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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 29-56. REQUIREMENTS FOR THE MEDICAID MANAGED CARE PROGRAM FOR CHILDREN AND YOUTH WITH DISABILITIES |
Section 29-5601. MANAGED CARE PROVIDER QUALIFICATIONS
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5601.1The managed care provider shall execute a Medicaid managed care provider agreement with the Department.
5601.2The managed care provider shall admit or refer all enrolled children requiring hospital care only to hospitals located in the District unless:
(a)Emergency care is required and a non-District hospital is the closest emergency facility to the enrolled child at the time of the emergency; or
(b)The enrolled child requires a specialized service not available in a hospital located in the District.
5601.3The managed care provider shall maintain a staffed business office in the District.
5601.4The managed care provider shall enter into a risk comprehensive or other risk contract with the Department to provide a predefined set of services to children eligible for the demonstration for a fixed, prepaid, capitated fee.
5601.5The managed care provider shall be a federally qualified Health Maintenance Organization (HMO) or shall meet the requirements of an HMO as defined in the State Plan of Medical Assistance.
5601.6The managed care provider may maintain the sum of its membership of Medicaid and Medicare beneficiaries at or above seventy-five percent (75%) of its total enrollment only if the demonstration has received a waiver from the federal Health Care Financing Administration.
5601.7The managed care provider shall establish an advisory committee, which meets at least quarterly to advise the provider on matters regarding service to eligible children.
5601.8Twenty-five (25) percent of the advisory committee membership shall be made up of eligible children who are enrolled in the provider’s plan or their representatives.