WY Medicaid Behavior Health Program Administration

October 19, 2018

PAGE 1

PROGRAM MONITORING AND EXPENDITURES

WY Medicaid coverage of behavioral health services is an optional program benefit for adults and a

mandatory program benefit for children under the age of 21. The state of Wyoming has elected to cover

eligible behavioral health services for both adults and children pursuant to federal and state regulations

and guidelines. As part of the program’s routine monitoring of provider participation, client utilization,

coding/billing and expenditures, it was noted that there were significant changes in program data

throughout 2015 and 2016 that suggested potential compliance challenges.

The WY Medicaid Annual Report showed an 18% increase in spending on covered behavioral

health services over a 5 year timeframe

The WY Medicaid PMPM Report showed an increase in the PMPM for behavioral health services

from $32.19 PMPM in SFY 2012 to $43.17 PMPM in SFY 2016

In SFY 2014 and SFY 2015, there was legislative action directed at expanding qualified provider

participation in Medicaid.

2014 SEA 49 – provided authority for the following licensed practitioners to enroll and receive

payment from Medicaid; Licensed Clinical Social Workers, Licensed Professional Counselors,

Licensed Addictions Counselors, Licensed Marriage and Family Therapists

2015 SEA 21 – provided authority for provisional level practitioners working under the

supervision of a licensed mental health clinician to enroll and receive payment from Medicaid

Consistent with routine data monitoring and post-payment review processes, WY Medicaid staff

completed a number of detailed provider-specific coding/billing trend analyses, reviewed charts and

medical records and analyzed overall provider reimbursement detail for compliance with federal and

state program rules and regulations. Post-payment reviews conducted during this time frame resulted

in the referral of over 50 behavioral health service providers to the program integrity unit for further

investigation and potential overpayment recovery action. Important to note, from the receipt of a

referral through an overpayment recovery (or case closure), it can take up to 225 days to fully resolve an

open case. Additional time may also be necessary for reviewing provider appeals or working through

administrative hearings. In most cases, throughout the course of the investigation, the provider

continues receiving payment from Wyoming Medicaid until a final case determination is rendered.

These timelines exclude cases that, upon state review, are referred to other federal and/or criminal

entities (Medicaid Fraud Control Unit, FBI, DCI or the OIG) for administrative and legal support.

In SFY 2016, and in response to declining state fund revenue, the Wyoming Department of Health

Budget was reduced by $90 million general fund, with $54.4 million general fund coming from the WY

Medicaid program. Given the financial relationship of the WY Medicaid program with its federal

counterpart, a loss of $54.4 million general fund resulted in an equitable loss of matching federal

dollars. WY Medicaid program staff were required to evaluate and adjust all aspects of program

administration, coverage and reimbursement in order to work within the confines of a reduced budget.

As noted in a June 2016 correspondence from the WDH Director, steps taken to implement the

reductions were identified based on several key principles –

Avoid across the board reductions

Distribute reductions throughout the agency

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Reduce administrative costs where possible

Minimize impact on safety net services

Minimize impact on programs that provide services to a broader population vs. a narrower

population

Minimize impact on vulnerable provider groups

Evaluating measures that could be taken to monitor spending, in conjunction with the increase

in compliance concerns noted within the behavioral health service line, WY Medicaid made the

decision to administer the benefit and monitor compliance through a prior authorization process as

opposed to a post-pay review process. The benefit administration change was not intended to deny

appropriate services to Medicaid beneficiaries, but to confirm service compliance prior to rendering

payment.

Over the course of the benefit administration change, the clinical criteria for WY

Medicaid coverage of behavioral health services for both adults and children has remained

the same. No changes have been made to service definitions, clinical coverage criteria or

documentation and retention requirements.

Based on continuous monitoring and feedback from Qualis Healthcare, LLC as the entity

contracted to conduct the clinical reviews on behalf of the program, WY Medicaid staff have worked

diligently to provide technical assistance documents, webinar training, policy reminder bulletins,

FAQ documents, and helpful tips and hints for achieving and maintaining ongoing compliance with

existing service coverage criteria and documentation requirements.

