D.C. Mun. Regs. tit. 29, r. 29-10211

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

Rule 29-10211 - MY HEALTH GPS SANCTIONS, WITHDRAWAL AND TERMINATION

10211.1

DHCF may determine at any time during a My Health GPS entity's enrollment in the program that the entity has failed to meet one (1) or more requirements of program participation, and may request the submission of a Corrective Action Plan (CAP) to remedy the identified issue(s). All My Health GPS entities shall be required to submit a proposed Corrective Action Plan (CAP) under circumstances including, but not limited to, the following:

(a) Failure to meet any requirements set forth in this chapter;

(b) Failure to comply with all terms of the D.C. Medicaid Provider Agreement; or

(c) Failure to meet any quality standards using the measures described in § 10208.1.

10211.2

If DHCF identifies a My Health GPS entity's non-compliance in any of the areas described in § 10211.1, DHCF shall notify the entity of the identified issue(s) and a timeframe for submission of a proposed CAP to remedy the issue(s).

10211.3

If a My Health GPS entity is notified of a non-compliance issue as set forth in § 10211.2 and fails to submit a proposed CAP within the timeframe identified in the notification, DHCF shall notify the entity of the failure to submit the proposed CAP and may impose the following sanctions:

(a) Deny further assignments of beneficiaries;

(b) Deny incentive payments as described in § 10209.1;

(c) Seek repayment from the My Health GPS entity for services rendered during the time period of non-compliance; or

(d) Terminate the entity's participation in the My Health GPS program.

10211.4

A proposed CAP shall include, at minimum, the following components:

(a) A comprehensive statement of the non-compliance issue identified in the notice issued pursuant to § 10211.2;

(b) The entity's proposed course of action for resolving the identified non-compliance issue;

(c) Identification of the staff members responsible for resolving the issue;

(d) Timeframes for execution of the proposed course of action; and

(e) Designation of reporting periods for providing updates to DHCF.

10211.5

DHCF shall review each proposed CAP to determine whether it meets all requirements set forth in § 10211.4.

10211.6

If an entity's proposed CAP fails to meet any of the requirements set forth in § 10211.4, DHCF shall notify the entity of the identified deficiencies in the proposed CAP and provide a timeframe in which the CAP must be re-submitted.

10211.7

Once the proposed CAP meets all requirements set forth in § 10211.4, DHCF shall approve the CAP and monitor the entity's progress towards timely correction of all deficiencies. If the My Health GPS entity fails to resolve the deficiencies, DHCF may impose the sanctions described in § 10211.3.

10211.8

If DHCF determines that any of the actions set forth in §§ 10211.3 or 10211.7 are necessary, DHCF shall issue a notice to the entity containing the following information:

(a) A clear statement of the intended action;

(b) The effective date of the intended action;

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

(d) Specific reference to the particular sections of the statutes, regulations or provider manual supporting the intended action; and

(e) Information regarding the entity's right to dispute the allegations and to submit evidence to support his or her position.

10211.9

The My Health GPS entity may submit documentary evidence to refute DHCF's argument for imposition of an alternative sanction within thirty (30) days of the date of the notice described in § 10211.8.

10211.10

DHCF may extend the thirty (30) day period prescribed in § 10211.10 for good cause on a case-by-case basis.

10211.11

If DHCF determines that any of the actions set forth in §§ 10211.3 or 10211.7 is necessary after the My Health GPS entity has issued a response under § 10211.9, DHCF shall issue a final notice to the entity at least fifteen (15) days before the imposition of the alternative sanction, including the following information:

(a) The reason for the decision;

(b) The effective date of the sanction;

(c) Information regarding the right to appeal the decision by filing a hearing request with the Office of Administrative Hearings and the timeframe and procedures for filing a hearing request; and

(d) If applicable, information regarding the transfer of beneficiaries to another My Health GPS entity and the timeframe for completing the transfer.

10211.12

If the My Health GPS entity files a hearing request with the Office of Administrative Hearings within fifteen (15) days of the date of the notice described in § 10211.11, then the effective date of the proposed action shall be stayed until the Office of Administrative Hearings has rendered a final decision.

10211.13

If a My Health GPS entity wishes to withdraw from the program or to remove a provider from the My Health GPS portion of its D.C. Medicaid Provider Agreement, the entity shall take the following action:

(a) If the entity wishes to withdraw from the program, the entity shall give ninety (90) days written notice of the intended withdrawal to DHCF, which includes a comprehensive plan to transfer all of the entity's affected beneficiaries to another My Health GPS provider or entity; and

(b) If the entity wishes to remove a provider from the My Health GPS portion of its D.C. Medicaid Provider Agreement, the entity shall give ninety (90) days written notice of the intended removal to DHCF, which includes a comprehensive plan to transfer all of the entity's affected beneficiaries to another My Health GPS provider or entity and execute a modified My Health GPS Agreement.

D.C. Mun. Regs. tit. 29, r. 29-10211

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