048-46 Wyo. Code R. § 46-13

Current through April 27, 2019

Section 46-13 - Extraordinary Care Committee

(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, Division's Registered Nurse, or a behavioral specialist. Members may also consult other specialists in the field as appropriate.

(b) The ECC may 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 12 of this Chapter; and

• (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 8(c) and 8(d);
  • (C) Concerns about a Level of Service score; or
  • (D) Requests requiring ECC approval under these Rules.

(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 12(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) An ECC request for emergency services shall contain verification of how the participant's situation meets emergency criteria. Evidence shall at least include, as applicable:

• (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 physician or licensed psychologist 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) The temporary shelter is 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 if temporarily in a temporary shelter; 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) The ECC may request additional assessments, including a new ICAP, a Supports Intensity Scale, or another appropriate and standardized assessment targeted for a specific diagnosis or condition.

• (i) The additional assessment in these cases may provide more detailed information about the person's support needs and assist the ECC in evaluating the need for a different level of service or extraordinary service or support.

• (ii) Information from the ICAP, along with information from other assessments and information submitted by the participant's team shall be used to make the final decision on the request for level of service score. The additional assessments and information reviewed by the ECC may result in a level of service score increase, decrease, or no change.

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

(k) In cases of a tie vote among members, the Administrator shall issue the final vote.

(l) The Division Administrator or his/her designee may approve a time limited exception while the ECC is rendering a final decision.

(m) Any 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.

048-46 Wyo. Code R. § 46-13

Adopted, Eff. 6/21/2017.

Amended, Eff. 7/26/2018.