RULES AND REGULATIONS

FOR THE WYOMING COLORECTAL CANCER SCREENING PROGRAM

CHAPTER 15

GENERAL PROVISIONS

            Section 1.        Statutory Authority.  This chapter is promulgated by the Wyoming Department of Health pursuant to various provisions of the 2007 General Session, Senate Enrolled Act (SEA) 92, to be codified as W.S. 35-25-204, which authorizes the Department to establish the Wyoming Colorectal Cancer Screening Program (WCCSP).

            Section 2.        Purpose and Applicability. 

(a) To provide the WCCSP the authority to issue vouchers for colonoscopies to eligible Wyoming residents who are at or below 250% of the Federal Poverty Level.

            Section 3.        General Provisions.

            (a)       These rules shall provide for the following:

(i) Case management services to Wyoming men and women enrolled in the WCCSP;

(ii) Collection of data pertaining to the colonoscopies performed through the WCCSP; and

(iii) Public education and clinical outreach to educate Wyoming men, women, and providers about colorectal cancer and evidence-based screening guidelines, as well as promote the WCCSP.

(b)      The WCCSP may issue manuals, brochures, or other documents to interpret the provisions of these rules and regulations.  Such documents shall be consistent with and reflect the policies contained in these rules and regulations.  The provisions contained in manuals and brochures shall be subordinate to the provisions of these rules and regulations, except as otherwise provided in W.S. 35-25-204.

            (c)      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, except as otherwise provided in W.S. 35-25-204.

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 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. For the purpose of the rules, the following shall apply:

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(a) “Adverse Event” is an injury or complication resulting from the colonoscopy procedure.

(b)  “Colonoscopy” is an endoscopic medical procedure that uses a long, flexible, lighted tubular instrument called a colonoscope to view the rectum and the entire inner lining of the colon (large intestine).

(c) “Department” means the Wyoming Department of Health, its agent, designee, or successor.

(d) “Enrollment Start-Date” is the date the application is approved by the WCCEDP enrollment specialist.

(e) “Federal Poverty Level” means the set minimum amount of income that a family needs for food, clothing, transportation, shelter and other necessities.  In the United States, this level is determined by the United States Department of Health and Human Services.

(f) “Team Member” refers to the Enrollment Specialist, Nurse Manager, or Program Manager for the WCCSP.

(g)  “WCCSP-approved CPT code list” refers to a code list created by the WCCSP which identifies various colonoscopy-related codes which are reimbursable by the program.  The list will be posted on the program website and accessible to all providers.

(h) “Wyoming Medical Assistance and Services Act” refers to W.S. 42-4-101 et seq. 

Section 5.        Severability.  If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in force and full effect.

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CHAPTER 16

PROGRAM APPLICANT ELIGIBILITY

& ENROLLMENT REQUIREMENTS

Section 1.        Statement of Purpose.  These rules and regulations are adopted to establish eligibility and enrollment guidelines of program applicants for the WCCSP benefits.

Section 2.        Eligibility Guidelines.  A completed and signed application must be submitted to the WCCSP for approval.  The following eligibility criteria must be met before an application may be approved for enrollment:

(a)       Residency:  Applicant must have been a resident of the State of Wyoming for at least one (1) year prior to making application under the program.  Applicant shall swear to an oath of residency when completing the application for enrollment;

(b)       Age:  Applicant must be age 50 or over, unless an order is completed by the healthcare provider indicating the need for earlier screening.  A minimum age requirement of age 18 is necessary to be screened through the program;

(c) Insurance:  Applicant shall not be eligible for reimbursement under the federal Medicare program or Wyoming Medicaid. 

(d)       Income:  Applicant must be at or below 250% of the Federal Poverty Level (as evidenced by most previous year’s income tax return or most recent proof of income);

(e)       Provider:  Applicant, upon approval, must receive their colonoscopy from a provider contracted with the WCCSP; and

(f)        10 Year Rule:  Upon approval of application for enrollment, applicant will be eligible for one (1) colonoscopy every ten (10) years, counting any colonoscopy completed before July 1, 2007, or before the applicant became a Wyoming resident.

Section 3.        Enrollment Guidelines.

(a) Payment for Colonoscopies Performed Prior to Enrollment Approval.  There will be no reimbursement to providers for colonoscopies performed prior to the date the applicant obtains WCCEDP approval.  The applicant/patient assumes all responsibility for any costs relating to procedures performed prior to the Enrollment Start Date.

(b) Enrollment Period.  A client who is enrolled in the WCCEDP will remain in the program until they are eligible for Medicare at age 65, or until proper insurance coverage and financial resources become available to the client.  If a client does not obtain a screen within three (3) months of initial enrollment approval, he/she will be notified in writing that enrollment approval may be terminated if screening is not obtained within the next ninety (90) calendar days.  If provider capacity is insufficient at the time of enrollment approval, an extension may be given at the Department’s sole discretion. 

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(c) Decision-Making Process.  Upon receipt of an application, it will be reviewed and approved or denied by a minimum of two WCCEDP team members.  If a decision is complex and cannot be determined by the team members, the case may be referred to the Program Manager for an enrollment decision.  If a decision still cannot be made, the State Health Officer may assist in making enrollment decisions.

(d)       Notification to Applicants of Approval or Denial.  Eligibility is not determined online or over the telephone.  Applicants are informed in writing whether their application has been approved or denied.  Reasons for denial will be specified in the letter. 

