c) of this Chapter.

(x) "Cognitive retraining services." Training provided to the participant or family members that shall assist the compensation or restoring of cognitive function, including but not limited to ability/skills for learning, analysis, memory, attention, concentration, orientation, and information processing.

(y) "Conservator." A person appointed by the court to manage the estate for an individual incapable of managing his or her financial affairs.

(z) "Covered services." Those services that are Medicaid reimbursable pursuant to Section 7 of this Chapter.

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

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

(cc) "Dietician." A person who is registered as a dietician by the Commission on Dietetic Registration.

(dd) "Dietician services." Services furnished by a registered dietician, including:

(i) Menu planning.

(ii) Consultation with and training of caregivers, and

(iii) Education of participants.

(ee) "Director." The Director of the Department or the Director's agent, designee, or successor.

(ff) "Division." The Developmental Disabilities Division of the Department, its agent, designee or successor.

(gg) "Drug used as a restraint." Any drug that:

(i) Is administered to manage a participant's behavior in a way that reduces the safety risk to the participant or others, and

(ii) Has the temporary effect of restricting the participant's freedom of movement, and

(iii) Is not a standard treatment for the participant's medical or psychiatric condition.

(hh) "Emergency." A circumstance or set of circumstances or the resulting state that calls for immediate action or an urgent need for assistance or relief as defined in Section 14 of this Chapter.

(ii) "Emergency case." A participant currently receiving services who has an emergency.

(jj) "Emergency referral." A person who:

(1) is potentially eligible for covered services; and

(2) has an emergency.

(kk) "Enrolled." Enrolled as defined in Chapter 3.

(ll) "Environmental modification." The physical modification of a residence of a participant pursuant to Chapter 44.

(mm) "Excess payments." Excess payments as defined in Chapter 16 and Chapter 39.

(nn) "Extended Wyoming Medicaid state plan services." Services which are available to the general Medicaid population through the Wyoming Medicaid state plan, but which may be made available to a participant whose needs exceed state plan service limitations. Extended services include:

(i) Occupational therapy services.

(ii) Physical therapy services.

(iii) Speech, hearing, and language services.

(iv) Any other services covered by Medicaid.

(nn) "Extraordinary Care Committee (ECC)." A committee that has the authority to approve or deny individual plans of care, emergency funding, and funding due to a material change in circumstance or other condition justifying an increase in funding as defined in Section 12 of this Chapter. Membership of the ECC shall include a representative of the Division, a representative of the State Medicaid Program, and a representative of the Department's Fiscal Office.

(oo) "Extraordinary care rate." Payment in addition to the individualized budget amount, pursuant to Section 12 of this Chapter, because of an emergency, a material change in circumstances, or other condition justifying an increase in funding.

(pp) "Financial records." All records, in whatever form, used or maintained by a provider in the conduct of its business affairs and which are necessary to substantiate or understand the information contained in the provider's cost reports or a claim.

(qq) "Functionally necessary." A waiver service that is:

(i) Required due to the diagnosis or condition of the participant, and

(ii) Recognized as a prevailing standard or current practice among the provider's peer group, or

(iii) Intended to make a reasonable accommodation for functional limitations of a participant, to increase a participant's independence, or both.

(iv) Provided in the most efficient manner and/or setting consistent with appropriate care required by the participant's condition.

(v) For the purposes stated, utilization is not experimental or investigational and is generally accepted by the medical community.

(ss) "Funding." That combination of federal and state funds available to pay for covered services. Funding does not include any other funds available to the Department that are not designated for covered services.

(tt) "Generally Accepted Auditing Standards (GAAS)." Current auditing standards, practices and procedures established by the American Institute of Certified Public Accountants.

(uu) "Guardian." A person lawfully appointed as a guardian to act on the behalf of the participant or applicant.

(vv) "Habilitation." Services designed to assist participants in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings. Habilitation includes:

(i) Day habilitation - Assistance with acquisition, retention, or improvement in self-help, socialization, and adaptive skills which take place in a non-residential setting, separate from the home or facility in which the participant resides.

(ii) In-home support - The provision of intermittent one-to-one habilitation services provided in the participant's home or the community to participants who reside with family, guardians, or independently. Individuals receive skills training to increase independence related to their own health care, self-care, safety, and access and use of community services.

(iii) Prevocational services - Services that prepare an individual for paid or unpaid employment, but are not job-task oriented. Services include teaching such concepts as compliance, attendance, task completion, problem solving, and safety. Prevocational services furnished under the waiver shall not be available under a program funded under the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Improvement Act of 2004.

(iv) Residential habilitation - The provision of habilitation services provided in the participant's home or community that provide assistance with acquisition, retention, or improvement in skills related to activities of daily living, such as personal grooming and cleanliness, bed making and household chores, eating and preparation of food, and the social and adaptive skills necessary to enable the individual to reside in a non-institutional setting. Residential habilitation services shall include access to residential habilitation services on a 24-hour basis.

(v) Supported employment services - Services provided to assist participant in sustaining paid employment, including supervision and training. Supported employment services furnished under the waiver shall not be available under a program funded by either the Rehabilitation Act of 1973 or Disabilities Education Improvement Act of 2004.

