Health, Department of

Renal Disease Program, Administrative Procedure for End Stage

Effective Date: 09/07/2010 to 07/24/2014

Rule Type: Superceded Rules & Regulations

Reference Number: 048.0049.1.09072010

CHAPTER 1

Rules and Regulations for the Wyoming End Stage Renal Disease Program

General Provisions

Section 1. Authority.

These rules and regulations are promulgated by the Wyoming Department of Health, Rural and Frontier Health Division, 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.

Section 2. Statement of Purpose.

These rules and regulations are adopted to implement the authority of the Wyoming End Stage Renal Disease Program, Wyoming Department of Health, Rural and Frontier Health Division to:

1. (a) Insure that no Wyoming resident requiring renal dialysis is denied treatment because of economic circumstances;
2. (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;
3. (c) Provide benefits for specific prescription drugs and limited transportation for all patients regardless of Medicare and/or Medicaid status;
4. (d) Provide benefits for dialysis treatment and medical care for patients not eligible for Medicare/Medicaid coverage;
5. (e) Provide benefits for Medicare/Medicaid and other eligible patients who dialyze at home but do not receive all their support from a dialysis facility;
6. (f) Provide benefits for medical care for Medicare/Medicaid and other eligible patients who dialyze at home and do receive full support from a dialysis facility;
7. (g) Provide benefits for specific prescription drugs for Medicare/Medicaid and other eligible patients who have received a kidney transplant; and
8. (h) Provide benefits for medical care for Medicare/Medicaid 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 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) “Administrator” - the Administrator of the Rural and Frontier Health Division.

(b) “Adverse Action” - a termination, suspension, or reduction of benefits or covered services.

(c) “Affidavit” - a written notarized statement of facts made voluntarily under oath.

(d) “Aggrieved” - any person, approved facility, or provider who has been subject to an adverse action by the Rural and Frontier Health Division.

(e) “Appeal” - a Contestant’s resort to district court after a final adverse agency determination or decision.

(f) “Applicant” - a person whose written application for the Wyoming End Stage Renal Disease Program has been submitted to the Rural and Frontier Health Division, but who has not received final action.

(g) “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 units.

(h) “Complaint” - a written request for a hearing that includes at a minimum: the name, address, and the reason for the request, including the nature of the Program action, order, or determination being contested.

(i) “Contestant” - the person, a facility, or representative who brings the complaint against the Division.

(j) “Contested case” - a disputed action taken by the Department involving eligibility, termination of eligibility, suspension of eligibility, denial of medical services, or denial of payment for medical services.

(k) “Date of Action” - the intended date on which a termination, suspension, or reduction becomes effective.

(l) “Department” - the Wyoming Department of Health.

(m) “Designee” - the appointed agent of the Director or the Administrator having all the authority of the Director or the Administrator.

(n) “Director” - Director of the Wyoming Department of Health.

(o) “Division” - The Rural and Frontier Health Division (RFHD).

(p) “End Stage Renal Disease (ESRD)” - that stage of renal impairment which is virtually always irreversible and permanent and requires dialysis or kidney transplantation to ameliorate uremic symptoms and maintain life.

(q) “Hearing” - a contested case hearing before a designated hearing officer.

(r) “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.

(s) “Notice of Action” - a written statement to the applicant/Contestant informing him of the action the Department intends to take, 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.

“Program” - The Wyoming End Stage Renal Disease (ESRD) Program.

“Provider” - all parties who have ESRD Program approval and provide related services to Program recipients.

“Recipient” - an ESRD patient that has been determined eligible for and is receiving program benefits.

“Respondent” - the Wyoming Department of Health.

(x) “Request for a Hearing” - written notice by the Contestant, or her authorized representative, requesting the opportunity to present her case to a reviewing authority.

“Service Approval Agency” - the ESRD Program, Rural and Frontier Health Division, Wyoming Department of Health.

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 responsibilities to pay, or after it is determined that there are no third parties that may be liable for payment.

(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 Wyoming ESRD

Program will provide funding for his dialysis services until his eligibility status for all other possible third party payers has been determined or is waived.

(ii) Available funds;

(iii) Covered services, supplies and prescription drugs;

(iv) The reimbursement rate as determined by the Division and as specified in Medicaid and/or Medicare standards.