CurrentWyoming Department of HealthPolicy N/A

Comprehensive Waiver IBA Methodology

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This document governs how the Wyoming Department of Health assesses participant need and calculates individual budget amounts (IBAs) for people participating in or waiting for Wyoming Comprehensive Waiver services. It explains the use of ICAP scores, level of service, living situation, age, service-rate assumptions, reviews, appeals, and participant notification.

Policy Summary

PayerWyoming Department of Health

PolicyComprehensive Waiver IBA Methodology

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionOnce an IBA is assigned, the participant may choose to use it for any waiver service for which the participant qualifies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Factors determining an individual budget amount

1.0–6.0Level of service score range

2Algorithmic passes used

3–7 hoursApproximate daily service range

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CurrentWyoming Department of HealthPolicy N/A

Comprehensive Waiver IBA Methodology

Customize your policy alerts

Sign up for all Wyoming Department of Health policy alerts

Know when Wyoming Department of Health releases new policies or updates existing guidance.

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Policy Summary

PayerWyoming Department of Health

PolicyComprehensive Waiver IBA Methodology

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionOnce an IBA is assigned, the participant may choose to use it for any waiver service for which the participant qualifies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Factors determining an individual budget amount

1.0–6.0Level of service score range

2Algorithmic passes used

3–7 hoursApproximate daily service range

Adult day-service frequency

±7%Historical IBA change range

Individual Budget Amount Methodology

Initial IBA Determination

A participant's Individual Budget Amount (IBA) is determined using ALL of the following factors:

ALL of the following

An assessed Level of Service (LOS) score assigned based on the participant's ICAP scores.
The participant's living situation: family home; independent or semi-independent living; or community living services.
The participant's age: over 21, or under 21 and in school.

Level of Service Calculation

The LOS algorithm uses two separate passes. The participant's LOS is reported on a continuous scale from 1.0 through 6.0 and may include decimals; the higher result from the two passes is used.

TWO-PASS LOS CALCULATION

First pass: calculate LOS from the overall ICAP Service Score using the equation LOS = (-0.0619 × ICAP Service Score) + 6.827.
Second pass: calculate LOS from the ICAP sub-scores most closely corresponding to behavioral and medical needs: the ICAP General Maladaptive score (General Score) and the ICAP Personal Living Domain score (Personal Living score). Use the equation LOS = (-0.2232 × General Score) + (-4.21 × 10⁻⁸ × Personal Living³) + (-8.12 × 10⁻¹⁰ × Personal Living³ × General Score) + 7.2457.
Use the higher LOS score calculated by the first and second passes.
Retain fractional LOS results rather than rounding to a discrete level; for example, a score of 3.5 is not treated as either a rounded Level 3 or Level 4. Fractional levels support fair assignment when a participant's score falls near a rounding point.

Budget Amount Assignment

The IBA is assigned using the participant's LOS, living situation, age, applicable service rates, and estimated service units or days. IBAs are assigned at discrete LOS points and interpolated between those points using the curve connecting the discrete amounts.

BUDGET ASSIGNMENT

For fractional LOS scores, determine the dollar amount from the curve connecting the adjacent discrete LOS amounts. For example, if LOS 2.0 were $20,000 and LOS 3.0 were $30,000, LOS 2.5 would be close to $25,000; these figures are illustrative and are not actual IBAs.
As LOS increases, estimated service needs generally increase from approximately 3 hours per day for 3.75 days per week at the low end to approximately 7 hours per day for 5 days per week at the high end. The IBA is not limited to the hours listed in this assumption.
Because provider reimbursement rates differ by service, the number of hours available may vary depending on how the participant chooses to budget waiver services.
LIVING SITUATION CALCULATION

Scoring and Budgeting Factors

Level of Service score range

Score rangeContinuous scale from 1.0 through 6.0

Decimal scoresDecimal scores are permitted

ExampleA participant may be assigned a LOS score of 3.5 rather than a rounded score of 3 or 4

Age distinction

Over age 21Participants over age 21 are assessed under the applicable adult age methodology

Under age 21Participants under age 21 are distinguished based on whether they are in school

IBA factor

Participant, Case Manager, and Committee Actions

Note

Use the Assigned IBA

A participant may use the assigned IBA for any waiver service for which they qualify.

Prior Authorization

Request an IBA Review or Additional Funding

If the plan of care team believes the participant’s IBA does not reflect assessed needs, and the situation meets Chapter 46 criteria, the team may request an Extraordinary Care Committee (ECC) review or additional funding through the ECC process. The participant may also request a short-term increase when specific Chapter 46 conditions apply, all other available resources have been accessed, and the team has explored options in the participant’s environment, circle of support, and community.

IBA adjustments may follow a qualifying life-changing event, including onset of a medical or behavioral condition, an injury, or an emergency as defined in Chapter 46, Section 14.
Permanent adjustments may be approved when evidence demonstrates a change in assessed needs measured by the ICAP.
After additional funding is approved, the Division may conduct follow-up monitoring to confirm that funds are used appropriately and the assessed need continues.

