DEVELOPMENTAL DISABILIIES DIVISION

DEVELOPMENTAL DISABILITIES DIVISION

CHAPTER 2

RULES AND REGULATIONS FOR FUNDING EMERGENCY SERVICES

Section 1. Authority.

This chapter is promulgated by the Department of Health pursuant to the Wyoming Medical Assistance and Services Act at W.S. § 42‑4‑101 et seq. and the Wyoming Administrative Procedures Act at W. S. § 16‑3‑101 et seq.

Section 2. Purpose and Applicability.

(a) This chapter shall apply to and govern state funded services authorized by W.S. § 42‑4‑120 provided to persons 18 years of age or older who are determined to be an emergency referral and who may be eligible for the Adult Developmental Disabilities Waiver, the Children’s Developmental Disabilities Home and Community Based Waiver, the Acquired Brain Injury Home and Community Based Waiver, or any other Home and Community Based Waiver administered by the Division, until eligibility is determined.

(b) The Division may issue provider manuals, provider bulletins, or both, to providers and/or other affected parties to interpret the provisions of this chapter. Such provider manuals and provider bulletins shall be consistent with and reflect the rules and procedures contained in this chapter. The provisions contained in provider manuals or provider bulletins shall be subordinate to the provisions of this chapter.

Section 3. General Provisions.

(a) Terminology. Except as otherwise specified, the terminology used in this chapter is the standard terminology and has the standard meaning used in accounting, healthcare, Medicaid and Medicare.

(b) Unless otherwise specified, the incorporation by reference of any external standard is intended to be the incorporation of that standard as it is in effect on the effective date of this chapter, including any applicable amendments, corrections, or revisions, but excluding any subsequent amendments or changes.

Section 4. Definitions.

The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indicates 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.” As defined in Chapter 43 of the Wyoming Medicaid rules.

(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 applicant or legal guardian, who supports and represents the rights and interests of the applicant in order to ensure the applicant’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 an applicant.

(d) “Adult.” A person eighteen years of age or older for purposes of this rule.

(e) “Adult Developmental Disabilities Home and Community Based Waiver.” The Adult Developmental Disabilities 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.

(f) “Applicant.” An individual who has been through the screening process pursuant to Section 7 of this chapter and who is receiving emergency funding.

(g) “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.

(h) “Assessment.” A determination, pursuant to Section 6 of Chapter 41, Chapter 42, or Chapter 43 of the Wyoming Medicaid rules, of an individual’s functional capacity and needs.

(i) “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.

(j) “Caregiver.” A person who provides services to an applicant.

(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 of the Developmental Disabilities Division rules, Rules for Individually-Selected Service Coordination.

(m) “Chapter 41.” Chapter 41, Adult Developmental Disabilities Home and Community Based Waiver of the Wyoming Medicaid Rules.

(n) “Chapter 42.” Chapter 42, Children Developmental Disabilities Home and Community Based Waiver of the Wyoming Medicaid Rules.

(o) “Chapter 43.” Chapter 43, Acquired Brain Injury Waiver Home and Community Based Waiver of the Wyoming Medicaid Rules.

(p) “Chapter 44.” Chapter 44, Environmental Modifications and Specialized Equipment for Home and Community Based Waivers of the Wyoming Medicaid Rules.

(q) “Chapter 45.” Chapter 45, Waiver Provider Certification and Sanctions of the Wyoming Medicaid Rules.

(r) “Children’s Developmental Disabilities Home and Community Based Waiver.” The Children’s Developmental Disabilities 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.

(s) “Claim.” A request by a provider for payment for covered services provided to an applicant.

(t) “Clinically eligible.” Determination that an applicant has met the requirements set forth in Section 6 of Chapter 41, Chapter 42, or Chapter 43 of the Wyoming Medicaid rules.

(u) “Covered services.” Those services that are reimbursable pursuant to Section 8 of this chapter.

(v) “Department.” The Wyoming Department of Health, its agent, designee, or successor.

