wyoming end stage renal disease programwyoleg.gov/arules/2012/rules/err16-015.pdf · (a)...

CHAPTERS 1 through 5

Wyoming End Stage Renal Disease Program

Emergency Rules

Statement of Reasons

The Wyoming Department of Health (WDH) proposes to repeal the following Rules to comply

with the provisions of Wyo. Stat. Ann. § 42-4-117 and the Wyoming Administrative Procedure

Act at Wyo. Stat. Ann. §§ 16-3-101 through -115.

Chapters 1 through 5 are being repealed because funding for the Wyoming End Stage Renal

Disease Program (ESRD) is being eliminated at the end of the SFY 15/16 budget. Without

funding, the program is unable to meet its obligation to clients and providers.

Reason for Emergency Rule

The decrease in revenue for the state general fund has made fiscal restructuring a necessity.

ESRD has been identified as one of the WDH programs to be discontinued as of June 30, 2016.

Because the ESRD Rules have the force and effect of law, they need to be repealed effective the

same day the program is discontinued.

Wyoming statute states that: “the department shall expand coverage for services authorized

under Wyo. Stat. Ann. § 42-4-103(a) (xxiii) for qualified individuals in need of end stage renal

dialysis to the extent funding is available.” Wyo. Stat. Ann. § 42-4-117(a) (emphasis added).

For the above-stated reasons, the WDH requests Chapters 1 through 5 of the Wyoming End

Stage Renal Disease Program be repealed.

As required by Wyo. Stat. Ann. § 16-3-103(a)(i)(G), this proposed rule change meets minimum

substantive state statutory requirements.

CHAPTER 1

Rules and Regulations for the Wyoming End Stage Renal Disease Program

EMERGENCY RULES ARE NO LONGER IN EFFECT 120 DAYS AFTER

FILING WITH THE SECRETARY OF STATE

CHAPTER 2




CHAPTER 3




CHAPTER 4




CHAPTER 5




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CHAPTER 1


General Provisions



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 authority of the

Wyoming End Stage Renal Disease Program, Wyoming Department of Health, to

provide assistance with costs for treatment of end stage renal disease to and/or for eligible

Wyoming residents.

Section 3. Changes or Restrictions in Service Category Reimbursement.

The Wyoming End Stage Renal Disease Program may restrict or categorize

service reimbursement to meet budgetary limitations.

(a) Categories will be prioritized based upon medical necessity, Medicare

eligibility and projected Medicare/Medicaid payments for different treatment modalities.

(b) In the event program benefits are reduced, they will be reduced in a

manner that takes into consideration medical necessity and other available coverage.

(c) The Program may affect changes in benefits by either adding or deleting

entire categories or by proportionate changes across categories, or by a combination of

both of these methods.

Section 4. Definitions.

The following definitions shall apply in the interpretation and enforcement of

these rules. Where the context in which words are used in these rules indicates that such

is the intent, words in the singular number shall include the plural and vice-versa.

Throughout these rules gender pronouns are used interchangeably, except where the

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context dictates otherwise. The drafters have attempted to utilize each gender pronoun in

equal numbers in random distribution. Words in each gender shall include individuals of

the other gender.

(a) “Acknowledgment” – written verification of receipt of information

provided to the applicant/recipient by the Program.

(b) “Applicant” - a person whose written application for the Wyoming End

Stage Renal Disease Program has been submitted to the Program, but who has not yet

received final action.

(c) “Approved Facility” - a facility approved to participate in the Program,

which includes, but is not limited to:

(i) Hospital outpatient dialysis facilities;

(ii) Free-standing ESRD clinics or centers;

(iii) In-state or out-of-state facilities, including free-standing facilities;

(iv) Medicare approved hospitals and transplant centers; and

(v) Veterans Administration and military hospitals which have Joint

Commission, formerly known as Joint Commission on Accreditation of Healthcare

Organizations (JCAHO), approved renal dialysis units.

(d) “Critical need” – Need for assistance based upon the applicant’s certified

diagnosis of and treatment for End Stage Renal Disease (ESRD) and household income at

or below 185% of Federal Poverty Guideline when adjusted by applicant specific ESRD

related expenses.

(e) “Department” - the Wyoming Department of Health.

(f) “Director” - Director of the Wyoming Department of Health.

(g) “End Stage Renal Disease (ESRD)” - chronic, irreversible renal (kidney)

failure which requires dialysis or kidney transplantation to maintain life.

(g) “Hearing” - a contested case hearing before a designated hearing officer.

(i) “Program” - the Wyoming End Stage Renal Disease Program.

(j) “Provider” - any party who has ESRD Program approval and provides

related services to Program recipients.

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(k) “Recipient” - an ESRD patient that has been determined eligible for and is

receiving Program benefits.

