WAC 182-540-015 Kidney disease program (KDP) - General eligibility criteria

WAC 182-540-015 Kidney disease program (KDP)—General eligibility criteria

Effective January 1, 2014

1. Persons must meet the following criteria to be eligible for the kidney disease program (KDP):
   1. Reside in the state of Washington as required under WAC 182-503-0520 or 182-503-0525;
   2. 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. 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:
      1. 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;
      2. 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;
      3. 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;
      4. 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.
   4. 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:
      1. Clients that have any employer group health plan (EGHP) or COBRA plan; and
      2. Clients who are still within the thirty-month EGHP period.
   5. Have countable income which is equal to or less than two hundred twenty percent of the federal poverty level (FPL);
   6. 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;
   7. Report changes in circumstances as required under WAC 182-540-023.
2. Persons are not eligible for KDP if they:
   1. 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;
   2. 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;
   3. Are in custody of, or confined in, a public institution such as a state penitentiary or county jail;
   4. 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:
   1. Meets the KDP financial eligibility criteria in this section;
   2. Has a diagnosis of ESRD requiring dialysis or kidney transplant as defined in WAC 182-540-005 or has received a kidney transplant; and
   3. 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:
   1. Transportation expenses;
   2. Health insurance premiums;
   3. 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.