Section 26-18 - Hospice Services (a) Eligible providers. Hospice providers certified by Medicare and located within the State of Wyoming. Services provided by a hospice provider located outside the State of Wyoming shall not be eligible for Medicaid reimbursement unless the services are pre-approved.
(b) Covered services. The following services shall be covered if provided pursuant to a written plan of care established by the hospice provider and approved by the client's attending physician: - (ii) Continuous home care;
- (iii) Inpatient respite care;
- (iv) General inpatient care;
- (v) Hospice, nursing facility room and board; and
- (vi) Hospice, inpatient hospice facility room and board.
(c) Limitations. During the time a client elects to receive Hospice Services, the client shall waive all rights to Medicaid payments for the following services: - (i) Hospice Services provided by a provider other than the hospice provider designated by the client (unless provided under arrangements by the designated hospice); and
- (ii) Any Medicaid services that are related to the treatment of the terminal illness (or a related condition) for which Hospice Services were elected, or services that are equivalent to Hospice Services, except for services:
- (A) Provided by the designated hospice, either directly or by arrangement with another provider;
- (B) Provided by the client's attending physician if that physician is neither an employee of the designated hospice nor receiving compensation from the hospice for furnishing such services;
- (C) Provided as room and board by a nursing facility if the client is a resident of a nursing facility;
- (D) Provided by a Home and Community Based Waiver; or
- (E) Delivered to a client under the age of twenty-one (21) years. Clients under the age of twenty-one (21) shall be eligible for curative services as well as terminal illness hospice care.
(d) Medicaid allowable payment. The Medicaid allowable payment shall be determined as follows: - (i) The Medicaid allowable payment to the hospice provider for room and board furnished in a nursing facility shall be ninety-five percent (95%) of the nursing facility's per diem rate as determined by Chapter 7. The hospice provider shall be responsible for paying the nursing facility for the room and board services furnished to a client of Hospice Services.
- (ii) Providers providing Hospice Services in an inpatient hospice facility that does not meet eligibility criteria for inpatient hospice care billing may receive room and board payments. Payments for room and board shall not exceed fifty percent (50%) of the average Wyoming Medicaid nursing home room and board rate.
- (iii) Total Medicaid payments to a hospice provider for inpatient care furnished to clients of Hospice Services shall not exceed twenty percent (20%) of the aggregate number of days of hospice care provided by the hospice provider to all Medicaid clients during the applicable twelve-month period. The limit shall be applied as follows:
- (A) For each twelve-month period beginning on November 1, the Department shall determine the aggregate number of days of inpatient care furnished by each hospice provider to clients of Hospice Services (the number of days of inpatient care shall include general inpatient care and inpatient respite care); and
- (B) If payments for inpatient services exceed twenty percent (20%) of the total days of Medicaid services, the Medicaid payments for such services shall be considered overpayments and shall be recovered pursuant to Chapter 16.
048-26 Wyo. Code R. § 26-18
Amended, Eff. 12/17/2015.