Health, Department of

Renal Disease Program, Administrative Procedure for End Stage

Effective Date: 10/12/1988 to 09/07/2010

Rule Type: Superceded Rules & Regulations

Reference Number: 048.0049.2.10121988

CHAPTER II

ELIGIBILITY REQUIREMENTS

Section 1. 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 2. Eligibility

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

(i) Has a certified medical diagnosis of ESRD;

(ii) Is a bonafide resident of Wyoming, is actually present in the State, and has furnished documentation of residency;

(iii) Has made application through:

(A) A ESRD center and/or facility (in-state and/or out-of-state) that has received program approval or interim approval;

(B) A Medicare approved hospital/transplant center.

(C) A military or Veterans Administration hospital with a JCAHO approved renal unit.

(D) A Public Health Nursing Field Office or a Division of Public Assistance & 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 Title XVIII), 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 participating facilities and providers;

Section 3. Application Process.

In making application, a person must submit or have submitted for him the following documents:

(a) A properly completed and signed original Application for Program Benefits; a Social Summary Face sheet, a signed authorization to Furnish/Release Information, or a Reapplication for Benefits form;

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

(i) A current, valid Wyoming driver's license, or an identification card with a current address and telephone number;

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

(iii) Mortgage or rent payment receipts from two of the three months immediately preceding the date of application;

(iv) Utility payment receipts for two of the three months immediately preceding the date of application;

(v) A current, valid Wyoming Medicaid card;

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

(vii) Employment/unemployment records; (viii) Postal verification of address; or

(ix) Current resident hunting or fishing license.

(c) A copy of the properly completed, signed and dated Chronic Renal Disease Medical Report Form (HCFA Medical Form 2728-U4);

(d) A copy of the applicant's Social Security Card (or allowable substitute);

(e) A copy of an official Social Security Administration 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 4. Co-payment Liability. Copies of financial data must be provided to determine applicant co-pay liability. Although basic program eligibility will be determined without the financial data documents, specific benefit eligibility cannot be determined, and claims against the benefit cannot be processed and will be rejected until co-pay liability is established. (Co-payment liability is outlined in the Division'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., CHS form, etc.); 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 routinely requested for application up-date every twelve months.

Section 5. 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 submitting agency, facility or hospital for correction, with deficiencies noted.

(i) A copy of the letter notifying the facility or hospital that the application is incomplete will be sent to the applicant.

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

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

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

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

Section 6. Eligibility Date.

(a) The ESRD Program eligibility date will be based on the date the Division receives a completed Application for Benefits, or Reapplication for Benefits as specified in this chapter.

(b) 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) 30 days prior to the first dialysis treatment or transplant surgery; or

(iii) The date Wyoming residency was established and application was made.