Health, Department of

Renal Disease Program, Administrative Procedure for End Stage

Chapter 4: Denial of App/Modification/Suspension/Termination of Patient Benefits

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

Rule Type: Superceded Rules & Regulations

Reference Number: 048.0049.4.10121988

CHAPTER IV

DENIAL OF APPLICATION; MODIFICATION, SUSPENSION, OR TERMINATION OF PATIENT BENEFITS

Section 1. Statement of Purpose. These rules and regulations are adopted to implement the Division's authority to deny application or modify, suspend or terminate a person's benefits under the ESRD Program for the following reasons:

1. (a) The applicant/recipient is not a bona fide resident of the State;
2. (b) The applicant/recipient fails or refuses to provide the periodic documentation of residency;
3. (c) The applicant/recipient fails or refuses to submit a recipient financial status report for the purpose of determining reimbursement obligation/co-pay liability;
4. (d) The applicant/recipient submits an application or any documents required in support of the application which contains false statements of fact designed to enhance that person's eligibility status for ESRD Program benefits;
5. (e) The applicant/recipient does not have end-stage renal disease, regains kidney function, or voluntarily stops treatment for end-stage renal disease;
6. (f) The recipient refuses to reimburse the Division after being notified of third party benefits or recipient reimbursement obligation;
7. (g) The recipient notifies the Program in writing that he no longer wishes to claim ESRD Program benefits;
8. (h) The applicant/recipient dies;
9. (i) The recipient submits false claims to the ESRD Program;
10. (j) The ESRD Program has not paid a claim for benefits on behalf of the recipient during any period of twelve (12) consecutive months;
11. (k) ESRD Program funds are curtailed;
12. (l) Funds allocated for payments on behalf of the recipient are exhausted.

Section 2. Procedures for the denial of applications or the modification, suspension, or termination of benefits.

(a) Any applicant for ESRD Program benefits will be notified in writing if his application has been denied. The notification will state the reasons for denial and his rights to request a hearing.

(b) Any recipient of benefits from the ESRD Program will be notified if his benefits are to be modified, suspended or terminated. Notification will be by certified mail to the most recent address known to the Program and shall contain the reasons for the intended action, as well as the contestant's right to a hearing and the method by which he may obtain a hearing.

(c) These procedures do not apply to adjustments made by the ESRD Program in the type of Program benefits or the amount of benefits available when such adjustments are necessary to conform to budgetary limitations.