Tenn. Comp. R. & Regs. 1200-11-01-.03 - ELIGIBILITY REQUIREMENTS

(1) Any resident of Tennessee with the presence of end stage renal failure which currently requires chronic dialysis or has necessitated a kidney transplant within the past twelve (12) months is eligible to apply for program services.
(2) To receive program services, the applicant must meet the following criteria.
(a) The applicant must submit a completed, properly signed and dated application provided by the Department. If the applicant is legally incompetent to consent to medical treatment because of age or mental condition, said application shall be completed and signed by the applicant's parent or legal guardian.
(b) The applicant must meet the medical criteria established in these Rules and must meet the financial criteria at the time of application and/or recertification.
(3) The following is a list of medical criteria to be used in determining diagnostic eligibility for the program.
(a) End stage renal disease shall be determined by the chemical/medical criteria established by the Health Care Finance Administration and available through Renal Network 8, which includes Tennessee; or
(b) If the criteria in 1200-11-1-.03(3)(a) are not met, a detailed explanation of the uremic symptoms leading to a diagnosis of ESRD must be submitted with the application; or
(c) Following successful kidney transplantation, a patient will be considered to continue to meet the requirements of 12-11-.03 (3) (a)-(b).
(4) Eligibility for special coverage of Cyclosporine over and above the patient's monthly drug cap will be determined separate from, and in addition to, program eligibility. The patient must not be eligible for any other third party coverage for the medication other than Medicare.
(5) Individuals will be financially eligible for the Renal Disease Program if the family's gross income is at or below 200% of the federal poverty level for the number in family. When a family has more than one (1) individual with ESRD, one person may be added to the total number of family members when determining eligibility. All participants in the Renal Disease Program must be financially recertified annually.

The Department shall determine the family income of the applicant as a family according to the following.

(a) Income shall include:
1. wages, salaries and/or commissions;
2. income from rental property or equipment;
3. profits from self-employment enterprises, including farms;
4. alimony and/or child support;
5. inheritances;
6. pensions and benefits; and
7. public assistance grants.
(b) After the income of the family is determined, any verified medical payments, including medical or health insurance premiums made by the family for any family member during the previous twelve (12) months, shall be prorated over twelve months and deducted from the gross monthly income.
(c) Verified child support or alimony paid to another household shall be deducted from the gross monthly income.
(6) All applicants to, or participants in, the Renal Disease Program who have no third party insurance coverage must apply for Medicare and TennCare coverage and provide proof of acceptance or denial to the Renal Disease Program. Denial of coverage by Medicare or TennCare will not prevent the individual from participation in the Renal Disease Program, so long as program eligibility requirements are met. Once accepted for TennCare coverage, Renal Disease Program participants must meet all TennCare eligibility requirements in order to maintain eligibility for the Renal Disease Program.
(7) Applicants will be denied participation in the Renal Disease Program if they are diagnostically ineligible, financially ineligible, or fail to apply for TennCare and Medicare coverage.
(8) Once a patient has been certified for services, the certification extends for twelve months regardless of changes in family income.
(9) The Commissioner may prioritize acceptance into the program according to medical need (as defined in these rules), pharmaceutical requirements, and available program dollars. As vacancies occur each month, those applicants without TennCare or private third party coverage with pharmacy benefits will be given first preference in chronological order of the receipt of the application to fill those vacancies until all slots are filled for the month. Once capitated authorized funding has been exhausted, there will be no more funding.

Notes

Tenn. Comp. R. & Regs. 1200-11-01-.03
Original rule certified June 7, 1974. Amendment filed January 17, 1975; effective February 16, 1975. Repeal and new rule filed October 9, 1985; effective January 14, 1986. Repeal and new rule filed September 17, 1998; effective January 28, 1999.

Authority: T.C.A. ยง 68-35-103 and 4-5-202.

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