District of Columbia Administrative Code

5601 MANAGED CARE PROVIDER QUALIFICATIONS 5601.1 The managed care provider shall execute a Medicaid managed care provider agreement with the Department. 5601.2 The managed care provider shall admit or refer all enrolled children requiring hospital care only to hospitals located i…

5602 FINANCIAL REQUIREMENTS: MANAGED CARE PROVIDER 5602.1 The managed care provider shall ensure, through its contracts, subcontracts and any other appropriate manner that in the event of the provider’s insolvency neither enrolled children, their families, nor the District are he…

5603 REQUIRED INFORMATION 5603.1 The managed care 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 managed care provider, including an organizational …

5604 MARKETING 5604.1 The managed care 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) Written descriptions of proposed marketing approaches; (c)…

5605 EVIDENCE OF COVERAGE 5605.1 The managed care provider shall provide each enrolled child with written evidence of coverage prior to the effective date of enrollment, which shall include the following: (a) Notification of the child’s effective date of enrollment; (b) A plan me…

5606 SERVICE DELIVERY AND QUALITY ASSURANCE REQUIREMENTS 5606.1 The managed care provider shall provide each enrolled child with high quality health care at locations that ensure reasonable availability and accessibility. 5606.2 The managed care provider shall provide, either dir…

5607 PAYMENT FOR SERVICES 5607.1 The Department shall not make any payment for Medicaid services to the managed care provider unless the provider has executed a Medicaid managed care provider agreement. 5607.2 The managed care provider’s Medicaid managed care provider agreement w…

5608 GRIEVANCE SYSTEM - MANAGED CARE PROVIDER 5608.1 The managed care provider shall have a grievance system with reasonable procedures for the prompt resolution of complaints initiated by enrolled children and their families. 5608.2 The managed care provider shall submit its pro…

5609 GRIEVANCE SYSTEM - THE DEPARTMENT 5609.1 Each enrolled child who is aggrieved by an individual decision of the Department affecting that child’s right to select a provider or receive a covered service through the D.C. Medicaid Managed Care Program for Disabled Children and Y…

5610 CONFIDENTIALITY OF INFORMATION - GENERAL 5610.1 All information, records, and data collected and maintained by the managed care provider or its subcontractors that relate to enrolled children shall be protected by the managed care provider from unauthorized disclosure. 5610.…

5611 THIRD PARTY LIABILITY RECOVERY 5611.1 The managed 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 43 DCR 4833, 4848 (Sept…

5612 SUBCONTRACTS 5612.1 Each subcontract entered into by the managed care provider for services covered by the Medicaid managed care provider agreement shall be submitted to the Department for approval prior to the execution of the subcontract. 5612.2 No subcontract shall termin…

5613 AUDIT AND REPORTING REQUIREMENTS 5613.1 The managed care 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 ninety (…

5614 ACCESS TO INFORMATION 5614.1 The managed care 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 include al…

5615 USE OF INFORMATION AND DATA 5615.1 The Department shall have a non-exclusive license, free of charge, to use any data or information system, including software, documentation and manuals, developed by the managed care provider pursuant to the implementation of the provider’s…

5616 ASSIGNMENT OF RIGHTS 5616.1 The managed care provider shall not assign or transfer any right gained by qualifying as a contractor with the Department. SOURCE: Final Rulemaking published at 43 DCR 4833, 4854 (September 6, 1996). AUTHORITY: DC-DCMR Unless otherwise noted, the …

5617 MEDICAID PROGRAM AND BENEFICIARIES HELD HARMLESS 5617.1 The managed care provider shall hold harmless the District government, the Department and eligible children enrolled in the provider’s plan against any loss, damage, expense and liability of any kind that arises from an…

5618 NON-DISCRIMINATION 5618.1 The managed care 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 disabili…

5619 SANCTIONS FOR NON-COMPLIANCE 5619.1 If the Department determines that the managed 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 enrollment of eligible…

5700 GENERAL PROVISIONS 5700.1 This chapter establishes the standards and procedures under which Medicaid beneficiaries are enrolled and disenrolled from a District of Columbia (District) Dual Eligible Special Needs Plan (D-SNP) under the District Dual Choice program pursuant to …

