Hospice Program – Wyoming Licensure Information
Important note: Following this section on Wyoming Licensure is information regarding Federal certification of Hospice Programs.
The definition of a Hospice Program is a program of care for the terminally ill and their families given in a home or health facility which provides medical, palliative, psychological, spiritual, and supportive care and treatment.
A valid state license is required prior to providing care to any client/patient/resident.
Following are the requirements and procedures through which your agency may be approved to be licensed as a provider of Hospice Program services.
Click below for a license application for State licensure. Please fill out the application in its entirety and submit to our office, along with the required fee. A list of required paperwork which must be sent to this office for review and approval before your agency can receive a State license is available below (Hospice Program Licensure Checklist). If you are going to be an inpatient facility, after reviewing the regulations, please contact one of our engineers at (307) 777-7123
to discuss the building requirements and any construction review approval process. Once we have approved these items, a provisional license will be issued, and you will be able to start providing services to clients/patients/residents.
When you have clients for which you are providing services, your agency must request, in writing, that a health survey be conducted. an unannounced survey will be provided by state surveyors as soon as scheduling permits.
A valid license permits an applicant to operate a healthcare facility in Wyoming. It does not enroll or certify a provider or supplier of healthcare services to participate in federal certification programs (Medicare/Medicaid).
Hospice Program License Application
Please note: This license application is provided in MS Word format. If you experience problems opening the license application or want to request that the application be e-mailed to you in PDF format, please contact us by e-mail or by telephone: (307) 777-7123.
Hospice Program Licensure Checklist
Word Format PDF Format
Hospice Program Rules and Regulations
Chapter 11 (Licensure) - 09-03-1999
Chapter 10 (Program Administration) - 09-03-1999
Healthcare Facility Construction Rules and Regulations
Chapter 3 - 04-03-2008
Chapter 3 Guidelines: Word Format PDF Format
Hospice Facility - Federal Certification Information
Following are the requirements and procedures through which your agency may be approved to participate in Medicare as a provider of Hospice Facility services. The Office of Healthcare Licensing and Surveys (OHLS) certifies and periodically recertifies providers of services to assure Medicare Conditions of Participation are met. This assists the Centers for Medicare & Medicaid Services (CMS) in determining if agencies can participate in Medicare. Such approval is prerequisite to qualifying to participate in the state Medicaid program as well.
You are subject to complete a CMS-855A or CMS-855B. The CMS-855A is the Medicare Federal Health Care Provider/Supplier Application for Health Care Providers that will Bill Medicare Fiscal Intermediaries, and the CMS-855B is the Medicare Federal Health Care Provider/Supplier Application for Health Care Suppliers that will Bill Medicare Carriers. Please see application link and fee information link below.
It is your responsibility to contact the appropriate fiscal intermediary (FI) or carrier (see link below) for the appropriate enrollment application. Please be aware your FI of preference does not automatically guarantee you will be assigned to that FI. Questions regarding this enrollment application must be directed to the FI or carrier. Once you have received and completed this enrollment application form, you must submit it directly to the FI or carrier. Our office will be notified by the FI or carrier of their review and recommendations to CMS with regard to your application. Until such time the state agency will not perform the federal survey.
At the end of this narrative are links to the survey and certification forms which are necessary to complete if you desire to participate. Please complete and submit them promptly in order to avoid unnecessarily delaying approval, since your facility cannot claim provider reimbursement for services furnished prior to approval. If the forms are not self-explanatory, you may telephone (307)777-7123 for assistance. Complete and SUBMIT ALL COPIES OF THE FORMS. Please note that there are three (3) Health Insurance Benefits Agreements; please submit three (3) signed originals.
On the second line of the Health Insurance Benefits Agreement after the term Social Security Act, enter the entrepreneurial name of the enterprise, followed by the trade name (if different from the entrepreneurial name). Ordinarily, this is the same as the business name used on all official IRS correspondence concerning payroll withholding taxes, such as the W-3 or 941 forms. For example, the ABC Corporation, owner of the Community General Hospital, would enter on the agreement, AABC Corporation d/b/a Community General Hospital. A partnership of several persons might complete the agreement to read: ARobert Johnson, Louis Miller and Paul Allen, ptr., Easy Care Home Health Services. A sole proprietorship could complete the agreement to read: AJohn Smith d/b/a Mercy Hospital. The person signing the Health Insurance Benefits Agreement must be someone who has the authorization of the owners of the enterprise to enter into this agreement.
Our surveyors will inspect the agency, interview you and members of your staff, review documents, and undertake other procedures necessary to evaluate the extent to which your agency meets the Conditions of Participation. If your agency has significant deficiencies in any of the Conditions, you will be informed and given an opportunity to correct them. After we have completed the survey of your facility, we will forward, with our recommendation, all documentation pertaining to your application to participate in the Medicare program to the Centers for Medicare and Medicaid Services (CMS), Regional Office in Denver, Colorado. They will review the documents, determine the effective date of your participation in the Medicare program, and will send you official notification. Until you receive such notification, Medicare certification is not official. Reimbursement cannot be made for services provided to Medicare beneficiaries prior to the effective date of participation.
After it is determined by CMS that all requirements are met, the Health Insurance Benefits Agreement will be countersigned. One copy will be returned to you along with the notification that your agency has been approved. If operation of the entire agency is later transferred to another owner, ownership group, or to a lessee, the agreement will automatically be assigned to the successor. You are required to notify OHLS and CMS at the time you are planning such a transfer.
Those institutions and agencies that are denied approval to participate in the Medicare program are sent notification giving the reasons for the denial and information about their rights to appeal the decision.
It is to your benefit to read the Hospice Facility Interpretive Guidelines and Conditions of Participation very carefully. You must meet the minimum guideline qualifications to be eligible to participate. Please do not hesitate to telephone this office if you have any questions.
Also, Hospice Facilities are required to be licensed by the State of Wyoming.
Federal Certification Forms and Regulations:
Hospice Interpretive Guidance Update (CMS S&C-09-19; 01/02/09)
Fiscal Intermediaries List
CMS 855 Enrollment Application Information
CMS 855 Application Fee Information
Provider/Supplier Enrollment Forms and List (855 Application, etc.)
Health Insurance Benefit Agreement Form (CMS-1561) – 3 originals required
Hospice Multiple Location Checklist: Word Format PDF Format
Office of Civil Rights
Notice re the Office of Civil Rights Packet. Do not send OCR Pre-Grant Clearance paperwork directly to Office of Civil Rights, or to the CMS Regional Office. It must be sent to the Wyoming Office of Healthcare Licensing and Surveys so it can be included in the initial or Change of Ownership (CHOW) certification kit. The CMS Regional Office cannot process initials or CHOWs for providers until they have the OCR Pre-Grant Clearance paperwork, along with the other documentation, from the Office of Healthcare Licensing and Surveys. Important note. Please use these two recently-updated Office of Civil Rights forms when completing your paperwork.
Civil Rights Information Request For Medicare Certification Form
Technical Assistance-Civil Rights Information Request