D.C. Mun. Regs. tit. 29, r. 29-9900

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

Rule 29-9900 - GENERAL PROVISIONS

9900.1

This chapter establishes general standards for conditions of participation for Medicaid providers and delineates specific standards governing Medicaid reimbursement for the following Home Health services:

(a) Skilled Nursing services as described in Section 9901;

(b) Home Health Aide services as described in Section 9902;

(b) Physical Therapy services as described in Section 9903;

(c) Occupational Therapy services as described in Section 9904; and

(d) Speech Pathology and Audiology services as described in Section 9905.

9900.2

In addition to the services identified in Subsection 9900.1, Medicaid reimbursable Home Health services include Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).

9900.3

The standards of participation and specific requirements governing reimbursement for Home Care agencies enrolled in the Medicaid program providing DMEPOS services are set forth in Sections 996 and 997 of Chapter 9 of Title 29 DCMR.

9900.4

In order to qualify for Medicaid reimbursement, Home Health services listed in Subsection 9900.1 are services that are:

(a) Ordered by a physician;

(b) Provided at the beneficiary's residence or in a setting in which normal life activities take place, unless the exceptions referenced in Subsections 9900.5 and 9900.6 are met; and

(c) Delivered in accordance with a plan of care developed by a Registered Nurse (R.N.) under a process that meets the requirements under Subsection 9900.11.

9900.5

Except as provided in Subsection 9900.6 and in accordance with 42 CFR § 440.70(c)(1), Home Health services shall not be delivered in a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF/IID), or any setting in which payment is or could be made under Medicaid for beneficiary services that include room and board.

9900.6

Home Health services may be provided in an ICF/IID if the home health service is not provided as part of the facility's services as required under 42 CFR § 483.460.

9900.7

A beneficiary shall be eligible for the Medicaid reimbursable Home Health services referenced in Subsection 9900.1 if the following conditions are met:

(a) DHCF or its designee receives an order for Home Health services from the beneficiary's physician establishing that the services are medically necessary in accordance with the requirements set forth in this chapter; and

(b) DHCF or its designee provides prior authorization in accordance with the service delivery requirements set forth in this chapter.

9900.8

In order for the services contained in the physician's order described in Subsection 9900.7(a) to be reimbursed by Medicaid, the order must be signed and dated by a physician knowledgeable about the beneficiary's needs and conditions and must state the amount, frequency, scope and duration of the service. The physician's signature on the order constitutes certification by the physician that the services ordered reflect the health status and needs of the beneficiary, and that the beneficiary is eligible for the service.

9900.9

For all Medicaid reimbursable Home Health services described in Subsection 9900.1, in order to be reimbursed the ordering physician shall:

(a) Document that a face-to-face encounter, related to the primary reason the beneficiary requires Home Health services, occurred between the beneficiary and the health practitioner, as defined in Subsection 9900.10, within ninety (90) days before or within thirty (30) days after the start of services; and

(b) Indicate the name of the practitioner who conducted the face-to- face encounter and the date of the encounter on the order.

9900.10

In order for the services contained in the physician's order described in Subsection 9900.7(a) to be reimbursed by Medicaid, the face-to-face encounter described in Subsection 9900.9 shall be related to the primary reason the beneficiary requires Home Health services and shall be conducted by one of the following health practitioners:

(a) The ordering physician;

(b) A nurse practitioner working in collaboration with the physician;

(c) A certified nurse mid-wife as authorized under District law;

(d) A physician assistant acting under the supervision of the ordering physician; or

(e) For beneficiaries receiving Home Health services immediately after an acute or post-acute stay, the attending acute or post-acute physician.

9900.11

In order for the services contained in the physicians' order described in Subsection 9900.7(a) to be reimbursed by Medicaid, the plan of care described in Subsection 9900.4 shall be developed and signed by an R.N. who is employed or under contract to the Home Health services provider. The signature of the R.N. on the plan of care constitutes a certification that the plan of care accurately reflects the assessed needs of the beneficiary and that the services identified in the plan of care are in accordance with the physician's order described in Subsections 9900.7 and 9900.8.

9900.12

The beneficiary's physician shall approve the initial plan of care by signing it within thirty (30) calendar days of the development of the plan of care, and noting his or her license number and National Provider Identification number on the plan of care.

9900.13

The plan of care for services described in Subsection 9900.1 shall be reviewed, updated and signed by the physician every sixty (60) calendar days.

9900.14

All home health services described in the plan of care shall require prior authorization and approval by DHCF in order to be reimbursed by Medicaid.

9900.15

Limitations on the delivery of Skilled Nursing services are described under Section 9901.

9900.16

Limitations on the delivery of Home Health Aide services are described under Section 9902.

D.C. Mun. Regs. tit. 29, r. 29-9900

Final Rulemaking published at 64 DCR 418 (1/19/2018)