(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.
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.
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
(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;
(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
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
The Department shall determine the family income of the
applicant as a family according to the following.
Income shall include:
1. wages, salaries and/or
2. income from rental
property or equipment;
from self-employment enterprises, including farms;
4. alimony and/or child support;
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.
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
(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
(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.