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Rule Type: Superceded Rules & Regulations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: 048.0049.2.09072010

CHAPTER 2

Rules and Regulations for the Wyoming End Stage Renal Disease Program

Eligibility Requirements

Section 1. Authority.

These rules and regulations are promulgated by the 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 Division’s authority to establish the eligibility of recipients for ESRD Program benefits.

Section 3. Eligibility.

(a) An applicant will be eligible to receive Program benefits when the applicant receives Division approval after meeting the following requirements:

(i) Has a certified medical diagnosis of ESRD;

(ii) Is a bona fide resident of Wyoming, being actually present in the state, and having furnished documentation of residency;

(iii) Has made application through the Division. Applications may be obtained through the Division or the following:

(A) An approved ESRD center or facility;

(B) A Medicare approved hospital/transplant center;

(C) A military or Veterans Administration hospital with a Joint Commission approved renal unit; or

(D) A Public Health Nursing Field Office or Social Service Field Office.

(iv) Has provided income data as requested by the Division for purposes of determining reimbursement obligation/co-pay liability.

(v) Agrees to maintain or continue to make premium payments on insurance plans (individual, group or Medicare), prepaid medical plans, or is willing to provide a financial statement detailing why such insurance coverage cannot be maintained.

(vi) Agrees to receive services only through approved facilities and providers.

Section 4. Application Process.

In making application, a person must submit or have submitted on their behalf the following documents:

(a) A properly completed and signed original Application for Program Benefits, a signed authorization to Furnish/Release Information, and documentation of insurance coverage (private, Medicaid or Medicare) and income;

(b) Copies of acceptable documentary evidence of residency. Copies of any two of the following documents will be considered acceptable to determine residency:

(i) A current, valid Wyoming driver’s license, or an identification card with a current Wyoming address;

(ii) A copy of a current, valid Wyoming voter’s registration card;

(iii) Mortgage or rent payment receipts from two (2) of the three (3) months immediately preceding the date of application revealing a Wyoming address;

(iv) Utility payment receipts for two (2) of the three (3) months immediately preceding the date of application revealing payment of utilities for a Wyoming address;

(v) A current, valid Wyoming Medicaid card;

(vi) Wyoming property tax receipts for the most recently completed tax year;

(vii) Wyoming employment/unemployment records;

(viii) Postal verification of a Wyoming address; or

(ix) Current Wyoming resident hunting or fishing license.

(c) A copy of the properly completed, signed and dated End Stage Renal Disease Medical Evidence Report (CMS Form 2728);

(d) A copy of the applicant’s Social Security card (or allowable substitute);

(e) A copy of an official Medicare denial notification; (f) A copy of an official Medicaid denial notification; (g) A copy of an official IHS medical contract payment denial notification.

Section 5. Co-payment Liability.

Copies of financial data must be provided to determine applicant co-pay liability. Co-payment liability is outlined in the Program's Administrative policies and procedures.

(a) The financial documents required are:

(i) A copy of a financial statement form acceptable to the Division (e.g., filed income tax returns, Social Security statements, bank statements, copies of W-2 forms, retirement statements); or

(ii) If the applicant's current gross income has become significantly reduced, a more detailed financial statement listing income information may be required for program benefit and co-payment liability consideration.

(b) Financial data will be requested for application updates on an annual basis.

Section 6. Incomplete Applications.

(a) An application shall be deemed incomplete for any one of the following reasons:

(i) Failure to provide information requested on the application form; (ii) Lack of supporting documents; (iii) Lack of or improper signature; (iv) Lack of legal residency documentation; (v) Lack of financial documentation.

(b) An incomplete application will be returned to the applicant for corrections, with deficiencies noted.

(i) If the application is incomplete, specific benefit eligibility will not be determined.

(ii) The benefit eligibility date will be established when a properly completed and signed application is received and eligibility is determined.

(iii) Payment of claims will not be made until an eligibility date has been established.

(c) A recipient must reapply for benefits in cases where her eligibility has lapsed in order to regain receipt of ESRD Program benefits.

Section 7. Eligibility Date.

The ESRD Program eligibility date will be based on the date the Division receives a properly completed and signed Application for Benefits, and once eligibility is determined.

(a) The ESRD Program eligibility date will be computed from the latest date of the following:

(i) The date application/reapplication and supporting documentation was received by the Division; or

(ii) The first dialysis treatment or transplant surgery.