Health, Department of

Renal Disease Program, Administrative Procedure for End Stage

Effective Date: 07/24/2014 to 12/20/2016

Rule Type: Superceded Rules & Regulations

Reference Number: 048.0049.2.07242014

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 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.

Section 2. Statement of Purpose.

These rules and regulations are adopted to implement the Department's authority to establish the eligibility of recipients for Program benefits.

Section 3. Eligibility.

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

(i) Has a determined critical need for assistance;

(ii) Is a resident of Wyoming, being actually present in the state continuously for the sixty (60) days preceding the date of application, and having furnished documentation of residency;

(iii) Has made application through the Program. Applications may be obtained through any of the following:

(A) An approved dialysis center or facility;

(B) A Medicare approved hospital/transplant center;

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

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

(E) On-line at the Wyoming Department of Health website, End Stage Renal Disease page.

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, including the signed authorization to Furnish/Release Information;

(b) Copies of acceptable 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 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 in the name of the applicant or her spouse from the two (2) months immediately preceding the date of application revealing a verifiable Wyoming address;

(iv) Utility payment receipts in the name of the applicant or his spouse for the two (2) months immediately preceding the date of application revealing payment of utilities for a Wyoming address;

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

(vi) Wyoming employment/unemployment records;

(vii) Postal verification of a Wyoming address; or

(viii) 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);

(i) This requirement is waived for kidney transplant recipient applicants. A letter from the applicant’s nephrologist attesting to the transplanted kidney will be considered an acceptable substitute in this circumstance.

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

(e) Copies of all current insurance cards;

(f) Copies of outstanding or current bills relating to the applicant’s ESRD;

(g) Verification of income for all members of the household to determine financial eligibility;

(i) A copy of a financial statement form acceptable to the Program (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.

Section 5. Incomplete Applications.

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

1. (i) Failure to provide information requested on the application form;
2. (ii) Lack of supporting documents;
3. (iii) Lack of or improper signature;
4. (iv) Lack of Wyoming residency documentation;
5. (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, 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 and any required Acknowledgements have been received by the Program.

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

Section 6. Eligibility Date.

The applicant's eligibility date will be based on the date the Program receives a properly completed and signed Application for Benefits, including all required documentation.

(a) The eligibility date will be determined by the latest date of the following:

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

(ii) The date of the first dialysis treatment or transplant surgery.

Section 7. Benefit Continuation.

(a) Continuation of Program benefits for recipients will be based on an annual update to certify her continued eligibility.

(b) To ensure recertification for continued benefits, the recipient must complete and return to the Program an annual update packet. The packet is due to the Program by June 30th each year for the recipient to maintain continued eligibility with the program.

(c) To maintain continuing eligibility for the program;

(i) The recipient must still reside in Wyoming;

(ii) The recipient must still be medically eligible;

(iii) The recipient must still be financially eligible.

(d) An annual update packet will be mailed to Program recipients that are eligible as of December 31 of the previous year, at his last known address;

(i) The packet will be mailed in mid-March of each year;

(ii) Instructions for the completion of the update will be included.

(e) Failure by the recipient to provide a complete annual update by June 30th will result in the file being closed with no benefits paid for services received or expenses incurred after June 30th.

(f) Previous recipients may reapply for Program benefits at any time.