(e)       Review Process.  Applicants who are denied enrollment approval may submit a written letter explaining their situation or they may request that their healthcare provider submit a written explanation.  These letters shall be submitted to the Program Manager for review.  A review team, including the program nurse, is formed within the Department to respond to the applicant’s letter.  The Department will make every effort to respond to the applicant’s letter within thirty (30) work days.

(f)        Cancer Treatment.  The WCCEDP does not cover costs of treatment relating to a cancer diagnosis.  In the event the patient does not qualify for Medicaid, the Nurse Manager acts as a patient navigator to aid the individual in locating or identifying resources to help reduce the burden of a cancer diagnosis on the enrolled program participant. 

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CHAPTER 17

PROVIDER ELIGIBILITY, SCREENING METHODS,

& REIMBURSEMENT GUIDELINES

Section 1.        Statement of Purpose.  The following rules and regulations are adopted to establish provider eligibility, screening methods, and reimbursement guidelines.

Section 2.        Eligibility.  A physician must be licensed to practice medicine as determined by the credentialing state’s Board of Medicine to be an eligible provider for reimbursement of colorectal cancer screening services (i.e. colonoscopy) by the WCCSP.   

Section 3.        Reimbursement for Services.  Pursuant to W.S. 35-25-204, the WCCSP will reimburse providers for the costs relating to colonoscopy screening only.  If complications arise, and a successful screening cannot be completed via colonoscopy, an alternate method will be considered for reimbursement on a case by case basis as determined by the Department’s staff physician.

(a) Services covered by the WCCSP.  Expenses that may be reimbursed by the WCCEDP at the rate paid under the Wyoming Medical Assistance and Services Act are as follows:

(i)         Pre-operative consultation fee;

(ii)       Colonoscopy procedure;

(iii) Level IV surgical pathology, gross and microscopic examination; and

(iv) Facility and anesthesiology fees.

For a detailed look at the WCCSP approved CPT-code list, please visit http://www.health.wyo.gov/phsd/ccp/provider.html.

(b)       Services not covered by the WCCSP.

(i) There will be no reimbursement to providers for colonoscopies or related costs performed prior to the WCCSP enrollment start date.  The applicant/patient must have a WCCSP payment voucher to present to the provider prior to the procedure.  If applicant/patient does not have proper enrollment approval, the applicant/patient will assume responsibility for any costs relating to procedures performed prior to enrollment approval.

 (ii)                  Other screenings, such as Standard or Immunochemical Fecal Occult Blood Testing (FOBT), Flexible Sigmoidoscopy, Barium Enema, Stool Mutational Analysis, CT and MRI Colonography (Virtual Colonoscopy), Screening tests requested at intervals sooner than are recommended by program guidelines (unless the Department provides a written waiver to applicant pursuant to a written explanation letter by the attending physician), Medical therapy for Inflammatory Bowel Disease, or Genetic Testing are not reimbursable by the WCCEDP.

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(iii)                  Reimbursement for adverse events is not covered by the WCCSP.  The program will only reimburse for procedures identified in the WCCSP-approved CPT coding list.

(iv)      The WCCSP shall not reimburse for follow up surgery or additional care needed if an actual cancer or other condition requiring additional medical care is found. 

Section 4.        Payment Policy.  Screening by the WCCSP will be paid by the program at the Wyoming Medicaid allowable rates.  For circumstances where multiple biopsy/removal techniques are used during one colonoscopy, the program will pay 100% for the allowable Medicaid reimbursement amount for the service of the highest cost, then 50% of the allowable Medicaid reimbursement amount for the second service and 25% of the allowable Medicaid reimbursement amount for the third and sequential techniques. 

(a)       The contractor must accept as payment in full the current Medicaid allowable charge in effect on the date of the covered service as identified on the WCCSP CPT code set.

(b)       The Contractor is prohibited from making additional charge(s) to the client, any member of the client’s family, or other sources of supplementation for those services covered by the WCCSP.

(c)       The Contractor shall have and/or retain the express right to bill clients enrolled in WCCSP for any services not covered by the WCCSP.

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CHAPTER 18

PROGRAM EVALUATON & REPORTING

Section 1.        Statement of Purpose.  The following rules and regulations are adopted to institute a mechanism for evaluating program process, clinical outcomes, and cost data relating to the WCCSP.

Section 2.        Data Collection and Reporting.  Healthcare providers are required to submit the following data for each individual screened through the WCCSP.

(a) Provider Data

(i) Screening Procedure Report; and

(ii) Pathology Report (if biopsy performed).

Additionally, the WCCSP is responsible for obtaining demographic data relating to the applicant, including but not limited to the following:

(b) Demographic Information:

(i)      Age;

(ii)      Gender;

(iii)      Income;

(iv)      Residency status;

(v)      Insurance information; and

(vi)      Past health history relating to colorectal cancer.

The WCCSP will be responsible for outcome data relating to program process.  The following data will be reported to the Wyoming State Legislature with regard to program outcomes and successes:

(c) Process-related outcomes:

(i)     Marketing efforts;

(ii)     Time to process applications;

(iii)     Screening completion rates;

(iv)     Number of patients reporting barriers to transportation/translation services;

(v)     Quality and timeliness of care; and

(vi)     Patient satisfaction with screening program.

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The WCCSP is responsible for cost data relating to program.  The following cost-related data will be reported to the Wyoming State Legislature:

(d) Cost-related outcomes:

(i)      Total amount billed to the WCCSP by providers;

(ii)      Total amount paid by the WCCSP to providers;

(iii)      Provider write off amount to support the WCCSP;

(iv)      Billing averages by provider type;

(v)      Average screening cost per patient; and

(vi)      Total screening costs per year and per biennium.

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