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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-A34. MENTAL HEALTH REHABILITATION SERVICES PROVIDER CERTIFICATION STANDARDS |
Section 22-A3403. ELIGIBLE CONSUMERS
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3403.1 Consumers eligible for Medicaid-funded MHRS must meet the following requirements:
(a) Be enrolled in Medicaid, or be eligible for enrollment and have an application pending;
(b) Be a bona fide resident of the District, as defined in D.C. Official Code § 7-1131.02(29) (2008 Repl.);
(c) Be a child or youth with mental health problems, as defined in D.C. Official Code § 7-1131.02(1), or an adult with mental illness as defined in D.C. Official Code § 7-1131.02(24); and
(d) Be certified as requiring MHRS by a qualified practitioner.
3403.2 Eligible consumers of MHRS shall have a primary diagnosis on either Axis 1 or 2 of the DSM-IV.
3403.3 Persons with a primary substance abuse diagnosis only are not eligible consumers of MHRS.
3403.4 Subject to Subsection 3403.5, consumers eligible for locally-funded MHRS 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, and who meet the following requirements:
(a) Be a bona fide resident of the District, as defined in D.C. Official Code § 7-1131.02(29);
(b) Be a child or youth with mental health problems, as defined in D.C. Official Code § 7-1131.02(1), or an adult with mental illness as defined in D.C. Official Code § 7-1131.02(24);
(c) Be certified as requiring MHRS by a qualified practitioner; and
(d) 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.
3403.5 Consumers eligible for Medicare remain eligible for the following locally-funded MHRS only to the extent these services are not otherwise covered by Medicare:
(a) Community support; and
(b) Specialized services identified in Subsection 3414.3.
3403.6 Providers shall not bill Medicaid and/or the Department for MHRS provided to any consumer that does not meet the eligibility requirements set forth above.
3403.7 For new enrollees and those enrollees whose Medicaid certification has lapsed, 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 Economic Security Administration makes an eligibility or recertification determination. 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. Upon expiration of the eligibility grace period, MHRS services provided to the consumer are no longer reimbursable by DMH. Nothing in this section alters the Department’s timely-filing requirements for claim submissions.