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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 29-5307. SERVICE DELIVERY AND QUALITY ASSURANCE REQUIREMENTS GENERAL
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5307.1Each prepaid, capitated provider shall provide each enrollee with high quality health care at locations that ensure reasonable availability and accessibility to enrollees.
5307.2Each prepaid, capitated provider shall provide either directly or by referral, each service in the Medicaid managed care benefits package, including patient management and referrals and approvals.
5307.3Each prepaid, capitated provider shall ensure that urgent and emergency medical care are available to AFDC and AFDC-related Medicaid enrollees on a twenty four (24) hour basis, seven (7) days a week, either through the prepaid, capitated provider or through other appropriate facilities.
5307.4Each prepaid, capitated provider shall conduct an orientation program to inform AFDC and AFDC-related recipients of available services and facilities.
5307.5Each AFDC and AFDC-related Medicaid recipient enrolled in a prepaid, capitated provider’s plan shall receive service through the same health care providers and facilities that serve non-AFDC and AFDC-related Medicaid enrollees.
5307.6Each AFDC and AFDC-related Medicaid enrollee shall be fully integrated into the prepaid, capitated provider’s plan membership and shall not be treated in a manner different from non-AFDC or AFDC-related Medicaid enrollees.
5307.7Each prepaid, capitated provider shall allow each enrollee, to the maximum extent feasible, the freedom to choose from among its participating providers of primary health care and shall notify the Department in writing of the primary health care provider to whom the AFDC or AFDC-related recipient is assigned by the end of the first month of enrollment and monthly for reassignments.
5307.8Each prepaid, capitated provider shall provide health education programs for its enrollees in languages understood by the population being served. The education programs shall include, at a minimum, the following:
(a)Information regarding the importance and availability of preventive care;
(b)Information regarding the importance and availability of childhood immunizations;
(c)Information regarding the importance of, right to, and procedure for scheduling the Early Periodic Screening, Diagnosis and Treatment (EPSDT) screens for children covered by Medicaid;
(d)Information on birth control and on the importance and availability of prenatal and well baby care;
(e)Information regarding proper nutrition for pregnant women and children; and
(f)Information regarding preventive and treatment measures for drug abuse and alcoholism.
5307.9The prepaid, capitated provider shall have a system of follow -up of patient care for enrollees with chronic and acute illnesses, including an appointment follow-up system for persons who do not appear for appointments.
5307.10Waiting times for appointments for AFDC and AFDC -related Medicaid enrollees shall not exceed the waiting times for non-AFDC or AFDC-related Medicaid enrollees of the prepaid, capitated provider.
5307.11Each prepaid, capitated provider shall maintain a current, unified medical record on each enrollee.
5307.12Each prepaid, capitated provider shall establish and maintain a quality assurance program to review the quality, appropriateness and timeliness of the services performed. The quality assurance program shall be approved by the Department in accordance with the requirements of §5307.13.
5307.13The prepaid, capitated provider’s quality assurance program shall:
(a)Be consistent with federal Medicaid utilization review and control regulations;
(b)Provide for review, by appropriate health care professionals, of the process followed in providing health services; and
(c)Provide for systematic data collection on performance, utilization and treatment outcomes.
5307.14The prepaid, capitated provider shall obtain accreditation through an external review by an independent quality accreditation organization such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the National Committee for Quality Assurance (NCQA). This process must begin within 12 months of entry into the D.C. Medicaid Managed Care Program and provisional accreditation must be received by the end of the third year of participation in the program.