Section 29-9500. GENERAL PROVISIONS

 

9500.1 This chapter shall govern eligibility determinations for the District of Columbia (District) Medicaid programs authorized under Title XIX and XXI of the Social Security Act (the Act).

 

9500.2 Pursuant to 42 U.S.C. Sections 1396 et seq., and amendments thereto, the Department of Health Care Finance (Department) shall be responsible for supervising and administering the District of Columbia State Plan (the State Plan) for Medical Assistance.

 

9500.3 The Department may delegate its authority to determine eligibility for non-pregnant individuals, ages twenty-one (21) through sixty-four (64), without dependent children;  individuals, ages zero (0) through twenty (20); pregnant women; parents and other caretaker relatives; individuals formerly in foster care, and individuals who are aged, blind, or disabled pursuant to 42 C.F.R. Subsection 431.10.

 

9500.4 The Department may delegate its authority to conduct administrative reviews and fair hearings with respect to denials of eligibility pursuant to 42 C.F.R. Subsection 431.10.

 

9500.5 The Department shall exercise appropriate oversight over the eligibility determinations and appeal decisions of its designees and incorporate such written delegations in the State Plan.

 

9500.6  The Department shall apply the following general standards in the administration of its Medicaid programs:

 

(a) Information explaining the policies governing eligibility determinations and appeals shall be provided in plain language and in a manner that is accessible and timely to all applicants and beneficiaries, including those with limited or no-English proficiency and those living with disabilities;

 

(b) District Medicaid program information shall be provided to applicants and beneficiaries who have limited or no-English proficiency through the provision of language services at no cost to them pursuant to Title VI of the Civil Rights Act of 1964, effective July 2, 1964 (42 U.S.C. §§ 2000d, et seq.), the Language Access Act of 2004, effective June 19, 2004 (D.C. Law 15-167; D.C. Official Code §§ 2-1931 et seq.) (Language Access Act), and Mayor's Order 2007-127, dated May 31, 2007;

 

(c) District Medicaid program information shall be provided to applicants and beneficiaries who are living with disabilities through the provision of auxiliary aids and services at no cost to the individual in accordance with Title II of the Americans with Disabilities Act of 1990, effective July 26, 1990 (42 U.S.C. §§ 12101 et seq.), § 504 of the Rehabilitation Act of 1973, effective September 26, 1973 (29 U.S.C. § 794), and the District of Columbia Human Rights Act of 1977, effective December 13, 1977 (D.C. Law 2-38; D.C. Official Code §§ 2-1401.01 et seq.);

 

(d) Applicants and beneficiaries shall be informed at the time of application, renewal, or redetermination that the Department, shall obtain and use available information to verify income, eligibility, and the correct amount of Medicaid payments, except for aged, blind, or disabled individuals whose eligibility is determined by the U.S. Social Security Administration (SSA) under an agreement between the District and SSA pursuant to Section 1634 of the Act;

 

(e) Information obtained by the Department under this section may be exchanged with the District Health Benefit Exchange Authority (DC HBX) and with other District or federal agencies for the purpose of:

 

(1) Verifying eligibility for Medicaid, the DC HBX, or other Insurance Affordability Programs (IAP), defined as one of the following:

 

(i) A State Medicaid program under Title XIX of the Social Security Act;

 

(ii) A State children’s health insurance program (CHIP) under Title XXI of the Social Security Act;

 

(iii) A State basic health program established under the Affordable Care Act; or

 

(iv) A program that makes coverage available through an Exchange with advance payments of premium tax credits or cost-sharing reductions;

 

(2) Establishing the amount of tax credit or cost-sharing reduction due;

 

(3) Improving the provision of services; and

 

(4) Administering IAPs; and

 

(f) Income and eligibility information shall be furnished to the appropriate District agencies responsible for the child support enforcement program under part D of Title IV of the Act; and the provision of old age, survivors, and disability benefits under Title II and for Supplemental Security Income (SSI) benefits under Title XVI of the Act.

 

9500.7 The Department shall establish and maintain policies that govern the types of information about applicants and beneficiaries that are protected against unauthorized disclosure for purposes unrelated to the determination of Medicaid eligibility. Protected information may include, but is not limited to, the following:

 

(a) Name and address;

 

(b) Phone number;

 

(c) Social security number;

 

(d) Medical services provided;

 

(e) Social and economic conditions or circumstances;

 

(f) Department evaluation of personal information;

 

(g) Medical data, including diagnosis and past history of disease or disability;  

 

(h) Any information received for verifying income eligibility and the amount of Medicaid  payments; and

 

(i) Any information received in connection with the identification of legally liable third party resources pursuant to applicable federal regulations.

 

9500.8  Protected information, in accordance with Subsection 9500.7, shall not include Medicaid beneficiary identification numbers.