5701 ENROLLMENT 5701.1 The Department shall enroll certain Medicaid eligibility groups into either a D-SNP or a fee-for-service (FFS) delivery system based on the beneficiary’s voluntary election to either enroll in a D-SNP or to continue to receive services through an FFS delive…

5702 DISENROLLMENT 5702.1 A beneficiary in an eligibility group enrolled on a voluntary basis (as described in § 5701.2) shall have the right to disenroll from their D-SNP upon request, for the reasons described in § 5702.5 and pursuant to the requirements under 42 CFR § 438.56. …

5799 DEFINITIONS For the purposes of this chapter, the following terms shall have the meanings ascribed: Applicant -- shall have the same meaning as set forth in § 9599.1 of Chapter 95 of Title 29 DCMR. Beneficiary -- an individual who has been determined eligible and is currentl…

57A00 GENERAL PROVISIONS 57A00.1 There is established in the District of Columbia (District) a program to provide medical assistance to any immigrant child who: (a) Resides in the District; and (b) Has an annual family income of up to 200% of the federal poverty level (FPL). 57A0…

57A99 DEFINITIONS When used in this chapter, the following terms and phrases shall have the following meanings: Immigrant child- Any child who is ineligible for Medicaid by virtue of the child's immigration status. Medical Assistance- Health care services provided by a health mai…

5800 SCHOOL ATTENDANCE REQUIREMENTS FOR PREGNANT OR PARENTING TEENS 5800.1 Pregnant or parenting TANF recipients under the age of twenty (20) who have not completed high school shall attend high school or an approved alternate education or training program. This requirement is ca…

5801 LIVING ARRANGEMENTS FOR PREGNANT OR PARENTING MINORS 5801.1 If a pregnant or parenting minor who is applying for or receiving TANF benefits claims an exemption to the requirement to live in an adult-supervised setting, DHS shall refer the pregnant or parenting minor's claim …

5802 MINORS ABSENT FROM THE HOME 5802.1 A minor who is absent from the home for more than ninety (90) days or who is expected by the minor's parent or other caretaker relative to be absent from the home for more than ninety (90) days shall be ineligible to receive TANF benefits u…

5803 CONFIDENTIALITY 5803.1 For the purposes of this chapter, the following definitions shall apply: (a) "Information concerning applicants and recipients" means documents and records, and all information contained therein, that are: (1) Related to an individual's application for…

5804 WORK PARTICIPATION STANDARDS 5804.1 Work participation standards governing the TANF Program shall be: (a) Work Participation Rates for all Families: FY 1998--30% FY 2001--45% FY 1999--35% FY 2002 and beyond--50% FY 2000--40% (b) Work Participation Rates for Two-Parent Famili…

5805 ADVERSE ACTION OR DETERMINATION BY NON-GOVERNMENTAL ENTITIES 5805.1 An individual against whom any adverse finding or recommendation has been made or taken by a non-governmental entity shall have the right to have the adverse finding or recommendation reviewed pursuant to th…

5806 JOB READINESS AND JOB SEARCH 5806.1 All TANF applicants shall be preliminarily assessed by an IMA eligibility worker for skills, prior work experience, employability, barriers to employment, including, but not limited to, disability, domestic violence, or English proficiency…

5807 POST ELIGIBILITY ASSESSMENT AND INDIVIDUAL RESPONSIBILITY PLAN 5807.1 Unless otherwise exempt under subsection 5810.3, each TANF applicant or recipient shall be assessed in-depth as to their prior work experience, employability, barriers to employment and employment goals. P…

5808 WORK ACTIVITIES 5808.1 The individual responsibility plan shall include the requirement to participate in one (1) or more of the following activities: (a) Unsubsidized employment; (b) Subsidized private sector employment; (c) Subsidized public sector employment; (d) Work exp…

5809 EXEMPTIONS 5809.1 At or before the preliminary assessment, all TANF applicants shall receive written and oral notice of exemptions as set forth in subsection 5809.4. 5809.2 The applicant or recipient shall acknowledge receipt of the notice in subsection 5809.1. IMA shall pro…

