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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-9. MEDICAID PROGRAM |
Section 29-999. DEFINITIONS
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999.1For purposes of this chapter, the following terms shall have the meanings ascribed:
Accrual method of accounting - a method of accounting pursuant to which revenue is recorded in the period earned, regardless of when collected and expenses are recorded in the period incurred, regardless of when paid.
Active treatment services - a program of specialized and generic training, treatment, health services and related services designed toward the acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible, and the prevention or deceleration of regression or loss of current optimal functional status. This definition shall be consistent with the federal standard.
Actual time method - the number of months the asset is owned in both the year of acquisition and the year of disposal.
Acuity - the level of care required for an individual in an ICF/MR which correlates to an acuity level. Customers with a high acuity level require more care; those with lower acuity levels require less care.
Allowable costs - those actual costs, after appropriate adjustments, incurred by ICF/MR facilities which are reimbursable under the Medicaid Program.
Annual District DSH limit - the annual District established aggregate limit for DSH payments. This term shall not be construed to mean the annual Federal DSH allotment for the District of Columbia.
Applicable percent of minimum monthly maintenance needs allowance - will include the following:
(a) For the period October 1, 1989 through June 30, 1991, one hundred and
twenty-two percent (122%);
(b) For the period July 1, 1991 through June 30, 1992, one hundred and thirty-
three percent (133%); and
(c) For the period July 1, 1992 and thereafter, one hundred and fifty percent
(150%).
Audit or audited - either a full scope or limited scope audit.
Average per diem cost - the facility total allowable costs divided by the total actual patient/resident days for the same level of care for a reporting period.
Bad debts - amounts considered to be uncollectible from accounts and notes receivable, which were created or acquired in providing services.
Base year - the standardized year on which rates for all facilities are calculated to derive a prospective reimbursement rate.
Beneficiary – Any individual who has been designated as eligible to receive or who receives any item or service under the D.C. Medicaid program.
Brand - any registered-trade name commonly used to identify a drug.
Ceiling - a predetermined rate that sets the upper limit of reimbursement.
Charity care - care provided to individuals who have no source of payment, third-party coverage, or personal resources. Charity care shall not include contractual allowances, or discounts except those for indigent patients who are eligible for services under a sliding fee scale or the District of Columbia’s Medical Charities Program.
Claim - A claim is a submission requesting payment for specific services rendered to a recipient by the Billing provider.
Community spouse - a spouse who is not either a patient or resident in a medical institution.
Consumable – Items that are designed or intended to be used up and then replaced.
D.C. Medicaid Program - The program authorized by Title XIX of the Social Security Act and by D.C. Official Code § 1-307.02 (2001) and administered by the Medical Assistance Administration within the Department of Health.
Department of Health Care Finance - The executive department responsible for administering the Medicaid program within the District of Columbia effective October 1, 2008.
DHCF - Department of Health Care Finance
Discount - Any form of rebate, wholesale pricing, sale pricing, and similar adjustments to the manufacturer’s suggested retail price for an item.
Durable Medical Equipment - Supplies, equipment and appliances required by a recipient of Medicaid services that can withstand repeated use, primarily and customarily used to serve medical purposes, and generally not useful to a person in the absence of an illness or injury.
Excess shelter allowance for a community spouse - the amount by which the sum of the following exceeds thirty percent (30%) of the amount described in §966.3(a), except that, in the case of a condominium or cooperative for which the maintenance charge includes utility expenses, the standard utility allowance shall be reduced to the extent of those utility expenses:
(a) The spouse’s expenses for rent or mortgage payment (including principal
and interest), taxes and insurance and, in the case of a condominium or cooperative, required maintenance charge, for the community spouse’s principal residence; and
(b)The spouse’s expenses for utilities as determined under these rules.
Facility -
(a)As used in §§950 - 960, a nursing facility.
(b)As used in §§968 - 978, an intermediate care facility for mentally retarded.
Fair market value - the value at which an asset could be sold in the open market in a transaction between unrelated parties.
HCFA - the U.S. Department of Health and Human Services, Health Care Financing Administration.
Indexed for inflation - the amount by which the specified dollar amount is increased by the same percentage as the percentage increase in the consumer price index for all urban consumers (all items: U.S. city average) between September 1988 and the September before the calendar year involved.
Individual Habilitation Plan (IHP) - The same meaning as set forth in §403 of the Mentally Retarded Citizens Constitutional Rights and Dignity Act of 1978, effective March 3, 1979 (D.C. Law 2-137; D.C. Code, 2001 Ed. §7-1304.03).
Individual Service Plan (ISP) - the successor to the individual habilitation plan (IHP) as defined in the court-approved Joy Evans Exit Plan
Institutional Facility or Provider - Medicaid enrolled hospitals, nursing facilities, and intermediate care facilities for individuals with intellectual disabilities.
Institutionalized spouse - a person who is in a medical institution, is likely to require treatment in a medical institution for at least thirty (30) consecutive days, and is married to a spouse who is not in a medical institution.
Leasehold improvements - the improvements made by the owners of a facility to leased land, buildings or equipment.
