District of Columbia Administrative Code

8701 THE DISTRICT OF COLUMBIA’S HEALTH INFORMATION EXCHANGE (DC HIE) 8701.1 The DC HIE shall be a privately-operated interoperable system of registered and designated HIE entities that shall facilitate person-centered care through the secure electronic exchange of health informat…

8702 HIE REGISTRATION REQUIREMENTS AND APPLICATION 8702.1 An HIE entity wishing to participate in the DC HIE must apply for registration in a form and manner consistent with this section and policy guidance provided by DHCF. Application materials and guidance will be published by…

8703 REGISTERED HIE ENTITY PROTECTED HEALTH INFORMATION ACCESS, USE, AND DISCLOSURE REQUIREMENTS 8703.1 A registered HIE entity shall only disclose PHI for an authorized purpose, as set forth in §§ 8703.2 and 8703.3. 8703.2 An authorized user may use, access, or disclose PHI for …

8704 AUDITING REQUIREMENTS FOR REGISTERED HIE ENTITIES 8704.1 In order to ensure that only an authorized user, who is appropriately authenticated, is granted access and has access to health information, a registered HIE entity shall: (a) Develop and implement protocols, methodolo…

8705 REMEDIAL ACTIONS TO BE TAKEN BY A REGISTERED HIE ENTITY 8705.1 A registered HIE entity shall immediately suspend an authorized user’s access when it is necessary to avoid a HIPAA privacy breach, other violation of federal or District law, or a threat to the security of healt…

8706 NOTICE OF HIPAA BREACH OR OTHER VIOLATION BY A REGISTERED HIE ENTITY 8706.1 Notification of a HIPAA breach by a registered HIE entity shall be consistent with notification requirements under applicable federal and District laws and regulations, including HIPAA, the HITECH Ac…

8707 REGISTERED HIE ENTITY CONSUMER PARTICIPATION, ACCESS, AND EDUCATION REQUIREMENTS 8707.1 A registered HIE entity shall require its enrolled participating organization to comply with the consumer participation, access, and education requirements set forth in this section. 8707…

8708 HIE DESIGNATION REQUIREMENTS AND APPLICATION 8708.1 Registered HIE entities that meet additional requirements and are selected by DHCF through a competitive application process shall become designated HIE entities. Designated HIE entities are partners with DHCF that operate …

8709 DESIGNATED HIE ENTITY AUDITING REQUIREMENTS 8709.1 A designated HIE entity shall conduct an annual privacy and security audit performed by a qualified third-party auditor, that: (a) Detects inappropriate access, use, maintenance, and disclosure of information that are in vio…

8710 DESIGNATED HIE ENTITY REQUIREMENTS TO PROMOTE CONSUMER PARTICIPATION, ACCESS, AND EDUCATION 8710.1 A designated HIE entity and its participating organizations shall take affirmative steps to ensure health care consumers have: (a) Information regarding the health care consume…

8711 OVERSIGHT AND ENFORCEMENT 8711.1 DHCF shall take enforcement actions as necessary, including the suspension or revocation of registration or designation in accordance with the requirements set forth below: When DHCF is considering suspension or revocation of an HIE entity’s …

8712 EXEMPTIONS 8712.1 DHCF may exempt a registered or designated HIE entity from certain requirements if such an exemption does not pose substantial risks to the privacy or security of health care consumers and: (a) The HIE entity’s infrastructure does not allow the registered o…

8713 APPEALS AND ADMINISTRATIVE REVIEW 8713.1 Within thirty (30) calendar days of receipt of notice of a DHCF enforcement action in accordance with § 8711 or notice from DHCF denying an HIE entity’s application for registration or designation pursuant to §§ 8702.5 and 8708.8, an …

8799 DEFINITIONS 8799.1 When used in this this chapter, the following terms shall have the meanings ascribed: Authentication - The process of establishing confidence in user identities electronically presented to an information system. Authorization - Has the meaning provided in …

8800 GENERAL PROVISIONS 8800.1 This chapter establishes standards governing enrollment eligibility, conditions of participation for providers, and program requirements of the District of Columbia’s (District) Program of All-Inclusive Care for the Elderly (PACE). 8800.2 DHCF, in c…

8801 PARTICIPANT ENROLLMENT 8801.1 To be eligible to enroll in PACE, an individual shall meet the following requirements, as determined by the PACE organization: Be fifty-five (55) years of age or older; Reside in the designated service area of the PACE organization; Meet the lev…

