WSR 13-23-065 PERMANENT RULES HEALTH CARE AUTHORITY (Medicaid Program) [Filed November 18, 2013, 2:15 p.m., effective January 1, 2014] Effective Date of Rule: January 1, 2014.
Purpose: The proposed rules contain the following amendments necessary in restructuring the kidney disease program (KDP):
Citation of Existing Rules Affected by this Order: Repealing WAC 182-540-035; and amending WAC 182-540-001, 182-540-005, 182-540-015, 182-540-025, 182-540-045, 182-540-055, and 182-540-065.
Statutory Authority for Adoption: RCW 41.05.021.
Adopted under notice filed as WSR 13-19-097 on September 18, 2013.
Changes Other than Editing from Proposed to Adopted Version: The following changes (including housekeeping changes) were made to the rule as a result of written comments received from stakeholders and other agency changes occurring January 1, 2014, which require terminology changes and/or WAC citation changes:
(1) In several places throughout the text, "client" or "clients" is changed to "person" or "persons" to more accurately reflect the fact that the individual is not a client yet.
(2) WAC 182-540-005 Definitions:
Application documentation - Definition updated to reflect WAH eligibility determination letter beginning January 1, 2014.
KDP contract manual - Definition changed to "KDP manual." The word contract is removed.
KDP contractor - Removed "Washington state" from definition.
(3) WAC 182-540-015 Kidney disease program (KDP)—General eligibility criteria, "clients" is changed to "persons" to more accurately reflect the fact that the individual is not a client yet.
Subsection (1)(a), Updated WAC references that were recodified by the agency and changed to Title 182 WAC: WAC 388-468-0005 is changed to WAC 182-503-0520 or 182-503-0525, chapter 388-424 WAC is changed to WAC 182-503-0520 or 182-503-0525, and WAC 388-476-0005 is changed to WAC 182-503-0515.
Subsection (1)(c), changed to read:
"Be determined ineligible for any other Washington apple health (WAH) program, including medicaid under Title XIX or XXI of the Social Security Act; the alien medical program described in WAC 182-507-0110; the medical care services (MCS) program described in WAC 182-508-0005; or and another state-funded medical program with the following exceptions …."
Subsection (1)(c)(iv), added "kidney" before the word center.
Subsection (1)(d), change "with" to "to." "Submit an application for medicare with to the Social Security Administration (SSA) …."
Subsection (2)(a), made the following changes: "Become eligible for another WAC program, including medicaid, the alien emergency medical program described in WAC 182-507-0110, medical care services or and any other state-funded medical program, …"
Subsection (3), changed cross-reference to updated agency rules: Applicants for KDP do not have to meet citizenship criteria described in chapter 388-424 WAC WAC 182-503-0535 to qualify for KDP.
Subsection (4), changed cross-reference to updated agency rules: Rules governing Social Security number are described in WAC 388-476-0005 182-503-0515.
Subsection (6), changed "medicaid or another medical program" to "another WAH program …" as follows:
"A person who is subsequently found retroactively eligible for medicaid or another medical WAH program during the three-month retroactive period is not eligible for KDP reimbursement of expenses which are billable to the other medical WAH program."
Subsection (7), added "… the time of …" to second sentence as follows:
"The KDP contractor is responsible for certifying that the person meets the functional criteria for ESRD at the time of application and at the time of review."
(4) WAC 182-540-023(3), changed "medicaid eligible" to "eligible for Washington apple health …."
(5) WAC 182-540-026 (1)(b)(i), changed:
"Health benefit exchange" to "Washington Healthplanfinder."
"Medical assistance" to "Washington apple health (WAH)," and "medical application" to "application for WAH."
(6) WAC 182-540-026 (1)(b)(ii), updated the references to medical assistance and health benefit exchange as follows:
"Submit an application for medical assistance WAH with to DSHS and/or the health benefit exchange via the Washington Healthplanfinder, as applicable, and provide the kidney center KDP contractor with a copy of the application documentation when an eligibility determination has been made; and"
Subsection (2)(b) and (3), changed "kidney center" to "KDP contractor."
(7) WAC 182-540-055 (1)(e) and (f), Kidney disease program (KDP) covered services:
Changed as follows: "(e) Pretransplant work-up including, but not limited to dental treatment, transportation, lodging, and physician visits; and" Dental treatment falls under (i) Other services as approved by the agency's KDP program manager.
