WAC 182-540-021 Kidney disease program (KDP) - Household size

WAC 182-540-021 Kidney disease program (KDP)—Household size

Effective January 1, 2014

  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:
    1. The applicant's spouse if living in the same home;
    2. 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;
    3. Children nineteen through twenty-one years of age who are attending full-time school or college; and
    4. 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.
 

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

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.)

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-540-001 Purpose

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.

 

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-551-1000 Hospice program - General

WAC 182-551-1000 Hospice program—General

Effective May 18, 2012

  1. The medicaid agency's hospice program is a twenty-four hour a day program that allows a terminally ill client to choose physical, pastoral/spiritual, and psychosocial comfort care and a focus on quality of life. A hospice interdisciplinary team communicates with the client's nonhospice care providers to ensure the client's needs are met through the hospice plan of care. Hospitalization is used only for acute symptom management.
  2. A client, a physician, or an authorized representative under RCW 7.70.065 may initiate hospice care. The client's physician must certify the client as terminally ill and appropriate for hospice care.
  3. Hospice care is provided in a client's temporary or permanent place of residence.
  4. Hospice care ends when:
    1. The client or an authorized representative under RCW 7.70.065 revokes the hospice care;
    2. The hospice agency discharges the client;
    3. The client's physician determines hospice care is no longer appropriate; or
    4. The client dies.
  5. Hospice care includes the provision of emotional and spiritual comfort and bereavement support to the client's family member(s).
  6. Medicaid agency-approved hospice agencies must meet the general requirements in chapter 182-502 WAC, Administration of medical programs—Providers.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-546-0150 Client eligibility for ambulance transportation

WAC 182-546-0150 Client eligibility for ambulance transportation

Effective July 6, 2018

  1. Except for people in the Family Planning Only and TAKE CHARGE programs, fee-for-service clients are eligible for ambulance transportation to covered services with the following limitations:
    1. People in the following Washington apple health programs are eligible for ambulance services within Washington state or bordering cities only, as designated in WAC 182-501-0175:
      1. Medical care services (MCS) as described in WAC 182-508-0005;
      2. Alien emergency medical (AEM) services as described in chapter 182-507 WAC.
    2. People in the apple health categorically needy/qualified medicare beneficiary (CN/QMB) and apple health medically needy/qualified medicare beneficiary (MN/QMB) programs are covered by medicare and medicaid, with the payment limitations described in WAC 182-546-0400(5).
  2. People enrolled in an agency-contracted managed care organization (MCO) must coordinate:
    1. Ground ambulance services through the agency under fee-for-service, subject to the coverage and limitations within this chapter; and
    2. Air ambulance services through the agency under fee-for-service, subject to the coverage and limitations within this chapter.
  3. People enrolled in the agency's primary care case management (PCCM) program are eligible for ambulance services that are emergency medical services or that are approved by the PCCM in accordance with the agency's requirements. The agency pays for covered services for these people according to the agency's published billing guides and provider alerts.
  4. People under the Involuntary Treatment Act (ITA) are not eligible for ambulance transportation coverage outside the state of Washington. This exclusion from coverage applies to people who are being detained involuntarily for mental health treatment and being transported to or from bordering cities. See also WAC 182-546-4000.
  5. See WAC 182-546-0800 and 182-546-2500 for additional limitations on out-of-state coverage and coverage for people with other insurance.
  6. The agency does not pay for ambulance services for jail inmates and people living in a correctional facility, including people in work-release status. See WAC 182-503-0505(5).

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-540 Family planning only program - Noncovered services

WAC 182-532-540 Family planning only program—Noncovered services

Effective September 1, 2013

  1. Medical services are not covered under the family planning only program unless those services are:
    1. Performed in relation to a primary focus and diagnosis of family planning; and
    2. Medically necessary for a client to safely and effectively use, or continue to use, her chosen contraceptive method.
  2. The medicaid agency does not cover inpatient services under the family planning only program except for complications arising from covered family planning services. For approval of exceptions, providers of inpatient services must submit a report to the medicaid agency, detailing the circumstances and conditions that required inpatient services. (See WAC 182-501-0160.)