SERVICE UTILIZATION AND PAYMENT TRENDS

Service Unit Trends

SFY2016 SFY2017 SFY2018 SFY2019 SFY2016 vs SFY2018 Notes

2016 is ___% of 2018101YA0400X Licensed Additions Therapist 5,500 14,407 10,307 470 187.40%

101YP2500X Licensed Professional Counselor 178,389 234,427 218,431 38,332 122.45%

103G00000X Clinical Neuropsychologist 23 145 307 87 1334.78%

103TC0700X Clinical Psychologist 858,034 426,907 261,748 59,077

30.51% Decrease 2 Fraud Cases and 3 Pending

1041C0700X Licensed Clinical Social Worker 112,289 149,087 161,541 32,407 143.86%

106H00000X Licensed Marriage and Family Therapist 13,718 12,472 16,887 3,690 123.10%

2084P0800X Psychiatrist 110,421 101,319 96,007 13,205

86.95% Decrease Shortage of providers in Wyoming

261QM0801X Community Mental Health Center 648,979 503,640 373,146 57,208

57.50% Decrease

Increase in community based

providers through legislative

action

261QR0405X Substance Abuse Treatment Center 295,960 210,817 219,398 27,039

74.13% Decrease

Increase in community based

providers through legislative

action

364SP0808X Advanced Practice Registered Nurse, Psych 5,610 6,333 6,355 1,110 113.28%

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Reimbursement Trends by Provider Type

Noted Observations based on data reviewed:

Legislative action taken in SFY 2014 and SFY 2015 to expand the network of Medicaid enrolled

community based behavioral health providers impacted service units billed and overall Medicaid

reimbursement to Community Mental Health Services (CMHCs) and Substance Abuse Treatment

Centers (SATCs)

To the extent Medicaid reimbursement and services provided decreased at CMHCs and SATCs,

units of service and total reimbursement to other types of licensed and enrolled practitioners

increased

WY Medicaid’s efforts to identify and pursue action against providers billing inappropriately

resulted in a significant decrease in reimbursement in the area of clinical psychology services

The low number of licensed and enrolled psychiatrists in Wyoming continues to be a concern, and

is insufficient for the service demand identified

PROVIDER ENROLLMENT AND REIMBURSEMENT

SFY2016 SFY2017 SFY2018 SFY2019 SFY2016 vs SFY2018

2016 is ___% of 2018101YA0400X Licensed Additions Therapist 113,353.88$ 240,747.37$ 210,775.55$ 14,400.73$ 185.94%

101YP2500X Licensed Professional Counselor 3,999,103.96$ 5,489,663.74$ 4,884,797.59$ 831,123.86$ 122.15%

103G00000X Clinical Neuropsychologist 1,894.11$ 23,325.99$ 69,329.21$ 8,803.46$ 3660.25%

103TC0700X Clinical Psychologist 13,495,523.00$ 7,667,549.09$ 5,578,450.92$ 1,138,296.56$

41.34% Decrease 2 Fraud Cases and 3 Pending

1041C0700X Licensed Clinical Social Worker 2,628,100.21$ 3,368,623.63$ 3,386,001.49$ 670,337.81$ 128.84%

106H00000X Licensed Marriage and Family Therapist 326,600.95$ 304,343.79$ 446,808.34$ 92,487.65$ 136.81%

2084P0800X Psychiatrist 2,668,105.38$ 2,709,112.04$ 2,422,235.76$ 308,575.46$

90.78% Decrease Shortage of providers in Wyoming

261QM0801X Community Mental Health Center 8,622,989.61$ 7,704,626.20$ 6,074,841.89$ 958,736.27$

70.45% Decrease

Increase in community based

providers through legislative

action

261QR0405X Substance Abuse Treatment Center 4,049,401.34$ 2,985,973.85$ 3,158,876.68$ 437,062.49$

78.01% Decrease

Increase in community based

providers through legislative

action

364SP0808X Advanced Practice Registered Nurse, Psych 280,151.10$ 331,153.73$ 362,134.32$ 69,652.74$ 129.26%

