Section 29-5799. DEFINITIONS

 

Capitation rate - the fixed, monthly rate established by the Department payable to the managed care provider for providing covered services to an enrolled child.

 

Default - the inability of the managed care provider to provide the services described in the Medicaid managed care provider agreement; insolvency of the provider; or, failure of the managed care provider 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.

 

Eligible child - any individual, under twenty-two (22) years old, who receives Supplemental Security Income disability benefits.

 

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.

 

Emergency services - covered inpatient or outpatient services that (1) are furnished by an appropriated source other than the managed care provider; (2) are needed immediately because of an injury or sudden illness; and (3) cannot be delayed for the time required to reach the managed care provider’s nearest available network provider without risk or permanent damage to the child’s health.

Enrolled child - a Medicaid beneficiary whose family has elected to enroll the child in the demonstration or who has been autoassigned to the demonstration and has not exercised the right to choose to remain in the current Medicaid fee-for-service program.

 

Evidence of coverage - any certificate, agreement or contract issued to an enrolled child that sets forth the responsibilities of the child and services available to the child.

 

Federally qualified health center (FQHC) - 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 section 1310 (d) of the Public Health Service Act, as amended, 42 U.S.C. §254c(d)(1) .

 

Involuntary disenrollment - termination of the membership of an enrolled child by the managed care provider or the Department under conditions permitted by this chapter or the Medicaid managed care provider agreement.

 

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 an eligible child enrolled in the managed care provider’s plan may disenroll only under the conditions prescribed in §5701 of these rules.

 

Managed care provider - the managed care organization selected by the Department to provide for or arrange for health care services to eligible children under the terms and conditions of the Section 1115 demonstration.

 

Medicaid managed care provider agreement - the agreement between the Department and the managed care provider that sets forth the responsibilities of the District government and the provider for providing or arranging for the provision of, and making payment for all services that enrolled children are entitled to under the D.C. Medicaid Managed Care Program for Disabled Children and Youths.

 

Primary care physician - a qualified physician enrolled in the District’s Medicaid Managed Care Program whose specialty is pediatrics, internal medicine, or family medicine. Specialty care providers qualified to deliver primary care services may also be included under this definition.

 

Reinsurance - the insurance protection to be obtained by the managed care provider for costs over a certain level incurred by the provider for services rendered to an enrolled child.

 

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.

 

Stop loss - protection that limits the financial liability of the managed care provider for expenses incurred for rendering services to an enrolled child under the Medicaid managed care provider agreement.

 

Subcontract - any written agreement between the managed 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 the managed care provider’s plan by an enrolled child under conditions permitted by this chapter or the Medicaid managed care provider agreement.

 

source

Final Rulemaking published at 43 DCR 4833, 4857 (September 6, 1996).