D.C. Code § 1-307.02

Current through codified legislation effective September 18, 2024

Section 1-307.02 - District of Columbia medical assistance program

(a)

(1) The Mayor may submit, under title XIX of the Social Security Act (Title XIX) to the Secretary of the United States Department of Health and Human Services, a plan for medical assistance (and any modifications of the plan) to enable the District to receive federal financial assistance under Title XIX for a medical assistance program established by the Mayor under such plan.

(2) Repealed.

(3) Review and approval by the Council of the Fiscal Year 2010 Budget and Financial Plan shall constitute the Council review and approval required by paragraph 2 of this subsection of any modification or waiver to the state plan required to implement during fiscal year 2010 an initiative to:

(A) Utilize Disproportionate Share Hospital funding to support the transition of individuals into health insurance programs through the modification of the Disproportionate Share Hospital qualification and distribution methodology;

(B) Change service limit methodology for personal care aide services;

(C) Enhance prescription drug utilization and review activities;

(D) Reduce reimbursement rates for prescription drugs to align pharmaceutical spending with national payment trends;

(E) Change methodologies for recovering improper payments;

(F) Obtain available State Children's Health Insurance Program funding for immigrant children and pregnant women;

(G) Shift coverage for unborn children of undocumented immigrants from the D.C. HealthCare Alliance to Medicaid;

(H) Implement a new methodology for fee-for-service inpatient hospital reimbursement; and

(I) Reduce disallowances for public provider agencies.

(4) Review and approval by the Council of the fiscal year 2011 budget and financial plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any waiver, modification to the state plan, or modification to a waiver required during fiscal year 2011 for purposes of implementing federal health care reform initiatives as set forth in the Patient Protection and Affordable Care Act, approved March 23, 2010 (124 Stat. 119; Pub. L. No. 111-148 ); provided, that the Department of Health Care Finance publishes a copy of any waiver, modification to the state plan, or modification to a waiver available on its website for at least 5 business days prior to submission to the Secretary of the United States Department of Health and Human Services.

(5) Review and approval by the Council of the Fiscal Year 2012 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of:

(A) Any modification or waiver to the state plan required to change the methodology used for the reimbursement for single source brand name drugs from the average wholesale price minus 10% to wholesale acquisition cost plus 3%; and

(B) Any modification or waiver to the state plan required to change in whole or in part the level of personal-care services offered as a state plan benefit.

(6) Review and approval by the Council of the Fiscal Year 2013 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any modification or waiver to the state plan required to:

(A) Update the diagnosis-related group ("DRG") grouper the agency uses to pay hospitals for inpatient care and other characteristics of the reimbursement system, such as base rates, DRG weights, outlier thresholds and transfer policy to adjust the average payment to cost ratio for inpatient care at DRG hospitals from 114% to 98%;

(B) Update the reimbursement methodology model to one based on acuity for Intermediate Care Facilities for the Intellectually Disabled;

(C) Exclude the cost of therapies, including physical therapy, occupational therapy, and speech therapy, from the calculation of the nursing and resident care component of the nursing home rate; and

(D) Transition beneficiaries to the replenishing pharmacy network for antiretroviral medications.

(7) Review and approval by the Council of the Fiscal Year 2014 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:

(A) Establish a supplemental payment to rectify historic underpayments to District Medicaid hospitals for outpatient and emergency room services;

(B) Implement Title II of the Patient Protection and Affordable Care Act, approved March 23, 2010 ( Pub. L. No. 111-148; 124 Stat. 119), to:

(i) Provide for new Modified Adjusted Gross Income eligibility methodologies;

(ii) Streamline the application process;

(iii) Align Medicaid eligibility determinations, renewals, and appeals with eligibility determinations and appeals of cost sharing and advanced premium tax credits for the Health Benefit Exchange;

(iv) Secure enhanced federal medical assistance percentages for newly eligible Medicaid beneficiaries and preventive services, including tobacco cessation;

(v) Provide coverage for former foster care children through age 25;

(vi) Implement presumptive eligibility by hospitals;

(vii) Extend the District's current Section 1115 demonstration for childless adults ages 21 through 64 years with incomes between 133% and up to 200% of the federal poverty level to provide stop-gap coverage for these beneficiaries until the District establishes the basic health plan; and

(viii) Create health homes for chronically ill District residents;

(C) Implement needed reforms to Medicaid-funded, long-term care services and supports, including:

(i) The establishment of a single-point-of-entry system and a standardized, conflict-free assessment tool and process;

(ii) Clarification of eligibility requirements for institutional long-term care services; and

(iii) The creation of new programming, including adult day health services pursuant to Title XIX of the Social Security Act to ensure that District residents may be served in the most integrated setting appropriate to their needs; and

(D) Implement an annual inflation rate adjustment for nursing facilities.

