Presented by:

Amy Buxton – Provider Services Manager, Medicaid

Lindsey Schilling – Provider Operations Manager, Medicaid

Julie Newlin – Provider Support Unit Manager, BHD

Code of Federal Regulations (CFR) • Outlines federal regulations for Medicaid and

Medicare services

• All state Medicaid programs must adhere to the

CFR guidelines

• http://www.ecfr.gov

• Title 42 – Public Health

42 CFR 440.90 • Clinic services means preventive, diagnostic,

therapeutic, rehabilitative, or palliative services

that are furnished by a facility that is not part of a

hospital but is organized and operated to

provide medical care to outpatients.

42 CFR 440.130(d) • “Rehabilitative services,” except as otherwise

provided under this subpart, includes any

medical or remedial services recommended by

a physician or other licensed practitioner of the

healing arts, within the scope of his practice

under State law, for maximum reduction of

physical or mental disability and restoration of

a beneficiary to his best possible functional

level.

Center for Medicare and Medicaid

Services (CMS) • Oversees all Medicaid programs and regulates

compliance with the CFR

• Must approve the Medicaid State Plan for each

state

• Conversations with CMS have clarified and

confirmed that only rehabilitative services are

covered under the Wyoming Medicaid State Plan

Wyoming Medicaid State Plan • Contract/Agreement between CMS and the State

of Wyoming

• Violations of State Plan can result in the recovery

of federal funds by CMS from the state, and of all

funds paid by Medicaid from the provider

• http://health.wyo.gov/healthcarefin/medicaid/s

pa/

Physical Therapy – Attachment 3.1A Section 11.A (3/1/1992) • PHYSICAL THERAPY SERVICES ARE LIMITED TO

THOSE REHABILITATIVE AND RESTORATIVE SERVICES WHICH ARE PRESCRIBED BY A PHYSICIAN WHICH THE STATE DEEMS APPROPRIATE CONSISTENT WITH THE PATIENT’S CONDITION AND WHICH ARE PROVIDED FOLLOWING PHYSICAL DEBILITATION DUE TO ACUTE TRAUMA OR PHYSICAL ILLNESS

Occupational Therapy – Attachment 3.1A Section 11.B (7/1/2003) • OCCUPATIONAL THERAPY SERVICES ARE

LIMITED TO THOSE REHABILITATIVE AND RESTORATIVE SERVICES WHICH ARE PRESCRIBED BY A PHYSICIAN WHICH THE STATE DEEMS APPROPRIATE CONSISTENT WITH THE PATIENT’S CONDITION AND WHICH ARE PROVIDED FOLLOWING PHYSICAL DEBILITATION DUE TO ACUTE TRAUMA OR PHYSICAL ILLNESS

Speech Therapy – Attachment 3.1A

Section 11.C (7/1/2009) • Speech pathology services are limited to those

rehabilitative and restorative services which are

prescribed by a physician which the state deems

appropriate consistent with the patient’s

condition and which are provided following

physical debilitation due to acute trauma or

physical illness

Appropriate use of services - nationwide

issue for fraud and abuse

National ramp up of policy compliance

enforcement

Budget cuts

Risk of federal funds recovery

Services must be prescribed by

a physician • Plan of care and prescription must be

updated by physician at least every 30

days

Services must be rehabilitative in nature • Services that help you keep, get back, or

improve skills and functioning for daily living

that have been lost or impaired because you

were sick, hurt, or disabled.

Services must be prescribed after an

illness, injury, surgery or

unexpected/sudden acute debilitation

Habilitative services are not covered • Services that help you keep, learn, or improve skills

and functioning for daily living. These services may be covered under other programs

such as the Developmental Disabilities Supports or Comprehensive Waiver.

Note – this includes the initial 20 visits – services billed under the first 20 visits must also be rehabilitative in nature and can be reviewed by Program Integrity. If it is found that services were billed inappropriately, recovery can be initiated.

Cap Limits – Soft Cap • 20 visits for each type of therapy (physical,

occupational, or speech)

• Providers can submit a cap limit waiver to

request additional visits after the 20 initial visits

have been used

If the documentation included on the cap limit waiver

request supports the medical necessity and

rehabilitative nature of the services, Medicaid will

waive the cap and continue to pay for services

No cap limit

May receive all medically necessary

services • Must be supported by a specific plan of care and

meet all other documentation requirements

Habilitative services are not available

under the Wyoming Medicaid State Plan

(or Traditional Medicaid)

Services may be available under other

programs such as the Developmental

Disabilities Support and Comprehensive

Waivers or the Acquired Brain Injury

Waiver

Medicaid HCBS Waiver

Physical Therapy $29.71 / 15 minutes $20.83 / 15 minutes

Occupational Therapy $31.21 / 15 minutes $17.02 / 15 minutes

Speech Therapy $25.19 / 15 minutes $50.34 / session

The Developmental Disability Waiver is a voluntary Medicaid program for individuals with intellectual and developmental disabilities.

There are 3 Developmental Disability Waivers • Comprehensive, Supports and Acquired Brain Injury

(ABI)

The therapies offered through the waiver include physical therapy, occupational therapy and speech therapy.

