District of Columbia Administrative Code

9400 MEDICAID PROVIDER GENERAL PROVISIONS 9400.1 Health care providers, including individual practitioners, institutional providers, and providers of medical equipment or goods related to care, seeking to provide services or goods to District of Columbia (District) Medicaid benef…

9401 MEDICAID PROVIDER APPLICATION 9401.1 All provider applications shall be completed consistent with the requirements enumerated in § 9401.6 and submitted using the designated online application system, which may be accessed via www.dc-medicaid.com. Each provider shall complete…

9402 APPLICATION FEE 9402.1 A provider may be required to remit an application fee at the time of submission of the application for initial enrollment, re-enrollment, or revalidation of enrollment. Assignment of application fees shall be subject to the following principles: The a…

9403 MEDICAID PROVIDER SCREENING 9403.1 Pursuant to 42 CFR § 455.450, DHCF shall screen all applications for initial enrollment, re-enrollment, or revalidation of enrollment based on the level of categorical risk to which the provider type is assigned. 9403.2 All providers shall …

9404 SCREENING PROVIDERS DESIGNATED AS “LIMITED” RISK 9404.1 Pursuant to 42 CFR § 455.450, any provider not designated as “moderate” risk or “high” risk under §§ 9405 or 9406 shall be assigned to the “limited” risk category. 9404.2 Screening for providers designated as “limited” …

9405 SCREENING PROVIDERS DESIGNATED AS “MODERATE” RISK 9405.1 Pursuant to 42 CFR § 455.450, the following provider types shall be assigned to the “moderate” risk category: Adult day health service providers under the 1915(i) State Plan option; Ambulance service suppliers; Communi…

9406 SCREENING PROVIDERS DESIGNATED AS “HIGH” RISK 9406.1 Pursuant to 42 CFR § 455.450, the following provider types shall be assigned to the “high” risk category: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) providers; DMEPOS providers of medical aler…

9407 OWNERSHIP AND FINANCIAL DISCLOSURES 9407.1 Each disclosing entity, fiscal agent, and managed care entity shall disclose, at the time of application, the following information in accordance with 42 CFR § 455.104(a)-(e): The name and address of any individual or corporation wi…

9408 CRIMINAL BACKGROUND CHECKS AND FINGERPRINTING 9408.1 In accordance with 42 CFR § 455.434, a provider shall consent to criminal background checks, including fingerprinting, when required to do so under District laws and regulations or by the level of screening based on the ri…

9409 SITE VISITS 9409.1 In accordance with 42 CFR § 455.432, DHCF shall conduct unannounced, pre-enrollment and post-enrollment site visits of providers who are designated as “moderate” risk or “high” risk. Site visits shall be used to verify the following: The accuracy of the in…

9410 DENIAL OF ENROLLMENT AND CONDITIONS FOR TERMINATION OF ENROLLMENT 9410.1 Upon the occurrence of any of the circumstances described in this Section, any action taken by DHCF to terminate an existing provider agreement shall occur in accordance with the Medicaid Program Admini…

9411 NOTICE AND APPEALS 9411.1 If the Director proposes to deny enrollment to a provider pursuant to this chapter, then the Director shall send written notice to the affected party. The notice shall include the following: The basis and reasons for the proposed denial of enrollmen…

9412 PROVIDER INACTIVITY 9412.1 DHCF may terminate enrollment of a provider due to inactivity if: A provider fails to submit the first claim under the provider number initially issued to the provider within a period of twelve (12) months from the date the provider number was issu…

9413 CHANGE OF OWNERSHIP 9413.1 The following shall constitute a change of ownership: (a) For a Partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree that the removal, addition, or substitution of a partner shall not constitute a ch…

9414 FINANCIAL VIABILITY STANDARDS 9414.1 Each provider shall, at the time of application and upon request by DHCF, provide documented evidence of adequate financial resources to deliver all required services and operate a financially viable business, in accordance with the requi…

9415 UNIVERSAL CONTRACTING 9415.1 Effective October 1, 2020, all enrolled hospitals, hospital-affiliated physician groups, Federally Qualified Health Centers (FQHC), and FQHC Look-Alikes shall be required to contract with District Medicaid managed care organizations for the same …

9499 DEFINITIONS 9499.1 For the purposes of this chapter, the following terms shall have the meanings ascribed: Abuse – Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the District Medicaid program, …