(ww) "HHS." The United States Department of Health and Human Services, its agent, designee, or successor.

(xx) "ICF/MR." An intermediate care facility for people with mental retardation as defined in 42 U.S.C. § 1396 d(d), which is incorporated by this reference.

(yy) "Individualized Budget Amount (IBA)." The Division's allocation of Medicaid waiver funds that may be available to a participant to meet his or her needs pursuant to Section 8 of this Chapter.

(zz) "Individual Plan of Care (IPC)." A written plan of care for a participant that describes the type and frequency of services to be provided to the participant regardless of the funding source and that identifies the provider or provider types that furnish the described services. The IPC shall reflect the services and actual units that providers are agreeing to provide over the plan year.

(aaa) "Individual Plan of Care (IPC) team." A group of persons who are knowledgeable about the person and are qualified, collectively, to assist in developing an individual plan of care for that person. Membership of the team shall include the participant, the guardian if applicable, the individually-selected service coordinator, providers on the person's individual plan of care, an advocate if applicable, and any other person chosen by the participant.

(bbb) "Individually-selected Service Coordinator (ISC)." An individual or entity that is qualified pursuant to Chapter 1, Rules for Individually-selected Service Coordinators of the Rules of the Developmental Disabilities Division to act as an individually-selected service coordinator, also known as case manager.

(ccc) "Informed choice." A decision made by a participant or guardian if applicable, that is made voluntarily, without coercion or undue influence, and that is based on sufficient experience and knowledge, including exposure, awareness, interactions, and/or instructional opportunities, to ensure that the choice is made with adequate awareness of all the available alternatives to and consequences of options available.

(ddd) "Inventory for Client and Agency Planning (ICAP)." An instrument used by the Division to help determine eligibility and to determine the needs of the participant, available from Riverside Publishing, its successor or designee.

(eee) "Institution." An Intermediate Care Facility for people with Mental Retardation (ICF/MR), nursing facility, hospital, prison, or jail.

(fff) "LT-ABI-105." A document, or its successor, completed by the individually-selected service coordinator that verifies that the participant or applicant meets the ICF/MR level of care.

(ggg) "Mechanical restraint." Any device attached or adjacent to a participant's body that he or she cannot easily move or remove that restricts freedom of movement or normal access to the body.

(hhh) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act and/or the Wyoming Medical Assistance and Services Act. "Medicaid" includes any successor or replacement program enacted by Congress and/or the Wyoming Legislature.

(iii) "Medicaid allowable payment." Medicaid reimbursement for covered services as determined pursuant to Section 18 of this Chapter.

(jjj) "Medicaid Fraud Control Unit (MFCU)." The Medicaid Fraud Control Unit of the Wyoming Attorney General's Office, its agent, designee, or successor.

(kkk) "Medical determination." Determination that a person has met the requirements set forth in Section 6 of this Chapter.

(lll) "Medical records." All documents, in whatever form, in the possession of or subject to the control of a provider, which describe the participant's diagnosis, condition, or treatment, including, but not limited to, the individual plan of care.

(mmm) "Medically necessary." A health service that is required to diagnose, treat, cure, or prevent an illness, injury, or disease which has been diagnosed or is reasonably suspected to relieve pain or to improve and preserve health and be essential to life. The services must be:

(i) Consistent with the diagnosis and treatment of the participant's condition.

(ii) Recognized as the prevailing standard or current practice among the provider's peer group.

(iii) Required to meet the medical needs of the participant and undertaken for reasons other than the convenience of the participant and the provider, and

(iv) Provided in the most efficient manner and/or setting consistent with appropriate care required by the participant's condition.

(nnn) "Medicare." The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.

(ooo) "Medication administration." Medication physically given by someone other than a participant because the participant cannot take his or her own medications or administer treatments.

(ppp) "Medication management training." Medication management training completed by a nurse, including instructing and assisting the participant in setting up medications.

(qqq) "Medication monitoring." Observation and documentation of participant's self-administration of medication by provider or provider staff for participants who do not require medication administration or medication management by a nurse.

(rrr) "Modification to individual plan of care." A change to an individual plan of care pursuant to Section 9 of this Chapter. A modification may include the addition, substitution, or deletion of providers, covered services, or both. Modifications may increase or decrease the Medicaid waiver allowable payment.

(sss) "Neuropsychological evaluation." Evaluation using a battery of tests identified by the Division administered by a psychologist trained in administering neuropsychological assessments.

(ttt) "Objectives." Set of meaningful and measurable goals for the participant and the methods used to train the person on the goals.

(uuu) "Occupational therapist." A person licensed to practice occupational therapy pursuant to W. S. § 33-40-102(a)(iii).

(vvv) "Occupational therapy services." Occupational therapy services that are:

(i) Provided by or under the scope of practice of an occupational therapist, and

(ii) Necessary to keep a participant in his or her home or out of an institution.

(iii) Occupational therapy services may include individual therapy and group therapy.

