Section 29-5619. SANCTIONS FOR NON-COMPLIANCE

 

5619.1If the Department determines that the managed care provider has failed to comply with the provisions of this chapter or other applicable federal or District law or regulations, the Department may:

 

(a)Suspend further enrollment of eligible children by the managed care provider;

 

(b)Withhold part of the provider’s Medicaid payments;

 

(c)Use all or part of the deposit detailed in §5602.2; and

 

(d)Terminate the Medicaid managed care provider agreement within thirty (30) days from the date of notice of termination to the managed care provider.

 

5619.2Before taking any action described in §5619.1, the Department shall provide written notice which shall include at lease the following:

 

(a)Citation of the law or regulation which has been violated;

 

(b)Sanction to be applied and the date the sanction will be imposed;

 

(c)Basis for the Department’s determination that the sanction should be imposed; and

 

(d)Timeframe and procedure for the managed care provider to appeal the District’s determination.

 

5619.3A provider’s appeal of action pursuant to §5619.1(a) and (b) shall stay the effective date of the proposed action.

 

5619.4The Department shall provide reasonable written notice of a proposed sanction to eligible children enrolled in the managed care provider’s plan and others who may be affected by the proposed sanction. Notice to enrolled children shall be by first-class mail, postage prepaid, at the address reflected in the Department’s records.

 

5619.5Except as specifically provided in this section, 29 DCMR Chapter 13 shall apply to any administrative action taken with respect to the managed care provider’s participation in the program.

 

source

Final Rulemaking published at 43 DCR 4833, 4854 (September 6, 1996).