Section 29-5599. DEFINITIONS

 

AFDC - the categorical eligibility designation for a person who is eligible for Medicaid assistance because the person is eligible for cash assistance from the Aid to Families with Dependent Children (AFDC) program.

 

AFDC-related - the categorical eligibility designation for a person who is eligible for Medicaid because the person is a pregnant woman with an income at or below 185% of poverty as defined in federal regulations, a child under the age of one in a family with an income at or below 133% of poverty, or a child born after September 30, 1983 in a family with an income at or below 100% of poverty.

 

Capitation rate - the fixed, monthly rate per covered person established by the Department payable to a prepaid capitated provider for providing covered services to the covered person.

 

Default - the inability of a health maintenance organization to provide the services described in the Medicaid managed care provider agreement; insolvency of an HMO health maintenance organization; or, failure of the health maintenance organization to adhere to the provisions of the Medicaid managed care provider agreement.

 

Department - the District of Columbia Department of Human Services or its agent.

 

District - the District of Columbia.

 

Emergency medical care - care provided in response to the sudden unexpected onset of a condition which may result in permanent physical injury or a threat to life if care is not secured immediately after the onset of the condition or as soon thereafter as care can be made available.

 

Enrollee - a Medicaid recipient who is enrolled in the plan of a health maintenance organization primary care provider that has a Medicaid managed care provider agreement with the Department.

 

Evidence of coverage - any certificate, agreement or contract issued to an enrollee that sets forth the responsibilities of the enrollee and services to which the enrollee is entitled.

 

Federally qualified health center - is a Federally Qualified Health Center as defined in 42 C.F.R. §405.2340 - 2470.

 

Federally qualified health maintenance organization (FQHMO) - a health maintenance organization (HMO) that has been determined by the U.S. Public Health Service to be a qualified HMO under §1310(d) of the Public Health Service Act, as amended, 42 U.S.C. 254c(d)(1).

 

Health care provider - any physician, hospital, or other person or facility that provides health care services, but does not have a Medicaid managed care agreement to furnish health care services to AFDC and AFDC-related Medicaid recipients enrolled in the District’s Medicaid program.

 

Health Maintenance Organization - a public or private organization operating in the District, which contract with the District government on a risk comprehensive, other risk, or non-risk basis to provide comprehensive health, maintenance, preventive and treatment services to AFDC and AFDC-related recipients though its own network of physicians and hospitals for a fixed, prepaid premium.

 

Involuntary disenrollment - the termination of membership of an enrollee by the health maintenance organization under conditions permitted by this chapter or the health maintenance organization’s Medicaid managed care provider agreement.

 

Key Personnel - a Health Maintenance Organization’s President, Vice President, Chief Executive Officer, Medical Director, Chief Financial Officer, Director of Quality Improvement/Quality Assurance, Director of Operations, Director of Management Information Systems, and Director of Health Services.

 

Lock in Period - the period between the first day of the second month and the last day of the sixth month of enrollment, during which a recipient enrolled in a prepaid, capitated provider that meets the requirements of 42 C.F.R. §434.27(d)(1) may disenroll only under the conditions prescribed in §5501 of these rules. Recipients shall not be locked into non-risk and other risk contract plans.

 

Medicaid managed care provider agreement - the agreement between the primary care provider and the Department that sets forth the responsibilities of the prepaid, capitated or fee-for-service primary care provider and the District government for providing or arranging for the provision of, and making payment for all services that AFDC and AFDC-related recipients are entitled to receive under the District’s Medicaid Managed Care Program.

 

Non-risk Contract - a contract in which the contractor is not at financial risk for changes in the cost or utilization of services provided for in the payment rate set at the beginning of the contract period. The contractor is reimbursed for costs actually incurred, subject to the federal upper payment limits described in 42 C.F.R. §447.362.

 

Other Risk Contract - a risk contract for a scope of services other than those specified in 42 C.F.R. §434.21(b).

 

Prepaid, Capitated Provider - Any qualified organization or individual willing and able to offer quality health care services to a District AFDC or AFDC-related Medicaid recipient on an at-risk basis for a fixed, prepaid, capitated fee shall be referred to throughout this chapter as a capitated provider.

 

Prepaid health plan - an entity not subject to the requirements of §1903(m)(2)(A) of the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) that renders medical services to enrolled recipients under contract with the Department on the basis of a prepaid, capitated fee.

 

Primary care physician - a qualified physician enrolled in the D.C. Medicaid Managed Care program whose specialty is pediatrics, obstetrics/gynecology, internal medicine, family medicine or general medicine.

 

Primary care provider - a qualified primary care physician, clinic, hospital outpatient department, neighborhood health center, group or prepaid capitated provider that has a contract with the District government to provide primary care to AFDC and AFDC-related recipients enrolled in the D.C. Medicaid Managed Care program and to coordinate referrals, when necessary, to other health care providers.

 

Regional Administrator - The Administrator, Region III, Health Care Financing Administration, United States Department of Health and Human Services.

 

Reinsurance - the insurance protection to be obtained by a capitated provider for costs over a certain level incurred by a capitated provider for services rendered to an enrollee.

 

Reserves - a sum of money accumulated by a health maintenance organization that may be:

 

(a)Applied against known liabilities not yet paid;

 

(b)Used as a contingency for unanticipated expenses; or

 

(c)Used for future services.

 

Risk Comprehensive Contract - a prepaid, capitated provider contract for a scope of services specified in 42 C.F.R. §434.21(b), where the exposure to financial loss is retained by the provider.

 

Start-up health maintenance organization - a health plan that has provided prepaid health services to members for less than twelve (12) months at the time application is made to participate in the D.C. Medicaid Managed Care Program, or that has not provided prepaid health services in the District.

 

Stop loss - protection that limits the financial liability of an at-risk, prepaid capitated provider for expenses incurred for rendering services to an enrollee under a prepaid Medicaid managed care provider agreement.

 

Subcontract - any written agreement between a health maintenance organization primary care provider and another party that requires the other party to provide services or benefits that the managed care provider is required to provide, or provide for pursuant to a Medicaid managed care provider agreement.

 

Voluntary disenrollment - the voluntary termination of membership in a provider’s managed care plan by an enrollee under conditions permitted by this chapter or the health maintenance organization’s or primary care provider’s Medicaid managed care provider agreement.

 

source

Final Rulemaking published at 42 DCR 1566, 1600 (March 31, 1995).