D.C. Mun. Regs. tit. 22, r. 22-A6301

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

Rule 22-A6301 - ELIGIBILITY FOR SUBSTANCE USE DISORDER SERVICES

6301.1

SUD is a chronic relapsing disease characterized by a cluster of cognitive, behavioral, and psychological symptoms indicating that the client continues using the substance despite significant substance-related problems. A diagnosis of SUD requires a client to have had persistent, substance related problem(s) within a twelve (12)- month period in accordance with the most recent version of the American Psychiatric Association's Diagnostic and Statistical Manual ("DSM").SUD services as described throughout this chapter include both treatment and Recovery Support Services ("RSS").

6301.2

To be eligible for SUD treatment, a client must have received a diagnosis of SUD in accordance with § 6301.1. Eligibility for Medicaid- funded or Department-funded SUD services shall be determined in accordance with § 6301.4.

6301.3

To be eligible for RSS, a client must have an identified need for RSS and:

(a) Be actively participating in the Department treatment system;

(b) Have completed treatment; or

(c) Have a self- identified substance use issue that is not assessed as needing active treatment.

6301.4

A client shall meet the following eligibility requirements in order to receive Medicaid-funded SUD services:

(a) Be bona fide residents of the District, as required in 29 DCMR §2405.1(a); and

(b) Be referred for SUD services by a treatment provider or other intake center authorized by the Department.

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

(d) For new enrollees and those enrollees whose Medicaid coverage has lapsed:

(1) 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.

(2) In the event the client 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.

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

6301.5

Clients eligible for locally- funded SUD treatment 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. Health care Alliance, or who are enrolled in a third-party insurance program that does not cover SUD treatment and who meet the following requirements:

(a) 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.

(b) A client that does not meet the income limits of § 6301.5(a) above may receive treatment services in accordance with the following requirements:

(1) The client must, within ninety (90) calendar days of enrollment for services, apply to the ESA for certification, which will verify income ; and

(2) An individual with income over the limits in paragraph (a) above may receive treatment services in accordance with rates determined by the Department.

D.C. Mun. Regs. tit. 22, r. 22-A6301

Final Rulemaking published at 62 DCR 12056 (9/4/2015); amended by Final Rulemaking published at 67 DCR 11585 ( 10/9/2020 ).