District of Columbia Administrative Code

4109 UTILIZATION REVIEW REQUIREMENTS In accordance with 42 C.F.R. § 456.401, each ICF/IID shall develop, implement, and maintain a written Utilization Review Plan (URP) for each Medicaid beneficiary receiving services furnished by the ICF/IID. The URP shall provide for a review o…

4110 TERMINATION AND ALTERNATIVE SANCTIONS FOR ICF/IID NONCOMPLIANCE In order to qualify for Medicaid reimbursement, intermediate care facilities for persons with intellectual and developmental disabilities (ICFs/IID) shall comply with federal conditions of participation (CoPs), …

4111 ALTERNATIVE SANCTIONS FOR ICFs/IID – NON-IMMEDIATE JEOPARDY In accordance with Section 1902(i)(1)(B) of the Social Security Act, the District of Columbia may impose alternative sanctions against an ICF/IID when that facility fails to meet the CoPs, but the violation does not…

4112 DENIAL OF PAYMENT Pursuant to Section 1902(i) of the Act and 42 C.F.R. § 442.118, and in lieu of termination in situations where residents are not in immediate jeopardy, DHCF may initiate a one-time denial of payment for claims associated with new admissions at ICFs/IID that…

4113 DIRECTED PLAN OF CORRECTION (DPoC) In lieu of termination in situations where the ICF/IID is not in compliance with the federal CoPs, and residents are not in immediate jeopardy, DHCF may require an ICF/IID to take prompt, timely action specified by DHCF to achieve and maint…

4114 DIRECTED IN-SERVICE TRAINING (DIST) In lieu of termination in situations where the ICF/IID is not in compliance with federal CoPs, but residents are not in immediate jeopardy, DHCF may require an ICF/IID to implement Directed In-Service Training (DIST) for deficiencies deter…

4115 STATE MONITORING State monitoring shall be the District’s oversight of efforts made by the ICF/IID to correct cited deficiencies. State monitoring shall be a safeguard against the facility’s further noncompliance. The following entities may serve as the State Monitor: DOH; D…

4116 ACCESS TO RECORDS 4116.1 Each ICF/IID shall grant full access to all records during announced and unannounced audits and reviews by DHCF personnel, representatives of the U.S. Department of Health and Human Services, and any authorized agent(s) or official(s) of the federal …

4117 PAYMENT FOR RESERVED BEDS 4117.1 Payment for reserved bed days for hospitalization or therapeutic leaves of absence for a beneficiary who is a resident of an ICF/IID may be authorized for up to sixty (60) days during a District fiscal year, if there is a reasonable expectati…

4199 DEFINITIONS 4199.1 For purposes of this chapter, the following terms shall have the meanings ascribed: Active Treatment - A program of specialized and generic training, treatment, health services, and related services designed toward the acquisition of the behaviors necessar…

4200 GENERAL PROVISIONS: IDENTIFICATION OF SERVICES; PROGRAM RESPONSIBILITIES; AND SERVICE SETTING REQUIREMENTS 4200.1 The following Home and Community-Based Services (HCBS) Waiver services are included in the Persons who are Elderly and Individuals with Physical Disabilities wai…

4201 ELIGIBILITY 4201.1 Individuals shall be deemed eligible for the EPD Waiver prior to the receipt of the services described in this chapter. 4201.2 To be eligible for the EPD Waiver services described in this chapter, a beneficiary shall: Require the level of care furnished in…

4202 APPEAL RIGHTS FOR APPLICANTS/BENEFICIARIES 4202.1 An applicant or beneficiary shall receive advance notice and shall have the opportunity to request a fair hearing if: They are found ineligible for participation in the EPD Waiver based on the criteria set forth in Subsection…

4203 CASE MANAGEMENT SERVICES REQUIRED 4203.1 As a condition of participation in the EPD Waiver services program, each beneficiary shall receive case management services which meet the requirements of Sections 4222 – 4224. SOURCE: Final Rulemaking published at 50 DCR 9025 (Octobe…

4204 WRITTEN PERSON-CENTERED SERVICE PLAN REQUIRED (PCSP) 4204.1 Services under the EPD Waiver program shall be provided to eligible beneficiaries pursuant to a written Person-Centered Service Plan (PCSP) developed for each individual. 4204.2 The PCSP shall be developed by the Ca…

4205 DISCHARGE, SUSPENSION, TRANSFER, TERMINATION, AND DISENROLLMENT 4205.1 The grounds for disenrollment from the EPD Waiver program are limited to the following: The beneficiary no longer meets the financial eligibility criteria; The beneficiary no longer meets the required lev…

