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    OpenPayerPolicy UpdatesWyoming Department of HealthWyoming Medicaid Nursing Facility Coverage | OpenP…
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    CurrentWyoming Department of HealthPolicy 048.0037.22.10052021

    Determination of Nursing Facility Level of Care

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    Establishes the methods, standards, request requirements, and reconsideration process for determining whether an individual requires or continues to require nursing facility level of care under Wyoming Medicaid, including applicable home and community-based waiver programs.

    Policy Summary
    PayerWyoming Department of Health
    PolicyDetermination of Nursing Facility Level of Care
    Policy CodePolicy 048.0037.22.10052021
    Change TypeNo material change
    Effective DateOct 5, 2021
    Next Review DateN/A
    Key ActionRequest and obtain approval for a nursing facility level-of-care determination when required for the applicable long-term care service or program.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    5Approval criteria
    20 business daysReconsideration deadline
    2Possible assessment levels
    Wyoming MedicaidProgram context

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Purpose and Scope

    The rule uses an assessment of the individual’s current functional status to determine whether the person requires or continues to require nursing facility level of care. The Department makes the determination based solely on the results of a level-of-care assessment conducted by a qualified assessor.

    Key Definitions

    Nursing Facility Level of Care Determination
    DefinitionA determination as to whether an individual requires or continues to require the level of care provided in a nursing facility.
    Level of Care Assessment
    DefinitionAn assessment of an individual's current functional status used by the Department in making nursing facility level-of-care determinations.
    Level of Care Assessor
    DefinitionA registered nurse licensed to practice in the State of Wyoming and qualified by the Department or its agent as having successfully completed all requisite education and training to conduct a level-of-care assessment.

    Level-of-Care Determination Requirements

    Initial Request Approval

    A nursing facility level-of-care determination may be requested by the individual, by a guardian or legal representative with legal decision-making authority, or by an employee of a nursing facility, hospital, or other healthcare or social services provider responsible for providing or coordinating the individual’s healthcare services. The Department shall approve the request only when ALL of the following criteria are met:

    ALL of the following

    • The request is complete and submitted in accordance with the Department’s established procedures.
    • The individual to be assessed is a resident of, or intends to reside in, Wyoming.
    • The individual demonstrates a reasonable indication of need for long-term care services under any initial screening criteria established by the Department.
    • The individual is currently receiving, or has expressed interest in, a long-term care service or program that requires a nursing facility level-of-care determination.
    • The individual is a current Wyoming Medicaid recipient, has submitted an application for Wyoming Medicaid, or has been identified by a Preadmission Screening and Resident Review (PASRR) Level I Screening to require a PASRR Level II screening under Chapter 19.

    Assessment-Based Determination

    The Department makes the nursing facility level-of-care determination through the established assessment process and determination rules below:

    ALL of the following

    • The Department establishes the procedures, instruments, methods, and criteria used to conduct a level-of-care assessment.
    • The level-of-care assessment is conducted by a qualified level-of-care assessor.
    • The Department is the sole entity authorized to make nursing facility level-of-care determinations for the purposes established by the Chapter.
    • The Department makes the determination based solely on the results of the level-of-care assessment conducted by the qualified level-of-care assessor.
    • The Department makes the determination and provides notification in accordance with its established timelines and procedures.

    Reconsideration and Administrative Hearing

    The individual for whom the determination was made, or the individual’s guardian or legal representative when applicable, may request reconsideration. Reconsideration is an opportunity for alternative dispute resolution; it is not a prerequisite to requesting an administrative hearing and does not impede the right to request an administrative hearing under Chapter 4. The Department shall approve a reconsideration request only when ALL of the following requirements are met:

    ALL of the following

    • The request is submitted in writing within twenty (20) business days of the notice of adverse action.
    • The request is submitted in accordance with the Department’s established procedures.
    • For an approved reconsideration request, the Department or its agent reviews the level-of-care assessment results to determine whether the Department’s procedures, instruments, methods, and criteria were applied appropriately.

    • The reconsideration determination follows ONE of these pathways

    The level-of-care assessment conducted under this Chapter is not intended to serve as an instrument for the identification, diagnosis, or treatment of any disease or medical condition.

    A determination indicating a need for nursing facility level of care does not constitute a determination of eligibility or guarantee reimbursement for Wyoming Medicaid services. The individual must meet any additional eligibility criteria for the applicable Wyoming Medicaid services and programs.

    Request, Documentation, and Reconsideration Actions

    Prior Authorization

    Request Level-of-Care Determination

    Request a nursing facility level-of-care determination when an individual is currently receiving, or has expressed interest in, a long-term care service or program that requires the determination. An individual, authorized guardian or legal representative, or responsible provider employee may submit the request.

