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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 22. HEALTH |
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SubTilte 22-A. MENTAL HEALTH |
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Chapter 22-A63. CERTIFICATION STANDARDS FOR SUBSTANCE USE DISORDER TREATMENT AND RECOVERY PROVIDERS |
Section 22-A6301. ELIGIBILITY FOR SUBSTANCE USE DISORDER SERVICES
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6301.1 Substance Use Disorder (“SUD”) is a chronic relapsing disease characterized by a cluster of cognitive, behavioral, and psychological symptoms indicating that the beneficiary continues using the substance despite significant substance-related problems. A diagnosis of an SUD requires a beneficiary to have had persistent, substance related problem(s) within a twelve (12)-month period in accordance with the requirements of the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual (“DSM”) in use by the Department.
6301.2 To be eligible for SUD treatment, a client must have received a diagnosis of an SUD in accordance with Subsection 6301.1 of this chapter from a qualified practitioner. Eligibility for Medicaid-funded or Department-funded SUD services shall be determined in accordance with Subsection 6301.4.
6301.3 Qualified Practitioners eligible to diagnose a substance use disorder pursuant to this Chapter are Qualified Physicians, Psychologists, Licensed Independent Clinical Social Workers (“LICSWs”), Licensed Professional Counselors (“LPCs”), Licensed Marriage and Family Therapists (“LMFTs”), and Advanced Practice Registered Nurses (“APRNs”).
6301.4 A client shall meet the following eligibility requirements in order to receive Medicaid-funded services:
(a)Be bona fide residents of the District, as required in 29 DCMR Subsection 2405.1(a); and
(b)Be referred for SUD services at the level of care determined by a Level I-AR provider or other intake center authorized by the Department, unless the clients are only receiving Recovery Support Services.
(c)Be enrolled in Medicaid, or be eligible for enrollment and have an application pending; or
(d)For new enrollees and those enrollees whose Medicaid certification has lapsed:
(1) There is an eligibility grace period of ninety (90) days from the date of first service for new enrollees, or from the date of eligibility expiration for enrollees who have a lapse in coverage, until the date the District’s Economic Security Administration makes an eligibility or recertification determination.
(2) In the event the consumer appeals a denial of eligibility or recertification by the Economic Security Administration, the Director may extend the ninety (90)-day eligibility grace period until the appeal has been exhausted. The ninety (90)-day eligibility grace period may also be extended in the discretion of the Director for other good cause shown.
(3) Upon expiration of the eligibility grace period, SUD services provided to the consumer are no longer reimbursable by Medicaid. Nothing in this section alters the Department's timely-filing requirements for claim submissions.
6301.5Clients eligible for locally-funded SUD treatment are those individuals who are not eligible for Medicaid or Medicare or are not enrolled in any other third-party insurance program except the D.C. HealthCare Alliance, or who are enrolled but the insurance program does not cover SUD treatment and who meet the following requirements:
(a)For individuals nineteen (19) years of age and older, live in households with a countable income of less than two hundred percent (200%) of the federal poverty level, and for individuals under nineteen (19) years of age, live in households with a countable income of less than three hundred percent (300%) of the federal poverty level.
(b)A client that does not meet the income limits of Subsection 6301.6(a) above may receive treatment services in accordance with the following requirements:
(1) The client must, within ninety (90) days of enrollment for services, apply to the Department of Human Services Economic Security Administration for certification, which will verify income.
(2) An individual with income over the limits in paragraph (a) above may receive treatment services with payment on a sliding scale.
(3) The provider shall ensure it develops a sliding scale fee policy, reviewed by the Department, and shall be able to provide documentation to the Department of its collection of fees.