Arkansas Administrative Code › Agency 007 - ARKANSAS DEPARTMENT OF HEALTH › Division 35 - Center for Health Protection › Rule 007.35.22-001 - Rules Pertaining to Arkansas Kidney Disease Commission

Current through Register Vol. 49, No. 6, June, 2024
INTRODUCTION
Pursuant to A.C.A. §
								20-15-603
				these Rules delineate operation and standards for the program administered by
				the Arkansas Kidney Disease Commission. Changes, additions, and deletions shall
				be made from time to time in order to insure the best possible services for
				clients with permanent kidney failure who are residents of the State of
				Arkansas. Rule changes shall only be considered during Commission meetings when
				a quorum is declared. A majority vote is required for any change. Promulgation
				of a rule revision is required for any Commission decision which affects
				patient qualification or services. No Rule, Rule amendment or Rule revision
				shall be effective until promulgation under the Arkansas Administrative
				Procedure Act at §
								25-15-201 et
				seq.
AUTHORITY
The Arkansas Kidney Disease Commission (AKDC) was established
				by the General Assembly of the State of Arkansas through Act 450 of 1971 to
				establish a program for the care and treatment of persons suffering from
				chronic renal disease. The legislation charged the AKDC to "provide financial
				assistance for persons suffering from chronic renal disease who require
				life-saving care and treatment to the extent as determined by the
				Commission."
Act 910 of 2019 authorizes the Secretary of the Arkansas
				Department of Health as the disbursing officer of funds appropriated by the
				Arkansas General Assembly and any other funds made available to the Commission
				for such purposes.
Legislative Findings and Purpose
Legislative findings declared and found that one of the major
				problems facing medicine and the public health and welfare is the lack of an
				adequate program to assist in the treatment and cure of persons suffering from
				chronic kidney disease. It is estimated that a number of citizens of this State
				annually are confronted with chronic kidney disease, requiring complicated and
				expensive treatment, which is often beyond the financial resources of such
				individuals. There is a critical shortage of adequate facilities within the
				State for the discovery, evaluation, diagnosis, treatment, and cure of
				individuals suffering from chronic kidney disease. In order to provide for the
				care and treatment of persons suffering from acute or chronic kidney disease,
				and in order to encourage and assist in the development of adequate treatment
				facilities for persons suffering from acute or chronic kidney disease, it is
				essential that the State develop a program of financial assistance to aid in
				defraying a portion of the cost for the care and treatment of chronic renal
				disease to the extent that the individual suffering from such disease is unable
				to pay for such services on a continuing basis.
COMMISSION
Powers and Duties of the Commission
The Commission shall have the following functions, powers and
				duties:
* To establish a program to assist persons suffering from acute
				or chronic renal failure in obtaining care and treatment requiring dialysis.
				The program shall provide financial assistance for persons suffering from
				chronic renal diseases who require life-saving care and treatment for the renal
				disease to the extent, as determined by the Commission, that a person is unable
				to pay for such services on a continuing basis without causing unjust and
				unusual hardship to himself or herself and his or her immediate family,
				including without limitation a drastic lowering of the standard of
				living.
* To develop standards for determining eligibility for
				assistance in defraying the cost of care and treatment of renal disease under
				this program.
* To cooperate with hospitals, private groups, and
				organizations, and public agencies in the development of positive programs to
				bring about financial assistance and support of evaluation and treatment of
				patients suffering from chronic kidney disease.
* To cooperate with the national and state kidney foundations
				and with medical programs of the state and federal government for the purpose
				of obtaining the maximum amount of federal and private assistance possible in
				support of a kidney disease treatment program.
* To establish criteria and standards for evaluating the
				financial ability of persons suffering from chronic renal disease to pay for
				their own care, including the availability of third party insurance coverage,
				for the purpose of establishing standards for eligibility for financial
				assistance in defraying the cost of the care and treatment from funds
				appropriated to the commission for renal disease treatment purposes.
* To accept gifts, grants, and donations from private sources,
				and the federal government and support from municipal and county governments to
				be used for the purposes of this Act in defraying costs incurred by persons
				suffering from acute or chronic renal disease who are unable to meet the total
				cost of life-saving care and treatment for renal disease.
* To accept gifts, grants, and donations from private sources
				and the federal government and support from municipal and county governments to
				be used to honor persons who have provided living kidney donations to Arkansans
				in need of kidney transplantation.
Commission Committees: The Commission may establish ad hoc
				committees from time to time. The ad hoc committees shall review issues and
				make recommendation to the full Commission.
CHAIN OF LIFE AWARD
The AKDC Chain of Life award recognizes individuals who have
				made a living kidney donation to a current resident of Arkansas who is in need
				of kidney transplantation. Nominations for the award are received by the AKDC
				and presented to the Commission Board for approval. The AKDC shall not use
				state funds appropriated for program services but may accept gifts, grants, and
				donations from private sources and the federal government and support from
				municipal and county governments to maintain the award.
