Wyo. Code R. 048-0049-1
Renal Disease Program, Administrative Procedure for End Stage
Effective Date: 07/24/2014 to 12/20/2016
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0049.1.07242014
These rules and regulations are promulgated by the Wyoming Department of Health, pursuant to its authority under the general provisions of the Wyoming Medical Assistance and Services Act at W.S. 42-4-101, et seq., more specifically W.S. 42-4-103(a)(xxiii) and 42-4-117, and the Wyoming Administrative Procedures Act at W.S. 16-3-101, et seq.
These rules and regulations are adopted to implement the authority of the Wyoming End Stage Renal Disease Program, Wyoming Department of Health, to provide assistance with costs for treatment of end stage renal disease to and/or for eligible Wyoming residents.
The Wyoming 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 are reduced, they will be reduced in a manner that takes into consideration medical necessity and other available coverage.
(c) The Program 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.
The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indicates that such is the intent, words in the singular number shall include the plural and vice-versa. Throughout these rules gender pronouns are used interchangeably, except where the context dictates otherwise. The drafters have attempted to utilize each gender pronoun in equal numbers in random distribution. Words in each gender shall include individuals of the other gender.
(a) 'Acknowledgment' – written verification of receipt of information provided to the applicant/recipient by the Program.
(b) “Applicant” - a person whose written application for the Wyoming End Stage Renal Disease Program has been submitted to the Program, but who has not yet received final action.
(c) “Approved Facility” - a facility approved to participate in the Program, which includes, but is not limited to:
(i) Hospital outpatient dialysis facilities;
(ii) Free-standing ESRD clinics or centers;
(iii) In-state or out-of-state facilities, including free-standing facilities;
(iv) Medicare approved hospitals and transplant centers; and
(v) Veterans Administration and military hospitals which have Joint Commission, formerly known as Joint Commission on Accreditation of Healthcare Organizations (JCAHO), approved renal dialysis units.
(d) “Critical need” – Need for assistance based upon the applicant’s certified diagnosis of and treatment for End Stage Renal Disease (ESRD) and household income at or below 185% of Federal Poverty Guideline when adjusted by applicant specific ESRD related expenses.
(e) “Department” - the Wyoming Department of Health.
(f) “Director” - Director of the Wyoming Department of Health.
(g) “End Stage Renal Disease (ESRD)” - chronic, irreversible renal (kidney) failure which requires dialysis or kidney transplantation to maintain life.
(g) “Hearing” - a contested case hearing before a designated hearing officer.
(i) “Program” - the Wyoming End Stage Renal Disease Program.
(j) “Provider” - any party who has ESRD Program approval and provides related services to Program recipients.
(k) “Recipient” - an ESRD patient that has been determined eligible for and is receiving Program benefits.
(l) “Residency” - proof by documentation acceptable to the Program that an individual meets the Program definition of “resident”.
(m) “Resident” – an individual who can document his residence in Wyoming exclusively for sixty (60) continuous days immediately preceding the date he applies for Program assistance.
(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 responsibilities to pay, or after it is determined that there are no third parties that may be liable for payment.
(i) If dialysis has begun and there is no verifiable third party payer, the Program will pay the dialysis center a flat rate fee, as determined by the Program, per treatment for up to ninety (90) days.
(ii) One sixty (60) day extension of the flat rate fee may be granted at the discretion of the Program in an extenuating circumstance.
(b) Benefits for dialysis treatments, home training, home dialysis partners/technicians, stabilization, hospitalization, laboratory charges, home dialysis supplies, Program-approved medications, and transportation, are payable to Providers, up to a maximum per recipient per year.
(i) Recipients who have a kidney transplant are eligible for the Program-approved medications benefit only.
(c) Reimbursement for Program-approved medications, insurance premiums, and ESRD related travel expenses are payable to recipients up to a maximum per recipient per year.
(i) Kidney transplant recipients are eligible for the Program-approved medications benefit only.