42-4-103 and consistent with limitations and reimbursement

42-4-103 and consistent with limitations and reimbursement methodologies established by the department, which are provided on behalf of a qualified recipient, excluding those services and supplies provided by any relative of the recipient, unless the relative is a family caregiver providing services through a corporation or a limited liability company, which corporation or limited liability company the relative may own, under a home and community based waiver program, or for cosmetic purposes only;

(iii) "Qualified" means any categorically eligible individual satisfying eligibility criteria imposed by this chapter, the state plan for medical assistance and services and by rule and regulation of the department;

(iv) "Relative" means any person as defined by department rule and regulation;

(v) "Resident" means any individual residing in this state, including any individual temporarily absent from this state;

(vi) "Institutionalized spouse" means as defined by the Medicare Catastrophic Coverage Act of 1988, P.L. 100-360;

(vii) "Department" means the state department of health;

(viii) "Direct patient care personnel" means only:

(A) Certified nursing assistants;

(B) Licensed practical nurses;

(C) Registered nurses.  (ix) "Skilled nursing home extraordinary care" means skilled nursing home services clearly exceeding standard skilled nursing home services and meeting the criteria established by the department pursuant to W.S. 42-4-104(d);

(x) "Intermediate care facility for people with intellectual disability" means "intermediate care facility for the mentally retarded" or "ICFMR" or "ICFs/MR" as those terms are used in federal law and in other laws, rules and regulations;

(xi) "Family caregiver" means a relative of a waiver recipient with a developmental disability or acquired brain injury, who provides waiver services through a corporation or a limited liability company, which corporation or limited liability company the relative may own, to the person with a developmental disability or acquired brain injury and who meets the requirements for a qualified family caregiver as established by rules promulgated by the department. Family caregivers shall be certified by the department in the same manner as nonfamily caregivers. For purposes of providing for reimbursement of services to a family caregiver, the department shall amend the state plan and apply for a waiver from the centers for Medicaid and Medicare services, as necessary;

(xii) "Intentional" means that a person, with respect to information, intended to act in violation of the law;

(xiii) "Knowing" or "knowingly" includes intentional or intentionally and means that a person, with respect to information, acts:

(A) With actual knowledge of the information;

(B) In deliberate ignorance of the truth or falsity of the information; or

(C) In reckless disregard of the truth or falsity of the information.

42-4-103. Authorized services and supplies.

(a) Services and supplies authorized for medical assistance under this chapter include:

(i) Inpatient hospital services;  (ii) Outpatient hospital services;

(iii) Laboratory and x-ray services;

(iv) Skilled nursing home services;

(v) The professional services of a licensed and certified physician, osteopathic physician or chiropractic doctor;

(vi) Home health services;

(vii) Family planning services;

(viii) Services provided by an authorized rural health care clinic;

(ix) Midwife services provided by a:

(A) Certified nurse midwife licensed by the board of nursing;

(B) Midwife licensed by the board of midwifery.

(x) Early and periodic screening, diagnosis and treatment for individuals who have not attained the age of twenty-one (21) years in accordance with Title XIX of the federal Social Security Act;

(xi) Premiums, deductibles and coinsurance under federal Medicare Part A, hospital insurance, and Part B, supplemental medical insurance;

(xii) The professional services of a licensed optometrist;

(xiii) Prescription drugs and oxygen;

(xiv) Prosthetic devices which are necessary to replace a missing portion of the body or assist in correcting a dysfunctional portion of the body including training required to implement the use of the device but excluding dental prostheses;

(xv) Licensed rehabilitation center services and if specifically prescribed by a licensed physician, outpatient services of a privately operated licensed occupational, speech, audiology or physical therapy center and the professional services of a licensed occupational therapist, licensed speech pathologist, licensed audiologist or a licensed physical therapist;

(xvi) Services provided by an institution for mental illnesses;

(xvii) Services provided under a federal home and community based waiver;

(xviii) The professional services of a licensed dentist which may be legally and alternatively performed by a licensed physician or osteopathic physician and except as provided under paragraph (a)(x) of this section, which are not primarily provided for the care, treatment or replacement of teeth or structures directly supporting teeth;

(xix) Services provided by a freestanding ambulatory surgical center;