(www) "Overpayments." Overpayments as defined in Chapter 16 and Chapter 39.

(xxx) "Participant." An individual who has been determined eligible for covered services on the Waiver.

(yyy) "Personal care services." Services to assist a participant with the activities of daily living, including eating, bathing, dressing and personal hygiene, and household activities.

(zzz) "Personal restraint." The application of physical force or physical presence without the use of any device, for the purposes of restraining the free movement of the body of the participant. The term personal restraint does not include briefly holding without undue force a participant in order to calm or comfort him or her, or holding a participant's hand to safely escort him or her from one area to another.

(aaaa) "Person-centered planning." A process, directed by a participant, that identifies the participant's strengths, capacities, preferences, needs, the services needed to meet the needs, and providers available to provide services. Person-centered planning allows a participant to exercise choice and control over the process of developing and implementing the individual plan of care.

(bbbb) "Physical therapist." A person licensed to practice physical therapy pursuant to W. S. § 33-25-101(a)(ii).

(cccc) "Physical therapy services." Maintenance or restorative physical therapy services that are:

(i) Prescribed by a physician.

(ii) Provided by or under the scope of practice of a licensed physical therapist, and

(iii) Necessary to keep a participant in his or her home or out of an institution.

(iv) Physical therapy services may include individual therapy and group therapy.

(dddd) "Physician." A person licensed to practice medicine or osteopathy by the Wyoming Board of Medical Examiners or a similar agency in a different state.

(eeee) "Power of Attorney." An instrument in writing whereby one person, as principal, appoints another as his agent and confers authority to perform certain specified acts or kinds of acts on behalf of principal (Black's Law Dictionary, Sixth Edition, 1990).

(ffff) "Prior authorization." Prior authorization as defined in Chapter 3.

(gggg) "Provider." A person or entity that is certified by the Division to furnish covered services and is currently enrolled as a Medicaid waiver provider.

(hhhh) "Psychologist." A person licensed to practice psychology pursuant to W.S. § 33-27-113(a)(v).

(iiii) "Representative payee." A person or organization appointed by the Social Security Administration to manage Social Security, Veterans' Administration, Railroad Retirement, Welfare Assistance or other state or federal benefits or entitlement program payments on behalf of an individual who cannot manage or direct the management of his/her own money.

(jjjj) "Respite" or "Respite services." Services provided:

(i) On a short-term basis pursuant to the individual plan of care.

(ii) To a participant who is unable, unassisted, to care for himself or herself, and

(iii) Because the participant's primary caregiver is absent or in need of relief from furnishing such services.

(kkkk) "Restraint." A personal restraint, mechanical restraint, or drug used as a restraint as defined in this section.

(llll) "Schedule." A personalized list of tasks or activities that describe a typical week for a participant. The schedule shall reflect the desires of the participant and shall include the service being provided, details on training on specific goals for habilitation services, level of supervision needed if specified in the individual plan of care, health and safety needs, activities, date, time in and time out for provision of services, provider signatures, and approximate number of hours in service.

(mmmm) "Seclusion." The involuntary confinement of a participant alone in a room or an area from which the participant is physically prevented from leaving. Providers seeking reimbursement for waiver services shall not use seclusion.

(nnnn) "Services." Medical, habilitation or other services, equipment, or supplies, appropriate to meet the needs of a participant.

(oooo) "Skilled nursing services." Services listed in the individual plans of care that are within the scope of the Wyoming Nurse Practice Act.

(pppp) "Specialized equipment." New or used devices, controls, or appliances that enable a participant to increase his or her ability to perform the activities of daily living or to perceive, control, or communicate with the environment in which the participant lives, pursuant to Chapter 44.

(qqqq) "Speech, hearing, and language services." The following services, if furnished by a speech pathologist or audiologist or under the scope of practice of a speech pathologist or audiologist:

(i) Speech pathology and audiology services, including articulation, pragmatic language training, and devices used by the participant.

(ii) Assessment of participant's use of visual cues.

(iii) Assessment of the need for and use of amplification.

(iv) Assessment of a person's need for alternative speech output devices.

(v) Speech, hearing, and language services may be provided as individual therapy and group therapy.

(rrrr) "Speech pathologist." A person licensed to practice speech pathology pursuant to W. S. 33-33-102(a)(iii).

(ssss) "Third-party liability." Third-party liability pursuant to Chapter 35.

(tttt) "Time out." The restriction of a participant for a reasonable period of time to a designated area from which the participant is not physically prevented from leaving, for the purpose of providing the participant an opportunity to regain self-control.

(uuuu) "Transition process." The process of changing from one provider of services to another, from one home and community based service to another, or from one residential location to another.

(vvvv) "Waiting list." A list of persons who are eligible for covered services and who have submitted a completed application, but the services are unavailable because of limits imposed by funding or the waiver. The waiting list is maintained by the Division as specified in Section 13 of this Chapter.

(wwww) "Waiver." The Acquired Brain Injury Home and Community Based Waiver submitted to and approved by the Centers for Medicare and Medicaid Services pursuant to Section 1915(c) of the Social Security Act.

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