(8) Review and approval by the Council of the Fiscal Year 2015 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:

(A) Implement needed amendments to the Elderly and Individuals with Physical Disabilities waiver to ensure compliance with federal law and promote best practices;

(B) Establish new payment rates for Federally-Qualified Health Centers;

(C) Establish a new payment method and make other improvements to the payment methodology for hospital inpatient treatment;

(D) Establish a new payment method and make other improvements to the payment methodology for hospital outpatient services;

(E) Implement needed amendments to the Intellectual Disabilities/Developmental Disabilities waiver to ensure compliance with federal law and promote best practices;

(F) Align specialty hospital payments with the complexity of their patient mixes and national best practices and to describe payment standards for sub-acute services for children who are inpatients in private psychiatric specialty hospitals; and

(G) Update transplantation coverage standards and provide coverage for lung transplantation and autologous bone marrow transplantation.

(9) Review and approval by the Council of the Fiscal Year 2016 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:

(A) Update the reimbursement methodology model for intermediate care facilities for persons with developmental disabilities to ensure compliance with federal law;

(B) Update the payment methodology for hospital services;

(C) Update the payment methodology for Federally-Qualified Health Centers;

(D) Update the payment methodology and program standards for Home Health Agencies;

(E) Create health homes for chronically ill District residents;

(F) Establish a provider fee on District Medicaid hospitals for in-patient services; and

(G) Establish a supplemental payment to District Medicaid hospitals for outpatient services.

(10) Review and approval by the Council of the Fiscal Year 2017 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:

(A) Implement needed amendments to:

(i) The Intermediate Care Facilities for Individuals with Developmental Disabilities reimbursement methodology;

(ii) The payment methodology for hospital services;

(iii) The payment methodology for nursing homes;

(iv) The payment methodology for the Disproportionate Share Hospital program;

(v) The health homes program;

(vi) Renew and update the Elderly and Individuals with Physical Disabilities waiver program and make conforming changes to the state plan; and

(vii) The payment methodology for prescription drugs; and

(B) Increase the number of participants in the Home and Community-Based Services Waiver for Persons with Intellectual and Developmental Disabilities program.

(11) Review and approval by the Council of the Fiscal Year 2018 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:

(A) Continue a provider fee on District Medicaid hospitals for in-patient services;

(B) Continue a supplemental payment to District Medicaid hospitals for outpatient services;

(C) Update the payment methodology and rates for fee-for-service providers;

(D) Renew and amend the Intellectual and Developmental Disabilities waiver;

(E) Make changes to the health homes program; and

(F) Make changes to mental health rehabilitation services.

(b)

(1) Notwithstanding any other provision of law, the Mayor may take such action as may be necessary to submit such plan to the Secretary and to establish and carry out such medical assistance program, except that in prescribing the standards for determining eligibility for and the extent of medical assistance under the District of Columbia's plan for medical assistance, the Mayor may not (except to the extent required by Title XIX of the Social Security Act):

(A) Prescribe maximum income levels for recipients of medical assistance under such plan which exceed:

(i) The Title XIX maximum income levels if such levels are in effect; or

(ii) The Mayor's maximum income levels for the local medical assistance program if there are no Title XIX maximum income levels in effect; or

(B) Prescribe criteria which would permit an individual or family to be eligible for such assistance if such individual or family would be ineligible, solely by reason of his or its resources, for medical assistance both under the plan of the State of Maryland approved under Title XIX of the Social Security Act and under the plan of the State of Virginia approved under such title.

(2) For purposes of subparagraph (A) of paragraph (1) of this subsection:

(A) The term "Title XIX maximum income levels" means any maximum income levels which may be specified by Title XIX of the Social Security Act for recipients of medical assistance under state plans approved under that title;

(B) The term "the Mayor's maximum income levels for the local medical assistance program" means the maximum income levels prescribed for recipients of medical assistance under the District of Columbia's medical assistance program in effect in the fiscal year ending June 30, 1967; and

(C) During any of the first 4 calendar quarters in which medical assistance is provided under such plan there shall be deemed to be no Title XIX maximum income levels in effect if the Title XIX maximum income levels in effect during such quarter are higher than the Mayor's maximum income levels for the local medical assistance program.

(c) The District state plan required under Title XIX of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396 et seq.), shall provide that all persons in the following categories are eligible for Medicaid benefits:

(1) A pregnant woman or an infant under 1 year of age with an income up to 185% of the federal poverty line, as authorized by § 1902(a)(1) of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396a(a)(1) );

(2) A child born after September 30, 1983, who has not attained the age of 8 years and whose family income is not more than 100% of the federal poverty line, as authorized by § 1902 of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396a ); and

(3) A pregnant woman or a child during a presumptive eligibility period as authorized by § 1902(a) of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396a(a) ).