4206 ASSURING CULTURAL COMPETENCY 4206.1 In accordance with Title VI of the Civil Rights Act of 1964 and its implementing regulations (42 U.S.C. §§ 2000d et seq., 45 CFR part 80), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794), and Title II of the Americans with …

4207 RECORDS AND CONFIDENTIALITY OF INFORMATION 4207.1 Each provider of waiver services shall establish and implement a privacy plan to protect the privacy and confidentiality of a beneficiary's records. 4207.2 The disclosure of information by a provider of waiver services shall …

4208 ACCESS TO RECORDS 4208.1 Each provider of waiver services shall allow appropriate DHCF personnel, representatives of the U.S. Department of Health and Human Services and other authorized designees or officials of the District of Columbia government and federal government ful…

4209 REIMBURSEMENT: GENERAL 4209.1 DHCF shall not reimburse any provider of Waiver services who: (a) Fails to comply with any applicable regulation in this chapter; (b) Fails to comply with all applicable federal and District of Columbia laws, and regulations; (c) Fails to comply…

4210 REIMBURSEMENT: CASE MANAGEMENT SERVICES 4210.1 Case management services shall be reimbursed on a per member per month (PMPM) basis. 4210.2 Reimbursement for case management services at the PMPM rate shall be contingent on the performance of the monthly and ongoing care coord…

4211 REIMBURSEMENT: PERSONAL CARE AIDE (PCA) SERVICES 4211.1 A home care agency seeking reimbursement for PCA services shall meet the conditions of participation for home health agencies set forth in 42 CFR part 484, and shall comply with the requirements set forth in the Health-…

4212 [REPEALED] SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 64 DCR 6784 (July 21, 2017); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025). District of Columbia Municipal Regulations Pu…

4213 REIMBURSEMENT: RESPITE SERVICES 4213.1 Reimbursement for respite services shall be limited to a total of seventeen (17) hours per day per beneficiary. 4213.2 Consistent with Section 4232, respite services shall be limited to a total of four hundred eighty (480) hours per yea…

4214 REIMBURSEMENT: HOMEMAKER SERVICES 4214.1 Reimbursement for homemaker services shall be limited to a total of two hundred eight (208) hours per beneficiary per year. 4214.2 A unit of homemaker services shall be fifteen (15) minutes of service. 4214.3 DHCF shall not reimburse …

4215 REIMBURSEMENT: CHORE AIDE SERVICES 4215.1 Reimbursement for chore aide services shall be limited to a total of thirty-two (32) hours per beneficiary per Waiver period. 4215.2 A unit of chore aide services shall be fifteen (15) minutes of service. 4215.3 DHCF shall not reimbu…

4216 REIMBURSEMENT: ASSISTED LIVING SERVICES 4216.1 The reimbursement rate for assisted living services shall be an all-inclusive rate for all services provided, as set forth in Section 4238. 4216.2 Medicaid reimbursement will not be made for twenty-four (24) hour skilled care or…

4217 REIMBURSEMENT: ENVIRONMENTAL ACCESSIBILITY ADAPTATION 4217.1 Environmental accessibility adaptations services shall be reimbursed in accordance with the applicable requirements set forth in Sections 4239 through 4240 of this chapter. 4217.2 Reimbursement for environmental ac…

4218 REIMBURSEMENT: ADULT DAY HEALTH 4218.1 A provider shall not be reimbursed for adult day health services when provided concurrently with the following services: Intensive day treatment or day treatment mental health rehabilitative services (MHRS) under the District’s State Pl…

4219 [REPEALED] SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 64 DCR 6784 (July 21, 2017); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025). District of Columbia Municipal Regulations Pu…

4220 [REPEALED] SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 64 DCR 6784 (July 21, 2017); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025). District of Columbia Municipal Regulations Pu…

4221 REIMBURSEMENT: COMMUNITY TRANSITION SERVICES 4221.1 Reimbursement for community transition services household set-up expenses specified under Subsection 4252.2 shall not exceed five thousand dollars ($5,000) per beneficiary per Waiver period. 4221.2 Reimbursement shall begin…

4222 PROVIDER REQUIREMENTS: GENERAL 4222.1 Each provider approved to provide one or more Waiver services shall meet the following minimum requirements: (a) Demonstrate compliance with all applicable provisions of Chapter 94 (Medicaid Provider and Supplier Screening, Enrollment, a…