ELIGIBILITY
Persons suffering from chronic renal failure may be referred to
				the Arkansas Kidney Disease Commission. Referrals shall come from clients
				themselves, physicians, social workers, hospital or kidney dialysis center
				personnel, pharmacists, rehabilitation counselors, and others including
				individuals and agencies familiar with the person's kidney disease.
Eligibility Requirements
Eligibility requirements shall be applied without regard to
				sex, race, creed, color, or national origin. With respect to age, no upper or
				lower limit shall be set as a guide to turn away a referral.
Residency Requirement
Clients must be a resident of Arkansas. To be eligible, an
				applicant must provide a copy of his or her driver's license or identification
				card issued by the State of Arkansas.
Physician Certification requirement
Certification by a Nephrologist (or other physician) or Advance
				Practice Registered Nurse is required confirming the applicant has a diagnosis
				of ESRD with an indication that the individual is in need of regular renal
				dialysis treatments or has been the recipient of a kidney transplant.
Financial Eligibility
A client's annual income may not exceed 250% of the Federal
				Poverty Level (FPL) percentage for the year in which they are applying for
				assistance. The AKDC shall consider the available financial resources of the
				total household. Income sources to be considered include wages; business
				income; social security, SSDI, and SSI benefits; retirement income; veteran's
				benefits; income from stocks, bonds, or other investments; and other
				identifiable liquid assets.
If the applicant is a dependent, the resources of the parent(s)
				shall be determined. The exception is if the applicant is a dependent and is
				receiving SSI benefits, he/she may be considered a family of one.
Insurance Eligibility
Clients with insurance must provide proof of insurance
				coverage. Individuals with or without insurance are not prohibited from
				receiving services on the basis of their insurance status. However, AKDC shall
				be payor of last resort.
Application for Services
Individuals applying for services available through the program
				shall complete the AKDC Initial Referral Application. The Initial Referral
				Application includes the required Nephrologist or other health professional
				certification indicating the applicant has ESRD or has been the recipient of a
				kidney transplant.
Certificate of Eligibility/Ineligibility
A certificate of eligibility-ineligibility (AKDC-10) shall be
				completed prior to the provision of services, or the refusal of services, as
				the case may be. The AKDC Program Manager shall review the Initial Referral
				Application, applying the established financial needs and residential criteria
				and ensuring the applicant's physician has certified that the applicant meets
				the medical criteria. AKDC Program Manager sign the Certificate of
				Eligibility/Ineligibility for each applicant, indicating the applicant's
				eligibility or ineligibility
Other Resources/ Similar Benefit
Applicants shall be required to apply and provide evidence of
				acceptance/denial from all applicable pharmaceutical company patient assistance
				programs. Any services that the applicant may receive or be eligible to receive
				from other sources shall be used first. The AKDC may only supplement these
				benefits.
Co-Payment
The Commission shall establish a co-payment for services paid
				by a client of the program at the point of sale. The co-payment amount is $2.00
				for each medication each month.
EFFECTIVE DATE OF SERVICE
The effective date a client shall be eligible to receive paid
				for services provided by the AKDC shall be established by the program. An
				applicant must be determined eligible prior to funds being authorized. The AKDC
				shall not authorize payment for any service provided prior to the effective
				date of service.
Financial Cap
The Commission may establish an annual limit on per-client
				expenditures prior to the beginning of the new state fiscal year, based on
				funds available and number of clients participating in the program in prior
				year. This annual cap is subject to change based on increase or decreases in
				the number of patients in the programs and or changes in program funding.
				Exceptions may be made on a case by case basis as determined by the Commission.
				During the course of a fiscal year, should expenditures for a client exceed the
				limit allowed, the case will be referred to the Commission for review to
				determine a course of action.
Termination of Services
AKDC will pay for services and medication prescribed up to the
				client's date of death. Eligibility for covered services will also be ended the
				day a client moves out of state or the last day of the month a client's course
				of dialysis is terminated unless the individual has received a kidney
				transplant.
Annual Review
Individuals determined eligible to receive AKDC services shall
				submit an eligibility renewal application annually to determine continued
				program eligibility. The review process will consist of a determination as to
				whether the individual continues to meet program medical, residential and
				financial need eligibility criteria. Clients who meet eligibility requirements
				will continue to receive AKDC services. Any client who no longer meets program
				eligibility requirements shall be issued a letter of termination of services
				effective thirty (30) days after the date of review. AKDC shall not pay for
				services for patients who fail to renew within one and a half years of their
				last date of eligibility (year of eligibility, plus six-month grace period).
				Medications prescribed within a client's annual eligibility period (plus
				six-month grace period) shall be covered, even if the claim is received by AKDC
				after the patient's eligibility has lapsed.
SERVICES
The services provided by the AKDC shall be dependent on the
				availability of funds. The Commission may determine specific services to be
				funded by the program prior to the beginning of each new state fiscal year.