PAGE 4

WY MEDICAID COVERAGE POLICY FOR BEHAVIORAL HEALTH SERVICES

Wyoming Medicaid Coverage Policy

Provider Manual Effective 7/1/18 (prior versions available via the same link)

https://wymedicaid.portal.conduent.com/MHSA.html

Page 178 – 222

Wyoming Medicaid Rule

https://rules.wyo.gov/Search.aspx?mode=1

Chapter 13

Wyoming Medicaid State Plan

https://health.wyo.gov/healthcarefin/medicaid/spa/

Section 3.1A, 13D

A formal State Plan Amendment was completed in 2016 to add Medicaid coverage of Applied

Behavior Analysis services for children with autism under the age of 21, as well as to add

Medicaid authority to prior authorize behavioral health services after 20 dates of service. The

public notice for the proposed State Plan Amendment was released on 3/3/2016. WY Medicaid

received no public comments on the proposed benefit administration change.

UTILIZATION MANAGEMENT REQUIREMENTS

42 CFR 456.22 – Sample basis evaluation of services - To promote the most effective and

appropriate use of available services and facilities the Medicaid agency must have procedures for

the on-going evaluation, on a sample basis, of the need for and the quality and timeliness of

Medicaid services.

§ 456.2 State plan requirements.

(a) A State plan must provide that the requirements of this part are met.

(b) These requirements may be met by the agency by:

(1) Assuming direct responsibility for assuring that the requirements of this part are met; or

(2) Deeming of medical and utilization review requirements if the agency contracts with

a QIO to perform that review, which in the case of inpatient acute care review will also

serve as the initial determination for QIO medical necessity and appropriateness review

for patients who are dually entitled to benefits under Medicare and Medicaid.

(c) In accordance with § 431.15 of this subchapter, FFP will be available for expenses incurred in

meeting the requirements of this part.

§ 456.3 Statewide surveillance and utilization control program.

The Medicaid agency must implement a statewide surveillance and utilization control program

that -

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(a) Safeguards against unnecessary or inappropriate use of Medicaid services and against excess

payments;

(b) Assesses the quality of those services;

(c) Provides for the control of the utilization of all services provided under the plan in

accordance with subpart B of this part; and

(d) Provides for the control of the utilization of inpatient services in accordance with subparts C

through I of this part.

WY Medicaid, in accordance with federal law, is required to establish and implement processes

to monitor and assess for appropriate versus inappropriate service delivery and billing, as well as to

ensure services being paid for are medically necessary.

§ 440.230 Sufficiency of amount, duration, and scope.

(a) The plan must specify the amount, duration, and scope of each service that it provides for -

(1) The categorically needy; and

(2) Each covered group of medically needy.

(b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its

purpose.

(c) The Medicaid agency may not arbitrarily deny or reduce the amount, duration, or scope of a

required service under §§ 440.210 and 440.220 to an otherwise eligible beneficiary solely because

of the diagnosis, type of illness, or condition.

(d) The agency may place appropriate limits on a service based on such criteria as medical

necessity or on utilization control procedures.

DETERMINATION OF MEDICAL NECESSITY – CASE LAW

Applicable Case Law in the State’s Determination of “medically necessary services” –

CMS has indicated that states have great flexibility in defining the criteria for placing limits on a service

based on criteria such as medically necessary or utilization control procedures. In a 2002 response to a

comment suggesting CMS establish a Federal definition of medical necessity, CMS stated, “States have

flexibility to place appropriate limits on a service based on such criteria as medical necessity or on

utilization control procedures, and have great flexibility in defining those criteria. Therefore we do not

believe it is appropriate to promulgate a national definition [of medical necessity]” Department of Health

and Human Services; Medicaid Program; Medicaid Managed Care; New Provisions; Final Rule, 67 Fed.

Reg. 40989, at 41047.67 Federal Register 41047 (June 14, 2002) (codified at 42 CFR Parts 400, 430, 431, 424,

435, 438, 440, and 447) (emphasis added).

