D.C. Mun. Regs. tit. 29, r. 29-10207

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

Rule 29-10207 - REIMBURSEMENT

10207.1

DHCF shall reimburse My Health GPS entities for the provision of covered My Health GPS services described in § 10206 using a per member per month (PMPM) payment structure.

10207.2

Effective upon December 1, 2018, DHCF shall establish three (3) distinct PMPM rates. A My Health GPS entity shall be eligible to receive only one of the following rates, per month, for each beneficiary enrolled in the My Health GPS program:

(a) The PMPM rate to support the initial development of the person-entered care plan and annual, comprehensive re-evaluations of the beneficiary's care needs for both higher acuity and lower acuity beneficiaries. This PMPM shall only be available in the month in which the care plan is initially developed or an annual, comprehensive, re-evaluation of the beneficiary's care needs is performed;

(b) The PMPM rate for higher acuity (Group Two) beneficiaries; and

(c) The PMPM rate for lower acuity (Group One) beneficiaries.

10207.3

The PMPM rate set forth in § 10207.2(a) shall be higher than the acuity based PMPM rates set forth in §§ 10207.2(b) and (c). The PMPM rate for Group Two beneficiaries established in § 10207.2(b) shall be higher than the PMPM rate for Group One beneficiaries established in § 10207.2(c), reflecting the greater anticipated needs of Group Two beneficiaries for My Health GPS services and the additional My Health GPS provider staff required to serve Group Two beneficiaries.

10207.4

Except as set forth in § 10207.6, DHCF shall use a nationally- recognized risk adjustment tool and other criteria to determine the acuity level of each beneficiary in accordance with guidance published on the DHCF website. Based upon the results of the analysis, DHCF shall place the beneficiary into the appropriate acuity group.

10207.5

DHCF shall publish guidance on the methodology used to determine the acuity level of beneficiary on the DHCF website at dhcf.dc.gov. DHCF shall publish any changes to the methodology on the DHCF website at least thirty (30) calendar days before the changes are scheduled to take effect.

10207.6

A My Health GPS entity may request re-determination of a beneficiary's assigned acuity level as follows:

(a) If re-determination is requested, a My Health GPS entity shall submit clinical documentation of a significant change in the beneficiary's health status to DHCF in the manner specified in the My Health GPS manual; and

(b) If the documentation submitted in accordance with the My Health GPS manual by the My Health GPS entity is complete, DHCF shall re-determine the beneficiary's acuity level in accordance with the procedure set forth in §§ 10207.4.

10207.7

DHCF shall provide the My Health GPS entity with written notification of the results of the re-determination described in § 10207.6, including a copy of the re-determination analysis.

10207.8

The base PMPM rates for the rates set forth in § 10207.2 shall be established based on the staffing model described in §§ 10205.3 through 10205.5, and adjusted to take into account regional salaries, including fringe benefits. The rates shall also take into account the average expected service intensity for beneficiaries and shall be determined in accordance with the requirements of 42 USC § 1396a(a)(30)(A).

10207.9

Two (2) payment enhancements shall be added to the each PMPM rate set forth in § 10207.2 to:

(a) Reflect the My Health GPS provider's overhead or administrative costs; and

(b) Support the My Health GPS provider in procuring, using, or modifying health information technology.

10207.10

DHCF shall review the PMPM rates set forth in § 10207.2 on an annual basis to ensure that the rates are consistent with requirements set forth in 42 USC § 1396a(a)(30)(A).

10207.11

The PMPM rates set forth in § 10207.2 shall be listed in the D.C. Medicaid fee schedule, available at: www.dc-medicaid.com.

10207.12

In order to receive the first PMPM payment for an eligible beneficiary, a My Health GPS provider shall:

(a) Inform the beneficiary about available My Health GPS program services;

(b) Obtain the beneficiary's informed consent to receive My Health GPS program services in writing; and

(c) Complete the following components of the person-centered plan of care in accordance with the standards for Comprehensive Care Management set forth in § 10206.3:

(1) Conduct an in-person needs assessment in accordance with § 10206.3(a);

(2) Enter available clinical information and information gathered at the in-person needs assessment into the person-centered plan of care which shall include individualized goals pursuant to § 10206.3(b)(4); and

(3) Retain documentation demonstrating the delivery of each of the activities described in (1) and (2) above.

10207.13

In order to receive a subsequent PMPM payment for an eligible beneficiary, a My Health GPS provider shall complete the person-centered plan of care in accordance with the standards set forth in § 10206.3, provide a copy of the completed plan of care to the beneficiary, and deliver at least one (1) My Health GPS program service to the beneficiary within the calendar month as follows:

(a) For Group One beneficiaries, the service(s) provided during the month may be delivered face to face or remotely; and

(b) For Group Two beneficiaries, at least one (1) service provided during the month shall be delivered face to face.

10207.14

My Health GPS entities shall be eligible for the PMPM payment set forth in § 10207.2(a) for the development of an initial person-centered care plan for each eligible beneficiary in Group One and Group Two. In order for the entity to receive the initial PMPM payment, the My Health GPS provider(s) shall meet all requirements set forth in § 10207.12 for each qualifying beneficiary.

10207.15

My Health GPS entities shall be eligible for the PMPM payment set forth in § 10207.2(a) for annual, comprehensive re-evaluations of the beneficiary's care needs for each eligible beneficiary in Group One and Group Two. In order for the entity to receive the annual PMPM payment, the My Health GPS provider(s) shall meet all requirements set forth in § 10207.12(c) for each qualifying beneficiary.

10207.16

For the initial and annual PMPM payment set forth in § 10207.2(a), My Health GPS entities shall be eligible to receive a maximum of one (1) payment per twelve (12) month period per beneficiary. If a My Health GPS entity received an incentive payment set forth in § 10209.2 for a beneficiary, no My Health GPS entity shall be eligible to receive an initial or annual PMPM payment set forth in § 10207.2(a) for the same beneficiary, until the twelfth (12^th) month following the original month of service.

10207.17

For the initial and annual PMPM payments set forth in § 10207.2(a), a maximum of one (1) initial and annual PMPM payment is claimable per twelve (12) month period per beneficiary, regardless of a beneficiary's election to receive services from a different My Health GPS entity or "opt-out" of the program.

10207.18

Each My Health GPS provider shall document each program service and activity provided in each beneficiary's EHR. Any Medicaid claim for program services shall be supported by written documentation in the EHR which clearly identifies the following:

(a) The specific service(s) rendered and descriptions of each identified service sufficient to document that each service was provided in accordance with the requirements set forth in § 10206;

(b) The date and time the service(s) were rendered;

(c) The My Health GPS provider staff member who provided the services;

(d) The setting in which the service(s) were rendered;

(e) The beneficiary's person-centered plan of care provisions related to the service(s) provided; and

(f) Documentation of any further action required for the beneficiary's well-being as a result of the service(s) provided.

10207.19

Each claim for a My Health GPS service shall meet the requirements of § 10206 and shall be documented in accordance with § 10207.18 in order to be reimbursed.

D.C. Mun. Regs. tit. 29, r. 29-10207

Final Rulemaking published at 64 DCR 636 (1/26/2018); amended by Final Rulemaking published at 66 DCR 005382 (4/26/2019)