9500 GENERAL PROVISIONS This chapter shall govern eligibility determinations for the District of Columbia (District) Medicaid programs authorized under Title XIX and XXI of the Social Security Act (the Act). Pursuant to 42 U.S.C. Sections 1396 et seq., and amendments thereto, the…

9501 APPLICATION, REDETERMINATION, AND RENEWAL An individual may apply for Medicaid or other Insurance Affordability Programs (IAPs) using a single, streamlined application described at 42 C.F.R. Sections 435.907(b) and (c). The application and any required verification may be su…

9502 RESIDENCY An individual shall be a resident of the District as a condition of Medicaid eligibility. An individual shall be considered incapable of stating intent to reside in the District if one of the following applies to the individual: Individual has an I.Q. of forty-nine…

9503 CITIZENSHIP OR SATISFACTORY IMMIGRATION STATUS An individual shall meet applicable citizenship or satisfactory immigration status requirements as a condition of Medicaid eligibility. The following groups of individuals satisfy citizenship or satisfactory immigration status r…

9504 SOCIAL SECURITY NUMBER An individual, except as otherwise provided in this section, shall provide his or her SSN as a condition of Medicaid eligibility pursuant to 42 C.F.R. Section 435.910. An individual who cannot provide his or her SSN shall provide proof of an applicatio…

9505 VERIFICATION OF NON-FINANCIAL ELIGIBLITY FACTORS The Department shall verify the non-financial eligibility factors necessary for a MAGI-based Medicaid eligibility determination at the time of application, at each renewal of eligibility, and at each redetermination of eligibi…

9506 MODIFIED ADJUSTED GROSS INCOME (MAGI) ELIGIBILITY This section shall establish the factors of District Medicaid eligibility for modified adjusted gross income (MAGI) eligibility groups, as identified in Section 9500. 9506.2 Beginning January 1, 2026, to be determined eligibl…

9507 NON-MAGI ELIGIBILTY GROUP: DEEMED NEWBORNS To be determined eligible for Medicaid as a deemed newborn, an individual shall be born to a woman eligible for and receiving Medicaid from the District at the time of birth. The Department shall not require an application or income…

9508 NOTICE AND FAIR HEARING RIGHTS The Department shall provide timely and adequate notice of eligibility and enrollment determinations and the right to appeal to Medicaid applicants and beneficiaries consistent with the requirements set forth in Federal and District law and rul…

9509 [RESERVED] SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015). District of Columbia Municipal Regulations Public Welfare 29 DCMR § 9509 AUTHORITY: DC-DCMR Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27…

9510 TRANSITIONAL MEDICAID 9510.1 Under Section 1925 of the Social Security Act (the Act), as amended, 42 U.S.C §§ 1396r-6, the Department of Health Care Finance (DCHF) may extend Transitional Medical Assistance (TMA) to certain families and dependent children with low-income who…

9511 SUPPLEMENTAL SECURITY INCOME-BASED METHODOLOGY FOR CERTAIN NON-MAGI ELIGIBLITY GROUPS 9511.1 The Department shall determine financial eligibility for Medicaid using a Supplemental Security Income (SSI)-based methodology pursuant to 42 CFR Section 435.601 for the following no…

9512 NON-MAGI ELIGIBLITY GROUP: TEFRA/KATIE BECKETT 9512.1 A child below the age of nineteen (19) years old that applies for Medicaid eligibility under the “TEFRA/Katie Beckett eligibility group” shall comply with the following requirements: Submit a complete application for Medi…

9513 NON-MAGI ELIGIBILITY GROUP: OPTIONAL AGED, BLIND, AND DISABLED This section shall govern eligibility determinations pursuant to Sections 1902(a)(10)(A)(ii)(X), 1902(m)(1), 1902(a)(10)(A)(ii)(I), and 1905(a)(iv) of the Social Security Act, 42 CFR §§ 435.201(a)(1) - (3) for th…

9514 NON-MAGI ELIGIBILITY GROUPS: SUPPLEMENTAL SECURITY INCOME AND OPTIONAL STATE SUPPLEMENTAL PAYMENT 9514.1 This section shall govern eligibility requirements for the following: (a) The Supplemental Security Income (SSI) eligibility group pursuant to 42 CFR § 435.120; and (b) T…

9515 MEDICALLY NEEDY 9515.1 This section establishes the conditions of medically needy eligibility for individuals, identified in Subsection 9515.3, who have income in excess of District Medicaid or Medicaid Waiver standards at the time of application, renewal, or redetermination…