Physical Therapy • Improve abilities for independent function through

range of motion, strength, tolerance, and

coordination

• Must be done by a licensed physical therapist

• Service available for participants age 21 and older

• Service used for maintenance and preservation of

skill

• The units must be prior authorized and prescribed

by a physician

• For the Comprehensive, Supports and ABI Waivers

Occupational Therapy • Services include assessing needs, developing a

treatment plan, determining therapeutic

intervention, training and assisting with adapting

aids.

• Must be done by a licensed occupational therapist

• Service available to participants age 21 and older

• The units must be prior authorized and prescribed

by a physician

• For the Comprehensive, Supports and ABI Waiver

Speech Language and Hearing Services • Services include screening and evaluation in

respect to speech function, development of treatment plans, therapeutic intervention, selection, assistance, and training with communication devices, and ongoing therapy

• Must be done by a licensed speech therapist

• Services available for participants 21 and older

• The units much be prior authorized and prescribed by a physician

• For the Comprehensive, Supports and ABI waiver

Contact the Behavioral Health Division

Provider Support Specialist in your area

to start the application process.

Staff Contact Counties

Phone Email & Address

Dani Sullivan Albany, Carbon, Laramie (A-T) (307) 777-3407 dani.sullivan@wyo.gov

Physical & Mailing Address:

6101 Yellowstone Rd., Suite 220

Cheyenne, WY 82002

Glen Barrows Campbell, Crook, Johnson, Sheridan & Weston (307) 684-5147 glen.barrows1@wyo.gov

Physical Address:

963 Fort St., Suite 5

Buffalo, WY 82834

Mailing Address: PO Box 948

Buffalo, WY 82834

Jennifer Adams Fremont H-Z and all Case Managers, Big Horn Enterprises, Advancing Abilities,Brain Injury Alliance, Community Entry Services, Teton & Washakie counties

(307)335-6923 jennifer.adams@wyo.gov

Physical Address: 8204 Highway 789

Lander, WY 82520

Mailing Address: PO Box 160

Lander, WY 82520

Patrice Chesmore Fremont A-G, Hot Springs, except- BHE, & Sublette counties (307)335-6924 patrice.chesmore1@wyo.gov

Physical Address: 8204 Highway 789

Lander, WY 82520

Mailing Address: PO Box 160

Lander, WY 82520

Paul DeLap Natrona (A-Q)

(307) 235-1182 paul.delap@wyo.gov

Physical & Mailing Address:

800 Werner Ct. Suite 165

Casper, WY 82601

Phillip Browning

Lincoln, Sweetwater & Uinta (307) 789-0615 phillip.browning@wyo.gov

Physical & Mailing Address:

1565 Highway 150 S. Suite B

Evanston, WY 82930

Debra Spence Park, Big Horn (307) 527-4181 debra.spence@wyo.gov

Physical & Mailing Address:

2206 E. Sheridan Ave. Unit B

Cody, Wyoming 82414

Sheila Thomalla Converse, Goshen, Laramie (U-Z), Natrona (R-Z) Niobrara, Platte & Out of State (307) 777-3322 sheila.thomalla@wyo.gov

Physical & Mailing Address:

6101 Yellowstone Rd., Suite 220

Cheyenne, WY 82002

Staff Contact Counties Phone Email

Dani Sullivan Albany, Carbon, Laramie (A-

T)

(307) 777-3407 dani.sullivan@wyo.gov

Glen Barrows Campbell, Crook, Johnson,

Sheridan & Weston

(307) 684-5147 glen.barrows1@wyo.gov

Jennifer Adams Fremont H-Z and all Case

Managers, Big Horn

Enterprises, Advancing

Abilities, Brain Injury

Alliance, Community Entry

Services, Teton & Washakie

counties

(307) 335-6923 jennifer.adams@wyo.gov

Patrice Chesmore Fremont A-G, Hot Springs

(except for Big Horn

Enterprises), & Sublette

counties

(307) 335-6924 patrice.chesmore1@wyo.gov

Paul DeLap Natrona (A-Q)

(307) 235-1182 paul.delap@wyo.gov

Phillip Browning Lincoln, Sweetwater & Uinta (307) 789-0615 phillip.browning@wyo.gov

Deb Spence Park, Big Horn (307) 527-4181 debra.spence@wyo.gov

Sheila Thomalla Converse, Goshen, Laramie

(U-Z), Natrona (R-Z)

Niobrara, Platte & Out of

State

(307) 777-3322 sheila.thomalla@wyo.gov

The Case Manager will submit a Clinical Review Team (CRT) request with the physicians prescription and other supporting documentation to approve therapy units for the plan of care.

Once approved……. Case Manager will submit a request to

the Extraordinary Care Committee (ECC) to increase the IBA to accommodate new units approved in CRT.

The Case Manager modifies the Plan of

Care to include the therapy services

through the Electronic Medicaid Waiver

System (EMWS)

A Prior Authorization number will be

issued via EMWS and mailed to the case

manager.

Services can begin at the new plan start

date.