"(f) Post-transplant visit to assess client's ESRD status to include, but is not limited to, transportation, lodging, and physician visits;"
(8) WAC 182-540-060 (1)(c), (2)(b), (6), Kidney disease program (KDP) client appeal rights, changed "contractor" to "KDP contractor."
(9) WAC 182-540-065 (1)(c), Kidney disease program (KDP)—Reimbursement, changed "KDP contract manual" to "KDP manual" to match change in defined term.
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 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 6, Amended 7, Repealed 1.
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 6, Amended 7, Repealed 1.
Date Adopted: November 18, 2013.
Kevin M. Sullivan
Rules Coordinator
KIDNEY DISEASE PROGRAM (STATE-FUNDED)
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-540-001 Purpose.
This ((section)) chapter (WAC ((388-540-001)) 182-540-001 through ((388-540-065)) 182-540-065) contains rules for the state-funded kidney disease program (KDP) administered by the health care authority (the agency). The ((kidney disease program)) KDP is ((designed to help clients)) available for persons who have end-stage renal disease((,)) requiring dialysis or kidney transplant, or persons who have received a kidney transplant but who do not meet the eligibility standards for any other Washington apple health program including medicaid or state-only funded medical programs.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-540-005 Kidney disease program (KDP)—Definitions.
The following definitions and those found in chapter 182-500 WAC ((388-500-0005)), apply to this chapter for the purpose of administering the kidney disease program. (("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)) - A facility, hospital, unit, business, or person having an agreement with a kidney center to provide specified services to ESRD patients; (("Application for eligibility" means the form provided by MAA, which the client completes and submits to the contracted kidney center to determine KDP eligibility;)) "Applicant for KDP" - A person who submits a new application for assistance under the kidney disease program (KDP), or an existing client who has had a break in eligibility of over thirty days; "Application documentation" ((means either a)) - A "((medicaid)) medical eligibility determination" letter from the department of social and health services (DSHS) ((community services office, or a KDP "client recertification waiver" form. "Assets" means income, 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)) and/or a Washington apple health (WAH) eligibility determination letter from the health care authority (the agency) either approving or denying an application for WAH; "Certification" ((means)) - The kidney center or affiliate has determined a ((client)) person eligible for the KDP for a defined period of time; "End-stage renal disease (ESRD)" ((means that)) - The stage of renal impairment which is irreversible and permanent, and requires dialysis or kidney transplant to ameliorate uremic symptoms and maintain life. For purposes of the KDP, this includes persons who have received a transplant; (("KDP application period" means the time between the date the client signed the completed application for eligibility and the date the client is certified for participation in the program;)) "KDP application" - The agency Form 13-566 which the person completes and submits to the KDP contractor to determine KDP eligibility; "KDP client" ((means a resident of the state)) - A person who has a diagnosis of ESRD or had a diagnosis of ESRD and has received a kidney transplant and ((meets the financial and medical eligibility criteria)) has been determined eligible for the kidney disease program as determined by a KDP contractor; (("KDP client recertification waiver for medicaid review" means a KDP eligibility form that may in some circumstances be used in place of a "medicaid medical assistance determination letter." "KDP contract manual" means a set of policies and procedures for contracted kidney centers;)) "KDP contractor" ((means a)) - A kidney center or other ESRD facility that has contracted with the ((Washington state department of social and health services (DSHS))) health care authority (the agency), kidney disease program to provide ESRD((-related)) services to KDP clients((.)); "KDP manual" - A manual that describes the KDP contract guidelines and procedures for a KDP contractor; "Kidney center" ((means a)) - A facility as defined and certified by the federal government to((: (1))) provide ESRD services((; (2) Promote and encourage home dialysis for a client when medically indicated; and (3) For the purposes of WAC 388-540-032 through 388-540-060, it is a facility that has entered into a contract with Washington state department of social and health services (DSHS), kidney disease program to provide ESRD-related services)). "Kidney disease program (KDP)" ((means a)) - A state-funded program managed by the Washington state health care authority that provides financial assistance to eligible ((clients with)) persons for the costs of ESRD((-related)) medical care; (("Medicaid medical assistance determination letter" means a medical assistance client eligibility letter from the DSHS community services office. "Resident" means a person who lives in Washington state on more than a temporary basis. "Substantial financial change" means the increase or decrease of income or assets that may affect eligibility.)) "Spenddown" - The process by which a person uses incurred medical expenses to offset income to meet the financial standards established by the agency. (See WAC 182-519-0110.)