(w) “Department of Family Services (DFS).” The Wyoming Department of Family Services, its agent, designee, or successor.

(x) “Developmental disability.” As defined in Chapter 41 and 42 of the Wyoming Medicaid rules.

(y) “Director.” The Director of the Department of Health or the Director's agent, designee, or successor.

(z) “Division.” The Developmental Disabilities Division of the Department of Health, its agent, designee, or successor.

(aa) “Drug used as a restraint.” Any drug that:

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

(ii) Has the temporary effect of restricting the person’s freedom of movement, and

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

(bb) “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 6 of this chapter.

(cc) “Emergency Case Management.” Services provided, as defined in Section 8, that are provided by an Individually Selected Service Coordinator.

(dd) “Emergency referral.” A person who: (1) is potentially eligible for covered services; and (2) has an emergency.

(ee) “Emergency Service Plan.” A plan that addresses the basic health, safety, medical, and support needs of a person and that includes the services provided.

(ff) “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 Chapter 41, Chapter 42, or Chapter 43 of the Wyoming Medicaid rules.

(gg) “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.

(hh) “Functionally necessary.” A service that is:

(i) Required due to the diagnosis or condition of the applicant, 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 an applicant, to increase an applicant’s independence, or both.

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

(v) For the purposes stated, utilization is neither experimental nor investigational and is generally accepted by the medical community.

(ii) “Funding.” 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.

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

(kk) “Guardian.” A person lawfully appointed as guardian to act on the behalf of the applicant.

(ll) “Individually-Selected Service Coordinator (ISC).” For the purposes of this chapter, an individual or entity that is qualified pursuant to Chapter 1, Rules for Individually-Selected Service Coordination of the Rules of the Developmental Disabilities Division, to act as an individually-selected service coordinator, and to provide emergency case management services.

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

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

(oo) “Mechanical restraint.” Any device attached or adjacent to a person’s body that he or she cannot easily move or remove that restricts freedom of movement or normal access to the body.

(pp) “Medicaid.” Medical assistance and services provided pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1900 et seq. and the Wyoming Medical Assistance and Services Act. "Medicaid" includes any successor or replacement program enacted by Congress and/or the Wyoming Legislature.

(qq) “Medical records.” All documents, in whatever form, in the possession of or subject to the control of a provider, which describe the applicant’s diagnosis, condition or treatment, including, but not limited to, the emergency service plan.

(rr) “Medicare.” The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. "Medicare" includes any successor or replacement program enacted by Congress and/or the Wyoming Legislature.

(ss) “Mental retardation.” As defined in Chapter 41 and Chapter 42 of the Wyoming Medicaid rules.

(tt) “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 person. The term personal restraint does not include briefly holding without undue force a person in order to calm or comfort him or her, or holding a person’s hand to safely escort him or her from one area to another.

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

(vv) “Provider.” A person or entity that is certified by the Division to furnish covered services and is currently enrolled as a Medicaid Waiver provider.

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

(xx) “Related condition.” As defined in Chapter 41 and Chapter 42 of the Wyoming Medicaid rules.

(yy) “Restraint.” A ‘‘personal restraint,’’ ‘‘mechanical restraint,’’ or ‘‘drug used as a restraint,’’ as defined in this section.

(zz) “Seclusion.” The involuntary confinement of a person alone in a room or an area from which the person is physically prevented from leaving. Providers seeking reimbursement for services shall not use seclusion.

(aaa) “Services.” Medical, habilitation, or other services, equipment, or supplies appropriate to meet the needs of an applicant.

(bbb) “Skilled nursing services.” Services listed in the emergency service plan that are within the scope of the Wyoming Nurse Practice Act.

(ccc) “Supervision and Safety Services.” For the purposes of this chapter, services designed to meet the applicant’s health, safety, and supervision needs.

(ddd) “Waiver.” Any Home and Community Based Waiver administered by the Division that has been submitted to and approved by the Centers for Medicare and Medicaid Services pursuant to Section 1915(c) of the Social Security Act.

