Wyo. Code R. 048-0049-1
Renal Disease Program, Administrative Procedure for End Stage
Effective Date: 10/12/1988 to 09/07/2010
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0049.1.10121988
Section 1. Authority. These rules and regulations are promulgated by the Division of Health & Medical Services, Department of Health & Social Services pursuant to its authority under the general provisions of W.S. 35-1-240; 9-2-106(a)(viii); and W.S. 16-3-101 through 16-3-115.
Section 2. Statement of Purpose. These rules and regulations are adopted to implement the authority of Wyoming End Stage Renal Disease Program, Division of Health and Medical Services to:
(a) Insure that no Wyoming resident requiring renal dialysis is denied treatment because of economic circumstances;
(b) Provide dialysis service coverage assistance to eligible Wyoming patients during the pre-Medicare waiting period and, thereafter, pay the deductible Medicare does not cover;
(c) Provide benefits for specific drugs and limited transportation for all patients regardless of Medicare and/or Medicaid status;
(d) Provide benefits for dialysis treatment and medical care for patients not eligible for Medicare/Medicaid coverage;
(e) Provide benefits for Medicare/Medicaid eligible patients who dialyze at home but do not receive all their support from a dialysis facility;
(f) Provide benefits for medical care for Medicare/Medicaid eligible patients who dialyze at home and do receive full support from a dialysis facility;
(g) Provide benefits for medical care for Medicare eligible patients who have received a kidney transplant and;
(h) Provide benefits for medical care for Medicare and other eligible patients who dialyze in a dialysis facility.
Section 3. Changes or Restrictions in Service Category Reimbursement. The End Stage Renal Disease Program may restrict or categorize service reimbursement to meet budgetary limitations.
(a) Categories will be prioritized based upon medical necessity, Medicare eligibility and projected Medicare/Medicaid payments for different treatment modalities.
(b) In the event program benefits must be reduced, they will be reduced in a manner that takes into consideration medical necessity and Medicare/Medicaid coverage.
(c) The Division may affect changes in benefits by either adding or deleting entire categories or by proportionate changes across categories, or by a combination of both of these methods.
Section 4. Definitions. The following terms are hereby incorporated by reference into these rules and regulations and shall apply:
(q) “Hearing officer” - any employee of the Department or other individual designated by the Director to serve as the presiding officer at a hearing held under these rules.
(r) “Notice of Action” - a written statement to the applicant/contestant informing him of the action the Department intends to make, the reasons for the intended action, the specific regulations that support the action intended, an explanation of the person’s right to request a hearing, and an explanation of the circumstances under which a continuation of benefits may be maintained pending a hearing.
(s) “Participating facility” - a facility approved to participate in the Program, which includes, but is not limited to:
(t) “Program” - The Wyoming Chronic Renal Disease Program or The Wyoming End Stage Renal Disease Program.
(u) “Provider” - all parties who have in effect an agreement to participate in the ESRD Program and provide related services to Program recipients.
(v) “Recipient” - an ESRD patient that has been determined eligible for and is receiving program benefits.
(w) “Respondent” - the Department of Health & Social Services.
(x) “Request for a Hearing” - a clear expression in writing by the contestant, or his authorized representative, that he wants the opportunity to present his case to a reviewing authority.
(y) “Service Approval Agency” - the ESRD Program, Division of Health & Medical Services.
Section 5. Payment of Program Benefits.
(a) Benefits are only payable after all other possible third parties (e.g. private/group insurance, Medicare, Medicaid, Indian Health Service (IHS) or the Veterans Administration) have met their liability.
(b) Benefits for dialysis treatments, home training, non-family, home dialysis partners/technicians, stabilization, hospitalization, laboratory charges, home dialysis supplies, anti-rejection drugs, and transportation, are payable up to a maximum per recipient per year based upon:
(i) The recipient's eligibility status (Title IV of the Civil Rights Act of 1964);
(A) If any person's eligibility for one of the payment programs cannot be established with certainty before dialysis is started, the State ESRD Program will provide funding for his dialysis services until his eligibility status for Medicaid, Medicare or IHS has been determined or is waived.
(ii) Available funds;
(iii) Covered services, supplies & drugs;
(iv) Any contract between the Division and the recipient's participating facility; and
(v) The reimbursement rate as determined by the Division and as specified in Medicaid and/or Medicare standards.