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-540-015 ((Client eligibility for)) Kidney disease program (KDP)—General eligibility criteria.
((Clients)) (1) Persons must meet the following criteria to be ((considered)) eligible for the kidney disease program (KDP) ((eligible)): (((1) Be a)) (a) Reside in the state of Washington ((state resident)) as required under WAC 182-503-0520 or 182-503-0525; (((2))) (b) Be diagnosed with end-stage renal disease (ESRD) requiring dialysis or kidney transplant as defined in WAC 182-540-005 or have received a kidney transplant; (((3))) (c) Be determined ineligible for any other Washington apple health (WAH) program, including medicaid; (((4) Exhaust or be ineligible for all other resources providing similar benefits; (5))) the alien medical program described in WAC 182-507-0110; the medical care services (MCS) program described in WAC 182-508-0005; and another state-funded medical program with the following exceptions: (i) Persons who are found eligible for the medically needy (MN) program but are required to meet the spenddown liability under WAC 182-519-0110 or who are found or become eligible for the alien emergency medical programs described in WAC 182-507-0110, are eligible for KDP until the spenddown liability has been met; (ii) A KDP contractor may use KDP funding as available to pay for medical expenses on behalf of a spenddown client as expenses are incurred by the person, and those expenses will be treated as if the person incurred the financial liability for the expense; (iii) When a KDP contractor uses KDP funding to pay for monthly health insurance premiums (including WSHIP premiums) on behalf of a spenddown client, those committed funds may continue to be paid even if the person becomes eligible for MN coverage by meeting the spenddown liability. Payment may continue until the person is no longer otherwise eligible for KDP or until the person applies to the agency and is found eligible for assistance in paying the premiums; (iv) A KDP contractor may use KDP funding to pay for premiums under the health care for workers with disabilities program described in chapter 182-511 WAC if it is cost-effective for the kidney center and KDP funds are available. (d) Submit an application for medicare to the Social Security Administration (SSA) within thirty calendar days of applying for KDP and provide the KDP contractor with a copy of SSA's approval or denial determination notice with the following exceptions: (i) Clients that have any employer group health plan (EGHP) or COBRA plan; and (ii) Clients who are still within the thirty-month EGHP period. (e) Have countable income which is equal to or less than((: (a))) two hundred twenty percent of the federal poverty level (FPL) ((or)); (((b) Three hundred percent of the FPL with an annual deductible required equal to the income amount which is in excess of two hundred percent of the FPL. (6))) (f) Have countable resources ((that are either equal to or less than fifteen thousand dollars, or are exempt. Exempt resources are: (a) A home, defined as real property owned by a client as principal place of residence together with surrounding and contiguous property, not to exceed five acres; (b) Household furnishings; and (c) An automobile. (7))) in an amount that is equal to or less than the resource standards under the qualified medicare beneficiary (QMB) program. Resource rules are defined in WAC 182-540-030; (g) Report changes in circumstances as required under WAC 182-540-023. (2) Persons are not eligible for KDP if they: (a) Become eligible for another WAH program, including medicaid, the alien emergency medical program described in WAC 182-507-0110, medical care services and any other state-funded medical program, with the exceptions described in subsection (1)(c) of this section; (b) Fail to apply for medicare within thirty days of being approved for KDP, or fail to follow through with the medicare application process required by the Social Security Administration; (c) Are in custody of, or confined in, a public institution such as a state penitentiary or county jail; (d) Reside in an institution for mental disease and are twenty-one through sixty-four years of age. (3) Applicants for KDP do not have to meet citizenship criteria described in WAC 182-503-0535 to qualify for KDP. (4) When a Social Security number has been issued to a person, it must be provided to the KDP contractor. Rules governing Social Security numbers are described in WAC 182-503-0515. (5) The effective date of eligibility for KDP is the first day of the month in which the ((application for eligibility is signed by the client)) person submits the KDP application form, if eligible. A person may be eligible for retroactive coverage for expenses incurred within the three months immediately prior to the KDP application if the person: (a) Meets the KDP financial eligibility criteria in this section; (b) Has a diagnosis of ESRD requiring dialysis or kidney transplant as defined in WAC 182-540-005 or has received a kidney transplant; and (c) Has incurred medical expenses potentially payable by the kidney disease program during the three-month retroactive period. (6) A person who is subsequently found retroactively eligible for another WAH program during the three-month retroactive period is not eligible for KDP reimbursement of expenses which are billable to the other WAH program. KDP funds spent on the person's behalf must be reimbursed to the KDP with the following exceptions: (a) Transportation expenses; (b) Health insurance premiums; (c) Expenses paid by the KDP which were used to meet a spenddown liability. (7) There is no time limit on how long a person may be eligible for KDP as long as the person continues to meet ESRD criteria. The KDP contractor is responsible for certifying that the person meets the functional criteria for ESRD at the time of application and at the time of review. (8) Persons who have received a kidney transplant are eligible for KDP until they no longer meet the requirements as described in this section. (9) Persons who are aggrieved by a decision affecting eligibility for KDP have the right to an administrative hearing. See WAC 182-540-0060.