In a 2016 response to a comment suggesting CMS add the phrase “medically necessary” to 42 CFR

440.70(b), to read “Home Health services include the following medically necessary services and items,”

CMS responded, “We agree that states may limit covered services to only include medically necessary

services. This flexibility is already provided in regulation at § 440.230(d). Medical necessity is not

determined by us, but is determined by medical professionals. Many states employ medical professionals

to establish medical necessity criteria and then review individual circumstances in light of those criteria.

…” Department of Health and Human Services; Medicaid Program; Face-to-Face Requirements for Home

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Health Services; Policy Changes and Clarifications Related to Home Health; Final Rule, 81 Fed. Reg. 5530,

at 5534 (February 2, 2016) (codified at 42 CFR Part 440) (emphasis added).

WY Medicaid rules define medically necessary and/or medical necessity as:

“Medically necessary” or “medical necessity.” A health services that is required to diagnose, treat, cure,

or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected; to relieve

pain, or to improve and preserve health and be essential to life. The service must be:

(i) Consistent with the diagnosis and treatment of the recipient’s condition;

(ii) In accordance with the standards of good medical practice among the provider’s peer group;

(iii) Required to meet the medical needs of the recipient and undertaken for reasons other than

the convenience of the recipient and the provider; and

(iv) Performed in the most cost effective and appropriate setting required by the recipient’s

condition.

In accordance with federally mandated oversight of payment for services, WY Medicaid conducts

competitive procurements at various times to obtain resources for assessing prior authorization

requests and making a determination of compliance with (ii) listed above. WY Medicaid contracts with

nationally accredited Quality Improvement Organizations (QIOs as approved by CMS) to conduct

clinical reviews of services both prior to delivery (prior authorization) and after services have already

been paid for (post payment review).

Through 2015 and 2016, WY Medicaid became more aware of potential situations of inappropriate

service delivery and billing to WY Medicaid. Implementing the authority provided to the program in 42

CFR (above), WY Medicaid made the decision to move its oversight activities from a post-payment

review to a prior authorization. To a great extent, this change allowed WY Medicaid to evaluate the

compliance of services being provided prior to payment rather than work through a formal investigative

process and potential payment recovery.

WHAT IS A “QIO” AND WHO IS QUALIS HEALTH, LLC?

Qualis Health, LLC employs and utilizes clinically licensed reviewers as required to evaluate

prior authorization requests for medical necessity and therapeutic appropriateness in accordance with

the organization’s standard processes, and federal and state rules and regulations. Many of Qualis

Health’s clinical and operational requirements are governed by federal law as part of their national

Quality Improvement Organization (QIO) accreditation. These regulations are found at 42 CFR Part

476 and implement Section 1153 and Section 1154 of the Social Security Act. A first level review is

performed by a nurse reviewer using decision support criteria contained in a software product called

InterQual (computer based triage tool used to expedite approvable requests). For any requests not

approved by the first level reviewer, a second level review is completed by a physician (for medical

services) or a psychiatrist (for behavioral health services). Based on the psychiatrist’s training,

credentialing, experience and WY Medicaid coverage criteria, the documentation submitted is reviewed

to evaluate the clinical and therapeutic appropriateness (in amount, duration and scope) of the services

being requested. If the second level review upholds the initial denial, a letter is generated and the

provider is notified of the denial/partial denial.

PAGE 7

Qualis Health’s continued status as a nationally accredited QIO organization provides assurance

to WY Medicaid that administrative and clinical review processes meet the criteria outlined in federal

regulation.

Qualis Health, LLC was contracted to begin behavioral health prior authorization requests for

WY Medicaid starting with dates of service November 1, 2017 and forward. Qualis Health also conducts

prior authorization reviews on behalf of WY Medicaid for home health services, physical therapy,

occupational therapy, speech therapy and durable medical equipment. Optum, a second QIO entity

under contract with WY Medicaid to conduct prior authorization reviews, has oversight of all prior

authorization requests for psychiatric inpatient hospital admissions, psychiatric residential treatment

facilities for children under 21, and various surgical procedures such as back surgery, gastric bypass

procedures and vagal nerve surgery.

