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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 29-50. MEDICAID REIMBURSEMENTS FOR PERSONAL CARE AIDE SERVICES |
Section 29-5015. REIMBURSEMENT
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5015.1For dates of services beginning October 27, 2015 through December 31, 2015, each provider shall be reimbursed five dollars ($5.00) per unit of service for allowable services as authorized in the approved plan of care, of which no less than three dollars and forty five cents ($3.45) per fifteen (15) minutes for services rendered by a PCA, shall be paid to the PCA to comply with the Living Wage Act of 2006, effective June 8, 2006 (D.C. Law 16-118; D.C. Official Code §§ 2-220.01 et seq. (2012 Repl.)).
5015.2For dates of services beginning January 1, 2016, each provider shall be reimbursed five dollars and two cents ($5.02) per unit of service for allowable services as authorized in the approved plan of care, of which no less than three dollars and forty six cents ($3.46) per fifteen (15) minutes for services rendered by a PCA, shall be paid to the PCA to comply with the Living Wage Act of 2006, effective June 8, 2006 (D.C. Law 16-118; D.C. Official Code §§ 2-220.01 et seq. (2012 Repl.)).
5015.3Subsequent changes to the reimbursement rate(s) shall be posted on the Medicaid fee schedule at www.dc-medicaid.com and DHCF shall also publish a notice in the D.C. Register which reflects the change in the reimbursement rate(s).
5015.4Each Provider shall maintain adequate documentation substantiating the delivery of allowable services provided in accordance with the PCA service authorization and the beneficiary’s plan of care for each unit of service submitted on every claim.
5015.5Reimbursement for PCA services, when provided through the D.C. Medicaid program’s State Plan PCA benefit, shall not exceed eight (8) hours per day, seven (7) days a week, and shall be limited to the amount, duration, and scope of services set forth in the PCA Service Authorization and the plan of care, as described in Section 5003.
5015.6Claims for PCA services submitted by a Provider in any period during which the beneficiary is an in-patient at another health care facility including a hospital, nursing home, psychiatric facility or rehabilitation program shall be denied except on the day when a beneficiary is admitted or discharged.
5015.7When a beneficiary is discharged from a health care facility to the beneficiary’s home and requires PCA services on the date of discharge, the number of PCA hours on that day shall be authorized in accordance with the beneficiary’s discharge plan.
5015.8Claims for PCA service submitted by a Provider for any hour in which the beneficiary was receiving ADHP services under the § 1915(i) State Plan Option, or other similar service in which PCA services are provided concurrently to the beneficiary shall be denied.
5015.9If a beneficiary is also receiving ADHP services on the same day that PCA services are delivered, the combination of both PCA and ADHP services shall not exceed a total of twelve (12) hours per day.
5015.10Each Provider shall agree to accept as payment in full the amount determined by DHCF as Medicaid reimbursement for the authorized services provided to beneficiaries. Providers shall not bill the beneficiary or any member of the beneficiary’s family for PCA services.
5015.11Each Provider shall agree to bill any and all known third-party payers prior to billing Medicaid.
5015.12All reimbursable claims for PCA services shall include the NPI numbers for the:
(a) Provider;
(b)Physician or APRN who ordered the PCA services;
(c) The staffing agency, if applicable; and
(d)PCA who provided the PCA services, regardless of whether the PCA is an employee of the Provider or is from another staffing agency.
5015.13Pursuant to 42 C.F.R. § 424.22(d), DHCF shall deny PCA service claims or recoup paid claims when Provider records or other evidence indicate that the primary care physician or APRN ordering a beneficiary’s treatment has a direct or indirect financial relationship, compensation, ownership or investment interest as defined in 42 C.F.R. § 411.354 in the Provider billing for the services, unless the financial relationship, compensation, ownership or investment interest meets an exception as defined in 42 C.F.R. § 411.355.
5015.14Claims resulting from marketing by a staffing agency (including face-to-face solicitation at doctors’ offices, home visits, requests for beneficiary Medicaid numbers, or otherwise directing beneficiaries to any Medicaid Provider) shall not be reimbursed.