NEW SECTION
WAC 182-540-021 Kidney disease program (KDP)—Household size.
(1) Household size is used to determine the appropriate income standard for KDP eligibility and also whose income must be counted or not counted. (2) The following members of a person's household must be included when determining the household size: (a) The applicant's spouse if living in the same home; (b) Dependent children eighteen years of age and younger with no income who live in the same household and for whom the person is legally responsible; (c) Children nineteen through twenty-one years of age who are attending full-time school or college; and (d) Any other members of a person's household that the person claimed as a dependent on their most recent federal income tax return. (3) Children eighteen years of age and younger who have income or separate resources which may make an applicant ineligible for KDP may be included or excluded from the household size determination, depending on what is most beneficial for the KDP applicant. If a child is included in the household size, then their income and/or resources are also counted.
NEW SECTION
WAC 182-540-022 Kidney disease program (KDP)—Income eligibility.
(1) A household must have net countable income at or below two hundred twenty percent of the federal poverty level in order for a person to be eligible for the kidney disease program (KDP). See WAC 182-540-021 to determine who must be included in the household and whose income counts. (2) The KDP contractor makes the determination of the household's income based upon the information reported in the KDP application and may request additional verification if the information in the application is not clear. A KDP applicant must provide verification of all household income (and expenses, if self-employed) to the KDP contractor in order for eligibility for KDP to be determined. (3) The following income is not counted: (a) Fifty percent of the gross earned income of any person included in the household size; (b) Income received by a dependent child eighteen years of age and younger who is not included in the household size; (c) Any income source which is specifically excluded by federal law. (4) The agency follows rules for SSI-related medicaid described in chapter 182-512 WAC to determine what income types count when determining eligibility for KDP.
NEW SECTION
WAC 182-540-023 Kidney disease program (KDP)—Change of circumstances.
(1) A person who is approved for KDP is required to report changes in their circumstances to the KDP contractor within thirty days of the date of the change. The person is required to report the following changes: (a) When total income for household members included in the KDP household size goes above two hundred twenty percent FPL and the change is expected to last for thirty calendar days or longer; (b) When countable resources exceed the standards described in WAC 182-540-030; (c) When there is a change in household members or household size; (d) When the person is determined eligible for medicare; or (e) When the person is no longer a resident in the state of Washington. (2) If the change in circumstances reflects a change in the person's KDP eligibility, the person is required to fill out and submit a new KDP application, with a new effective date reflecting the changes made. The KDP contractor will end the person's previous application. (3) If the person fails to report their change in circumstance which would result in the person's ineligibility for the program, the KDP contractor is not liable for paying expenses on the person's behalf. If expenses are paid on behalf of a person who is not eligible for KDP or eligible for Washington apple health, the requirements in WAC 182-502-0160 billing a client, do not apply.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-540-025 Kidney disease program (KDP) ((eligibility determination))—Application and recertification requirements—KDP contractor.
