Section 29-5304. REQUIRED INFORMATION

 

5304.1Each prepaid, capitated provider shall submit the following to the Department with its application for a Medicaid managed care provider agreement:

 

(a)A copy of the basic organizational documents of the prepaid, capitated provider, including an organizational chart and current articles of incorporation;

 

(b)A copy of the by-laws or any other documents that regulate the conduct of the internal affairs of the prepaid, capitated provider;

 

(c)A description of the organization’s ownership structure and a list of major owners, including stockholders who own or control five percent (5%) or more outstanding shares;

 

(d)A list of board members and each member’s business affiliations, interests in, and ownership of, other health care providers or related services or providers;

 

(e)A statement of the prepaid, capitated provider’s policies and procedures governing payment of claims to health care providers;

 

(f)A statement of the prepaid, capitated provider’s policies and procedures governing the distribution of revenues to owners (distribution of revenues may include bonuses, dividends, stock options, and other incentives);

 

(g)A list of the name, address and specialty of each physician who participates in the prepaid, capitated provider’s plan and a copy of their licenses and evidence of any board certification for each physician who participates in the plan;

 

(h)A roster of key personnel, the qualifications of each person in a key position and a copy of the position description for each key position;

 

(i)A written description of the prepaid, capitated provider’s credentialing procedures;

 

(j)The number of clinical, administrative and marketing employees who will provide services to Medicaid recipients;

 

(k)The form of evidence of coverage to be issued to enrollees;

 

(l)For on-going prepaid, capitated providers, financial statements that show the provider’s assets, liabilities, and sources of financial support, including the most recent audited financial statement;

 

(m)For new, prepaid, capitated providers, pro forma operating statements and balance sheets and written documentation of sources of working capital, other sources of funding, and documentation that the organization has ready access to these funds;

 

(n)A written description of the proposed marketing plan;

 

(o)A written description of the medical record and statistical reporting systems;

 

(p)A copy of the proposed enrollee grievance process;

 

(q)A statement on the prepaid, capitated provider’s background and experience in serving low-income, diversified population groups in the District or similar populations in other states;

 

(r)A copy of the prepaid, capitated provider’s proposed plan for handling out-of-plan and out-of-area emergency coverage;

 

(s)A list of all companies in which the prepaid, capitated provider or its officers have a financial interest;

 

(t)A copy of any agreement with any hospital located in the District and a copy of the inpatient care admission policies, which shall ensure that each of the organization’s AFDC and AFDC-related Medicaid enrollees shall receive hospital inpatient care in a hospital located in the District;

 

(u)A list of subcontractors that will provide services to AFDC and AFDC-related Medicaid recipients and a copy of each subcontract;

 

(v)The address of each site at which services will be provided to AFDC and AFDC -related Medicaid recipients;

 

(w)A description of the procedures and programs that ensure the availability and accessibility of urgent and emergency services on a twenty-four (24) hour, seven (7) day per week basis;

 

(x)A copy of the prepaid, capitated provider’s plan to ensure that the services provided are effective and of a consistently high quality; and

 

(y)A written description of the enrollment process.

 

5304.2Each prepaid, capitated provider shall provide to the Department written notice of the termination of any agreement between the provider and a hospital to provide inpatient care, or any other significant change in the agreement between the health maintenance organization and the hospital, not less than thirty (30) calendar days prior to the effective date of the change.

 

5304.3Each prepaid, capitated provider shall notify the Department, in writing, within thirty (30) days of any material modification of the information in §5304.1.

 

5304.4Each prepaid, capitated provider shall make available to the Department for inspection and copying, copies of all standards, protocols, manuals, and other documents used to arrive at decisions on the provision of care to AFDC and AFDC -related Medicaid recipients.

 

5304.5At the beginning of each quarter, each prepaid, capitated provider shall provide to the Department a list of the names and qualifications of each physician enrolled or disenrolled in the provider’s plan during the previous quarter.

 

5304.6Except as provided in §5304.5, each prepaid, capitated provider shall notify the Department, in writing, within thirty (30) days of any material change in the information required in this section.

 

source

Final Rulemaking published at 42 DCR 1566, 1571 (March 31, 1995).