Key Terms

Definitions

Assessment nameInventory for Client and Agency Planning (ICAP)

Functioning assessedDetermines an individual's adaptive and general maladaptive functioning

Methodology roleSupports determination of the participant's assessed needs and calculation of the IBA

Definitions

Assigned amountThe individual budget amount assigned to a participant

Permitted useAvailable for waiver services for which the participant qualifies

Participant choice

Policy Summary

PayerWyoming Department of Health

PolicyComprehensive Waiver IBA Methodology

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionOnce an IBA is assigned, the participant may choose to use it for any waiver service for which the participant qualifies.

SourceLink

On This Page

Participant living with family: calculate the IBA as the 15-minute day-services rate for the corresponding day service and LOS level multiplied by the estimated annual units of day services.

Participant living independently or semi-independently: calculate the Community Living Services (CLS) portion as the daily CLS rate for the corresponding LOS multiplied by the estimated annual days the service is required; for participants age 21 and older, calculate the day-services portion as the 15-minute day-services rate for the corresponding day service and LOS level multiplied by the estimated annual day-service units.

Participant living in a group home and/or receiving CLS in the residence: calculate the CLS portion as the daily CLS rate for the corresponding LOS multiplied by the estimated annual days the service is required; for participants age 21 and older, calculate the day-services portion as the 15-minute day-services rate for the corresponding day service and LOS level multiplied by the estimated annual day-service units.

For participants age 21 and older who do not receive school services, increase the IBA to reflect the need for 5 days per week of day services; calculate hours per day using the existing method.

Assign dollar amounts to LOS scores using polynomial curves fitted to the dollar amounts at each discrete level. The curves use y for the IBA dollar amount and x for the assessed LOS level.

Applicable polynomial curves include: Family, ages 0–21, full supports: y = 346.52x⁴ − 3977.2x³ + 15776x² − 22004x + 18945; Family, age 21+, full supports: y = 267.02x⁴ − 3144.7x³ + 12726x² − 16462x + 18707.

Applicable polynomial curves also include: CLS 1–3 (formerly Supported Living), age 18+, home service: y = 408.29x⁵ − 5790.9x⁴ + 30948x³ − 77352x² + 95934x − 27372; CLS 1–3, age 21+, home service: y = 274.9x⁴ − 3222.7x³ + 13471x² − 19700x + 18038.

For CLS 4–6 (formerly Residential Habilitation), age 18+, home service: y = 676.25x⁴ − 7843.2x³ + 32315x² − 45664x + 46496; for CLS 4–6, age 21+, day services: y = 274.9x⁴ − 3222.7x³ + 13471x² − 19700x + 18038.

Age is one of the three factors used to determine an individual budget amount

Adult day-service adjustment

Applicable participantsParticipants age 21 and older who do not receive school services

Day-service frequencyThe IBA is increased to reflect five days per week of day services

Hours per dayHours per day are still figured as before

Illustrative service range

Low endApproximately 3 hours per day for 3.75 days per week

High endApproximately 7 hours per day for 5 days per week

Use of IBAUse of the IBA is not limited to the hours listed in the assumption

Documentation Required

Submit Additional Assessments When Requested

The ECC may request additional information or assessments when the ICAP did not capture the participant’s assessed needs. These materials help the ECC evaluate whether a behavioral or medical condition indicator or “flag” is warranted.

Additional information or assessments may include a new ICAP assessment.
The ECC may request another appropriate, standardized assessment targeted to a specific diagnosis or condition.
The review may result in an increase, decrease, or no change to the participant’s IBA.

Documentation Required

Notify the Participant of the IBA

Before an initial placement on the waiver or an annual individualized plan of care (IPC) review, the case manager receives the participant’s IBA through the Electronic Medicaid Waiver System (EMWS). The case manager must notify the participant and the participant’s legally authorized representative of the IBA so they can plan for waiver services.

The same notification process applies to IBA adjustments based on legislative decisions or other factors.

Note

Provide Fair-Hearing Notification

When a funding request is modified or denied under the applicable process, the participant must be notified of the right to request a fair hearing. In most instances, funding requests that are modified or denied are eligible for a fair hearing.

Fair-hearing rights are provided when the ECC decision is rendered.

Once assigned, the participant may choose to use the IBA for any qualifying waiver service

Definitions

Score rangeA continuous score from 1.0 to 6.0

Calculation basisCalculated from the participant's ICAP scores

Calculation ruleThe higher score calculated by the two algorithmic passes is used

Definitions

Committee nameExtraordinary Care Committee (ECC)

CompositionDivision staff, the Medicaid Medical Director, the Division's Psychiatrist, and other specialists as needed

FunctionReviews qualifying requests for additional or adjusted IBA funding

Definitions

Qualifying eventA life-changing event may be the onset of a medical or behavioral condition, an injury, or an emergency

Governing standardQualifying conditions are defined in Chapter 46 of Wyoming Medicaid rules

Funding relevanceA qualifying life-changing event may support a request for additional funding through the ECC process

Definitions

Service nameCommunity Living Services (CLS)

Supported residencesParticipants may live independently, semi-independently, or in a group home

IBA calculation roleThe CLS portion of the IBA is based on the applicable daily CLS rate multiplied by estimated service days each year