((The kidney center and client)) When a person applies for the kidney disease program (KDP), the KDP contractor must ((comply with the following rules to determine KDP eligibility)): (1) ((The KDP contractor must: (a))) Inform the ((client)) applicant of the requirements for KDP eligibility as defined in this chapter ((and)), provide the ((client)) applicant with the necessary ((department)) forms and instructions((; (b) Determine client eligibility using department policies, rules, and instructions; and (c) Forward the completed application for eligibility, and the application documentation to the KDP program manager at the medical assistance administration (MAA). (The KDP program manager may amend or terminate a client's certification period within thirty days of receipt if the application is incomplete or inaccurate.) (2) A person applying for KDP must: (a) Complete the application for eligibility and submit any necessary documentation to the kidney center; (b) Apply for medicaid, obtain a written medicaid medical assistance determination letter, submit a copy to the kidney center; and (c) Apply for medicare. (3) A client reapplying for continued eligibility must: (a) Complete the KDP application for eligibility and submit any documentation necessary to determine eligibility to the kidney center; (b) Apply for medicaid forty-five days before the end of the KDP certification period, obtain a written medicaid eligibility determination, and submit a copy to the kidney center; or (c) Have applied for medicaid within the previous five years and continue to be ineligible. (4) The KDP application period 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 KDP contractor may request an extension of application time limits from MAA when extenuating circumstances prevent the client from completing the application or recertification process within the specified time limits. (6) The KDP contractor certifies the client for no more than one year from the first day of the month of application, unless the client: (a) Needs medical coverage for less than one year; or (b) Has a substantial financial change, in which case the client must complete a new application for eligibility.)) to complete the KDP application, and provide the applicant with a copy of the person's rights and responsibilities. (2) If required, help the applicant submit an application for medical benefits with the department of social and health services (DSHS) community services office or the health benefits exchange. (a) The KDP contractor must obtain the person's application documentation from DSHS or the health benefits exchange and keep a copy in the person's record. (b) The KDP contractor may authorize KDP payment pending the outcome of the medical application; however, if the person is subsequently approved for medical coverage for any month in which KDP funds were authorized, those expenses must not be billed to KDP. If KDP has already reimbursed those funds, the contractor must refund the KDP, subject to exceptions for transportation expenses, health insurance premiums, and expenses paid by the KDP which were used to meet a spenddown liability as described in WAC 182-540-015 (6)(a), (b), and (c). (3) Inform the applicant of the requirement to apply for medicare and help with the application process. The KDP contractor must obtain a copy of the Social Security Administration's (SSA's) approval or denial of medicare entitlement and keep a copy in the person's record once a determination has been made by SSA. (4) Determine eligibility using the agency's policies, rules, and instructions and provide the applicant with a timely written approval or denial notice within no more than sixty calendar days from the date of the KDP application. (5) The KDP contractor may request an extension of the application time from the KDP program manager when extenuating circumstances prevent the person from completing the application or recertification process within the specified time limit. (6) Forward the completed KDP application and the application documentation to the KDP program manager at the health care authority (HCA). The KDP program manager may amend or terminate a person's certification period within thirty calendar days of receipt if the application is incomplete or inaccurate. (7) The KDP contractor certifies an eligible person for no more than one year from the first day of the month of application, unless the client: (a) Needs medical coverage for less than one year; or (b) Reports a change as described in WAC 182-540-0023 that makes the person ineligible for KDP. (8) Within sixty calendar days prior to the end of a person's certification period, the KDP contractor must assist a person with completing a recertification for KDP. To be eligible for ongoing KDP funding, a person must meet the requirements described in WAC 182-540-026(2).
NEW SECTION
WAC 182-540-026 Kidney disease program (KDP)—Application and recertification requirements—Client.
(1) An applicant for KDP must: (a) Complete the KDP application form and submit any necessary documentation to the KDP contractor in order to make an eligibility determination; (b) Do one of the following: (i) Provide application documentation from the department of social and health services (DSHS) or the Washington Healthplanfinder verifying that the applicant applied for Washington apple health (WAH) within the six-month period prior to the month of application for KDP, and that the application for WAH was denied due to an eligibility requirement and not because the person failed to complete the application process; or (ii) Submit an application for WAH to DSHS and/or via the Washington Healthplanfinder, as applicable, and provide the KDP contractor with a copy of the application documentation when an eligibility determination has been made; and (c) Apply for medicare within thirty calendar days of applying for KDP and provide written proof from the Social Security Administration that the application was approved or denied. A copy of the proof must be kept in the person's record. (2) At the end of the KDP certification period, a person may reapply for continued KDP eligibility. To complete the recertification, the client must: (a) Complete a new KDP application no later than thirty calendar days beyond the end of the original certification period and submit any documentation necessary to determine eligibility to the KDP contractor; and (b) Submit a new application for WAH and provide a copy to the KDP contractor. (3) A person who fails to follow through with the required application or recertification processes or fails to provide requested verifications within the time limits requested by the KDP contractor is not eligible for KDP funding and the application will be denied.
