WAC 182-540-045 Kidney disease program (KDP) contractor requirements

Effective January 1, 2014

1. The kidney disease program (KDP) contractor must:
   1. Be a medicare-certified end-stage renal disease (ESRD) facility; and
   2. Have a valid KDP client services contract with the agency.
2. The KDP contractor must provide, directly or through an affiliate:
   1. Professional consultation, personal instructions, medical treatment and care, drug products and all supplies necessary for carrying out a medically sound end-stage renal disease (ESRD) treatment program;
   2. Dialysis for clients with ESRD when medically indicated;
   3. Coordination of care with a kidney transplant center;
   4. Treatment for conditions directly related to ESRD such as anemia, vascular, or peritoneal access care; and
   5. Supplies and equipment for home dialysis.
3. The provider must maintain adequate records for audit and review purposes, including:
   1. Medical charts and records that meet the requirements of WAC 182-502-0020; and
   2. 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 its contract with the KDP program.

WAC 182-540-030 Kidney disease program (KDP)—Resource eligibility

Effective January 8, 2016

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: https://www.hca.wa.gov/health-care-services-supports/program-standard-i….
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:
   1. A home, defined as real property owned by a client as their principal place of residence together with surrounding and contiguous property;
   2. Household furnishings;
   3. One burial plot per household member or irrevocable burial plans with a mortuary;
   4. Up to one thousand five hundred dollars for a person or three thousand dollars for a couple set aside in a revocable burial account;
   5. 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 182-516 WAC when a person owns a trust, an annuity, or a life estate.

WAC 182-540-025 Kidney disease program (KDP)—Application and recertification requirements—KDP contractor

Effective January 1, 2014

When a person applies for the kidney disease program (KDP), the KDP contractor must:

1. Inform the applicant of the requirements for KDP eligibility as defined in this chapter, provide the applicant with the necessary forms and instructions 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.
   1. 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.
   2. 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:
   1. Needs medical coverage for less than one year; or
   2. 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).

WAC 182-540-023 Kidney disease program (KDP)—Change of circumstances

Effective January 1, 2014

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:
   1. 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;
   2. When countable resources exceed the standards described in WAC 182-540-030;
   3. When there is a change in household members or household size;
   4. When the person is determined eligible for medicare; or
   5. 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.

WAC 182-540-022 Kidney disease program (KDP)—Income eligibility

Effective November 8, 2015

1. A household must have countable income at or below two hundred twenty percent of the federal poverty level 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 determines 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 for a KDP eligibility determination.
3. The agency does not count the following income:
   1. The first twenty dollars per month of unearned income for the entire household;
   2. Cost-of-living adjustments (COLAs) to Social Security disability benefits and supplemental security income (SSI) benefits that take effect in the calendar year of a KDP eligibility determination and any subsequent COLAs to these benefits received by:
      1. The applicant;
      2. The applicant's spouse; or
      3. Other family members included in the household size.
   3. Fifty percent of the gross earned income of any person included in the household size;
   4. Income received by a dependent child age eighteen or younger who is not included in the household size; or
   5. Any income source which is specifically excluded by federal law.
4. The agency follows rules for SSI-related medical described in chapter 182-512 WAC to determine what income types count when determining eligibility for KDP.

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.

WAC 182-540-005 Kidney disease program (KDP)—Definitions

Revised January 1, 2014

The following definitions and those found in chapter 182-500 WAC, apply to this chapter for the purpose of administering the kidney disease program.

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

"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" - A "medical eligibility determination" letter from the department of social and health services (DSHS) 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" - The kidney center or affiliate has determined a person eligible for the KDP for a defined period of time;

"End-stage renal disease (ESRD)" - 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" - The agency Form 13-566 which the person completes and submits to the KDP contractor to determine KDP eligibility;

"KDP client" - A person who has a diagnosis of ESRD or had a diagnosis of ESRD and has received a kidney transplant and has been determined eligible for the kidney disease program as determined by a KDP contractor;

"KDP contractor" - A kidney center or other ESRD facility that has contracted with the health care authority (the agency), kidney disease program to provide ESRD services to KDP clients;

"KDP manual" - A manual that describes the KDP contract guidelines and procedures for a KDP contractor;

"Kidney center" - A facility as defined and certified by the federal government to provide ESRD services.

"Kidney disease program (KDP)" - A state-funded program managed by the Washington state health care authority that provides financial assistance to eligible persons for the costs of ESRD medical care;

"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.)

WAC 182-540-001 Purpose

Effective January 1, 2014

This chapter (WAC 182-540-001 through 182-540-065) contains rules for the state-funded kidney disease program (KDP) administered by the health care authority (the agency). The KDP is 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.