Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 46 - MEDICAID SUPPORTS AND COMPREHENSIVE WAIVERS
Section 46-15 - Extraordinary Care Committee

Universal Citation: WY Code of Rules 46-15

Current through September 21, 2024

(a) The ECC shall be composed of a Division waiver manager, a Medicaid manager, the Participant Support Specialist presenting the case, and a representative from the Department's fiscal unit. When appropriate, the ECC may also include the Division's licensed psychiatrist, the Medicaid Medical Director, the Division's registered nurse, or a behavioral specialist. Members may also consult other specialists in the field as appropriate.

(b) The ECC shall only approve additional funds for participant cases if funding is available in the Division's waiver budget appropriation.

(c) The ECC shall review:

(i) Emergency cases as defined by Section 14 of this Chapter;

(ii) Extraordinary cases that include a significant change in service need due to the onset of a behavioral or medical condition or injury including:
(A) A temporary change in circumstances, which requires a higher level of service or support to ensure the health, safety, and welfare of the participant;

(B) Temporary funding increases under Section 11(d) of this Chapter;

(C) Concerns about a Level of Service score; or

(D) Requests requiring ECC approval under these Rules; and

(iii) Other supplemental requests as defined in the Comprehensive and Supports Service Index, which is incorporated by reference.

(d) Emergency cases can arise for a person who is eligible for covered services but is on the wait list, or for participants currently receiving Comprehensive or Supports waiver services who may be determined to be in an emergency situation pursuant to Section 14(a) of this Chapter.

(e) The ECC shall have the authority to approve, partially approve, or deny a submitted funding request for any person deemed eligible for a waiver operated by the Division.

(f) Before submission, the participant's plan of care team shall meet and come to a consensus that an ECC request is necessary and other support or resource options have been explored. The case manager shall ensure the request contains, at a minimum:

(i) Written statements or reports from the other state or regional agencies that support the emergency case including specific incidents, notes related to the type of condition or injury, witnesses, follow-up, treatment summaries, and any documented accounts of events by witnesses;

(ii) Documentation of other approaches or supports that have been attempted;

(iii) Written statements from a credentialed professional related to the area of concern, explaining the significant change in the participant's functioning limitations that result in an assessed need for additional supports or services and how the person's life or health is in jeopardy without such supports and services;

(iv) Evidence that the person does not qualify for funding or services through any other agency that would alleviate the emergency situation; and

(v) For persons requesting services or supports due to homelessness, evidence that:
(A) Either:
(I) Other community resources, such as a victim's shelter, or other temporary residence are not available or appropriate; or

(II) Other community resources are insufficient to meet the person's immediate health and safety needs, and there is evidence of immediate and serious harm to the person's life or health; and

(B) Due to other conditions of the emergency or the person's condition, waiver services would be the necessary and appropriate intervention.

(g) A request may be made by the participant's plan of care team if they can demonstrate that a participant's Level of Service score does not reflect the participant's assessed need.

(h) A request shall be submitted on the form provided by the Division, and accompanied by additional information that the participant and the participant's plan of care team does not see adequately captured in the ICAP or in the information stored electronically by the Division.

(i) ECC requests that do not meet the criteria outlined in subsection (f) of this Section shall not be considered by the ECC.

(j) The ECC may request additional assessments, referrals, or outside consultation. The additional assessments and information may result in a level of service score increase, decrease, or no change. If the participant or plan of care team declines the additional requests, the ECC request shall be denied.

(k) Decisions of the ECC shall be by majority vote and issued in writing within twenty (20) business days of the ECC review.

(l) In cases of a tie vote among members, the Section Administrator or his/her designee shall issue the final vote.

(m) The Section Administrator or his/her designee may approve time limited funding while the ECC is rendering a final decision.

(n) An eligible individual denied services under this Section may request administrative review of that decision pursuant to Chapter 4 of the Department of Health's Medicaid Rules.

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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