WAC 182-540-060 Kidney disease program (KDP) client appeal rights

Effective January 1, 2014

1. Clients have the right to appeal:
   1. KDP eligibility decisions made by the person's KDP contractor;
   2. 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
   3. 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:
   1. Reimbursement based on covered or noncovered procedure codes or rates; or
   2. 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:
   1. Must clearly identify the name, address, and telephone number of the client requesting the hearing;
   2. 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:
   1. Client requests an in-person hearing to accommodate a disability; and
   2. 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.

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.