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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-B. PUBLIC HEALTH AND MEDICINE |
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Chapter 22-B55. STANDARDS FOR PREPAID PROVIDERS QUALIFYING TO SERVE DISTRICT OF COLUMBIA MEDICAID RECIPIENTS |
Section 22-B5515. PAYMENT FOR SERVICES
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5515.1 The QO shall be paid by the Department on a monthly per capita basis for the services it gives to Medicaid enrollees pursuant to its Medicaid benefits package.
5515.2 Each QO shall file with the Department both its community rate worksheets, and community rate worksheets adjusted to reflect the Medicaid program benefits package and characteristics of the segment of the Medicaid population it proposes to serve, such as aged, blind, disabled, child, and parent.
5515.4 No QO shall be paid a monthly capitation rate in excess of ninety percent (90%) of historical Medicaid program costs for the Medicaid population it proposes to serve.
5515.5 Each QO contract with the Department shall be for a twelve (12) month period.
5515.6 Each capitation rate specified in the contract shall be in effect for the entire twelve (12) month period.
5515.7 No QO shall impose any co-payment requirement or other fees on Medicaid enrollees.
5515.8 The Department shall pay the QO each month for each Medicaid recipient who is enrolled as of the fifteenth (15th) of the prior month.
5515.9 The QO shall enroll only those Medicaid recipients who are categorically eligible for assistance and are receiving monthly cash assistance under the Aid to Families with Dependent Children or the Supplemental Security Income Program.
5515.10 Except as provided in §5515.11, when an enrollee loses Medicaid eligibility, the Department shall not make capitation payments of the QO for that enrollee as of the second month following the loss of eligibility.
5515.11 The Department shall continue to pay the premium for six (6) months from the effective date of the recipient’s enrollment, even if the recipient loses eligibility during that time, if the following exists:
(a)The QO is a qualified health maintenance organization as defined in Title XIII of the U.S. Public Health Service Act, or an entity described in § 1903(m)(2)(G) of the Social Security Act; and
(b)The contract between the QO and the Department provided a six (6) month enrollment guarantee.