District of Columbia Administrative Code

5227 [RESERVED] SOURCE: Final Rulemaking published at 72 DCR 013719 (December 5, 2025). District of Columbia Municipal Regulations Public Welfare 29 DCMR § 5227 AUTHORITY: DC-DCMR Pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal …

5228 [RESERVED] SOURCE: Final Rulemaking published at 72 DCR 013719 (December 5, 2025). District of Columbia Municipal Regulations Public Welfare 29 DCMR § 5228 AUTHORITY: DC-DCMR Pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal …

5229 [RESERVED] SOURCE: Final Rulemaking published at 72 DCR 013719 (December 5, 2025). District of Columbia Municipal Regulations Public Welfare 29 DCMR § 5229 AUTHORITY: DC-DCMR Pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal …

5230 ELIGIBILITY REQUIREMENTS 5230.1 Only persons who are Medicaid recipients and meet the requirements set forth in Chapter 34 and Chapter 39 of Title 22-A DCMR shall be eligible to receive MHRS services billed under this Chapter. SOURCE: Final Rulemaking published at 72 DCR 013…

5231 TREATMENT RECORDS AND ACCESS TO RECORDS 5231.1 In addition to the requirements set forth in Chapter 34 of Title 22-A DCMR, each MHRS treatment record shall contain sufficient information which readily identifies and supports Medicaid billing. 5231.2 Each MHRS provider shall …

5232 REIMBURSEMENT 5232.1 Reimbursement for MHRS shall be made according to the District of Columbia Medicaid fee schedule available online at www.dc-medicaid.com. Updates to the reimbursement rates for MHRS services shall comply with the public notice requirements set forth in 2…

5233 AUDITS AND REVIEWS 5233.1 This section sets forth the requirements for audits and reviews of MHRS services. DHCF, or its designee, shall perform regular audits of MHRS providers to ensure that Medicaid payments are consistent with efficiency, economy, and quality of care, an…

5299 DEFINITIONS 5299.1 When used in this chapter, the following words shall have the meanings ascribed: Assertive Community Treatment – an intensive, integrated, rehabilitative, crisis, treatment, and mental health community support provided by an interdisciplinary team to indiv…

5300 PURPOSE AND APPLICABILITY 5300.1 The purpose of this chapter is to establish the standards under which managed care providers that are to be paid on a fixed, prepaid, capitated basis may qualify to participate as managed care providers serving District residents who are AFDC…

5301 PREPAID CAPITATED PROVIDER QUALIFICATIONS - GENERAL 5301.1 Each prepaid, capitated provider shall execute a Medicaid managed care provider agreement with the Department. 5301.2 Each prepaid, capitated provider shall admit or refer all AFDC and AFDC-related Medicaid recipient…

5302 SPECIFIC PROVIDER QUALIFICATIONS 5302.1 Prepaid, capitated providers shall enter into risk comprehensive, non -risk, or other risk contracts with the Department to provide a predefined set of services to AFDC and AFDC-related recipients for a fixed, prepaid, capitated fee. 5…

5303 FINANCIAL REQUIREMENTS - PREPAID, CAPITATED PROVIDERS 5303.1 Each prepaid, capitated provider shall ensure through its contracts, subcontracts, and any other appropriate manner that neither enrollees nor the District are held liable for debts of the prepaid, capitated provid…

5304 REQUIRED INFORMATION 5304.1 Each prepaid, capitated provider shall submit the following to the Department with its application for a Medicaid managed care provider agreement: (a) A copy of the basic organizational documents of the prepaid, capitated provider, including an or…

5305 MARKETING 5305.1 Each prepaid, capitated provider shall submit to the Department for its prior written approval all marketing plans, procedures, and materials including the following: (a) Marketing policies and manuals; (b) A written description of proposed marketing approac…

5306 EVIDENCE OF COVERAGE 5306.1 Each prepaid, capitated provider shall provide each enrollee with written evidence of coverage prior to the effective date of enrollment, which shall include the following: (a) Notification of the recipient’s effective date of enrollment; (b) A pl…

5307 SERVICE DELIVERY AND QUALITY ASSURANCE REQUIREMENTS GENERAL 5307.1 Each prepaid, capitated provider shall provide each enrollee with high quality health care at locations that ensure reasonable availability and accessibility to enrollees. 5307.2 Each prepaid, capitated provi…

5308 PAYMENT FOR SERVICES 5308.1 The Department shall not make any payment for Medicaid services to a prepaid, capitated provider unless the provider has executed a Medicaid managed care provider agreement. 5308.2 Each prepaid, capitated provider’s Medicaid managed care provider …

