D.C. Mun. Regs. tit. 29, r. 29-5701

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

Rule 29-5701 - ENROLLMENT

5701.1

The Department shall enroll certain Medicaid eligibility groups into either a D-SNP or a fee-for-service (FFS) delivery system based on the beneficiary's voluntary election to either enroll in a D-SNP or to continue to receive services through an FFS delivery system.

5701.2

The Department shall enroll the following Medicaid eligibility groups into a D-SNP, on a voluntary basis:

(a) Individuals who are dually eligible for Medicaid and Medicare, but not enrolled in the Medicare Savings Program (under 42 U.S.C. §§ 1396a(a) (10)(E), 1396d(p), or 1396d(s)) with dependent children;

(b) Individuals participating in a Home and Community Based Services (HCBS) Waiver pursuant to 42 U.S.C. § 1396n(c) that are subject to the non-financial requirements set forth in Chapter 42 and the financial requirements set forth in Chapter 98 of Title 29 DCMR;

(c) Individuals residing in nursing facilities or intermediate care facilities for individuals with intellectual disabilities (ICF/IID), subject to the nonfinancial eligibility requirements set forth under § 989 and Chapter 41 of Title 29 DCMR (respectively), and the financial eligibility requirements set forth in Chapter 98 of Title 29 DCMR; and

(d) Individuals participating in the Medicare Savings Program, including Qualified Medicare Beneficiaries (QMBs) and Qualified Disabled Working Individuals (QDWIs), as described in 42 U.S.C. §§ 1396a(a)(10) (E), 1396d(p), and 1396d(s)) .

5701.3

The Department shall exclude the following Medicaid eligibility groups from D-SNP enrollment:

(a) Individuals participating in a Program of All-Inclusive Care for the Elderly under institutional rules, as described in 42 U.S.C. § 1396u-4, that are subject to the requirements set forth under Chapter 88 of Title 29 DCMR;

(b) Individuals simultaneously enrolled in the District's Health Home program described under Chapter 102 of Title 29 DCMR and

(c) Individuals simultaneously enrolled in another Managed Care Plan, which may include individuals in eligibility groups described under §§ 5501.2 and 5501.3.

5701.4

For beneficiaries who are enrolled on a voluntary basis, as described under § 5701.1, the Department shall send a notice within thirty (30) calendar days of the Department's receipt of an election for voluntary enrollment. The notice shall include the following information:

(a) The beneficiary's right to choose to enroll in a D-SNP or to receive services through a FFS delivery system;

(b) The timeframe during which the beneficiary may choose to enroll or disenroll in a D-SNP or receive services through the FFS delivery system, as described under § 5701.6;

(c) A list of available D-SNPs that are contracted with the Department, including contact information and website links; and

(d) An explanation that if the beneficiary does not elect to leave the D-SNP program, the Department shall continue the beneficiary's enrollment in the D-SNP of his or her choosing.

5701.5

Beneficiaries enrolled on a voluntary basis (in accordance with § 5701.1) may choose to maintain D-SNP coverage or return to the FFS delivery system and to send the selection to the Department through the following means:

(a) By email;

(b) By telephone;

(c) By mail;

(d) In-person; or

(e) Through other commonly available electronic means.

5701.6

For eligibility groups described if § 5701.2, if the beneficiary does not request to leave the D-SNP program, the Department shall automatically maintain the beneficiary's enrollment in a D-SNP, described under § 5799.

5701.7

If the Department approves a beneficiary's enrollment into a D-SNP by the seventh (7th) day of the month, the beneficiary's enrollment in a D-SNP shall be effective no earlier than the first (1st) day of that month.

5701.8

If the Department approves a beneficiary's enrollment into a D-SNP after the seventh (7th) day of the month, the beneficiary's enrollment in a D-SNP shall be effective on the first (1st) day of the month after the month in which the Department approves the enrollment.

5701.9

Beneficiaries enrolled in a D-SNP may elect to enroll in a different D-SNP for any reason during an annual open enrollment period, which shall be from October 15 through December 7 each year. Beneficiaries may also elect to enroll in a different D-SNP at least once per calendar quarter and during special open enrollment periods identified by the Department and specified in guidance published on the Department's website. For beneficiaries in eligibility groups described in § 5701.2 who are automatically enrolled in managed care as described in § 5701.6, the beneficiary shall additionally have the option to elect to enroll in the FFS delivery system during the open enrollment period.

5701.10

Thirty (30) calendar days before the open enrollment period, the Department shall send a notice to each currently enrolled D-SNP beneficiary to inform the beneficiary of the open enrollment period and the process and required timeframes for selection of a D-SNP for the upcoming plan year.

5701.11

If the beneficiary chooses to change the D-SNP in which they are currently enrolled, in accordance with § 5701.09, the beneficiary may submit their new election to the health plan in which they are enrolled, the State Health Insurance Assistance Program, Medicare, or the Department through the following means:

(a) By email;

(b) By telephone;

(c) By mail; or

(d) Through other commonly available electronic means.

D.C. Mun. Regs. tit. 29, r. 29-5701

Final Rulemaking published at 43 DCR 4833, 4855 (September 6, 1996); repealed by Final Rulemaking published at 69 DCR 2149 (3/18/2022); amended by Final Rulemaking published at 69 DCR 11758 (9/30/2022)

This section as adopted included two subsections numbered U5701.6". In this edition, the second § 5701.6 has been renumbered § 5701.7. Concurrently, original § 5701.7 and 5701.8 have been renumbered § 5701.8 and 5701.9, respectively.