(d)

(1) For purposes of this subsection, the term:

(A) "TANF-related Medicaid recipient" means a family that has dependent children under 21 years of age in the home and whose income is not low enough to qualify for financial assistance, but is low enough to qualify for medical assistance.

(B) "Health maintenance organization" means a public or private organization, operating in the District of Columbia, which contracts with the District government to provide comprehensive health maintenance, preventive and treatment services emphasizing access to primary care for enrolled members of the plan through its own network of physicians and hospitals for a fixed prepaid premium.

(C) "Managed care provider" means either a primary care provider or a health maintenance organization.

(D) "Primary care provider" means a physician, clinic, hospital, or neighborhood health center that is responsible for providing primary care and coordinating referrals, when necessary, to other health care providers.

(E) "Restricted recipient" means a person who has been restricted to one designated primary care provider for a minimum of one year after a finding of abuse or misuse of Medicaid services by the Commission on Health Care Financing.

(2) The Mayor shall establish a plan to mandate enrollment of TANF and TANF-related Medicaid recipients in a managed care program for the purpose of providing access to comprehensive and coordinated health care in an efficient and cost effective manner. The plan shall provide the following:

(A) TANF and TANF-related Medicaid recipients shall select any health maintenance organization with a current contract with the District of Columbia to provide managed care services to TANF and TANF-related Medicaid recipients on a capitated method of payment;

(B) The Mayor shall exclude TANF and TANF-related Medicaid recipients from the managed care program who are:

(i) Residents in a nursing facility or intermediate care facility for persons with intellectual or developmental disabilities;

(ii) Repealed.

(iii) Eligible for Medicaid for a period that is less than 3 months;

(iv) Eligible for a period that is retroactive;

(v) Foster children residing outside the District of Columbia; or

(vi) Restricted recipients.

(C) The Mayor shall assign any TANF and TANF-related Medicaid recipient who does not choose a provider within a reasonable time to a health maintenance organization described in subparagraph (A) of this paragraph.

(D) Repealed.

(E) TANF and TANF-related Medicaid recipients enrolled in a managed care program shall be exempted from any additional co-payment requirements other than those imposed by the Medicaid program.

(F) The Mayor shall develop an education program to fully inform TANF and TANF-related Medicaid recipients about the various managed care programs to ensure better care for recipients while avoiding unnecessary and inappropriate use of hospital based services for preventive and primary care.

(3) In order to participate in the managed care plan, a provider must:

(A) Be a Medicaid qualified provider and be accessible to enrollees on a 24 hours per day, 7 days per week basis. The Mayor shall establish a monitoring system to ensure that recipients have 24 hours per day, 7 days per week access to their managed care providers and that treatment is provided in a timely manner; and

(B) Have a written contract with the District government which provides detailed information regarding the responsibilities of the managed care provider and the District government for providing or arranging for the provision of, and making payment for all services to which the TANF and TANF-related Medicaid recipient is entitled under the District state Medicaid plan.

(4) The Mayor shall maintain a grievance and appeal process for TANF and TANF-related Medicaid recipients enrolled in a managed care program.

(5) The Mayor shall require that managed care providers, which receive a capitated method of payment, submit adequate assurances to protect the District government against risk in case a provider becomes insolvent.

(6) To implement the requirements of this subsection the Mayor shall:

(A) Amend the District state Medicaid plan pursuant to § 4-204.05; and

(B) Seek and obtain all necessary waivers of federal Medicaid statutes, rules and regulations.

(7) The Mayor shall submit to the Council on an annual basis an assessment of the cost effectiveness of the managed care plan and its impact on the TANF and TANF-related Medicaid recipient's access to care of adequate quality.

(e)

(1) The District state plan required under Title XIX of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396 et seq.), may provide for reimbursement of chiropractic services.

(2) The Mayor may develop and implement a reimbursement methodology for chiropractic services.

(f) [Not funded].

D.C. Code § 1-307.02

Dec. 27, 1967, 81 Stat. 744, Pub. L. 90-227, § 1; May 15, 1990, D.C. Law 8-124, § 2, 37 DCR 2087; Mar. 17, 1993, D.C. Law 9-247, § 2, 40 DCR 1150; Nov. 25, 1993, D.C. Law 10-65, § 101, 40 DCR 7351; Sept. 26, 1995, D.C. Law 11-52, § 501, 42 DCR 3684; Mar. 26, 1999, D.C. Law 12-175, § 102, 45 DCR 7193; Oct. 20, 1999, D.C. Law 13-38, § 2205, 46 DCR 6373; Apr. 24, 2007, D.C. Law 16-305, § 2, 53 DCR 6198; Mar. 3, 2010, D.C. Law 18-111, § 5031, 57 DCR 181; Sept. 24, 2010, D.C. Law 18-223, § 5002, 57 DCR 6242; Sept. 14, 2011, D.C. Law 19-21, § 5042, 58 DCR 6226; Sept. 20, 2012, D.C. Law 19-168, § 5152, 59 DCR 8025; Sept. 26, 2012, D.C. Law 19-169, § 2, 59 DCR 5567; Dec. 24, 2013, D.C. Law 20-61, § 5042, 60 DCR 12472; Feb. 26, 2015, D.C. Law 20-155, § 5022, 61 DCR 9990; Mar. 11, 2015, D.C. Law 20-225, § 2, 62 DCR 234; Oct. 22, 2015, D.C. Law 21-36, § 5012, 62 DCR 10905; Oct. 8, 2016, D.C. Law 21-160, § 5012, 63 DCR 10775; Dec. 13, 2017, D.C. Law 22-33, § 5042, 64 DCR 7652; June 5, 2018, D.C. Law 22-106, § 2, 65 DCR 3791.

