Section 29-995. MEDICAID PHYSICIAN AND SPECIALTY SERVICES RATE METHODOLOGY

 

995.1Medicaid reimbursement rates for fee-for-service physician and specialist services shall be eighty percent (80%) of the rates paid by the Medicare Program as set forth in this section, except for physician-administered chemotherapy drugs administered on or after May 1, 2016. Medicaid reimbursement for chemotherapy drugs that are administered on or after May 1, 2016 shall be one hundred percent (100%) of the Medicare fee schedule. The reimbursement rates for physician administered chemotherapy drugs shall be posted on DHCF’s website at www.dc-medicaid.com and updated annually.

 

995.2For services where the physician and specialist service procedure code falls within the Medicare (Title XVIII) fee schedule, payment shall be the lesser of the Medicare rate established pursuant to subsection 995.1 or the providers’ actual charges to the general public.

 

995.3For services where the procedure code does not fall within the Medicare fee schedule, an alternative method, as set forth in § 995.4, shall be used to establish the Medicaid reimbursement rate.

 

995.4When making a determination to establish the Medicaid reimbursement rate using an alternative method for physician and specialty services, in addition to using professional judgment, the following factors may be considered:

 

(a) Practitioner fees;

 

(b) Fee schedules from other states;

 

(c) Similar procedures with established fees; or

 

(d) Private insurance payments.

 

995.5All updates to the Medicaid fee schedule governing reimbursement rates for physician and specialty services shall comply with the requirements set forth under Section 988 (Medicaid Fee Schedule) of this chapter.

 

995.6All physician and specialty services reimbursement rates shall be located on the Department of Health Care Finance website.

 

995.7  The Department of Health Care Finance (DHCF) shall provide a supplemental payment to participating providers of physician and specialty services in accordance with the requirements set forth in Section 995.4 through 995.7.

 

995.8To qualify for a supplemental payment, a provider must have participated in the Medicaid program and have paid claims for physician and specialty services between the period January 1, 2011 and February 29, 2012. 

 

995.9For each provider who qualifies for payment in accordance with Section 995.4, DHCF shall:

 

(a)Establish a fund that shall be equal to and shall not exceed the difference between one hundred percent (100%) of the Medicare rate in effect for the period referenced in Section 995.4 and eighty percent (80%) of the Medicare rate in effect for the period referenced in Section 995.4 (Medicaid payment rate) for all claims paid to that provider between January 1, 2011 and February 29, 2012;

 

(b)Pay a provider-specific supplemental payment based on the claims submitted to DHCF during the three (3) month period beginning May 1, 2013; and

 

(c)Make certain that the total amount paid to each provider shall not exceed the amount set forth in Section 995.5(a).

 

995.10The supplemental payment shall be calculated as the total of each provider’s fund, divided by the paid claims submitted for the payment period by each provider and added proportionally to the fee-for-service rate paid to that provider during the payment period.

 

995.11All payments shall be made as a lump sum adjustment at the end of the defined three month payment period. 

 

 

authority

An Act to enable the District of Columbia 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 (2011 Supp.) 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) ( 2008 Repl.).

source

Final Rulemaking published at 44 DCR 5497 (September 26, 1997); as amended by Final Rulemaking published at 50 DCR 3473 (May 2, 2003); as amended by Final Rulemaking published at 50 DCR 9253(October 31, 2003); as amended by Final Rulemaking published at 52 DCR 7021(July 29, 2005); as amended by Final Rulemaking published at 55 DCR 338 (January 11, 2008); as amended by Final Rulemaking published at 56 DCR 005928 (July 24, 2009); as amended by Emergency and Proposed Rulemaking published at 57 DCR 950 (October 8, 2010)[EXPIRED]; as amended by Final Rulemaking published at 59 DCR 147 (January 13, 2012); as amended by Final Rulemaking published at 60 DCR 11955 (August 16, 2013); as amended by Final Rulemaking published at 63 DCR 10443 (August 12, 2016).