5309 GRIEVANCE SYSTEM - PREPAID, CAPITATED PROVIDERS 5309.1 Each prepaid, capitated provider shall have a grievance system with reasonable procedures for the prompt resolution of complaints initiated by enrollees. 5309.2 Each prepaid, capitated provider shall submit its proposed …

5310 GRIEVANCE SYSTEM - THE DEPARTMENT 5310.1 Each AFDC or AFDC-related recipient that is aggrieved by an individual decision of the Department affecting that recipient’s right to select a provider or receive a covered service through the District’s Medicaid Managed Care Program …

5311 CONFIDENTIALITY OF INFORMATION - GENERAL 5311.1 All information, records, and data collected and maintained by the prepaid, capitated provider or its subcontractors that relate to enrollees shall be protected from unauthorized disclosure by the prepaid, capitated provider. 5…

5312 THIRD PARTY LIABILITY RECOVERY 5312.1 Each prepaid, capitated provider shall comply with the Health Care Assistance Reimbursement Act of 1984, effective June 14, 1984 (D. C. Law 5 -86, D.C. Code, 2001 Ed. §4 -601 et seq.) SOURCE: Final Rulemaking published at 42 DCR 1566, 15…

5313 SUBCONTRACTS 5313.1 Each subcontract entered into by each prepaid, capitated provider for services covered by the organization’s Medicaid managed care provider agreement shall be submitted to the Department for approval prior to the execution of the subcontract. 5313.2 No su…

5314 AUDIT AND REPORTING REQUIREMENTS 5314.1 Each prepaid, capitated provider shall file a financial statement annually with the Department, which shall be certified by at least two (2) principal officers. The financial statement shall be filed with the Department not more than n…

5315 ACCESS TO INFORMATION 5315.1 Each prepaid, capitated provider and its subcontractors shall maintain all records required by the Medicaid managed care provider agreement, at cost, for five (5) years or until all audits are completed, whichever is longer. The records shall inc…

5316 USE OF INFORMATION AND DATA 5316.1 The Department shall have a license, free of charge, to use any data or information system, including software, documentation and manuals, developed by the prepaid, capitated provider pursuant to the implementation of the provider’s Medicai…

5317 ASSIGNMENT OF RIGHTS 5317.1 No prepaid, capitated provider shall assign or transfer any right gained by qualifying as a contractor with the Department. SOURCE: Final Rulemaking published at 42 DCR 1566, 1586 (March 31, 1995). AUTHORITY: DC-DCMR Unless otherwise noted, the au…

5318 MEDICAID PROGRAM AND RECIPIENTS HELD HARMLESS 5318.1 Each prepaid, capitated provider shall hold harmless the District government, the Department and AFDC or AFDC -related Medicaid recipients against any loss, damage, expense and liability of any kind that arises from any ac…

5319 NON-DISCRIMINATION 5319.1 Each prepaid, capitated provider shall comply with all applicable laws, regulations, and orders that prohibit discrimination on the basis of race, age, sex, marital status, personal appearance, sexual orientation, family responsibilities, physical d…

5320 SANCTIONS FOR NON-COMPLIANCE 5320.1 If the Department determines that a prepaid, capitated provider has failed to comply with the provisions of this chapter or other applicable federal or District law or regulations, the Department may: (a) Suspend further enrollment of Medi…

5400 PURPOSE 5400.1 The purpose of this chapter is to establish the standards under which individual physicians, clinics, outpatient hospital departments and group practices who/which are primary care providers paid on a fee-for-service basis may qualify as managed care providers…

5401 PROVIDER QUALIFICATIONS 5401.1 Each fee-for-service primary care provider shall execute a Medicaid managed care provider agreement with the Department. 5401.2 Each fee-for-service primary care provider shall admit or refer all AFDC and AFDC-related Medicaid recipients requir…

5402 REQUIRED INFORMATION 5402.1 Each fee-for-service primary care provider shall submit the address of each site at which services will be provided to AFDC and AFDC-related recipients to the Department at the time of filing an application for a Medicaid managed care provider agr…

5403 SERVICE DELIVERY AND QUALITY ASSURANCE REQUIREMENTS 5403.1 Each fee-for-service primary care provider shall provide each enrollee with high quality health care at locations that ensure reasonable availability and accessibility to enrollees. 5403.2 Each fee-for-service primar…