Section 5. Philosophy.

(a) All persons possess inalienable rights under the Constitutions of the United States and the State of Wyoming. Persons with developmental disabilities also possess the rights outlined in the Developmental Disabilities Assistance and Bill of Rights Act of 2000, 42 U.S.C. §15001.

(b) It is the philosophy of the Division to develop reasonable and enforceable rules for the provision of services to individuals with developmental disabilities and acquired brain injuries in community settings in lieu of unnecessary institutionalization. This philosophy is mandated in the Supreme Court ruling on Olmstead v. L.C, ex rel., Zimring, 527 U.S. 581 (1999).

(c) This chapter is designed not only to support the philosophy of community based services, but to also protect the health, welfare, and safety of applicants.

Section 6. Criteria for Identifying and Funding an Emergency Referral.

(a) Criteria for identifying persons in an emergency situation, including anyone who:

(i) Has a history of developmental disabilities or brain injury, but has not completed the eligibility process for a home and community based waiver, as defined in Chapters 41, 42, and 43 respectably, and

(ii) Requires 24-hour support or 24-hour access to services, and

(iii) For whom there exists a substantial threat to his or her life or health caused by:

(A) The death or incapacitation of the person’s primary caregiver that results in homelessness or inability to live safely in the home, or

(B) Abuse, neglect, abandonment, exploitation, or self neglect that is substantiated by the Wyoming Department of Family Services, Protection and Advocacy or law enforcement, and:

(I) The person is removed from the home, and

(II) A victim’s shelter or homeless shelter is not an appropriate setting for temporary shelter and support for the person, or there is no local shelter for the person to reside, or

(III) Due to other conditions of the emergency or the person’s condition, an existing waiver provider would be the most appropriate and safe emergency intervention or shelter.

(b) Criteria used to determine eligibility for services under this chapter includes:

(i) The screening tool defined in Section 7 of this chapter indicates person has a developmental disability or acquired brain injury and is likely to meet the clinical eligibility requirements for one of the waivers, and

(ii) The screening tool verifies the situation meets the definition of emergency pursuant to this chapter, and

(iii) The person does not qualify for any other emergency funding or emergency services that would alleviate the emergency situation.

Section 7. Process for Identification and Screening of Emergency Referrals.

(a) Any person may request that the Division consider whether an individual has an emergency.

(b) Once a potential emergency referral has been identified:

(i) A basic screening of the person and situation is coordinated by a representative from the Division within one business day with support from a team that may include a representative from each of the following:

(A) Department of Family Services Protective Services Unit;

(B) Community Mental Health Center;

(C) Registered nurse certified as a waiver home and community based waiver provider, registered nurse working for a Home and Community Based waiver provider, Division nurse or Public Health Nurse, if available;

(D) Law enforcement as appropriate.

(ii) The screening shall include the following components as determined by the Division:

(A) Interview with person, family, caregivers, or others involved in the person’s life to determine if there is documentation verifying or indicating a possible developmental disability or acquired brain injury, including, but not limited to:

(I) School records.

(II) Medical records.

(III) Psychological assessment, neuropsychological assessment, or other records.

(B) Screening of functional limitations, including, but not limited to:

(I) Communication.

(II) Activities of daily living.

(III) Mobility.

(C) Description of situation that resulted in emergency and description of which agency or agencies may have a role in providing funding or other services to person.

(D) Contact information on person’s guardian, family, or any other individual who could serve as person’s advocate.

(E) Any other information gathered during the interview that is pertinent to the assessment of the emergency situation.

(iii) The representative from the Division compiles the results of the screening and submits the information to the Division Administrator or designee within one business day of completion of the screening, unless there are significant and immediate health and safety concerns. In these cases, the representative from the Division shall contact the Division Administrator or designee immediately upon completion of screening tool.

(iv) The Division Administrator or designee reviews the report upon receipt, determines if the person meets the definition and criteria for an emergency, and shares report with other appropriate agencies.

