D.C. Mun. Regs. tit. 29, r. 29-5307
Each prepaid, capitated provider shall provide each enrollee with high quality health care at locations that ensure reasonable availability and accessibility to enrollees.
Each prepaid, capitated provider shall provide either directly or by referral, each service in the Medicaid managed care benefits package, including patient management and referrals and approvals.
Each prepaid, capitated provider shall ensure that urgent and emergency medical care are available to AFDC and AFDC-related Medicaid enrollees on a twenty four (24) hour basis, seven (7) days a week, either through the prepaid, capitated provider or through other appropriate facilities.
Each prepaid, capitated provider shall conduct an orientation program to inform AFDC and AFDC-related recipients of available services and facilities.
Each AFDC and AFDC-related Medicaid recipient enrolled in a prepaid, capitated provider's plan shall receive service through the same health care providers and facilities that serve non-AFDC and AFDC-related Medicaid enrollees.
Each AFDC and AFDC-related Medicaid enrollee shall be fully integrated into the prepaid, capitated provider's plan membership and shall not be treated in a manner different from non-AFDC or AFDC-related Medicaid enrollees.
Each prepaid, capitated provider shall allow each enrollee, to the maximum extent feasible, the freedom to choose from among its participating providers of primary health care and shall notify the Department in writing of the primary health care provider to whom the AFDC or AFDC-related recipient is assigned by the end of the first month of enrollment and monthly for reassignments.
Each prepaid, capitated provider shall provide health education programs for its enrollees in languages understood by the population being served. The education programs shall include, at a minimum, the following:
The prepaid, capitated provider shall have a system of follow -up of patient care for enrollees with chronic and acute illnesses, including an appointment follow-up system for persons who do not appear for appointments.
Waiting times for appointments for AFDC and AFDC -related Medicaid enrollees shall not exceed the waiting times for non-AFDC or AFDC-related Medicaid enrollees of the prepaid, capitated provider.
Each prepaid, capitated provider shall maintain a current, unified medical record on each enrollee.
Each prepaid, capitated provider shall establish and maintain a quality assurance program to review the quality, appropriateness and timeliness of the services performed. The quality assurance program shall be approved by the Department in accordance with the requirements of § 5307.13.
The prepaid, capitated provider's quality assurance program shall:
The prepaid, capitated provider shall obtain accreditation through an external review by an independent quality accreditation organization such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the National Committee for Quality Assurance (NCQA). This process must begin within 12 months of entry into the D.C. Medicaid Managed Care Program and provisional accreditation must be received by the end of the third year of participation in the program.
D.C. Mun. Regs. tit. 29, r. 29-5307