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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 29-53. STANDARDS FOR MANAGED CARE PROVIDERS THAT ARE PAID ON A FIXED, PREPAID, CAPITATED BASIS FOR SERVICES RENDERED TO AFDC AND AFDC-RELATED MEDICAID RECIPIENTS |
Section 29-5302. SPECIFIC PROVIDER QUALIFICATIONS
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5302.1Prepaid, capitated providers shall enter into risk comprehensive, non -risk, or other risk contracts with the Department to provide a predefined set of services to AFDC and AFDC-related recipients for a fixed, prepaid, capitated fee.
5302.2Prepaid, capitated providers shall be federally qualified HMOs or shall meet the requirements of an HMO as defined in the State Plan of Medical Assistance.
5302.3Unless a prepaid, capitated provider has received a waiver from the federal Health Care Financing Administration the provider shall maintain the sum of its membership of Medicaid and Medicare beneficiaries below seventy -five percent (75%) of its total enrollment.
5302.4Each prepaid, capitated provider shall establish a Medicaid Advisory Committee, which shall meet at least quarterly to advise the provider on matters regarding service to AFDC and AFDC -related Medicaid enrollees. At least two (2) members of the Advisory Committee shall be AFDC and AFDC -related Medicaid recipients enrolled in the provider’s plan.