Health, Department of

Renal Disease Program, Administrative Procedure for End Stage

Chapter 4: Denial of Application; Modification, Suspension or Termination of Recipient Benefits

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

Rule Type: Superceded Rules & Regulations

Reference Number: 048.0049.4.07242014

CHAPTER 4

Rules and Regulations for the Wyoming End Stage Renal Disease Program

Denial of Application; Modification, Suspension, or Termination of Recipient Benefits

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 deny an applicant benefits or modify, suspend or terminate a recipient's benefits under the Program for the following reasons:

1. (a) The applicant/recipient is not a resident of the State of Wyoming;
2. (b) The applicant/recipient fails or refuses to provide the required annual update or submits documents required in support of the annual update which contain false statements of fact designed to enhance that person's eligibility status for Program benefits;
3. (c) 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 Program benefits;
4. (d) The applicant/recipient does not have end stage renal disease, regains kidney function, or voluntarily stops treatment for end stage renal disease;
5. (e) The recipient refuses to reimburse the Department after being notified of third party benefits or recipient's reimbursement obligation;
6. (f) The recipient notifies the Program in writing that he no longer wishes to claim Program benefits;
7. (g) The applicant/recipient dies;
8. (h) The recipient submits false claims for benefits to the Program;
9. (i) The Program has not paid a claim for benefits on behalf of the recipient during any period of twelve (12) consecutive months;
10. (j) Program funds are reduced;

(k) Funds allocated for payments on behalf of the recipient are exhausted.

Section 3. Procedures for the Denial of Benefits or the Modification, Suspension, or Termination of Benefits.

(a) Any applicant for Program benefits will be notified in writing if her application has been denied. The notification will state the reasons for denial and her rights to request a hearing in compliance with the Wyoming Department of Health, Procedures For The Conduct of Contested Case Hearings, Chapter 1 (Aug. 4, 1983);

(b) Any recipient of benefits from the Program will be notified if his benefits are being 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 recipient's right to a hearing and the method by which he may obtain a hearing in compliance with the Wyoming Department of Health, Procedures For The Conduct of Contested Case Hearings, Chapter 1 (Aug. 4, 1983);

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

Section 4. Repayment of Funds.

(a) Any recipient who has been notified of a repayment obligation, for whatever reason, shall have sixty (60) days to respond to the Program;

(i) To arrange a repayment plan acceptable to the Program;

(ii) To request forgiveness of the debt for cause.

(b) Any recipient who has agreed to a repayment plan and is adhering to the plan shall remain eligible for Program benefits provided she is otherwise still eligible;

(c) Any recipient who has requested forgiveness of the debt for a cause deemed legitimate by the Program shall receive written notice of the amount forgiven;

(d) Any recipient who is no longer eligible for Program benefits and fails to arrange for or adhere to a repayment plan;

(i) Shall be subject to collection, at the discretion of the Department;

(ii) Shall be subject to costs and expenses incurred in collection, including attorney fees, at the discretion of the Department.