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-533 Family planning only program - Other covered services

WAC 182-532-533 Family planning only program—Other covered services

Effective September 1, 2013

Other family planning only services covered for women may include all the following:
  1. An office visit directly related to a family planning problem, when medically necessary.
  2. Food and Drug Administration (FDA)-approved prescription and nonprescription contraceptive methods, as identified in chapter 182-530 WAC.
  3. Over-the-counter (OTC) family planning drugs, devices, and drug-related supplies, as described in chapter 182-530 WAC.
  4. Sterilization procedures that meet the requirements of WAC 182-531-1550 if requested by the client and performed in an appropriate setting for the procedures.
  5. Screening and treatment for sexually transmitted infections (STI), including lab tests and procedures, only when the screening and treatment are:
    1. For chlamydia and gonorrhea as part of the comprehensive prevention visit for family planning for women ages thirteen through twenty-five; or
    2. Part of an office visit that has a primary focus and diagnosis of family planning, and is medically necessary for the client's safe and effective use of her chosen contraceptive method.
  6. Education and supplies for FDA-approved contraceptives, natural family planning, and abstinence.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-520 Family planning only programs - Provider requirements.

WAC 182-532-520 Family planning only programs—Provider requirements.

Effective January 1, 2026

To be paid by the medicaid agency for services provided to clients eligible for family planning only programs, providers must:

  1. Comply with the requirements under this chapter and chapters 182-501 and 182-502 WAC;
  2. Provide only those services that are within the scope of their licenses;
  3. Bill the agency according to the agency's published billing guides;
  4. Educate clients on Food and Drug Administration (FDA)-approved contraceptive methods and over-the-counter (OTC) contraceptive drugs, devices, and products, as well as related medical services;
  5. Provide medical services related to FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products as medically necessary;
  6. Supply or prescribe FDA-approved contraceptive methods and OTC contraceptive drugs, devices, and products as medically appropriate; and in compliance with WAC 182-530-2000 (1) (b); and
  7. Refer the client to available and affordable nonfamily planning primary care services, as needed.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-532-510 Family Planning only program - Client eligibility

WAC 182-532-510 Family planning only program—Client eligibility

Effective October 6, 2025

For the purposes of this section, "full-scope coverage" means coverage under either the categorically needy (CN) program, the broadest, most comprehensive scope of health care services covered or the alternative benefits plan (ABP), the same scope of care as CN, applicable to the apple health for adults program.

  1. To be eligible for family planning only services, as defined in WAC 182-532-001, a client must:
    1. Provide a valid Social Security number (SSN) or proof of application to receive an SSN, be exempt from the requirement to provide an SSN as provided in WAC 182-503-0515, or meet good cause criteria listed in WAC 182-503-0515(2);
    2. Be a Washington state resident, as described under WAC 182-503-0520;
    3. Have an income at or below two hundred sixty percent of the federal poverty level, as described under WAC 182-505-0100;
    4. Need family planning services; and
    5. Have been denied apple health coverage within the last 30 days, unless the applicant:
      1. Has made an informed choice to not apply for full-scope coverage as described in WAC 182-500-0035 and 182-501-0060, including family planning;
      2. Is age 26 or younger and seeking services in confidence;
      3. Is a domestic violence victim who is seeking services in confidence; or
      4. Has an income of 150 percent to 260 percent of the federal poverty level, as described in WAC 182-505-0100.
  2. A client is not eligible for family planning only medical if the client is:
    1. Pregnant;
    2. Sterilized;
    3. Covered under another apple health program that includes family planning services; or
    4. Covered by concurrent creditable coverage, as defined in RCW 48.66.020, unless they meet criteria in (1) (e) (ii) or (iii) of this section.
  3. The agency does not limit the number of times a client may reapply for coverage.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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