Section 29-5612. SUBCONTRACTS

 

5612.1Each subcontract entered into by the managed care provider for services covered by the Medicaid managed care provider agreement shall be submitted to the Department for approval prior to the execution of the subcontract.

 

5612.2No subcontract shall terminate the legal obligation of the managed care provider to ensure that all activities carried out by the subcontractor conform to the provisions of the managed care provider’s Medicaid managed care provider agreement. Subject to these conditions, any service or function required to be provided by the managed care provider may be subcontracted to a qualified organization or person.

 

5612.3The Department shall notify the managed care provider, in writing, of its approval or disapproval of the proposed subcontract and supporting documentation required by the Department with fifteen (15) business days of receipt of the proposed subcontract and supporting materials. The Department shall specify the reasons for any disapproval, which shall be based only on District or Federal law or regulations. The managed care provider may not directly or indirectly restrict a subcontractor from engaging in business with other providers of Medicaid services.

 

5612.4If the managed care executes a subcontract for services covered by the Medicaid managed care provider agreement without the prior written approval of the Department, the Department may terminate the managed care provider’s Medicaid managed care provider agreement in accordance with the procedures of §5619.

 

5612.5The Department may require the managed care provider to furnish additional information relating to the ownership of the subcontractor, the subcontractor’s ability to carry our the proposed obligations under the subcontract, and the procedures to be followed by the managed care provider to monitor the execution of the subcontract.

 

5612.6Subject to the provisions of §5612.1, the managed care provider may enter into a subcontract with a health care provider who is not enrolled in the Medicaid program but who otherwise meets all other federal and District requirements for participation in the Medicaid program.

 

5612.7The managed care provider shall not enter into a subcontract for Medicaid services with a health care provider who has been convicted of any crime or who has been the subject of any sanction described in §1128 of the Social Security Act (42 U.S.C. §1320a-7). The Department shall not reimburse the managed care provider for any services provided to an enrolled child by a subcontractor who has been convicted of a crime or who has been the subject of a sanction described in §1128 of the Social Security Act.

 

5612.8Except as provided in §5601.2, the managed care provider shall not enter into a subcontract with a hospital located outside the District to provide inpatient hospital services to eligible children enrolled in the D.C. Medicaid Managed Care Program for Disabled Children and Youths.

 

5612.9Each subcontract shall be in writing and shall contain, at a minimum, the following:

 

(a)Information identifying each party, including the name, address and type of organization;

 

(b)The legal basis for operating as a health care provider in the District, including licenses, accreditation, certificates of operation, and registration;

 

(c)Descriptions of services to be provided or other activities to be performed by the subcontractor in a form that permits the Department to definitively determine the nature and scope of the Medicaid obligations that have been subcontracted;

 

(d)An agreement that financial and programmatic information, records, and data collected and maintained by the subcontractor that relate to enrolled children and/or services provided to them shall be made available to the managed care provider and the Department for inspection;

 

(e)An agreement that the subcontractor shall look solely to the managed care provider for compensation for services provided to children enrolled in the managed care provider’s plan;

 

(f)A description of the payment methodology to be utilized to reimburse the subcontractor;

 

(g)Assurances of appropriate professional liability coverage;

 

(h)Assurances that the subcontractor shall comply with all applicable provisions of District and federal law and regulations pertaining to Title XIX of the Social Security Act and all District and federal laws and regulations applicable to the service or activity covered by the subcontract;

 

(i)An agreement that the subcontractor shall submit encounter data to the managed care provider; and

 

(j)If the subcontract is subject to assignment, an agreement that no assignment shall take effect without prior written approval from the Department.

 

5612.10The managed care provider shall notify the Department, in writing, of the termination of any subcontract and any arrangements made to ensure continuation of the services covered by the terminated subcontract not less than thirty (30) days prior to the effective date of the termination.

 

5612.11If the Department determines that the termination or expiration of a subcontract materially affects the ability of the managed care provider to carry out its responsibility under its Medicaid managed care provider agreement, the Department may terminate the Medicaid managed care provider agreement.

 

source

Final Rulemaking published at 43 DCR 4833, 4849 (September 6, 1996).