D.C. Mun. Regs. tit. 29, r. 29-10303

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

Rule 29-10303 - REIMBURSEMENT

10303.1

DHCF shall reimburse each HSS agency using a single per member per month (PMPM) rate that encompass all HSS services an HSS agency furnishes to each eligible beneficiary within a month.

10303.2

To be eligible for a PMPM payment from DHCF, an HSS agency shall:

(a) Provide a minimum of two (2) HSS services to an eligible beneficiary within a month;

(b) Receive prior authorization from DHS;

(c) Comply with the service requirements set forth by DHS in Chapter 74 of Title 29 DCMR; and

(d) Submit an accurate and adequate claim for reimbursement to DHCF that is consistent with the approved prior authorization and the beneficiary's Person-Centered Service Plan (PCSP).

10303.3

The PMPM rate shall be determined as follows:

(a) The PMPM rate shall equal total annual allowable HSS costs per participant divided by adjusted total enrollment months. Those values shall be calculated as follows:

(1) Total annual allowable HSS costs shall equal direct care costs plus non-direct care costs multiplied by the inflation adjustment factor;

(2) Total annual allowable HSS costs per participant shall equal total annual allowable HSS costs divided by the beneficiary capacity limit of one hundred (100); and

(3) Adjusted total enrollment months shall equal twelve (12) months times the productivity factor;

(b) The inflation adjustment factor described in this Section shall equal the Centers for Medicare and Medicaid Services Medicare Economic Index for the previous calendar year or two percent (2%), whichever is lower;

(c) In years that reimbursement rates are rebased in accordance with § 10303.5, the inflation adjustment factor shall not apply to the PMPM rate calculation;

(d) Allowable costs shall be determined in accordance with § 10304;

(e) Direct care costs for case managers shall be limited to no more than twenty five (25) beneficiaries per case manager; and

(f) Direct care costs for case manager supervisors shall be limited to no more than one-hundred and twenty-five (125) beneficiaries per case manager supervisor.

10303.4

The PMPM rate shall be set April 1, 2022, inflated on January 1, 2023, and annually adjusted thereafter in accordance with § 10304.3.

10303.5

Not later than January 1, 2026, and every four (4) years thereafter, the PMPM rate shall be rebased using the most recently submitted annual cost surveys.

10303.6

The PMPM rate shall be published on the Department of Health Care Finance's (DHCF) website at www.dc-medicaid.com ; notice shall be provided, consistent with 42 C.F.R. 447.205.

D.C. Mun. Regs. tit. 29, r. 29-10303

Final Rulemaking published at 69 DCR 6426 (6/3/2022)