Wyo. Medicaid Institutional Provider Manual § 16.1.5

For Medicaid to reimburse a hospice Provider, the following need to be completed as applicable:

• A physician certification statement of terminal illness certifying the Member’s medical prognosis

is a life expectancy of six (6) months or less if the terminal illness runs its normal course sent to

Provider Services.

o A copy must also be sent via fax or email to the Long Term Care Unit (see Section 2.1 Quick

Reference).

• A Wyoming Medicaid Hospice Benefit Election Form (see Section 16.1.1.1 Hospice Benefit

Election Form) has been completed. Only the WDH Medicaid Hospice Benefit Election Form will

be accepted.

o Members who are eligible for both Medicare and Medicaid (dual eligible) must elect hospice

under both programs.

o A copy must also be sent via fax or email to Long Term Care Unit (see Section 2.1 Quick

Reference).

• The hospice Provider must request a rate for nursing home care when the Member is residing in

the nursing home by submitting a Hospice NH Room & Board Request Form (16.1.1.2 Hospice

NH Room & Board Request Form) to Provider Services.

• Providers billing revenue code 0659 will need to provide a certification as a licensed inpatient

hospice facility.

Reimbursement rates are determined specific to each hospice for each of the allowed revenue codes

and will be re-determined on an annual basis. These rates are all inclusive and cover the services and

supplies used in the care of the Member, including:

• Drugs and biological

• Home health aide or homemaker services

• Physical therapy, occupational therapy and speech-language pathology services provided for

purposes of symptom control

• Durable medical equipment and supplies assisting in the use of durable medical equipment