 

9500.9  The Department shall provide notice or other communications concerning an applicant’s or beneficiary’s eligibility for Medicaid electronically only if the individual has affirmatively elected to receive electronic communications.  If the individual elects to receive communications from the agency electronically, the Department shall:

 

(a) Confirm by regular mail the individual’s election to receive notices electronically;

 

(b) Inform the individual of the right to change such election, at any time, to receive notices through regular mail;

 

(c) Post notices to the individual’s electronic account within one (1) business day of notice generation; and

 

(d) Send an email or other electronic communication alerting the individual that a notice has been posted to the individual’s account.

 

9500.10 If an electronic communication is undeliverable, a notice shall be sent by regular mail within three (3) business days of the date of the failed electronic communication.

 

9500.11 At the individual’s request, the Department shall provide a paper copy of any notice posted to the individual’s electronic account.

 

9500.12 The Department shall provide the following information by telephone, mail, in person, or through other commonly available electronic means, as appropriate, to all applicants and other individuals upon request:

 

(a) Eligibility requirements;

 

(b) Covered Medicaid services; 

 

(c) The rights and responsibilities of applicants and beneficiaries; and

 

(d) Appeals.

 

9500.13 The Department shall consider the following factors in determining eligibility for Medicaid:

 

(a) Income at or below the applicable Medicaid program standard;

 

(b) District of Columbia residency;

 

(c) Age;

 

(d) Social security number;

 

(e) U.S. Citizenship or satisfactory immigration status;

 

(f) Household composition;

 

(g) Pregnancy, where applicable; and

 

(h) Any other applicable non-financial eligibility factors under federal or District law, such as disability, blindness, or need for long-term services or supports.

 

9500.14 The Department shall use MAGI-based methodologies and non-MAGI-based methodologies in eligibility determinations for enrollment in and receipt of benefits from the District Medicaid program, in accordance with the requirements of this chapter, and any subsequent amendments thereto.

 

9500.15 MAGI-based income methodologies, under the provisions of this chapter, shall apply to the following groups:

 

(a) Non-pregnant individuals, ages twenty-one (21) through sixty-four (64), without dependent children; 

 

(b) Individuals, ages zero (0) through twenty (20);

 

(c) Pregnant women; and

 

(d) Parents and other caretaker relatives. For purposes of this section a caretaker relative is a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child’s care (as may, but is not required to, be indicated by claiming the child as a tax dependent for Federal income tax purposes), and who is one of the following:

 

(1)  The child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece;

 

(2) The spouse of such parent or relative, even after the marriage is terminated by death or divorce; or

 

(3) Another relative of the child based on blood (including those of half-blood), adoption, or marriage.

 

9500.16 No resource (assets) test shall apply to eligibility groups identified in Subsections 9500.15(a) through 9500.15(d).

 

9500.17 MAGI-based income methodologies, under the provisions of this chapter and 42 C.F.R. Section 435.603, shall not apply to the following groups:

 

(a) Individuals who are under the age of eighteen (18) for whom an adoption assistance agreement under Title IV-E of the Act is in effect and individuals who receive Title IV-E foster care maintenance payments;

 

(b) Individuals who are under the age of twenty-one (21) in foster care under the responsibility of the District and individuals receiving adoption subsidy payments;

 

(c) Individuals who are under the age of twenty-six (26) and were on District Medicaid and in foster care under the responsibility of the District at the time they reached the age of eighteen (18) or have aged out of foster care;

 

(d) Individuals who are age sixty-five (65) or older when age is a condition of eligibility;

 

(e) Individuals whose eligibility is being determined on the basis of being blind or disabled or on the basis of being treated as being blind or disabled, including but not limited to, individuals eligible under                42 C.F.R. Section 435.121, Section 435.232, Section 435.234, or under Section 1902(e)(3) of the Act;

 

(f) Individuals who request coverage for long-term services and supports for the purpose of being evaluated for an eligibility group under which long-term services and supports are covered;

 

(g) Individuals who are being evaluated for eligibility for Medicare cost sharing assistance under Section 1902(a)(10)(e) of the Act and 42 C.F.R. Section 435.603;

 

(h) Individuals who are being evaluated for coverage as medically needy; and

 

(j) Other individuals whose eligibility for Medicaid does not require a determination of income by the Department.

 

9500.18 For an applicant or beneficiary found not eligible based on MAGI methodology and who has been identified on the application or renewal form as potentially eligible on a non-MAGI basis, an eligibility determination shall be made on such basis.

 

9500.19 The meaning of foster care under this chapter shall be consistent with the definition of foster family home under 45 C.F.R Section 1355.20.

 

9500.20 The Department shall issue and maintain all policies relevant to Medicaid  eligibility determinations. The Department shall make its policies available at www.dhcf.dc.gov and shall provide updates as necessary. 

 

 

authority

An Act to enable the District of Columbia (District) to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat.774; D.C. Official Code § 1-307.02 (2014 Repl.)), and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)).

source

Final Rulemaking published at 62 DCR 11142 (August 14, 2015).