Section 22-B5501. PROVIDER QUALIFICATIONS

 

5501.1 Except for QOs operated by Department or D.C. General Hospital, each QO shall be incorporated in the District of Columbia.

 

5501.2 Each QO shall demonstrate to the satisfaction of the Department that it, if it is a new organization, a majority of its participating primary care physicians, has had experience in serving low income, diversified population groups in the District.

 

5501.3 Each QO shall have agreements in place that shall assure all its Medicaid enrollees will receive their hospital inpatient care in a District hospital unless one (1) of the following conditions exist:

 

(a)Emergency care is required and a non-District facility is the closest provider; or

 

(b)The enrollee requires a specialized service not available in a District hospital.

 

5501.4 The QO shall have the professional, financial, and administrative ability and staffing to carry out its duties and responsibilities under its contract with the Department.

 

5501.5 Within one (1) year from the date of qualification under this chapter, at least one-third (1/3) of the QO board shall be selected from QO subscribers.

 

5501.6 The subscriber board membership selection process shall be structured in a manner that prevents undue influence on the selection process by non-subscriber members of the board and obtains diverse representation of broad segments of subscribers covered under contracts with the QO.

 

5501.7 The QO shall establish a Medicaid Advisory Committee, which shall meet at least quarterly, to advise the board on matters regarding service to Medicaid enrollees.

 

5501.8 Except as otherwise provided, a QO shall maintain the sum of its membership of Medicaid and Medicare beneficiaries below seventy-five percent (75%) of its total enrollment.

 

5501.9 The requirement set forth in §5501.8 may be waived for up to three (3) years from the date the Regional Administrator has given the Department written notice that the QO meets the definition of an HMO, provided the QO submits annual reports demonstrating to the Regional Administrator’s satisfaction, that it is making continuous efforts and progress toward achieving compliance with the seventy-five percent (75%) ceiling requirement.

 

5501.10 The seventy-five (75%) ceiling for QOs operated by the Department or by D.C. General Hospital may be waived by the Regional Administrator so long as there continues to be special circumstances that justify a waiver and the QO demonstrates it is making reasonable efforts to enroll individuals who are not eligible for Medicare or Medicaid.

 

5501.11 The seventy-five percent (75%) ceiling requirement shall not apply to a QO which is receiving, and has received during the previous two (2) years, at least one-hundred thousand dollars ($100,000) in federal funds under §330(d)(1) of the Public Health Service Act.

 

5501.12 The seventy-five percent (75%) ceiling requirement shall apply to each QO permitted by contract with the Department to lock-in a Medicaid recipient as provided under §5509.10 of this chapter, unless the QO is an entity described in §5501.11.

 

 

source

Final Rulemaking published at 34 DCR 1550 (March 6, 1987).