(l) “Residency” - proof by documentation acceptable to the Program that an

individual meets the Program definition of “resident”.

(m) “Resident” – an individual who can document his residence in Wyoming

exclusively for sixty (60) continuous days immediately preceding the date he applies for

Program assistance.

Section 5. Payment of Program Benefits.

(a) Benefits are only payable after all other possible third parties (e.g.,

private/group insurance, Medicare, Medicaid, Indian Health Service (IHS) or the

Veterans Administration) have met their responsibilities to pay, or after it is determined

that there are no third parties that may be liable for payment.

(i) If dialysis has begun and there is no verifiable third party payer,

the Program will pay the dialysis center a flat rate fee, as determined by the Program, per

treatment for up to ninety (90) days.

(ii) One sixty (60) day extension of the flat rate fee may be granted at

the discretion of the Program in an extenuating circumstance.

(b) Benefits for dialysis treatments, home training, home dialysis

partners/technicians, stabilization, hospitalization, laboratory charges, home dialysis

supplies, Program-approved medications, and transportation, are payable to Providers, up

to a maximum per recipient per year.

(i) Recipients who have a kidney transplant are eligible for the

Program-approved medications benefit only.

(c) Reimbursement for Program-approved medications, insurance premiums,

and ESRD related travel expenses are payable to recipients up to a maximum per

recipient per year.

(i) Kidney transplant recipients are eligible for the Program-approved

medications benefit only.

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CHAPTER 2


Eligibility Requirements








3-101, et seq.


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

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(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;

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(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:

(i) Failure to provide information requested on the application form;

(ii) Lack of supporting documents;

(iii) Lack of or improper signature;

(iv) Lack of Wyoming 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, 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.

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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.

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CHAPTER 3


Conditions of Participation for Facilities








3-101, et seq.



to establish standards and conditions of participation for in-state dialysis facilities and

out-of-state facilities. The Program may, at its sole discretion, require the use of in-state

facilities when the in-state facilities are comparable and are equal in geographic

accessibility to out-of-state facilities.

Section 3. Conditions and/or Approval Requirements.

(a) An approved ESRD facility is one that:

(i) Has met all Medicare certification requirements; and

(ii) Has been assigned a Medicare ESRD provider number.

(b) The facility approval date may not be earlier than the date granted by

CMS for Medicare ESRD approval.

(c) Facilities under interim approval for Medicare participation also will be

classified as having interim approval by the Program for the purpose of receiving

payments on behalf of Program recipients.

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CHAPTER 4


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








3-101, et seq.



to deny an applicant benefits or modify, suspend or terminate a recipient’s benefits under

the Program for the following reasons:

(a) The applicant/recipient is not a resident of the State of Wyoming;

(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;

(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;

(d) The applicant/recipient does not have end stage renal disease, regains

kidney function, or voluntarily stops treatment for end stage renal disease;

(e) The recipient refuses to reimburse the Department after being notified of

third party benefits or recipient’s reimbursement obligation;

(f) The recipient notifies the Program in writing that he no longer wishes to

claim Program benefits;

(g) The applicant/recipient dies;

(h) The recipient submits false claims for benefits to the Program;

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(i) The Program has not paid a claim for benefits on behalf of the recipient

during any period of twelve (12) consecutive months;

(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;

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(ii) Shall be subject to costs and expenses incurred in collection,

including attorney fees, at the discretion of the Department.

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CHAPTER 5


Denial, Modification, Suspension, or Termination of Facility Approval








3-101, et seq.



to deny, modify, suspend, or terminate facility approval.

(a) A program approved dialysis facility, whether in-state or out-of-state, will

have its privilege to participate in the Program denied, modified, suspended, or

terminated if:

(i) The facility loses Medicare approval;

(ii) The facility, with interim approval from the Program, fails to

receive final Medicare/CMS approval;

(iii) The facility voluntarily withdraws from participation in the

Program by providing the Program with a sixty (60) day written notice;

(iv) By mutual written consent of the Program and the facility;

(v) The facility fails or refuses to submit, in a manner prescribed by

the Program, information which is requested for the purpose of determining the facility’s

compliance with program rules;

(vi) The facility submits materially false or intentionally misleading

information to the Program;

(vii) The facility fails to reimburse the Department within ninety (90)

days after it has been notified in writing that over payments have been made;

(viii) The facility files false claims.

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Section 3. Procedures for Denial, Modification, Suspension, or Termination

of Facility Approval.

(a) The Program shall notify the Administrator of the facility by certified mail

of its intent to deny, modify, suspend, or terminate Program approval, the reasons for the

adverse action, in compliance with the Wyoming Department of Health, Procedures For

The Conduct of Contested Case Hearings, Chapter 1 (Aug. 4, 1983).

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