5404 PAYMENT FOR SERVICES 5404.1 The Department shall not make any payment for Medicaid services to a fee-for-service primary care provider unless the provider has executed a Medicaid managed care provider agreement. 5404.2 Each fee-for-service primary care provider’s Medicaid ma…

5405 GRIEVANCE SYSTEM - THE DEPARTMENT 5405.1 Each AFDC or AFDC-related recipient enrolled in the D.C. Medicaid Managed Care program that is aggrieved by an individual decision of the Department affecting that recipient’s choice or assignment of providers, or receipt of a covered…

5406 CONFIDENTIALITY OF INFORMATION - GENERAL 5406.1 All information, records, and data collected and maintained by the fee-for-service primary care provider that relate to enrollees shall be protected from unauthorized disclosure by the fee-for-service provider. 5406.2 Except as…

5407 THIRD PARTY LIABILITY RECOVERY 5407.1 Each fee-for-service primary care provider shall comply with the Health Care Assistance Reimbursement Act of 1984, effective June 14, 1984 (D.C. Law 5-86, D.C. Code, 2001 Ed. §4-601 et seq.). SOURCE: Final Rulemaking published at 42 DCR …

5408 AUDIT AND REPORTING REQUIREMENTS 5408.1 Each fee-for-service primary care provider shall maintain adequate records and data to demonstrate service delivery and payment. 5408.2 Upon the Department’s written request, the fee-for-service primary care provider shall assist the f…

5409 ACCESS TO INFORMATION 5409.1 Each fee-for-service primary care provider shall maintain all records required by the Medicaid managed care provider agreement, at cost, for five (5) years or until all audits are completed, whichever is longer. The records shall include all phys…

5410 USE OF INFORMATION AND DATA 5410.1 The Department shall have a license, free of charge, to use any data or information system, including software, documentation and manuals, developed by the fee-for-service primary care provider pursuant to the implementation of the provider…

5411 ASSIGNMENT OF RIGHTS 5411.1 No fee-for-service primary care provider shall assign or transfer any right gained by qualifying as a contractor to the Department. SOURCE: Final Rulemaking published at 42 DCR 1566, 1594 (March 31, 1995). AUTHORITY: DC-DCMR Unless otherwise noted…

5412 MEDICAID PROGRAM AND RECIPIENTS HELD HARMLESS 5412.1 Each fee-for-service primary care provider shall hold harmless the District government, the Department and AFDC or AFDC-related Medicaid recipients against any loss, damage, expense and liability of any kind that arises fr…

5413 NON-DISCRIMINATION 5413.1 Each fee-for-service primary care provider shall comply with all applicable federal and District laws, regulations, and orders that prohibit discrimination on the basis of race, age, sex, marital status, personal appearance, sexual orientation, fami…

5414 SANCTIONS FOR NON-COMPLIANCE 5414.1 If the Department determines that a fee-for-service primary care provider has failed to comply with the provisions of this chapter or other applicable federal or District law or regulations, the Department may: (a) Suspend further enrollme…

5415 MANAGED CARE ORIENTATION 5415.1 The Department shall provide on a regularly scheduled basis, an orientation program for providers detailing the services included in the D.C. Medicaid Managed Care Program. SOURCE: Final Rulemaking published at 42 DCR 1566, 1596 (March 31, 199…

5500 GENERAL PROVISIONS 5500.1 This chapter establishes the standards and procedures under which Medicaid beneficiaries are enrolled and disenrolled from the District of Columbia (District) Medicaid Managed Care program (managed care) pursuant to section 1932a(1)(A) of the Social…

5501 ENROLLMENT The Department shall enroll certain Medicaid eligibility groups, as described in § 5501.2, into either DC Health Families managed care program or an alternative delivery system (e.g. fee-for-service (FFS), Program for All-Inclusive Care for the Elderly, Children &…

5502 DISENROLLMENT Eligibility groups enrolled on both a mandatory and voluntary basis (as described under §§ 5501.1(a)-(b)) shall have the right to disenroll from their DC Health Families MCO upon request, for the reasons described under § 5502.4 and pursuant to the requirements…

5599 DEFINITIONS 5599.1 For the purposes of this chapter, the following terms shall have the meanings ascribed: Applicant – the same meaning as is set forth under Chapter 95 of Title 29 DCMR. Beneficiary - An individual who has been determined eligible for Medicaid. Enrollment pe…

5600 PURPOSE AND APPLICABILITY 5600.1 The purpose of this chapter is to establish requirements for the District’s Section 1115 research and demonstration project entitled D.C. Medicaid Managed Care Program for Disabled Children and Youths. 5600.2 The demonstration project term sh…