Section 29-5404. PAYMENT FOR SERVICES

 

5404.1The Department shall not make any payment for Medicaid services to a fee-for-service primary care provider unless the provider has executed a Medicaid managed care provider agreement.

 

5404.2Each fee-for-service primary care provider’s Medicaid managed care provider agreement with the Department shall be for a twelve (12) month period.

 

5404.3Each fee-for-service primary care provider shall be paid by the Department a fee-for-service for the covered services it provides to AFDC and AFDC-related Medicaid enrollees. The fees paid shall be the standard rate for the same service by the District’s Medicaid program.

 

5404.4No fee-for-service primary care provider shall impose co-payment requirements or other fees that are not a part of the D.C. Medicaid Managed Care program on AFDC and AFDC-Related Medicaid enrollees.

 

5404.5If an enrollee loses Medicaid eligibility the Department shall not reimburse the fee-for-service primary care provider for any service rendered to that enrollee after the effective date of the termination of her/his eligibility.

 

5404.6If an enrollee voluntarily elects to change providers or is involuntarily assigned to another provider in accordance with the requirements of the program, the Department shall not reimburse the fee-for-service primary care provider from whose patient load the enrollee was reassigned for any service rendered to that enrollee after the effective date of the reassignment.

 

5404.7If an enrollee receives a service covered by the D.C. Medicaid Managed Care program from a provider other than her/his primary care provider of record, the Department shall not reimburse the provider rendering the service unless the service was authorized by the primary care provider in accordance with the requirements of the program.

 

source

Final Rulemaking published at 42 DCR 1566, 1591 (March 31, 1995).