D.C. Mun. Regs. tit. 29, r. 29-10203

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

Rule 29-10203 - BENEFICIARY DISENROLLMENT

10203.1

DHCF shall disenroll an enrolled beneficiary from the My Health GPS program if:

(a) The beneficiary's My Health GPS entity has not submitted claims for reimbursement for My Health GPS services provided to the beneficiary for three (3) consecutive quarters and DHCF has determined through an internal review that the beneficiary is no longer actively participating in the My Health GPS program; or

(b) DHCF determines that an enrolled My Health GPS beneficiary no longer meets the eligibility requirements as set forth under § 10201.

10203.2

If DHCF takes action to disenroll an enrolled beneficiary from the My Health GPS program as set forth in § 10203.1, DHCF shall issue a written notice to the beneficiary at least thirty (30) calendar days prior to the effective date of the intended disenrollment, which shall contain the following information:

(a) A clear statement of the intended action to disenroll the beneficiary from the My Health GPS program;

(b) An explanation of the reason(s) for the intended action;

(c) Citations to the laws or regulations supporting the intended action;

(d) An explanation of the beneficiary's right to request that DHCF reconsider its decision to disenroll the beneficiary, including the timeframe and procedures for making a request for reconsideration;

(e) An explanation of the beneficiary's right to request a Fair Hearing, including the timeframe and procedures for requesting a hearing; and

(f) The circumstances under which the beneficiary's current My Health GPS services will be continued if a reconsideration or Fair Hearing is requested.

10203.3

A request for reconsideration of the decision to disenroll a beneficiary made pursuant to § 10203.2(d) must be submitted in writing, by mail, fax, or in person, to DHCF within thirty (30) calendar days of the date of the notice of disenrollment described in § 10203.2. The request for reconsideration shall include information and documentation as follows:

(a) A written statement by the beneficiary, or the beneficiary's designated representative, describing the reason(s) why the decision to disenroll the beneficiary should not be upheld;

(b) A written statement by a clinician familiar with the beneficiary's health care needs describing the reason(s) why the decision to disenroll the beneficiary should not be upheld; and

(c) Any additional, relevant documentation in support of the request.

10203.4

For beneficiaries currently receiving My Health GPS services, a timely filed request for reconsideration will stay the termination of services until a reconsideration decision is issued.

10203.5

DHCF shall issue a reconsideration decision no more than thirty (30) calendar days from the date of receipt of the documentation required in § 102033.

10203.6

If DHCF decides to uphold the disenrollment determination, the reconsideration decision shall contain the following:

(a) A description of all documents that were reviewed;

(b) The justification(s) for the intended action(s) and the effective date of the action(s);

(c) An explanation of the beneficiary's right to request a Fair Hearing, including the timeframes and procedures for requesting a hearing; and

(d) The circumstances under which My Health GPS services will be provided during the pendency of a Fair Hearing.

10203.7

A request to appeal the reconsideration decision issued pursuant to § 10203.5 must be submitted within ninety (90) calendar days of the date of issuance of the reconsideration decision by requesting a Fair Hearing with the Office of Administrative Hearings in writing, in person, or by telephone, in accordance with 1 DCMR § 2971.

10203.8

DHCF shall not disenroll the beneficiary from the My Health GPS program while a Fair Hearing is pending if a beneficiary files the Fair Hearing request prior to the effective date of the proposed action to disenroll the beneficiary.

D.C. Mun. Regs. tit. 29, r. 29-10203

Final Rulemaking published at 64 DCR 636 (1/26/2018)