D.C. Mun. Regs. tit. 29, r. 29-8608
Medicaid reimbursable treatment provided in inpatient or residential treatment settings that qualify as institutions for mental disease (IMD) shall include services which are:
Medicaid beneficiaries are eligible for services provided within an IMD under the demonstration program, if they meet the following criteria:
The individualized plan of care, identified in § 8608.1(b) shall be developed by a multi-disciplinary team of practitioners following diagnosis of the beneficiary's underlying condition and comprehensive assessment of the beneficiary's treatment needs.
District SUD residential providers shall comply with plan of care requirements set forth in Chapter 63 of Title 22-A DCMR.
District inpatient and residential behavioral health service providers shall be licensed or certified in accordance with the Health-Care and Community Residence Facility, Hospice and Home Care Licensure Act of 1983, effective February 24, 1984 (D.C. Law 5-48; D.C. Official Code §§ 44-501 et seq.) or otherwise applicable licensure or certification requirements as set forth under District law.
District SUD residential treatment providers shall be certified in accordance with requirements set forth under Chapter 63 of Title 22-A DCMR.
Eligible providers must meet the definition of an institution for mental disease as set forth at 42 CFR § 435.1010 and interpreted by DHCF via guidance on its website at www.dhcf.dc.go.
Inpatient mental health and SUD treatment shall be delivered by a facility that meets the conditions of participation set forth in 42 Part 482 and be either:
Residential SUD treatment providers shall deliver care consistent with American Society of Addiction Medicine criteria or other nationally recognized, SUD-specific program standards for residential treatment facilities. Residential SUD treatment delivered by a District certified facility shall be provided in accordance with requirements set forth under Chapter 63 of Title 22-A DCMR.
Residential mental health treatment shall be delivered by a facility that, as assessed by the District or a nationally recognized accreditation organization, delivers care consistent with nationally recognized, mental health-specific program standards for residential treatment facilities.
To be eligible for Medicaid reimbursement, inpatient and residential SUD treatment providers must provide Medication Assisted Treatment (MAT) services directly or facilitate the provision of MAT services by ensuring transportation for beneficiaries to obtain medications at a MAT providing and participating in the coordination of care in conjunction with MAT providers.
Effective January 1, 2020, Medicaid reimbursement for services provided in an IMD located in the District of Columbia shall be made according to the District of Columbia Medicaid fee schedule available online at https://www.dc-medicaid.com/dcwebportal/home.
DHCF shall reimburse IMD providers located outside the District of Columbia at the rate established by the Medicaid State Agency where the IMD is located.
For Medicaid beneficiaries enrolled in a District Medicaid Managed Care Plan, DHCF shall only provide fee-for-service reimbursement to eligible providers for IMD stays that exceed the stays reimbursed by the Medicaid Managed Care Plan, pursuant to "in lieu of" requirements set forth under 42 CFR § 438 and interpreted by DHCF in guidance on its website at www.dhcf.dc.gov.
DHCF will provide services for a targeted statewide average length of stay of thirty (30) days in inpatient and residential treatment settings.
IMD stays for the treatment of SMI that exceed sixty (60) days are not Medicaid reimbursable.
Medicaid fee-for-service reimbursement for IMD stays shall be authorized by DHCF or its designee. DHCF or its designee shall provide oversight of total length of stay by conducting concurrent utilization reviews.
Inpatient SUD and SMI treatment services shall be reimbursed in accordance with the District of Columbia Medicaid fee schedule available online at https://www.dc-medicaid.com/dcwebportal/home. Information to assist providers billing Medicaid for these services is available on the DHCF website at dhcf.dc.gov.
Residential SUD services shall be shall be reimbursed in accordance with the District of Columbia Medicaid fee schedule available online at https://www.dc-medicaid.com/dcwebportal/home. Information to assist providers billing Medicaid for these services is available on the DHCF website at dhcf.dc.gov.
Reimbursement under this section is available for acute inpatient or residential treatment provided in settings that qualify as IMDs. Medicaid reimbursement for long-term residential or long-term inpatient treatment is not available under this section.
Effective July 1, 2020, IMD providers are required, as a condition of reimbursement for services authorized under this chapter, to participate through a formal agreement with a registered HIE entity of the DC Health Information Exchange (DC HIE), defined in Chapter 87 of Title 29 DCMR. Once they become a participating provider, IMD providers must also participate in a reporting process via the DC HIE throughout the demonstration period. DHCF shall publish guidance interpreting these requirements on the DHCF website at www.dhcf.dc.gov.
Medicaid reimbursement for services provided in general hospitals, intermediate care facilities, nursing facilities, or skilled nursing facilities is not governed or authorized under this section.
Medicaid reimbursement is not available for services provided to beneficiaries who are involuntarily residing in an inpatient or residential treatment facility by operation of criminal law.
IMD providers must meet provider requirements, goals, and milestones established in the STCs and the corresponding implementation plans governing the demonstration program. DHCF shall publish guidance interpreting these provider requirements on its website at dhcf.dc.gov.
D.C. Mun. Regs. tit. 29, r. 29-8608