WSR 98-06-025

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Medical Assistance Administration)

[Filed February 24, 1998, 2:23 p.m.]

Date of Adoption: February 20, 1998.

Purpose: This amendment is to clarify language, alphabetize definitions, and provide information about determining client eligibility for the state-funded kidney disease program. Editorial changes to improve readability do not change intent of this WAC.

Citation of Existing Rules Affected by this Order: Amending WAC 388-540-005, 388-540-030, and 388-540-060.

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: RCW 74.04.005 and 74.08.025.

Adopted under notice filed as WSR 98-02-059 on January 6, 1998.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, amended 0, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 0, amended 0, repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, amended 3, repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, amended 3, repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, amended 0, repealed 0; Pilot Rule Making: New 0, amended 0, repealed 0; or Other Alternative Rule Making: New 0, amended 3, repealed 0.

Effective Date of Rule: Thirty-one days after filing.

February 20, 1998

Edith M. Rice, Chief

Office of Legal Affairs

AMENDATORY SECTION (Amending Order 3600, filed 7/28/93, effective 8/28/93 WAC 388-540-005 Definitions. For the purpose of administering the state kidney disease program (KDP), the following shall apply:

(((1) "End stage renal disease (ESRD)" means that stage of renal impairment which is irreversible and permanent, and requires dialysis or kidney transplantation to ameliorate uremic symptoms and maintain life;

(2) "ESRD Client" means resident of the state with a diagnosis of ESRD;

(3) "Kidney center" means those facilities as defined and certified by the federal government to provide ESRD services and which provide the services specified in this chapter and which promote and encourage home dialysis for a client when medically indicated;

(4) "Affiliate" means a facility, hospital, unit, business, or person having an agreement with a kidney center to provide specified services to ESRD patients;

(5) "State kidney disease program" means state general funds appropriated to the department to assist clients with ESRD in meeting the cost of medical care;

(6) "Application for ESRD eligibility" means the form provided by the department which the client completes and submits to determine ESRD eligibility;

(7) "Certification" or "certified" means the department has approved a client for the state kidney disease program under this chapter;

(8) "ESRD application period" means the time between the date of application and certification;

(9) "Resources" means income or assets or any real or personal property that a person or the person's spouse owns and could convert to cash to be used for support or maintenance;

(10) "Fair market value" means the current worth of a resource at the time of transfer or, if earlier contract for sale, or date of application;

(11) "Adequate consideration" means that the reasonable value of goods or services received in exchange for transferred property approximates the reasonable value of the property transferred;

(12) "Transfer" means any act or omission to act whereby title to or any interest in property is assigned, set over, or otherwise vested or allowed to vest in another person;

(13) "Reasonable value" means the amount that the property is worth on the open market;

(14) A "substantial reduction" means:

(a) The elimination of a client's required annual deductible amount; or

(b) The reduction of resources to below fifteen hundred dollars.)) "Adequate consideration" means that the reasonable value of goods or services received in exchange for transferred property approximates the reasonable value of the property transferred;

"Affiliate" means a facility, hospital, unit, business, or person having an agreement with a kidney center to provide specified services to ESRD patients;

"Application for KDP eligibility" means the form provided by the department which the client completes and submits to determine KDP eligibility;

"Assets" means income or resources or any real or personal property that a person or the person's spouse owns and could convert to cash to be used for support or maintenance;

"Break in service" means a previously certified client does not have medical coverage for a period of time when a new application for eligibility is submitted more than thirty days after the end of a previous certification period;

"Certification" or "certified" means the kidney center has determined a client eligible for the KDP for a period of time under this chapter;

"Department" means the department of social and health services;

"End stage renal disease (ESRD)" means that stage of renal impairment which is irreversible and permanent, and requires dialysis or kidney transplantation to ameliorate uremic symptoms and maintain life;

"KDP application period" means the time between the date of application and certification;

"KDP Client" means resident of the state with a diagnosis of ESRD;

"Kidney center" means those facilities as defined and certified by the federal government to provide ESRD services and which provide the services specified in this chapter and which promote and encourage home dialysis for a client when medically indicated;

"Recertifying client" means a KDP client who was determined eligible the previous year for the KDP and will continue to qualify under this chapter;

"Resident." Refer to WAC 388-505-0510;

"State kidney disease program (KDP)" means state general funds appropriated to the department to assist clients with ESRD in meeting the cost of medical care;

"Substantial financial change" means:

(1) The elimination of a client's required annual deductible amount; or

(2) The increase or decrease of income or assets by fifteen hundred dollars.

"Transfer" - Refer to WAC 388-500-0005;

"Value-fair market" - Refer to WAC 388-500-0005.

[Statutory Authority: RCW 74.08.090. 93-16-039 (Order 3600), 388-540-005, filed 7/28/93, effective 8/28/93.]