Prior to implementation, Qualis Health provided training to providers on their web portal,

provided information on the types of documents that would be required as part of the review, and

remained open to assisting providers with becoming comfortable with the request process.

As the volume of prior authorization requests increased in the spring of 2018, Qualis Health LLC

did fall behind in reviewing submissions timely. In accordance with their contracted service level

metrics, Qualis Health has been working under a Corrective Action Plan (CAP) with WY Medicaid staff.

On July 1, 2018, communication was issued by WY Medicaid that Qualis Health had been instructed to

prioritize their review of prior authorization requests to focus on those submitted timely by providers

(before the end of the existing treatment period). Prior authorization requests submitted late by

providers were reviewed subsequent to on time reviews. On Friday September 21, 2018, WY Medicaid

program staff approved an amended clinical review process designed to reduce the documentation

required from providers when submitting a prior authorization request as well as expediting the review

process.

PROVIDER NOTIFICATION AND EDUCATION REGARDING WY MEDICAID CHANGES TO

UTILIZATION MANAGEMENT ACTIVITIES

Electronic Communications

State Plan Public Notice, 3/3/16 – Notified providers of the State’s intent to request permission

to limit coverage to 20 dates of service and require a prior authorization through a clinical

review for ongoing service coverage

Revisions to Chapter 13 Rule – All public comment processes were followed to formally adopt

changes reflected in Section 7.

7/8/16 – Provider Bulletin

11/15/16 – Provider Bulletin

2017 Provider Training Workshops (Statewide w/WY Medicaid Staff) – Trainings attached

3/3/17 – Provider Bulletin

4/18/17 – Provider Bulletin RE: 2017 Provider Training Workshops

5/22/17 – Provider Bulletin

7/10/17 – Provider Bulletin

8/1/17 – Provider Bulletin RE: 2017 Provider Training Workshops

8/28/17 – Notification of shift to Qualis for prior authorization reviews

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10/5 & 10/12/17 – Provider Training on Qualis system (slides)

2/2/18 – Provider Bulletin

2/26/18 – Provider Bulletin

4/25/18 – Billing Workshop/ Training for WY Medicaid, Dates and Times (RA Banner)

4/25/18 – Billing Workshops, Provider Bulletin

5/20/18 – Wyoming Psychological Association Training/Update

5/21/18 – Billing Workshops, Provider Bulletin (Updated)

6/21/18 – Clinical Guidelines for review of Medical Necessity (included as a link in the 6/26/18

bulletin)

6/26/18 – Behavioral Health Review, Provider Bulletin

Qualis Healthcare, Inc. Training Sessions

9/18/17

10/5/17 (BH specific)

10/12/17 (BH specific)

11/2/17 (BH specific)

7/23/18 – Technical assistance on review guidelines

7/26/18 – Technical assistance on review guidelines

7/27/18 – Technical assistance on review guidelines

One-to-one one provider technical assistance via phone and email between provider staff (Rod,

Galin and Maureen) and Qualis Staff (Teresa Kirn, RN and Lisa Layne)

Websites and Online Training Available

WY Medicaid Provider Website - https://wymedicaid.portal.conduent.com/provider_home.html

Qualis Website and Training Videos –

http://www.qualishealth.org/healthcare-professionals/wyoming-medicaid/provider-education

Registering for the Qualis Health Provider Portal – 9/18/17

Requesting an Outpatient Behavioral Health Review – 10/5/17

Requesting an Outpatient Behavioral Health Review – 10/12/17

Q&A for Outpatient Behavioral Health and Therapy Review – 11/2/17

Behavioral Health Review Guidelines – 7/23/18, 7/26/18, 7/27/18

UTILIZATION REVIEW PROCESS, RECONSIDERATION AND APPEALS

Prior authorization appeal processes are outlined in the provider manual

https://wymedicaid.portal.conduent.com/manuals/Manual_CMS1500_7_1_18_Update.pdf

Page 215

Qualis Health reviews each request in accordance with its standard process, including a first

level review performed by a nurse reviewer using decision support criteria contained in a software

product called InterQual. For any requests not approved by the first level reviewer, a second level

review is completed by a physician (for medical services) or a psychiatrist (for behavioral health

services). Based on the psychiatrist’s training, credentialing, experience and WY Medicaid coverage

criteria, the documentation submitted is reviewed to evaluate the clinical and therapeutic

PAGE 9

appropriateness (in amount, duration and scope) of the services being requested. If the second level

review upholds the initial denial, a letter is generated and the provider is notified of the denial/partial

denial.