    • Requests are subject to Department approval and established procedures.
    Documentation Required

    Complete the Determination Request

    Submit a complete request in accordance with the Department's established procedures. The Department approves only requests that include all information necessary to evaluate the applicable screening and eligibility criteria.

    • Incomplete submissions or submissions that do not follow Department procedures may not be approved.
    Documentation Required

    Document the Qualified Assessment

    The Department makes the nursing facility level-of-care determination based solely on the results of an assessment conducted by a qualified level-of-care assessor. Use the Department-established procedures, instruments, methods, criteria, and required assessment documentation.

    • The Department is the sole entity authorized to make the determination for purposes established by the Chapter.
    • The assessment is not intended to identify, diagnose, or treat a disease or medical condition.
    Prior Authorization

    Submit Written Reconsideration on Time

    A reconsideration request must be submitted in writing within twenty (20) business days after the notice of adverse action and in accordance with the Department's established procedures. Reconsideration is an alternative dispute-resolution opportunity; it is not a prerequisite to requesting an administrative hearing and does not impair that right.

    • For an approved request, the Department or its agent reviews whether the assessment procedures, instruments, methods, and criteria were applied appropriately.
    • The Department may require a second assessment by a different assessor or affirm the determination and provide notice of the right to request an administrative hearing.
    Denial Risk

    Incomplete or Ineligible Requests Risk Denial

    Approval may be denied when the submission is incomplete, does not comply with Department procedures, or concerns an individual who is not a Wyoming resident and does not intend to reside in Wyoming. The request must also satisfy the Department's initial screening and applicable service-status requirements.

    • The individual must demonstrate a reasonable indication of need for long-term care services under Department screening criteria.
    • A request that fails any required criterion is not approved.

    Unsupported block type: denial_risk על?

    Denial Risk

    Confirm Medicaid or PASRR Status

    The individual must be a current Wyoming Medicaid recipient, have submitted an application for Wyoming Medicaid, or have been identified through a PASRR Level I Screening as requiring a PASRR Level II screening under Chapter 19. Without one of these qualifying statuses, the request does not meet the Department's approval criteria.

    • Verify the individual's Wyoming Medicaid recipient or application status, or the qualifying PASRR Level I result, before submitting the request.
    Note

    Level of Care Does Not Guarantee Coverage

    A nursing facility level-of-care determination indicating a need for that level of care does not establish eligibility for Wyoming Medicaid services or guarantee reimbursement. The individual must satisfy all additional eligibility requirements for the applicable Wyoming Medicaid service or program.

    • The Department's determination and notification are issued under its established timelines and procedures.
    • Coverage or eligibility may still be denied, reduced, terminated, or suspended under applicable requirements.

    Skilled Nursing Facility Admission

    SNF Admission Criteria

    SNF admission requires a Department nursing facility level-of-care determination based on the applicable request and assessment requirements.

    Nursing facility level-of-care request: The individual must meet the Department's request approval requirements and receive a Department nursing facility level-of-care determination based on a qualified level-of-care assessment.

    A determination does not independently establish Medicaid service eligibility or guarantee reimbursement.

    Skilled Nursing Facility Continued Stay

    SNF Continued Stay Criteria

    Continued SNF stay requires the individual to continue to meet nursing facility level-of-care requirements.

    Continued nursing facility level of care: The individual must continue to require the level of care provided in a nursing facility, as determined by the Department from a level-of-care assessment of current functional status conducted by a qualified assessor.

    The Department establishes the assessment procedures, instruments, methods, and criteria and makes the determination solely from the assessment results.

    Policy Summary
    PayerWyoming Department of Health
    PolicyDetermination of Nursing Facility Level of Care
    Policy CodePolicy 048.0037.22.10052021
    Change TypeNo material change
    Effective DateOct 5, 2021
    Next Review DateN/A
    Key ActionRequest and obtain approval for a nursing facility level-of-care determination when required for the applicable long-term care service or program.
    SourceLink
    On This Page
    Purpose and ScopeKey DefinitionsLevel-of-Care Determination RequirementsRequest, Documentation, and Reconsideration ActionsSkilled Nursing Facility AdmissionSkilled Nursing Facility Continued Stay
    The Department requires a second level-of-care assessment conducted by a different level-of-care assessor.
  1. The Department affirms its nursing facility level-of-care determination and provides the individual a notice of adverse action and the right to request an administrative hearing in accordance with Chapter 4.
  2. When a second level-of-care assessment is required, the Department bases the reconsideration determination solely on the results of the second level-of-care assessment.
  3. In accordance with Chapter 4, the Department provides notice of adverse action and the right to request an administrative hearing to any individual whose Medicaid service coverage or eligibility is denied, reduced, terminated, or suspended as a result of the reconsideration determination.