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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: New Facility or Change of Ownership 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 


Important Notice for New Facilities
Seeking Federal Medicare Certification

The Centers for Medicare & Medicaid Services (CMS) has issued revised survey priorities due to very substantial federal resource limitations. In light of the federal Medicare resource constraints, initial surveys for most provider and supplier types have been classified at the lowest priority level. For facilities that qualify for deemed status there is an alternate route to obtain certification and this may well be the fastest way to obtain certification this year. However, there are other types of facilities for which deemed status is not an option. The Survey and Certification Letter S&C-08-03 can be accessed for additional 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


Office of Civil Rights:
http://www.hhs.gov/ocr/civilrights/clearance/index.html


If you are a healthcare provider seeking initial Medicare Part A certification and/or undergoing a change of ownership (CHOW), you need a civil rights clearance.


To receive a civil rights clearance, you must complete the Civil Rights Information Request for Medicare Certification Package. To guide you through completing the Package, we have created this portal that will help you develop/submit polices that meet your civil right requirements.


You may submit hard copies of the civil rights package to the Wyoming Healthcare Licensing and Surveys OR you may choose to submit the civil rights package online directly into the OCR intake queue at
https://ocrportal.hhs.gov/ocr/pgportal.


If you opt to submit online, you will receive an e-mail from OCR stating that you have completed the civil rights submission. The e-mail will contain an OCR number, which is critical to OCR’s ability to access your submission from the OCR intake queue. You must submit a copy of this e-mail to Healthcare Licensing and Surveys in lieu of the completed hard copy package.


Healthcare Licensing and Surveys will include the hard copy package or the OCR number, along with the initial or Change of Ownership (CHOW) certification paperwork, to the Centers for Medicare and Medicaid Services (CMS) Regional Office. The Centers for Medicare and Medicaid Services (CMS) will not certify you as a Medicare provider if you do not receive a clearance from OCR.