(a) Purpose. To determine whether ICF/MR services are medically necessary.
(b) Applicability. All applicants or recipients must undergo an evaluation of need for ICF/MR services before a facility may receive Medicaid reimbursement for services provided to that individual.
(c) Criteria. The medical necessity of ICF/MR services shall be determined using the factors in paragraphs (i) through (iv). - (i) The individual:
- (A) Is mentally retarded or is a person with a related condition;
- (B) Requires specialized services directed toward the development of skills necessary for maximum independence or the prevention of regression or loss of current skills and abilities:
- (C) Meets the criteria of paragraphs (ii) or (iii); and
- (D) Has at least one functional need specified in paragraph (iv).
- (ii) Medical needs: The individual requires:
- (A) Daily monitoring due to a medical condition where overall care planning is necessary; or
- (B) Staff supervision due to the effects of medication.
- (iii) Psychological needs. The individual:
- (A) Is expected to remain in a facility for thirty or more consecutive days; and
- (B) Requires supervision due to:
- (I) Impaired judgment and limited capabilities;
- (II) Behaviors, abusiveness or assaultiveness; or
- (III) The effects of psychotropic medications.
- (iv) Functional needs. The individual requires assistance with three or more of the following:
- (A) Activities of daily living and self-help skills such as feeding, toileting, dressing and bathing;
- (B) Ambulation or mobility;
- (C) Routine incontinence care, catheter care or ostomy care; or
- (D) Requires a structured and safe environment that provides 24-hour supervision.
(d) Reporting. After evaluating the individual pursuant to subsection (c), the evaluator shall complete and submit the forms specified by the Department in the manner specified by the Department.
(e) Transfers. - (i) The facility to which a recipient proposes to transfer shall not receive Medicaid reimbursement for ICF/MR services provided to the recipient unless the requirements of subsection (c) are met.
- (ii) Recipients that are temporarily absent from a facility must return to the facility from which they are absent before a transfer may be executed.
(f) Readmissions. A recipient that is discharged and subsequently seeks readmission to a facility must be evaluated pursuant to this Section. The facility in which the individual resided prior to discharge or the facility into which admission is sought shall not receive Medicaid payment for ICF/MR services provided to the recipient if the recipient does not meet the requirements of subsection (c).
(g) Redetermination of Medicaid eligibility. A recipient that loses Medicaid eligibility and subsequently seeks a redetermination of Medicaid eligibility must be evaluated pursuant to this Section, even if the individual has not been discharged. The facility in which the individual resides or into which admission is sought shall not receive medicaid payment for ICF/MR services provided to the recipient if the requirements of subsection (c) are not met.
(h) Procedure. - (i) Timely evaluation. An evaluation of need for ICF/MR services shall be timely if performed on or before the date of admission. The facility may receive Medicaid reimbursement for covered services provided on or after the date of admission if there is a timely evaluation.
- (iii) Untimely evaluation. An evaluation performed after the date of admission is not timely. The effective date of the evaluation shall be the date the evaluation is complete. The facility may not receive medicaid reimbursement for covered services provided before the effective date of the evaluation.
- (iv) The Department shall give written notice to the applicant or recipient if the evaluation of need for ICF/MR services determines that such services are not medically necessary. That determination shall be appealable pursuant to Chapter I of these rules.
(i) Not a guarantee of eligibility. An evaluation of need for ICF/MR services that determines that such services are medically necessary is not a guarantee of the individual's eligibility for Medicaid nor of Medicaid reimbursement for covered services provided to the individual.
048-25 Wyo. Code R. § 25-8