(xx) Services provided by a certified mental health center or community substance abuse treatment center; mental health services provided to qualified recipients by a licensed physician or under the direction of a physician if an individual treatment plan is established in writing, approved and periodically reviewed by a licensed physician; services provided by a licensed mental health professional. Authorized services shall include services provided by a person holding a provisional license as a mental health professional if the services were provided under the supervision of a licensed mental health professional. The department of health shall by rule and regulation or within the state plan for medical assistance and services, define those services qualifying as mental health services under this paragraph and, pursuant to W.S. 9-2-102, establish standards for certification under this paragraph. As used in this paragraph "licensed mental health professional" means a licensed professional counselor, a licensed marriage and family therapist, a licensed addictions therapist or a licensed clinical social worker;

(xxi) Services provided by intermediate care facilities;

(xxii) Services provided by an intermediate care facility as defined under 42 U.S.C. § 1396d(d);  (xxiii) Services provided by freestanding end stage renal dialysis clinics or centers;

(xxiv) Services provided by advanced practitioners of nursing;

(xxv) Hospice care as defined in W.S. 35-2- 901(a)(xii) and authorized under 42 U.S.C. § 1396a(a)(10)(A)(ii)(VII) including hospice care in a hospice facility for an eligible individual and room and board for individuals receiving the care in a hospice facility. Reimbursement rates for hospice care shall be set annually to match Medicare hospice reimbursement rates. The room and board reimbursement rate for hospice facilities shall not exceed one hundred percent (100%) of the statewide average of the Medicaid nursing home room and board rate when an eligible individual is receiving hospice. For the purposes of this paragraph, "eligible individual" means a person who is eligible for hospice care as defined in the state Medicaid plan in effect on July 1, 2012;

(xxvi) Tuberculosis ambulatory care authorized under 42 U.S.C. § 1396a(a)(10)(A)(ii)(XII);

(xxvii) Targeted case management services, which shall be services which will assist targeted individuals eligible under the state plan in gaining access to needed medical, social, educational and other services;

(xxviii) Skilled nursing home extraordinary care in accordance with W.S. 42-4-104(d);

(xxix) Bone marrow, kidney and liver transplant services;

(xxx) Programs and services provided under the school health program;

(xxxi) Services of a licensed dietitian;

(xxxii) Air ambulance transport services, consistent with W.S. 42-4-123;

(xxxiii) Clubhouse rehabilitation services in accordance with W.S. 42-4-124;

(xxxiv) The professional services of a school psychologist;  (xxxv) The professional services of a school social worker;

(xxxvi) School based services delivered pursuant to an individualized education program, including services:

(A) Provided by an otherwise enrolled Medicaid provider type;

(B) Provided by a licensed professional in a school setting; or

(C) Otherwise covered under this chapter to support delivery of special education programs and services.

(xxxvii) The professional services of a licensed pharmacist;

(xxxviii) Podiatry services provided by a podiatrist licensed by the board of registration in podiatry, if referred to a podiatrist by a physician, physician assistant or an advanced practice registered nurse.

(b) In addition to other payments authorized under this chapter, the department may provide payments to skilled nursing homes which are providing services covered under this chapter if:

(i) The nursing home demonstrates that one hundred percent (100%) of the additional amount received will be expended upon direct patient care personnel salaries and benefits; and

(ii) The nursing home agrees to provide sufficient data to the department substantiating compliance with paragraph (i) of this subsection.

(c) For purposes of implementing Medicaid reform pursuant to 2013 Wyoming Session Laws, Chapter 117, the department may apply for any applicable waivers or permissions to allow exceptions to federal conflict free case management definitions for frontier and rural areas, which to the extent consistent with federal law, shall implement a system using a neutral third party to ensure no conflicts exist. Consistent with federal law, the department may phase in the independent case management system. In negotiating a waiver pursuant to this subsection, the department shall, to the extent practicable and approved by the center for Medicare and Medicaid services:

(i) Allow an individual or agency to provide case management and direct services to discrete clients if the services are provided under conflict free circumstances;

(ii) When implementing updated case manager educational standards, provide for a three (3) year transition period and allow credit for prior case manager experience.

42-4-104. Powers and duties of department of health; state Medicaid agent appointed by governor.

(a) The department of health shall:

(i) Administer this chapter;

(ii) Develop a state plan for medical assistance and services provided to qualified recipients under this chapter and otherwise providing for the effective administration of this chapter;

(iii) Maintain records on the administration of this chapter, report to the federal government as required by federal law and regulation and within limitations imposed under W.S.