Providers are instructed regarding how to request a reconsideration if they disagree with the

initial determination. At times, providers have additional clinical history, medical records or treatment

data to support the services requested, but that documentation may have been omitted in the initial

submission. When a provider requests a reconsideration, the same review process is followed, but the

case is submitted to different clinicians (peer reviewer with the same licensure and credentialing) for

review.

If the reconsideration upholds the initial denial, the provider then has the opportunity to

request an appeal to the State. In this process, Qualis will forward all documentation received as part of

the prior authorization request to the State. The case will then be reviewed by internal clinicians on

staff with WY Medicaid.

If a State level appeal upholds the original denial, the provider may make alternate payment

arrangements with the client for the continuation of the denied services (or units), or the client may

submit a formal request to WY Medicaid for an administrative hearing to challenge the denial (or

reduction) in the coverage of services. Administrative hearings are most commonly handled through

the Office of Administrative Hearings, but may be facilitated through other options. In every instance of

a denial, instructions are included regarding the appeal process.

WY MEDICAID RESPONSE TO 10/5/18 JOINT COMMITTEE ON LABOR, HEALTH AND

SOCIAL SERVICES TESTIMONY BY MR. PAUL DEMPLE

Page 9 of 23 – “Medicaid changes over the past 12 months”

“1. Implementation of the 20 cap limit for behavioral health services”

State Response: There was a WY Medicaid benefit administration change proposed, approved and

implemented for the various reasons outlined previously. Public notice of the planned change was

posted in March of 2016, and the program received no comments at that time. Additionally, public

comment periods were also facilitated with the subsequent changes to Chapter 13 of Medicaid rule,

codifying the change in benefit administration. No public comment was received.

“2. Implementation of restrictive service guidelines”

State Response: WY Medicaid program criteria for coverage of behavioral health services has not

changed. The “Guidelines” document is a technical assistance document produced at the request of

several provider groups who sought additional insight in to the types of clinical conditions, baseline

treatment approaches and criteria Qualis Health clinicians were using to guide their initial review of

documentation submitted. It was expressly clarified that the guidelines were not being used to enforce

limitations on requested services or otherwise restrict the provision of medically necessary services

required in excess of what was outlined within the document. The document was simply intended to

provide transparency in the review process, and provide more clinical information regarding the

“baseline” of Qualis Health’s reviews.

3. “Rehabilitation vs. Habilitation”

PAGE 10

State Response: WY Medicaid program criteria for coverage of behavioral health services has not

changed, nor have the definitions of allowable services. Chapter 13 of Medicaid Rule was recently

updated to include the definitions of these terms, which had previously only existed in the provider

billing manuals. The Substance Abuse and Mental Health Services Administration (SAMHSA) compiled a

released a guidance document entitled “Medicaid Handbook” Interface with Behavioral Health Services”

(https://www.nasmhpd.org/sites/default/files/Medicaid-Handbook-Interface-with-Behavioral-Health-

Services%281%29.pdf). This document outlines the various authorities and mechanisms state Medicaid

programs use to cover behavioral health services. WY Medicaid also uses the state plan rehab option to

seek authority for coverage and payment. Medicaid law makes an important distinction between

rehabilitative services and habilitative services. Services provided through the rehabilitative option

must “involve the treatment or remediation of a condition that results in an individual’s loss of

functioning.” Habilitative services are services designed to assist individuals in acquiring, retaining, and

improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and

community-based settings. For clients over the age of 21, habilitative services may only be provided

through a home and community-based waiver.1 While the terminology used in WY Medicaid definitions

has been drafted to be applicable to a broader array of associated services (not just behavioral health),

WY Medicaid staff and Qualis Health are using the appropriate federal definitions within the context of

the work being done. As a note, the distinction between rehabilitative and habilitative services does not

apply to services provided to children under the age of 21. Federal regulations included in the Early and

Periodic Screening, Diagnostic and Treatment program preclude Medicaid denial based on the premise

that a service is habilitative in nature.

