(a) Purpose. To determine whether an applicant or client requires nursing facility services, swing bed services, LTC HCBS or ALF HCBS Waiver services, or PACE services equivalent to a nursing facility level of care.
(b) Applicability. - (i) All nursing facility, swing bed, LTC HCBS or ALF HCBS Waiver, and PACE applicants or clients shall undergo an evaluation of medical necessity which determines that nursing facility level of services are medically necessary before a provider may receive Medicaid reimbursement for services provided to that individual.
- (ii) Regardless of payment source, any nursing facility or swing bed client who is referred for a PASRR Level II evaluation shall undergo an evaluation of medical necessity as part of the determination of appropriateness of nursing facility placement, if the client does not have a valid evaluation of medical necessity as specified in this section.
(c) Criteria. The medical necessity evaluator shall determine whether nursing facility, swing bed, LTC HCBS or ALF HCBS Waiver, or PACE services are necessary by evaluating individuals according to criteria specified by the Department.
(d) Transfers. - (i) The facility to which a client requests to transfer shall not receive Medicaid reimbursement for services provided to the client unless the requirements of Section 4, Evaluations of Medical Necessity, are met.
- (ii) Any client requesting a transfer between the LTC HCBS Waiver Program, ALF HCBS Waiver Program, or PACE Program shall be evaluated if the client does not have a valid evaluation of medical necessity, as specified in this section, prior to the transfer request.
- (iii) Any client requesting a transfer to or from a nursing facility and the LTC HCBS Waiver Program, ALF HCBS Waiver Program, or PACE Program shall be evaluated if the client does not have a valid evaluation of medical necessity, as specified in this section, prior to the transfer request.
(e) Readmissions. A client who is discharged and subsequently requests readmission to a facility shall be evaluated pursuant to this section, and the facility shall not receive Medicaid payment for services provided to the client if the client does not require a nursing facility level of care. - (i) A client who is discharged from a facility and requests readmission to the facility shall be evaluated if the client does not have a valid evaluation of medical necessity as specified in this section.
(f) Redetermination of Medicaid eligibility. A client who loses Medicaid eligibility and subsequently requests a redetermination of Medicaid eligibility shall be evaluated pursuant to this Section, even if the individual has not been discharged from a program or facility. The facility in which the individual resides or into which admission is sought shall not receive Medicaid payment for services provided to the client if the level of care provided by that facility is not medically necessary.
(g) Procedure. - (i) A referral for nursing facility placement may be made by the nursing facility, hospital, Medicaid Long Term Care Eligibility Unit staff, or any representative of the individual to be evaluated.
- (A) The referral shall be communicated to the Department by the requesting person or entity indicating that an individual is requesting admission to or on the premises of a nursing facility and needs an evaluation of medical necessity.
- (B) A referral for a medical necessity evaluation for the LTC HCBS or ALF HCBS Waivers or PACE Program may be made only by the Department when the client applies for the specific program.
- (ii) Evaluations of medical necessity shall be performed by the medical necessity evaluator under guidelines outlined in the contract between the Department and the evaluating agency.
- (iii) If the evaluation determines that the level of care offered by the facility or program is not medically necessary, the medical necessity evaluator shall deliver a written denial letter to the applicant or client within three (3) working days, by hand-delivery, first class mail, or certified mail. If mailed, the date of receipt shall be deemed to be three (3) days after the date of the denial letter if sent by first class mail, or the date signed for if sent by certified mail.
- (iv) The effective date of the evaluation of medical necessity shall be the date the evaluation is performed.
(h) Validity of evaluation of medical necessity. - (i) An evaluation confirming medical necessity pursuant to this section is valid for ninety (90) days from the date of the evaluation.
- (ii) When a client applies for Medicaid while residing in a nursing facility, a new evaluation shall be performed if one has not been completed in the previous ninety (90) days.
- (iii) If the evaluation of medical necessity is less than ninety (90) days old at the time of application for Medicaid eligibility, it will be considered valid for eligibility determination purposes, regardless of the length of time the eligibility determination process takes.
(i) Re-evaluations. - (i) Nursing facility residents shall receive continued stay reviews as follows:
- (A) When a nursing facility identifies that a client's functional ability has improved, indicating the client may no longer need nursing home level of care required for Medicaid eligibility, the facility shall request a new evaluation of medical necessity in writing to the Department, regardless of the length of the client's stay in that facility.
- (B) Continued stay reviews shall be performed six (6) months from the date of the medical necessity evaluation that determines Medicaid eligibility.
- (C) Continued stay reviews shall be completed when a resident's condition has changed substantially in accordance with Chapter 19.
- (ii) Clients of LTC HCBS and ALF HCBS Waiver services or PACE services shall receive re-evaluations of medical necessity per the guidelines set forth in the applicable waiver agreements and state plan amendments.
- (iii) If more than one (1) evaluation is performed, for any reason, the results of the most recent evaluation will determine medical necessity.
(j) Not a guarantee of eligibility. An evaluation of medical necessity that determines that nursing facility, swing bed, LTC HCBS, ALF HCBS Waiver, or PACE services are medically necessary shall not be a guarantee of the individual's eligibility for Medicaid or of Medicaid reimbursement for services provided to the individual.
048-22 Wyo. Code R. § 22-4