D.C. Mun. Regs. tit. 22, r. 22-A3407

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 22-A3407 - ELIGIBLE CONSUMERS

3407.1

Consumers eligible for Medicaid- funded MHRS shall meet the following requirements:

(a) Be enrolled in Medicaid, or be eligible for enrollment and have an application pending;

(b) Be a bona fide resident of the District, as defined in D.C. Official Code § 7-1131.02(29);

(c) Be a child or youth with mental health problems, as defined in D.C. Official Code § 7-1131.02(1F), or an adult with mental illness as defined in D.C. Official Code § 7-1131.02(24); and

(d) Be recommended as requiring MHRS by a qualified practitioner licensed to diagnose mental illness or serious emotional disturbance.

3407.2

Subject to § 3407.4, consumers eligible for locally- funded MHRS are those individuals who are not eligible for Medicaid or Medicare or are not enrolled in any other third-party insurance program except the D.C. HealthCare Alliance, and who meet the following requirements:

(a) Be a bona fide resident of the District, as defined in D.C. Official Code § 7-1131.02(29);

(b) Be a child or youth with mental health problems, as defined in D.C. Official Code § 7-1131.02(1F), or an adult with mental illness as defined in D.C. Official Code § 7-1131.02(24);

(c) Be recommended as requiring MHRS by a qualified practitioner licensed to diagnose mental illness or serious emotional disturbance; and

(d) For individuals eighteen (18) years of age and older, live in households with a countable income of less than two hundred percent (200%) of the federal poverty level, and for individuals under eighteen (18) years of age, live in households with a countable income of less than three hundred percent (300%) of the federal poverty level.

3407.3

Eligible consumers of MHRS shall have a primary mental health diagnosis as described in the International Classification of Diseases ("ICD-10") and Diagnostic and Statistical Manual of Mental Health Disorders ("DSM-5"), or subsequent versions adopted by the Department pursuant to public notice in theDistrict of Columbia Register.

3407.4

Consumers eligible for Medicare shall remain eligible for the following locally-funded MHRS only to the extent these services are not otherwise covered by Medicare:

(a) Community support; and

(b) Specialty services identified in § 3417.3.

3407.5

Providers shall not bill Medicaid and/or the Department for MHRS provided to any consumer that does not meet the eligibility requirements set forth above.

3407.6

For new enrollees and those enrollees whose Medicaid coverage has lapsed:

(a) There is an eligibility grace period of ninety (90) calendar days from the date of first service for new enrollees, or from the date of eligibility expiration for enrollees who have a lapse in coverage, until the date the Department of Human Services' Economic Security Administration ("ESA") makes an eligibility or renewal determination.

(b) In the event the consumer appeals a denial of eligibility or renewal by the ESA, the Director may extend the ninety (90) calendar day eligibility grace period until the appeal has been exhausted. The ninety (90) calendar day eligibility grace period may also be extended at the discretion of the Director for other good cause shown.

(c) Upon expiration of the eligibility grace period, MHRS services provided to the consumer are no longer reimbursable by the Department. Nothing in this section alters the District's timely- filing requirements for claim submissions.

D.C. Mun. Regs. tit. 22, r. 22-A3407

Final Rulemaking published at 48 DCR 10297 (November 9, 2001); as amended by Final Rulemaking published at 51 DCR 9308 (October 1, 2004); as amended by Final Rulemaking published at 52 DCR 5682 (June 17, 2005); as amended by Notice of Emergency and Proposed Rulemaking published at 58 DCR 1482 (February 18, 2011)[EXPIRED]; as amended by Notice of Final Rulemaking published at 58 DCR 3476 (April 22, 2011); amended by Final Rulemaking published at 66 DCR 5638 (5/3/2019); amended by Final Rulemaking published at 67 DCR 10674 (9/4/2020)

Authority: The Director of the Department of Mental Health (Department), pursuant to the authority set forth in sections 104 and 105 of the Department of Mental Health Establishment Amendment Act of 2001, effective December 18, 2001 (D.C. Law 14-56; D.C. Official Code § 7-1131.04 and 7-1131.05 ).