8802 PARTICIPANT DISENROLLMENT 8802.1 A PACE participant may voluntarily disenroll from the program without cause at any time, in accordance with the following: Requests for voluntary disenrollment from PACE shall be initiated by the PACE participant or the participant’s authoriz…

8803 PARTICIPANT RIGHTS 8803.1 The PACE organization shall have a written participant bill of rights designed to protect and promote the rights of each participant, which include, at minimum: (a) The right not to be discriminated against in the delivery of required PACE services …

8804 PACE ORGANIZATION APPLICATION PROCESS 8804.1 To be eligible to become a PACE organization, an entity shall be, or be a distinct part of, one of the following: An entity of city, county, state, or tribal government; A private not-for-profit entity organized for charitable pur…

8805 PACE ORGANIZATION REQUIREMENTS 8805.1 The PACE organization shall comply with the federal organizational, administrative, and governance requirements at 42 CFR §§ 460.60 – 460.86. 8805.2 The PACE organization shall comply with the District requirements for Adult Day Health P…

8806 INTERDISCIPLINARY TEAM 8806.1 The PACE organization shall meet the following requirements: Establish an interdisciplinary team, in accordance with § 8806.2, at each PACE center to comprehensively assess and meet the individual needs of each participant; (b) Assign each parti…

8807 PARTICIPANT ASSESSMENT AND PLAN OF CARE 8807.1 The interdisciplinary team shall conduct an initial in-person comprehensive assessment of each participant following enrollment. The assessment shall be completed in a timely manner in order to comply with the plan of care devel…

8808 PACE SERVICES 8808.1 If a Medicare beneficiary or Medicaid beneficiary enrolls in PACE, the following conditions apply: The participant is not subject to Medicare and Medicaid benefit limitations and conditions relating to amount, duration, scope of services, deductibles, co…

8809 PACE CENTER 8809.1 PACE centers must be operated in accordance with the following requirements: (a) The PACE organization must operate at least one PACE center either in, or contiguous to, its defined service area with sufficient capacity to allow routine attendance by parti…

8810 EMERGENCY CARE 8810.1 The PACE organization must establish and maintain a written plan to handle emergency care in accordance with the following requirements: The plan must ensure that CMS, DHCF, and PACE participants are held harmless if the PACE organization does not pay f…

8811 REIMBURSEMENT 8811.1 Under the PACE program agreement, CMS shall make a prospective monthly payment to the PACE organization of a capitation amount for each Medicare participant, in accordance with 42 CFR § 460.180. 8811.2 Under the PACE program agreement, DHCF shall make a …

8812 DATA COLLECTION, RECORD MAINTENANCE, AND REPORTING REQUIREMENTS 8812.1 The PACE organization must collect data, maintain records, and submit reports in accordance with the following: (a) The PACE organization must collect data, maintain records, and submit reports as specifi…

8813 QUALITY IMPROVEMENT 8813.1 The PACE organization must develop, implement, maintain, and evaluate an effective, data-driven quality improvement program. The program must include all services provided by the PACE organization, and the PACE organization must take actions that r…

8814 SANCTIONS, ENFORCEMENT ACTIONS, AND TERMINATION 8814.1 If CMS determines that the PACE organization has committed any of the violations set forth at 42 CFR § 460.40(a), or CMS or DHCF makes a determination that could lead to a termination of the PACE program agreement under …

8899 DEFINITIONS When used in this chapter, the following terms and phrases shall have the meanings ascribed: Contract year - The term of a PACE program agreement, which is a calendar year, except that a PACE organization's initial contract year may be from twelve (12) to twenty-…

8900 PROVIDER ELIGIBILITY The Department of Health Care Finance (DHCF) shall administer the Medicaid Electronic Health Record Incentive Payment Program (MEIP), which provides incentive payments to certain eligible providers participating in the District of Columbia Medicaid progr…

8901 METHODOLOGY FOR VOLUME REQUIREMENTS An eligible professional shall establish and demonstrate, based on individual and group practice methodology, compliance with the following volume requirements: An eligible professional shall have at least thirty percent (30%) of the profe…

8902 PROVIDER INCENTIVE PAYMENTS For all payment years, MEIP incentive payments for each eligible provider shall be subject to all of the following conditions: Incentive payments shall be calculated pursuant to 42 C.F.R. § 495.310; An eligible provider may receive a MEIP incentiv…

8903 PROGRAM INTEGRITY An eligible provider shall retain documentation that verifies its eligibility for MEIP for a minimum of ten (10) years and cooperate with DHCF and any other duly authorized agent of a governmental agency seeking to audit compliance with MEIP requirements. A…