4223 SPECIFIC PROVIDER REQUIREMENTS: CASE MANAGEMENT SERVICES 4223.1 Each individual providing case management services shall meet the following requirements: Be at least eighteen (18) years of age; Be a United States citizen or alien who is lawfully authorized to work in the Uni…

4224 PROGRAM SERVICES: CASE MANAGEMENT SERVICES 4224.1 The goal of case management services shall be to ensure EPD Waiver beneficiaries have access to the services and supports needed to live in the most integrated setting, including: EPD Waiver services; Non-waiver services cove…

4225 CASE MANAGEMENT AGENCY AND CASE MANAGER RESPONSIBILITIES 4225.1 Case management agencies shall ensure compliance with the following requirements: At any point in time, no case manager has a client caseload exceeding forty- five (45) persons total (inclusive of Medicaid and n…

4226 SPECIFIC PROVIDER REQUIREMENTS: PERSONAL CARE AIDE SERVICES 4226.1 A personal care aide (PCA) services provider shall meet the provider requirements set forth in Chapter 50 (Medicaid Reimbursement for Personal Care Aide Services) of Title 29 DCMR. These shall include, but sh…

4227 SPECIFIC ELIGIBILITY REQUIREMENTS: PERSONAL CARE AIDE SERVICES 4227.1 To be eligible for Medicaid reimbursement of PCA services under the EPD Waiver program, a beneficiary shall have an assessed need for PCA services, as established by the conflict-free face-to-face assessme…

4228 PROGRAM SERVICES: PERSONAL CARE AIDE SERVICES 4228.1 A provider shall deliver PCA services consistent with the program service requirements set forth in Chapter 50 of Title 29 DCMR. These include: (a) Plan of Care requirements; (b) Scope of Services; and (c) Non-reimbursable…

4229 [REPEALED] SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 64 DCR 6784 (July 21, 2017); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025). District of Columbia Municipal Regulations Pu…

4230 [REPEALED] SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 64 DCR 6784 (July 21, 2017); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025). District of Columbia Municipal Regulations Pu…

4231 SPECIFIC PROVIDER REQUIREMENTS: RESPITE SERVICES 4231.1 In order to receive Medicaid reimbursement, a respite service provider shall be a Medicaid enrolled home care agency approved by DHCF to deliver respite services in the District of Columbia. 4231.2 In order to receive M…

4232 PROGRAM SERVICES: RESPITE SERVICES 4232.1 Respite services are intended to relieve the beneficiary’s primary caregiver to provide a range of activities associated with the PCA’s role. 4232.2 Medicaid reimbursable respite services shall include: (a) Basic personal care such a…

4233 SPECIFIC PROVIDER REQUIREMENTS: HOMEMAKER SERVICES 4233.1 In order to be reimbursed by Medicaid, homemaker services must be provided by the following Medicaid-enrolled providers: (a) A home care agency which meets the conditions of participation for home care agencies as set…

4234 PROGRAM SERVICES: HOMEMAKER SERVICES 4234.1 Homemaker services shall only be provided in cases where neither the beneficiary nor anyone else in the household (i.e., an unpaid family caregiver) is able to provide or deliver the service. 4234.2 Homemaker staff may perform the …

4235 SPECIFIC PROVIDER REQUIREMENTS: CHORE AIDE SERVICES 4235.1 In order to receive Medicaid reimbursement, Chore Aide services shall be provided by the following Medicaid-enrolled providers: (a) A home care agency which meets the conditions of participation for home care agencie…

4236 PROGRAM SERVICES: CHORE AIDE SERVICES 4236.1 In order to receive Medicaid reimbursement, a unit of service for chore aide services shall be one (1) hour spent performing allowable task(s). The maximum amount of service permitted under the waiver shall be thirty-two (32) unit…

4237 SPECIFIC PROVIDER REQUIREMENTS: ASSISTED LIVING SERVICES 4237.1 In order to receive Medicaid reimbursement, each facility providing assisted living services shall be licensed by the Department of Health and comply with the requirements set forth in the Assisted Living Reside…

4238 PROGRAM SERVICES: ASSISTED LIVING SERVICES 4238.1 In order to receive Medicaid reimbursement, assisted living services shall consist of personal care and supportive services that are furnished to beneficiaries who reside in a homelike, non-institutional setting that includes…

4239 SPECIFIC PROVIDER REQUIREMENTS: EAA 4239.1 In order to receive Medicaid reimbursement, the case manager shall ensure that a home adaptation assessment is conducted by a licensed physician, occupational therapist, or physical therapist per a physician’s order, prior to orderi…