(A) If the person meets the definition and criteria for an emergency, the Division will identify and contact a provider who is available to provide emergency services, including emergency case management services, within one business day.

(B) If the person does not meet the definition and criteria for an emergency, the Division shall work with the appropriate agencies to identify other resources for assistance.

Section 8. Covered Services.

The services listed in this section are covered services if they are functionally necessary and part of a current emergency service plan approved by the Division. The Division shall establish rates for covered services.

(a) Emergency Case Management Services.

(i) Due to the critical nature of emergency situations, completion of the following emergency case management services shall occur as quickly as possible to alleviate the emergency and to quickly identify resources, services, and supports that the applicant can access:

(A) Gathering and compiling medical, educational, social, and other information.

(B) Coordinating completion of applications for Title XIX services, Medicare, social security, mental health services, vocational rehabilitation, and any other pertinent services.

(C) Applying for a temporary Medicaid number for the applicant, so that the psychological or neuropsychological assessment and Inventory for Client and Agency Planning can be completed to determine eligibility for a home and community based waiver, pursuant to Section 10 of this chapter.

(D) Developing and submitting the emergency service plan to the Division.

(E) Providing on-going oversight of the services provided to the applicant to assure health and safety needs are met.

(b) Room and Board.

(i) Compensation for room and board until the applicant, if eligible, is funded on one of the home and community based waivers, or until the applicant receives social security income or other means to pay room and board, whichever comes first.

(d) Supervision and Safety Services.

(i) Supervision and Safety services for the purposes of this chapter shall include 24-hour services that may be provided in a residential, day program, community based setting, and/or the person’s home.

(e) The Division may pre-approve, in writing, other unusual or specialized needs necessary for the applicant’s health and safety or eligibility determination on a case-by-case basis.

Section 9. Development and Approval of the Emergency Service Plan.

(a) Within two (2) business days of the Division approving funding of an emergency referral, the provider shall submit an emergency service plan to the Division listing the services to be provided and the rates for services as agreed upon. The emergency service plan shall, as much as possible, be person-centered. The plan shall be completed on a form designed by the Division and shall include the following information:

(i) Pertinent health and safety information as available, including, but not limited to:

(A) Diagnoses.

(B) Medications.

(C) Behavioral support needs, including identification of rights restrictions and a basic positive behavior support plan, if targeted behaviors are known and if there is a possibility that restraints will be used.

(D) Supervision needs.

(E) Identification of assessments and health care visits being scheduled.

(ii) A basic schedule of services, including:

(A) Locations of service.

(B) Anticipated supervision level.

(iii) Preliminary information on a plan for action if the applicant ultimately is not eligible for home and community based waiver services.

(b) The emergency service plan shall be approved by the Division in order for services to be reimbursed.

(i) The Division shall have three (3) business days to review and approve the plan, which shall have an effective date of the date the provider assumed responsibility for the applicant.

(A) Reimbursement will only occur if the provider has been identified and contacted by the Division as the provider who is best available to provide emergency services.

(d) Providers approved to provide emergency services shall also adhere to all the applicable standards in Chapter 45.

(e) In no event shall the Division be required to provide or fund covered services in the absence of available funding, or if there is evidence that the applicant will not meet the clinical eligibility for a home and community based waiver.

Section 10. Application for Home and Community Based Waiver Services.

(a) The applicant’s emergency case manager shall schedule a psychological or neuropsychological assessment within two (2) business days of approval of the emergency funding for the applicant, informing the psychologist that this is an emergency situation.

(i) If the psychological or neuropsychological cannot be completed within 30 calendar days, including the written report submitted to the case manager, the emergency case manager shall contact the Division for assistance in identifying a psychologist who can complete the assessment within that time frame.

(b) The Division shall work with the emergency case manager to arrange for an emergency Inventory for Client and Agency Planning to be completed within the 30-day period.

(c) Upon completion of the assessments clinical eligibility for one (1) of the home and community based waivers shall be determined pursuant to Chapter 41, Chapter 42, or Chapter 43.