APPEALS A provider may appeal any of the following issues: Incentive payment amounts; Provider eligibility determinations; and Demonstration of adopting, implementing, upgrading, and meaningful use of technology. DHCF shall issue a written determination to a provider if it finds …

8999 DEFINITIONS Acute care hospital: A health care facility: (1) where the average length of patient stay is twenty-five (25) days or fewer; and (2) with a Centers for Medicare and Medicaid Services (CMS) certification number (previously known as the Medicare provider number) th…

900 TIME LIMITATION ON PAYMENT OF MEDICAID PROVIDER CLAIMS 900.1 A claim for Medicaid reimbursable services may be submitted electronically or on paper by the enrolled billing provider. 900.2 Effective October 1, 2012, the Department of Health Care Finance (DHCF) shall not pay an…

901 MEDICALLY NEEDY INCOME LEVELS 901.1 The medically needy income levels (MNILs), for each household size in the District of Columbia, shall be based on fifty percent (50%) of the respective amounts of the Federal poverty guidelines published each year by the United States Depar…

902 ASSIGNMENT OF MEDICAL SUPPORT RIGHTS 902.1 As a condition of eligibility for Medicaid in the District, an individual shall, in accordance with 42 CFR §§ 433.146 through 433.149, do the following: (a) Assign any rights to payment for medical care support available under an ord…

903 OUTPATIENT AND EMERGENCY ROOM SERVICES 903.1 The purpose of this section is to set forth the requirements governing Medicaid reimbursement of outpatient hospital services. 903.2 All hospitals that deliver outpatient hospital services to Medicaid-eligible individuals and are e…

904 SKILLED OR INTERMEDIATE NURSING CARE FACILITIES 904.1 In recognition of the fact that many Medicaid patients require more nursing care than the program presently will pay for, and therefore, it is difficult to locate sufficient placements for Medicaid patients, effective not …

905 MEDICAID REIMBURSEMENT TO OUT-OF-STATE SKILLED NURSING AND INTERMEDIATE CARE FACILITIES 905.1 Payment to a nursing home located outside of the District of Columbia serving D.C. Medicaid patients shall be in accordance with the rate schedule that applies to a nursing home prov…

906 STANDARDS FOR MEDICAID REIMBURSEMENT OF PARENTERAL, ENTERAL AND INFUSION THERAPY IN THE HOME 906.1 Parenteral, enteral or infusion therapy shall only be provided by home health agencies certified for participation in the D.C. Medicaid Program. 906.2 Parenteral, enteral or inf…

907 [REPEALED] SOURCE: Final Rulemaking published at 50 DCR 4395 (June 6, 2003); as amended by Final Rulemaking published at 55 DCR 2854 (March 21, 2008); as amended by Final Rulemaking published at 61 DCR 2470 (March 21, 2014). District of Columbia Municipal Regulations Public W…

908 QUALIFICATIONS FOR A DISPROPORTIONATE SHARE HOSPITAL A hospital located in the District of Columbia shall be deemed a disproportionate share hospital (DSH) for purposes of a special payment adjustment if a hospital has at least one percent (1%) Medicaid utilization and the ho…

SCREENING, DIAGNOSTIC, AND PREVENTIVE SERVICES 909.1 In accordance with Section 1905(a)(13) of the Social Security Act (“the Act”) (42 U.S.C. § 1396d(a)(13)), each beneficiary may be eligible to receive the following screening, diagnostic, and preventive services subject to the r…

910 MEDICAID-REIMBURSABLE TELEMEDICINE SERVICES 910.1 The purpose of this section is to establish the Department of Health Care Finance (DHCF) standards governing eligibility for Medicaid beneficiaries receiving healthcare services via telemedicine under the Medicaid program, and…

912 REIMBURSEMENT FOR RESTRICTED MEDICAID RECIPIENTS SOURCE: Final Rulemaking published at 31 DCR 465 (February 3, 1984). AUTHORITY: DC-DCMR An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical …

913 OTHER PREVENTATIVE SERVICES: REIMBURSEMENT OF DRUG ADMINISTRATION SERVICES AND CORONAVIRUS (COVID-19) VACCINES 913.1 Medicaid reimbursement for pharmacists' administration services, provided consistent with the requirements set forth in 42 CFR § 440.60(a) and the provisions s…

914 D.C. MEDICAID PRIOR APPROVAL REQUIRED FOR SELECTED PHARMACEUTICALS PROVIDED TO D.C. MEDICAID AMBULATORY CARE PATIENTS 914.1 Prior authorization from the D.C. Medicaid program shall be required for the dispensing of the following prescribed drugs to D.C. Medicaid ambulatory ca…