NEW SECTION
WAC 182-540-030 Kidney disease program (KDP)—Resource eligibility.
(1) The person's household must have countable resources at or below the limits established for the qualified medicare beneficiary (QMB) program for the person to be eligible for the kidney disease program. QMB resource standards for an individual and a couple are listed at: http://www.hca.wa.gov/medicaid/eligibility/documents/incomestandards.pdf. (2) See WAC 182-540-021 to determine who must be included in the household when making a determination of whose resources count. (3) The following resources are not counted: (a) A home, defined as real property owned by a client as their principal place of residence together with surrounding and contiguous property; (b) Household furnishings; (c) One burial plot per household member or irrevocable burial plans with a mortuary; (d) Up to one thousand five hundred dollars for a person or three thousand dollars for a couple set aside in a revocable burial account; (e) Any resource which is specifically excluded by federal law. (4) The agency follows rules for SSI-related medicaid determinations described in WAC 182-512-0200 through 182-512-0550 when determining whether any other resources are countable with the exception of subsection (5) of this section. (5) The agency follows rules in chapter 182-515 WAC when a person owns a trust, an annuity, or a life estate.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-540-045 Kidney disease program (KDP) ((provider)) contractor requirements.
(1) The kidney disease program (KDP) contractor must: (a) Be a medicare-certified end-stage renal disease (ESRD) facility; and (b) Have a valid KDP client services contract with the ((department)) agency. (2) The KDP contractor must provide, directly or through an affiliate: (a) Professional consultation, personal instructions, medical treatment and care, drug products and all supplies necessary for carrying out a ((medically-sound)) medically sound end-stage renal disease (ESRD) treatment program; (b) Dialysis for clients with ESRD when medically indicated; (c) Coordination of care with a kidney transplant ((treatment, either directly or by referral, when medically indicated)) center; (d) Treatment for conditions directly related to ESRD such as anemia ((or venous access infections)), vascular, or peritoneal access care; and (e) Supplies and equipment for home dialysis. (3) The provider must maintain adequate records for audit and review purposes, including: (a) Medical charts and records that meet the requirements of WAC ((388-502-0020)) 182-502-0020; and (b) ((Eligibility determination records)) Documentation of expenses and amounts paid by the KDP to assist clients in meeting a spenddown requirement as described in WAC 182-519-0100. (4) The contractor must meet other obligations as required by ((their)) its contract with the KDP program.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-540-055 Kidney disease program (KDP) covered services.
(1) The kidney disease program (KDP) ((program)) covers the cost of health care services essential to the treatment of end-stage renal disease (ESRD) and its complications. Within available funding and at the discretion of the KDP contractor covered services include: (((1) Mandatory services that must be provided by the KDP contractor:)) (a) Dialysis: (i) Center dialysis((—)) - Covers the cost of dialysis, necessary supplies, and related services provided in a kidney center; (ii) Home dialysis((—)) - Covers the cost of providing dialysis and related services in the home; and (iii) Dialysis while hospitalized((—)) - Covers the cost of dialysis and related services while the KDP client is confined to an acute care facility and is unable to dialyze at his/her regular site. (b) Medication((—)) - As defined in the approved drug list in the KDP manual((. (2) Optional services that may be provided by the KDP contractor: (a) Venous)); (c) Access surgery((—)) (venous and peritoneal) - Covers costs associated with surgically preparing the client for dialysis and medical complications related to the ((venous)) access site; (((b))) (d) Laboratory tests and X rays considered to be part of the overall treatment plan for ESRD; (((c) Post-transplant visit to assess client's ESRD status)) (e) Pretransplant work-up including, but not limited to, transportation, lodging, and physician visits; ((and (d) Health insurance premiums including copays and deductibles, when found to be cost-effective.)) (f) Post-transplant visit to assess client's ESRD status to include, but is not limited to, transportation, lodging, and physician visits; (g) Health insurance premium including copays and deductibles when found to be cost-effective; (h) Spenddown expenses when found to be cost-effective; and (i) Other services as approved by the agency's KDP program manager. (2) If the KDP pays for medical and dental services required to receive a transplant, and the KDP client does not follow through with their recommended treatment plan in order to receive or make progress towards receiving a transplant, the KDP contractor must submit a request for a determination of noncompliance to the agency's KDP manager. If the request is approved, KDP funds must not be used for any follow-up or additional services. Once the KDP client makes progress with their treatment plan, the agency may rereview the request.