Mayor authorized to issue rules: Section 3 of D.C. Law 9-247 provided that the Mayor shall issue rules necessary to implement subsection (d) of this section pursuant to subchapter I of Chapter 15 of Title 1.

Sections 5092 and 5093 of D.C. Law 16-192 provided:

"Sec. 5092. Within 30 days of the effective date of this subtitle, the Mayor shall submit Medicaid State Plan Amendments to the Council pursuant to section (1)(a) of An Act To enable the District of Columbia to receive Federal financial assistance under title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02(a) ) to achieve the following:

"(1) Increase the maximum eligibility standards of the State Children's Health Insurance Program from 200% of the Federal Poverty Guidelines to 300% of the Federal Poverty Guidelines;

"(2) Increase the maximum eligibility standards for Qualified Medicare Beneficiaries and Special Low-Income Medicare Beneficiaries to 300% of the Federal Poverty Guidelines;

"(3) Establish a comprehensive adult dental program; and

"(4) Draw down an additional $9,750,000 in presently uncaptured federal matching funds for the purpose of expanding school health services."

"Sec. 5093. Penalties. "An agency head, deputy agency head, agency chief financial officer, agency budget director, agency controller, manager, or other employee may be subject to adverse personnel action, including removal, for not submitting the plan in accordance with this subtitle."

Sections 5102 to 5104 of D.C. Law 16-192 provided:

"Sec. 5102. Non-Emergency Transportation Reform Report.

"The Medical Assistance Administration ('MAA') within the Department of Health shall provide a report to the Council by October 1, 2006, on the status of its efforts to reform the Medicaid Non-Emergency Transportation ('NEMT') Program. The report shall:

"(1) Describe MAA's plans and proposed timelines to:

"(A) Verify that all Medicaid NEMT services are provided to clients that have been certified as medically necessary and make such certifications subject to renewal;

"(B) Institute a prior-authorization system that maintains public transportation as the default method of NEMT;

"(C) Require transportation vendors to submit documentation of services provided, including purpose of trip, pick-up location, drop-off location, and times; and

"(D) Increase MAA oversight of NEMT abnormalities and high usage; and

"(2) Quantify the potential savings from the measures described in paragraph (1) of this section.

"Sec. 5103. Out-of-state reimbursement report.

"The MAA within the Department of Health shall provide a report to the Council by October 1, 2006, on the status of its efforts to decrease payments to providers located outside the District of Columbia. The report shall:

"(1) Describe MAA's plans and proposed timelines to:

"(A) Transition the residency of individuals in nursing facilities located outside the District to the state where the nursing facility is located; and

"(B) Implement fraud protections and increasing oversight of payments made to non-District providers for Medicaid services, including reimbursements to physicians, hospitals, nursing facilities, pharmacies, Intermediate Care Facilities for the Mentally Retarded, and day treatment centers; and

"(2) Quantify the potential savings from the measures described in paragraph (1) of this section.

"Sec. 5104. Penalties.

"An agency head, deputy agency head, agency chief financial officer, agency budget director, agency controller, manager, or other employee may be subject to adverse personnel action, including removal, for not submitting the report required by section 5102 or by 5103."

Section 35 of D.C. Law 19-169 provided that no provision of the act shall impair any right or obligation existing under law.

Applicability of D.C. Law 20-61: Section 11001 of D.C. Law 20-61 provided that, except as otherwise provided, the act shall apply as of October 1, 2013.

Section 3 of D.C. Law 20-225 provided:

"(a) This act shall apply upon the date of inclusion of its fiscal effect in an approved budget and financial plan.

"(b) The Chief Financial Officer shall certify the date of the inclusion of the fiscal effect in an approved budget and financial plan, and provide notice to the Budget Director of the Council of the certification.

"(c)(1) The Budget Director shall cause the notice of the certification to be published in the District of Columbia Register.

"(2) The date of publication of the notice of the certification shall not affect the applicability of this act."