Current through Register Vol. 24-18, September 15, 2024
(1) Persons must
meet the following criteria to be eligible for the kidney disease program (KDP)
:
(a) Reside in the state of Washington as
required under WAC
182-503-0520 or
182-503-0525;
(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;
(c) Be
determined ineligible for any other Washington apple health (WAH) program,
including medicaid; 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 two hundred twenty percent of the federal poverty level (FPL)
;
(f) Have countable resources
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 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.
Statutory
Authority: 11-14-075, recodified as §182-540-015, filed 6/30/11, effective
7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.510,
74.09.520,
74.09.522, and 42 C.F.R. 405.2101.
WSR 03-21-039, § 388-540-015, filed 10/8/03, effective 11/8/03. WSR
13-23-007, §182-540-015, filed 11/7/2013, effective
12/8/2013