9516 SPEND DOWN FOR MEDICALLY NEEDY COVERAGE 9516.1 This section establishes the calculation of spend down and eligibility determination process for medically needy individuals who have income above the income limit for their respective eligibility coverage group, pursuant to the…

9599 DEFINITIONS For the purposes of this chapter, the following terms shall have the meanings ascribed: Active treatment - A continuous program, which includes consistent implementation of training, therapies, health and related services designed to address the child's social, i…

9700 GENERAL PROVISIONS 9700.1 The purpose of this chapter is to establish the Department of Health Care Finance (DHCF) standards governing Medicaid eligibility for individuals receiving Adult Day Health Program (ADHP) services, to establish conditions of participation for provid…

9701 ELIGIBILITY REQUIREMENTS 9701.1 To qualify for ADHP services under these rules, the Medicaid beneficiary shall meet the following criteria: Be age fifty-five (55) and older; Be an adult with a chronic medical condition diagnosed by a physician; Have income up to one hundred …

9702 PROVIDER QUALIFICATIONS 9702.1 To be eligible to receive reimbursement for ADHP services, a Provider shall: Submit a Medicaid Provider Enrollment Application to DHCF, and comply with the requirements set forth in Chapter 94 (Medicaid Provider and Supplier Screening, Enrollme…

9703 PROGRAM ADMINISTRATION 9703.1 Each Provider shall have a current organizational chart that clearly identifies the organizational structure, lines of authority, staffing levels, and the use of contracted staff. 9703.2 Each Provider shall have a governing body with oversight r…

9704 STAFFING REQUIREMENTS: GENERAL 9704.1 Each ADHP shall develop and maintain a staffing and personnel training plan that ensures adequate personnel in number and skill to meet minimum required staffing levels in accordance with this section and to deliver required services to …

9705 PROGRAM REQUIREMENTS 9705.1 An Adult Day Health Program shall provide, at minimum, all of the following services: Nursing services, as described under Subsection 9704.6, including monitoring the participants’ health care-needs, providing health counseling, and the coordinati…

9706 NUTRITION SERVICES 9706.1 Nutrition services shall be provided in accordance with the requirements set forth in this Section. 9706.2 All meals and snacks shall be prepared under the direction of a dietician or nutritionist and shall be provided in accordance with the require…

9707 MEDICATION ADMINISTRATION, ASSISTANCE AND COUNSELING 9707.1 The ADHP shall provide medication administration, assistance and counseling in accordance with the requirements of this Section. 9707.2 Medication administration and counseling services shall be supervised by a regi…

9708 SAFETY AND ENVIRONMENTAL REQUIREMENTS 9708.1 Each provider rendering ADHP services shall ensure that the physical site where services are rendered is in compliance with safety and accessibility standards for disabled persons in accordance with the Americans with Disabilities…

9709 SERVICE AUTHORIZATION REQUEST REQUIREMENTS 9709.1 ADHP services shall not be initiated or provided on a continuing basis by a provider without an approved assessment determination and an authorization for the receipt of ADHP services from DHCF, DHCF’s designated agent to aut…

9710 ADMISSION REQUIREMENTS 9710.1 With respect to each new admission, an ADHP provider shall: Obtain the ADHP assessment determination that authorizes the need for ADHP services, as described in Section 9709, establishing that the participant meets the level of care for admissio…

9711 ADHP PLAN OF CARE 9711.1 An ADHP plan of care shall: (a) Be completed within fourteen (14) business days of the participant’s admission to the ADHP; (b) Be developed in consultation with the participant, or the participant’s representative and the participant’s Support Team;…

9712 PARTICIPANT RIGHTS AND RESPONSIBILITIES 9712.1 Each ADHP provider shall develop a written statement of the participant’s rights and responsibilities consistent with the requirements of this section, which shall be given to each participant in advance of receiving services. 9…

9713 RECORDKEEPING 9713.1 Each ADHP provider shall maintain complete and accurate participant records (paper or electronic) for each participant that documents the specific ADHP services provided to each participant for a period of ten (10) years or until all audits are completed…

9714 TERMINATION AND ALTERNATIVE SANCTIONS FOR ADHP NONCOMPLIANCE 9714.1 In order to qualify for Medicaid reimbursement, ADHP providers shall comply with programmatic requirements as part of its Provider Readiness Review. The programmatic requirements include adherence to accepta…