(i) If the applicant is determined to be clinically eligible for a waiver, the applicant is classified as an emergency referral, and funding for the waiver shall be determined pursuant to Section 14 of Chapter 41, Chapter 42, or Chapter 43.

(A) The Division shall continue to fund the emergency services pursuant to this rule until the Extraordinary Care Committee (ECC) meets to determine the status of funding for the person and an individual plan of care has been approved by the Division.

(ii) If the applicant is determined to not meet clinical eligibility requirements for a waiver, the applicant and provider shall be notified by certified mail.

(A) The Division shall fund the emergency services for 30 calendar days after the determination of ineligibility is completed.

(B) Immediately upon notification from the Division that the applicant is not eligible for a waiver, the emergency case manager shall begin implementing the contingency plan and work with other appropriate agencies and resources to assist the person in transitioning out of services.

Section 11. Submission and Payment of Claims.

(a) Providers shall submit claims on an invoice on a monthly basis to the Division within 60 calendar days after provision of services.

(i) The Division shall review claims to assure compliance with the service plan and shall submit the claim for payment to the Department of Health Fiscal Services and subsequently to the Wyoming Auditor’s office for final approval and payment.

(ii) No claims will be paid if submitted after 60 calendar days of service.

Section 12. Audits.

(a) The Division may audit a provider’s financial records, medical records, or employment records at any time to determine whether the provider has received excess payments or overpayments.

(b) The Division may perform audits through employees, agents, or through a third-party. Audits shall be performed in accordance with generally accepted auditing standards.

(c) Disallowance. The Division shall recover excess payments or overpayments for services that were not approved in the person’s service plan.

(d) Reporting audit results. If at anytime during a financial audit or a medical audit, the Division discovers evidence suggesting fraud or abuse by a provider, that evidence, in addition to the Division’s final audit report regarding that provider, shall be referred to appropriate authorities.

(e) The Division shall share the results of the audit with the provider before excess payments or overpayments are recovered. However, nothing in this section shall abrogate the rights of the State to recover excess payments or overpayments.

Section 13. Reconsideration. A provider may request that the Department reconsider a decision to recover excess payments or overpayments. The request for reconsideration, the reconsideration, and any administrative hearing shall be pursuant to the reconsideration provisions of Chapter 3, Chapter 16, or Chapter 39 as applicable.

Section 14. Disposition of Recovered Funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16.

Section 15. Interpretation of Chapter.

(a) The interpretation of this chapter is at the sole discretion of the Wyoming Department of Health.

(b) The order in which the provisions of this chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.

Section 16. Superseding Effect. This chapter supersedes all prior rules or policy statements issued by the Division, including provider manuals and provider bulletins, which may be inconsistent with this chapter.

Section 17. Severability. If any portion of this chapter is found to be invalid or unenforceable, the remainder shall continue in full force and effect.

Section 1	Authority…………………………………………………………………..….	2-1
Section 2	Purpose and Applicability……………………………………………….....	2-1
Section 3	General Provisions………………………………………………………….	2-1
Section 4	Definitions…………………………………………………………………....	2-1
Section 5	Philosophy………………………………………………………………..….	2-6
Section 6	Criteria for Identifying and Funding an Emergency Referral…………...	2-6
Section 7	Process for Identification and Screening of Emergency Referrals........	2-7
Section 8	Covered Services………………………………………………………..….	2-9
Section 9	Development and Approval of the Emergency Service Plan………..…	2-10
Section 10	Application for Home and Community Based Waiver Services……..…	2-11
Section 11	Submission and Payment of Claims…………………………………..….	2-12
Section 12	Audits…………………………………………………………………………	2-12
Section 13	Reconsideration………………………………………………………….….	2-13
Section 14	Disposition of Recovered Funds…………………………………….…….	2-13
Section 15	Interpretation of Chapter…………………………………………………...	2-13
Section 16	Superseding Effect………………………………………………………….	2-13
Section 17	Severability…………………………………………………………………..	2-13