				Covered services may include outpatient pharmaceutical drugs and nutritional
				supplements; pre-transplant dental services; transportation, patient education
				and referral. Specific services to AKDC clients, including those in need of
				continuing services, shall be provided based upon the availability of funds.
				During the course of a fiscal year should it be determined that available
				funding is insufficient to fund services provided by the program at existing
				levels for the remaining portion of the fiscal year, the Commission shall
				establish the manner in which services will be curtailed, or if required,
				terminated for the remainder of that fiscal year. Should the curtailing of
				services result, preference will be given to those in need of continuing
				services, as determined by the Commission.
Financial assistance from the AKDC may include:
* Outpatient prescriptions: AKDC may provide financial
				assistance for no more than 3 outpatient prescriptions per month. Amount
				payable to pharmacy is the allowable amount in the formulary fee schedule,
				after insurance payment and less client co-payment.
* Immunosuppressant drugs: AKDC may provide financial
				assistance for immunosuppressant drugs. A client co-pay for allowable drugs is
				required. The AKDC shall only participate in the purchase of immuno-suppressant
				medications as a co-payer. Program co-payment for immuno-suppressant drugs
				shall not exceed twenty percent of the Medicare allowable rate.
* Nutritional supplements: AKDC may provide for nutritional
				supplement if ordered by physician. Amount Payable to pharmacy is the allowable
				amount in the formulary fee schedule, after insurance and less client
				co-payment.
* Transportation: AKDC may provide for dialysis appointment
				transportation mileage reimbursement, at the state employee mileage
				reimbursement rate for the applicable year. Clients who prove they must take a
				taxi or other paid transportation service are eligible for transportation
				mileage reimbursement. Patients must first attempt to use personal or Medicaid
				transportation if available, prior to engaging a taxi or other paid
				transportation. Evidence of efforts to use Medicaid transportation must be
				provided. Taxi or paid transportation receipt is required prior to mileage
				reimbursement.
* Dental: AKDC may provide for dental care when a dental
				problem jeopardizes the health and treatment program outlined by the renal
				specialist and may be covered only for the purpose of kidney transplantation.
				Payment for services rendered will be prior approved and consistent with the
				established dental fee schedule herein attached as Appendix A.
Patient Education
The AKDC may partner with local, state, regional, and national
				agencies and organizations to educate its clients and the public at large
				regarding the importance of prevention and/or treatment of kidney
				disease.
Referral Services
The AKDC may assist clients diagnosed with ESRD with referral
				to other programs including vocational rehabilitation.
Formulary
AKDC shall establish a formulary. The formulary will include
				nutritional supplements designed for kidney dialysis patients. The formulary
				and fee schedule may be updated periodically and is attached as Appendix
				A.
Payment for Services to Vendors
The AKDC shall process payment for covered services to program
				clients when in receipt of a signed vendor statement or letter that includes
				the client's name and other necessary identifiable information, a description
				of services provided, date(s) of service provision, and cost. Claims made for
				payment of prescription drugs or transportation reimbursement are to be
				submitted on the appropriate AKDC claim form or applicable online form if
				available. The AKDC shall not pre-pay for a service, only providing payment
				after the service has been rendered. Requests for payment for services rendered
				must be received by the program within one calendar year of the date of
				service. The AKDC will not provide remittance for those requests for payment
				that exceed the one-year from date of service limit.
Confidentiality, Use, and Release of Client Records and
				Information
The AKDC shall maintain a case record for applicants and
				individuals determined eligible to receive services available through the
				program. Client information developed or received by the AKDC is the property
				of the program. Information contained in the case record shall only be used for
				determining eligibility/ineligibility for AKDC services, providing payment for
				services rendered, or other program operations. The AKDC shall maintain
				personal information contained in the case record in a secure manner and treat
				such information with the highest degree of confidentiality.
The AKDC Program Administrator is designated as the custodian
				of applicant and client case records. The Program Manager has the
				responsibility of ensuring such information is maintained in a safe and secure
				manner consistent with State and Federal law, rule or regulation. The Program
				Manager shall provide training to AKDC staff regarding how applicant and client
				information will be developed, maintained, and shared with affected parties.
				The Program Manager is responsible for the destruction of all closed case
				files.
When requested in writing, the AKDC shall make available to the
				applicant or client, or if appropriate the individual's representative,
				information contained in that person's case record. Should the applicant or
				client or, if appropriate, that individual's representative believes
				information contained in the case record to be inaccurate or misleading, a
				written request can be made to the program to amend such information.
In the event another agency or organization requests personal
				information contained in the case record of an AKDC applicant or client, the
				program shall only release such information with written consent of the
				applicant or client or, if appropriate, that individual's representative. It is
				the responsibility of the AKDC and parties involved to respect the confidential
				nature of personal information and limit information exchanged to that
				minimally necessary. The AKDC shall release personal information contained in
				the case record in response to investigations in connection with law
				enforcement, fraud, and abuse unless expressly prohibited by State and Federal
				laws and regulations and in response to an order issued by a judge, magistrate,
				or other authorized judicial official.