Low income utilization rate - the sum of two (2) fractions, both expressed as percentages. The numerator of the first fraction is the sum of (1) total revenues paid the hospital during its fiscal year for Medicaid inpatients; and (2) the amount of any cash subsidies for inpatient services received directly from state or the District government; the denominator shall be the total amount of revenues for inpatient services (including the amount of such cash subsidies) in the same fiscal year. The numerator of the second fraction is the total amount of the hospital’s charges for inpatient hospital services which are attributable to charity care in the fiscal year, minus the portion of the cash subsidies reasonably attributable to inpatient services; the denominator of the second fraction shall be the total amount of the hospital’s charges for inpatient hospital services in that fiscal year.
Median - the middle value in a distribution, above and below which lie an equal number of values.
Medicaid - A federally funded program that pays for medical care and health services for certain low-income persons.
Medicaid Fee Schedule - a comprehensive list of fee maximums used to reimburse providers on a fee-for-service basis.
Medicaid inpatient utilization rate - the percentage derived by dividing the total number of Medicaid inpatient days of care rendered during a hospital’s fiscal year by the total number of inpatient patient days for that year.
Medicaid patient day - a patient day paid for by any state program operating under Title XIX of the Social Security Act. A day for which the Medicaid program pays only a deductible, or co-payment, shall not be counted as a Medicaid patient day.
Medical institution - a hospital or nursing facility.
Minimum monthly maintenance needs allowance - the applicable percent of one-twelfth (1/12) of the official poverty line annual income for a family of two (2).
Mobility Assistive Equipment –Canes, crutches, walkers, manual wheelchairs, and power wheelchairs.
Multiple source drug - a drug marketed or sold by three (3) or more manufacturers or labelers, or a drug marketed or sold by the same manufacturer, or labeler under two (2) or more different proprietary names or both under a proprietary name and without such a name.
Natural Environment - Settings that are natural or typical for an infant or toddler of the same age without a disability, which may include the home or community settings.
New provider -
(a) As used in §§950 - 960, a provider that entered the Medicaid Program and
received a new provider number after December 31, 1995, or a provider whose management changed after December 31, 1995, as a result of a bankruptcy proceeding.
(b) As used in §§968 - 978, a provider that entered the Medicaid Program and
received a new provider number subsequent to December 31, 1993, or a provider whose management changed after December 31, 1993, as a result of a bankruptcy proceeding.
Official poverty line annual income - the income defined by the Federal Office of Management and Budget and revised annually in accordance with §§652 and 673(2) of the Omnibus Budget Reconciliation Act of 1981. The official poverty line annual income figure is revised annually and the revised amount shall be used in computing the institutionalized spouse’s cost of care as of the first day of the second calendar quarter (which will generally be July 1) beginning after federal publication of the latest poverty line data.
Patient day - care of one patient during the day of service. The day of admission is counted as a day of care but the day of discharge is not counted as a day of care.
Peer group -
(a) As used in §§950 - 960, a group of nursing facilities sharing similar
characteristics.
(b) As used in §§968 - 978, a group of intermediate care facilities for mentally
retarded which share similar characteristics.
Per diem rate - the average daily rate established by the Medical Assistance Administration for the facility’s current year expenditures.
Prescribed drugs - legend drugs approved as safe and effective by the U.S. Food and Drug Administration and those over-the-counter medications which fall into the following categories:
(a)Oral analgesics ethically advertised;
(b)Ferrous sulfate;
(c)Antacids ethically advertised;
(d)Diabetic preparations;
(e)Family planning drugs and supplies;
(f)Pediatric, prenatal and geriatric vitamin formulations; and
(g)Senna extract, single dose preparations when required for diagnostic
radiological procedures performed under the supervision of a physician.
Program - the District of Columbia Medicaid Program as administered by the Commission on Health care Finance, Department of Health.
Prospective payments - a predetermined rate based on prior year and anticipated allowable expenditures of an intermediate care facility for mentally retarded.
Prosthetics and Orthotics Supplies - Appliances or apparatuses used to support, align, prevent, or correct deformities as well as improve the function of movable body parts.
Provider - An individual or entity furnishing services under a provider agreement.
Provider Agreement - A contract executed by the District of Columbia and a provider pursuant to Title XIX of the Social Security Act and which contract sets forth the rights, duties and obligations of the parties.
Prudent buyer concept - the price paid by a prudent buyer in the open market under competitive conditions.
Recipient - Any individual who has been designated as eligible to receive or who receives any item or service under the D.C. Medicaid Program.
Reserved bed days - days for hospitalization or therapeutic leaves of absence, when provided for in the patient’s plan of care and when there is a reasonable expectation that the patient will return to the Nursing Facility. Reserved bed days may not exceed a total of 18 days during any 12 month period that begins on October 1st and ends on September 30th. A therapeutic leave of absence includes visits with relatives and friends and leave to participate in a State-approved therapeutic and rehabilitative program.
Total computable dollars - the total Medicaid DSH payments, including the federal and District share of financial participation.
Week - A seven-day cycle beginning on Sunday and ending on Saturday.