AMENDATORY SECTION (Amending Order 3600, filed 7/28/93, effective 8/28/93 WAC 388-540-030 ((ESRD)) KDP eligibility. ((The kidney center shall review at least annually the client's ESRD eligibility for the state kidney disease program according to procedures outlined in this chapter. A client shall be considered eligible when the client exhausts or is ineligible for all other resources providing similar benefits to meet the costs of ESRD-related medical care. Resources shall include:

(1) Income in excess of a level necessary to maintain a moderate standard of living, as defined by the department, using accepted national standards;

(2) Savings, property, and other assets;

(3) Government and private medical insurance programs;

(4) Government or private disability programs;

(5) Local funds raised for the purpose of providing financial support for a specified ESRD client: Provided, That in determining eligibility the following resources shall be exempt:

(a) A home, defined as real property owned by a client as a principal place of residence, together with the property surrounding and contiguous thereto, not to exceed five acres. Commercial property or property used for the purpose of producing income shall be considered excess property and shall be subject to the limitations of subsection (5)(d) of this section;

(b) Household furnishings;

(c) An automobile; and

(d) Savings, property or other assets, the value not to exceed the sum of five thousand dollars.))

(1) A client is KDP eligible who meets the following requirements:

(a) Is a Washington state resident;

(b) Has countable resources, not exempted under subsection (2) of this section, equal to or lower than fifteen thousand dollars;

(c) Has countable income as defined under WAC 388-500-0005 equal to or lower than three hundred percent of the federal poverty level (FPL); and

(d) Exhausts or is ineligible for all other resources providing similar benefits to meet the cost of ESRD-related medical care, such as:

(i) Government or private disability programs; or

(ii) Local funds raised for the purpose of providing financial support for a specified ESRD client.

(2) The following resources are exempt:

(a) A home, defined as real property owned by a client as a principal place of residence, together with the property surrounding and contiguous thereto, not to exceed five acres;

(b) Household furnishings; and

(c) An automobile.

[Statutory Authority: RCW 74.08.090. 93-16-039 (Order 3600), 388-540-030, filed 7/28/93, effective 8/28/93.]

AMENDATORY SECTION (Amending Order 3600, filed 7/28/93, effective 8/28/93 WAC 388-540-060 ((Procedures for ESRD)) KDP eligibility determination. The department, kidney center and ct shall comply with the following ((procedures)) rules to determine ((ESRD)) KDP eligibility:

(1) ((The department shall provide the kidney center with the necessary forms and instructions;

(2))) The kidney center shall:

(a) Inform the client of the requirements for ((ESRD)) KDP eligibility as defined in this chapter;

(((3) The kidney center shall))

(b) Provide the client with necessary department forms and instructions in a timely manner;

(((4) The)) (c) Review the KDP application and documentation;

(d) Determine client eligibility using department policies, rules, and instructions; and

(e) Forward the KDP application and documentation to the medical assistance administration (MAA). If necessary, the department may amend or terminate a client's certification period within thirty days of receipt

(2) A new client shall:

(a) Complete ((and submit the ESRD)) the KDP application and submit any necessary documentation for eligibility ((and any necessary documentation)) determination to the kidney center ((in the manner and form the department prescribes;

(5) A new client shall)); and

(b) Apply for Medicaid, obtain a written Medicaid eligibility determination and ((send)) submit a copy to the kidney center ((written documentation of Medicaid eligibility or denial;

(6) The kidney center shall review the ESRD application and documentation for completeness and accuracy according to instructions provided by the department;

(7) The kidney center shall forward to the medical assistance administration (MAA) the ESRD application and any documentation needed to approve or deny eligibility. The MAA shall review the ESRD application and documentation and notify the kidney center that the client has been certified, or request additional information as needed;

(8))).

(3) A recertifying client shall:

(a) Apply for Medicaid forty-five days before the end of the KDP certification period; and

(i) Obtain a written Medicaid eligibility determination; and

(ii) Submit a copy to the kidney center; or

(b) Be exempt from the requirement in (3)(a) of this subsection when the client has applied for Medicaid in the prior five years and will continue to:

(i) Be denied Medicaid due to:

(A) Failure to meet Medicaid categorical requirements;

(B) Assets exceeding Medicaid resource standards; or

(C) Income exceeding the categorically needy income standards.

(ii) Not meet medically needy spenddown amount because the cost of medical care is:

(A) Less than the spenddown amount; or

(B) Covered by third-party insurance.

(4) The ((ESRD)) KDP application period ((shall be limited to)) is :

(a) One hundred and twenty days for a new client; and

(b) Forty-five days prior to the end of a certification period for a client requesting recertification.

(5) The kidney center may request an extension of application time limits from the department when extenuating circumstances ((prohibit)) prevent the client from completing the application or recertification process within the ((allowed)) specified time limits. ((The department, at its discretion, may grant and specify the limits of the extension;

(9))) (6) The ((ESRD)) KDP client shall be certified as KDP eligible for a period of one year from the first day of the month of application unless the client's ((resources or income increase or decrease)):

(a) Need for medical coverage is less than one year; or

(b) Assets change substantially, in which case the client must complete a new application for ((ESRD)) KDP eligibility;

(((10) ESRD)) (7) KDP eligibility effective date is the first day of the month of ((ESRD)) KDP application if the person was eligible at any time during that month. The effective date of ((ESRD)) KDP eligibility shall be no earlier than four months before the month of ((ESRD)) KDP application provided the:

(a) Medical services received were covered; and

(b) Person would have been eligible had the person applied.

(((11) A client currently eligible shall be recertified before the end of the respective eligibility periods.

(12) A client who seeks continued program services does not need to reapply for Medicaid unless the client has a substantial reduction in resources during the year.))