5810 GOOD CAUSE CIRCUMSTANCES: WORK-RELATED ACTIVITIES 5810.1 At or before the preliminary assessment, all TANF applicants shall receive written and oral notice of good cause circumstances, as set forth in subsection 5810.3. 5810.2 The applicant or recipient shall acknowledge rec…

5811 WORKPLACE PROTECTIONS 5811.1 The following workplace protections shall apply to TANF recipients and applicants participating in work activities: (a) The right to work in a safe and healthy work environment, which shall include the requirement to provide protective gear for t…

5812 SANCTIONS 5812.1 A non-exempt TANF customer (Customer) is required to comply with his or her negotiated TANF Individual Responsibility Plan (IRP) as approved by the Director or his or her designee, or meet his or her work requirements, as set forth in D.C. Official Code §§ 4…

5813 WORK PARTICIPATION ALLOWANCE AND INCENTIVE PAYMENTS TO ELIGIBLE TANF RECIPIENTS 5813.1 The Director or his or her designee may provide recipients participating in mandatory programs an allowance for the cost of transportation or other costs that are reasonably necessary and …

5814 INCOME DISREGARDS 5814.1 In determining the eligibility of a TANF applicant or recipient, the term "earned income" means: (a) Income in cash or in kind earned by an individual through the receipt of wages, salary, commissions, or profit from activities in which he or she is …

5815 RESOURCES 5815.1 Resource limits are governed by the regulations which apply to the Food Stamp Program as currently contained, or as amended, in 7 C.F.R. Section 273.8. Accordingly, pursuant to the authority provided in 7 U.S.C. 2014(g)(2), vehicle(s) owned by applicants or …

5816 COLLECTION OF OVERPAYMENTS 5816.1 For purposes of this chapter, an "overpayment" shall mean a TANF payment received for the payment month which exceeds the amount for which that unit was eligible. 5816.2 The District shall recover an overpayment of TANF by seeking reimbursem…

5817 UNDERPAYMENT 5817.1 For purposes of this chapter, "underpayment" means a financial assistance payment received for the payment month which is less than the amount for which the assistance unit was eligible, or failure by the District to issue a TANF payment for the payment m…

5818 LUMP SUM PAYMENT OR SETTLEMENT 5818.1 Under the District of Columbia Public Assistance Act of 1982, as amended, a lump sum payment or settlement shall not include a personal injury award, worker's compensation payment or similar award if the payment or award is unavailable t…

5819 NOTICES REGARDING DOMESTIC VIOLENCE GOOD CAUSE WAIVERS 5819.1 The Director or his or her designee shall provide a notice to an applicant or recipient of his or her right to request a domestic violence good cause waiver from the work requirements and/or child support cooperat…

5820 SCREENING AND REFERRALS 5820.1 The Director or his or her designee shall screen TANF applicants at the initial interview, and recipients at the point of recertification, for the presence, history, or future risk of domestic violence. 5820.2 The Director or his or her designe…

5821 CONFIDENTIALITY REGARDING DOMESTIC VIOLENCE MATTERS 5821.1 In addition to existing confidentiality requirements, disclosure of any information pertaining to any applicant or recipient who claims he or she is currently experiencing domestic violence, has a history of domestic…

5822 VOLUNTARY REQUEST FOR WAIVERS 5822.1 A decision not to seek services or waivers due to domestic violence shall not bar the applicant or recipient from seeking services or waivers at a later date, or from future referrals to services. 5822.2 An applicant or recipient is free …

5823 WORK PARTICIPATION REQUIREMENT AND CHILD SUPPORT COOPERATION WAIVER DETERMINATION 5823.1 Waivers of the work participation requirements shall be granted when the requirements would make it more difficult for the applicant or recipient to escape family violence, place the app…

5824 WORK PARTICIPATION REQUIREMENT AND STANDARDS FOR ACCEPTING CLAIMS OF DOMESTIC VIOLENCE 5824.1 In determining whether domestic violence took place, the Director or his or her designee shall rely on the following evidence: (a) Police, government agency, or court records; docum…