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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-41. MEDICAID REIMBURSEMENT FOR INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES |
Section 29-4100. GENERAL PROVISIONS
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4100.1 This chapter shall establish principles of reimbursement that shall apply to each intermediate care facility for individuals with intellectual disabilities (ICF/IID) participating in the District of Columbia Medicaid program.
4100.2 For an ICF/IID to be eligible to receive reimbursement under this chapter, it shall be certified as an Intermediate Care Facility by the Health Regulation and Licensing Administration (HRLA) in the Department of Health (DOH), pursuant to 22-B DCMR §§ 3100 et seq. for a period up to fifteen (15) months.
4100.3 Medicaid reimbursement to ICFs/IID for services provided beginning on or after October 1, 2012, shall be on a prospective payment system consistent with the requirements set forth in this chapter.
4100.4 The Department of Health Care Finance (DHCF) shall pay for ICF/IID services through the use of rates that are reasonable and adequate to meet the costs that are incurred by efficiently, economically operated facilities in order to provide services in conformity with applicable District and federal laws, regulations, and quality and safety standards. DHCF used the following financial principles in developing the reimbursement methodology described in this chapter:
(a) Basing payment rates on the acuity of each individual, as determined by DHCF, or its designee;
(b) Establishing uniform reimbursement of services constituting the active treatment program for individuals who meet the requirements of 42 C.F.R. § 483.440(a);
(c) Establishing consistent payment rates for the same classes of facilities serving individuals with comparable levels of need; and
(d)Establishing one (1) day, inclusive of residential care and active treatment, as the unit of service.
4100.5 The reimbursement rates paid to ICFs/IID for Medicaid individuals residing in the facility shall be equal to one hundred percent (100%) of the following components:
(a) Residential component base rate determined by acuity level, as defined in § 4101 of this chapter, and inclusive of the following:
(1) Direct service;
(2) All other health care and program related expenses;
(3) Non-personnel operations;
(4) Administration;
(5) Non-Emergency Transportation;
(6) Capital; and
(7) Allowable share of the Stevie Sellows Intermediate Care Facility for the Intellectually and Developmentally Disabled Quality Improvement Fund Assessment.
(b) Services constituting an active treatment program, described in § 4103, as set forth in the individual’s Individual Service Plan (ISP); and
(c) Payments associated with participation in quality improvement initiatives, as set forth in § 4104.
4100.6 The reimbursement rates paid to ICFs/IID shall exclude all of the following services that are provided outside of the ICF/IID:
(a) Inpatient and outpatient hospital visits;
(b) Physician and specialty services;
(c) Clinic services;
(d) Emergency department services;
(e) Services delivered by any other long-term care facility;
(f) Durable medical equipment, prosthetic, orthotic, and supply items that either require prior authorization or are solely for the use of one (1) individual (such as a wheelchair); and
(g) Prescription drug costs, excluding copays for individuals who are also subject to the Evans court order.
4100.7 Medicaid reimbursement to each ICF/IID shall comply with the “Policy on Reserved Beds,” as set forth on page 2 of Attachment 4.19C of the State Plan for Medical Assistance.
4100.8 An organization related to an enrolled ICF/IID (“related organization”) may furnish services and supplies under the prudent buyer concept, provided the costs of such services and supplies are consistent with costs of such items furnished by independent third party providers in the same geographic area. These requirements shall apply to the sale, transfer, leaseback, or rental of property, plant, or equipment or purchase of services of any facility or organization.
4100.9 In accordance with 42 C.F.R. § 456.360, the District of Columbia Health Occupations Revision Act of 1985, as amended, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01 et seq.), and implementing rules, a qualified physician shall certify that an individual needs ICF/IID services. The certification shall be made at the time of admission for current Medicaid individuals, or for individuals who apply for Medicaid while residing in an ICF/IID, before any payment is made to the facility.
4100.10 Recertification of an individual’s need for continued ICF/IID services is required, at minimum, twelve (12) months following the date of the previous certification, pursuant to 42 C.F.R. § 456.360(b).
4100.11 A Medicaid individual shall be assessed by an interdisciplinary team within thirty (30) days of admission to an ICF/IID. This determination shall provide the foundation for requests to elevate an acuity level assignment beyond Acuity Level 1.