Page 12 of 23 –“Recommendations”, #1, #2, #3 and #4 –

State Response: Based on the level of inappropriate claiming and billing identified within the

behavioral health service line, suspending the current prior authorization review process jeopardizes

WY Medicaid’s ability to ensure services being reimbursed are allowable and meet all federal and state

rules and regulations. Should the suspension of current activities be mandated, WY Medicaid would

request consideration for an additional appropriation to cover the immediate increase in program

expenditures as well as additional staffing resources to facilitate the increased workload of the program

integrity unit. The WY Medicaid program integrity unit, upon this change in benefit administration,

would become responsible for requesting medical records, auditing and following through with post-

payment recoveries for all providers of behavioral health services. Historically, providers have been

more amenable to working with the program through a prior authorization process to ensure service

compliance up front rather than be required to return what can potentially be a large sum of money

upon identification of a billing, service or documentation error.

Page 12 of 23 – “Recommendations”, #5 and #6

State Response: These recommendations are outside the scope of the WY Medicaid program. Defer to

the Division of Behavioral Health for follow up.

Page 12 of 23 –“Recommendations”, #7 –

State Response: This recommendation has been addressed – see response to #3 on page 12.

Page 12 of 23 – “Recommendations”, #8 –

1 https://www.nasmhpd.org/sites/default/files/Medicaid-Handbook-Interface-with-Behavioral-Health-

Services%281%29.pdf, page 3-4

PAGE 11

State Response: The WY Medicaid program, with appropriate authority and funding, could seek

coverage of habilitative services for adults with serious and persistent mental illness in a number of

different ways. The two most notable would be an adult mental health waiver, or the submission and

approval of the 1915 (i) state plan option (used by many states to construct a comprehensive support

program for adults with a mental illness. Under this state plan option, the state has authority to specify

target criteria. Qualifying individuals would become eligible for both acute care medical services as well

as long-term support services such as respite, case management, supported employment and

environmental modifications in a home and community based setting. Habilitative service coverage

would also be permitted. The 1915 (i) state plan option may be an option to address this need without a

formal waiver program. The various federal requirements of the 1915 (i) state plan option may be found

at https://www.medicaid.gov/medicaid/hcbs/authorities/1915-i/index.html.

PAGE 12

Appendix Attachments include:

1) 2017 Provider Workshop Bulletin

2) 2018 Provider Workshop Bulletin (4/25/18)

3) Behavioral Health Prior Authorization Bulletin 2/2/2018

4) Behavioral Health Review Bulletin 6/26/18

5) Behavioral Health Services (web notice) 11/15/16

6) 2018 Provider Workshops, RA Banner 4/25/18

7) Chapter 13, Medicaid Rule

8) Clinical Assessment Bulletin 2/26/18

9) Consolidated Codes Bulletin 7/10/17

10) Discontinuing of the MH & SA Option Manual Bulletin 3/3/17

11) Documentation Standards and Rehab-Hab Bulletin 7//8/16

12) Guidelines for WY Medicaid Outpatient Behavioral Health Reviews 6/21/18

13) CMS 1500 Provider Manual

14) Policy Change Regarding OT, PT, ST and BH Services Bulletin 8/28/17

15) Provider Workshop Medicaid Updates PP Slide Deck 2017

16) Provider Workshop PS Unit Policy Updates PP Slide Deck 2017

17) Public Notice – State Plan for Implementation of PA and ABA Services 3/2/16

18) State Plan Amendment 2016

19) Targeted Case Management Bulletin 5/22/17

20) Updated Provider Workshop Bulletin 2018 5/21/18

21) Wyoming Psychological Association Policy Training PP Slide Deck 5/20/18

22) WY Medicaid Webinar PP Slide Deck 10/12/17