NEW SECTION
WAC 182-540-060 Kidney disease program (KDP) client appeal rights.
(1) Clients have the right to appeal: (a) KDP eligibility decisions made by the person's KDP contractor; (b) Coverage decisions made by the contractor or the first decision submitted by the agency for medical services or devices that are not considered to be for the treatment of the person's ESRD diagnosis; or (c) The denial, made by the KDP contractor, of services found in WAC 182-540-055(1) which have been denied by a KDP contractor. (2) Clients do not have the right to appeal: (a) Reimbursement based on covered or noncovered procedure codes or rates; or (b) The KDP contractor's decision to not cover services found in WAC 182-540-055(1) when the KDP contractor has gone over its KDP allotted funding. (3) A client who is aggrieved by a decision made by the KDP contractor may request review of the decision to the agency within thirty days of receiving the notice of the decision by sending a written request for review to the agency's KDP Program Manager, Health Care Authority, P.O. Box 45510, Olympia, WA 98504-5510. (4) The request for review must clearly identify the name and address of the client requesting the review. (5) Within thirty days of receiving the request for review, the KDP program manager will send the client a written decision. Failure to request review does not prevent the client from appealing the decision under subsection (6) of this section. (6) Within ninety days of receiving the KDP contractor's or the KDP program manager's written decision, the client can appeal the decision by sending a written request for hearing to the Health Care Authority, P.O. Box 45504, Olympia, WA 98504-5540. (7) The request for hearing: (a) Must clearly identify the name, address, and telephone number of the client requesting the hearing; (b) Should include a copy of the KDP program manager's written decision which the client is appealing. (8) The hearing is usually conducted by telephone by an agency presiding officer in accordance with WAC 182-526-0025(1). The client requesting the hearing is responsible for making sure that the agency's presiding officer has the correct telephone number to contact the party for the hearing. (9) The agency's presiding officer may refer the case in writing to the office of administrative hearings when the: (a) Client requests an in-person hearing to accommodate a disability; and (b) The presiding officer determines that the agency does not have the resources needed to conduct the in-person hearing. (10) When an administrative law judge (ALJ) employed by the office of administrative hearings conducts the hearing on behalf of the agency, the ALJ issues an initial order in accordance with WAC 182-526-0025(1) and 182-526-0215(4). Any party may appeal the initial order to an agency review judge in accordance with WAC 182-526-0575. (11) When a presiding officer employed by the agency conducts the hearing, the agency's presiding officer issues a final order. Any party may request reconsideration of the final order in accordance with chapter 182-526 WAC. The party who requested the hearing, but not the agency, may file a petition for judicial review as provided in WAC 182-526-0605 and 182-526-0620. (12) The hearing rules found in chapter 182-526 WAC apply to any administrative hearing requested in accordance with subsection (6) of this section. Where the program rules in this chapter conflict with the hearing rules contained in chapter 182-526 WAC, the program rules in this chapter prevail. (13) Failure to timely request a hearing will result in the loss of right to appeal.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-540-065 Kidney disease program (KDP)—Reimbursement.
(1) The ((medical assistance administration (MAA))) agency reimburses KDP contractors: (a) Within the limits of legislative funding for the program; (b) According to the terms of each kidney center's contract with the ((department)) agency; and (c) According to the provisions of the KDP ((contract)) manual. (2) The KDP contractor must submit the following documentation to ((MAA)) the agency's KDP program manager within the time limits specified within the KDP contract: (a) A description of the services for which reimbursement is requested; and (b) ((Statement of client's financial eligibility for the KDP. (3) MAA)) The person's approved KDP application if the application had not previously been provided to the KDP program manager. (3) A KDP client is not liable and must not be billed for charges incurred under KDP due to the failure of the KDP contractor to bill the agency within the time limits specified in the contract. (4) The agency limits KDP reimbursement for out-of-state services to fourteen days per calendar year. Reimbursement is paid only to KDP contractors. Out-of-state dialysis providers must operate under subcontract or agreement with an in-state KDP contractor in order to receive reimbursement under this program.
REPEALER
The following section of the Washington Administrative Code is repealed:
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