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DEPARTMENT OF HEALTH CARE FINANCE
NOTICE OF EMERGENCY AND PROPOSED RULEMAKING
The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in 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) 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)), hereby gives notice of the adoption, on an emergency basis, of an amendment to Chapter 50, “Medicaid Reimbursement for Personal Care Services,” of Title 29, “Public Welfare,” of the District of Columbia Municipal Regulations (DCMR).
Personal care aide services are basic health-related services that are provided by unskilled health care professionals to individuals who require services that range from bathing to meal preparation. These proposed rules will: 1) reduce the number of hours from one thousand forty (1,040) hours annually to five hundred twenty (520) hours annually that Medicaid personal care services (PCA) can be provided in the District; 2) expand the opportunity to provide PCA services to individuals associated with the Medicaid beneficiary who are not family members; and 3) require a relationship between the beneficiary and primary care professional in advance of receiving a prescription for personal care aide services.
In Fiscal Years 2009 and 2010, the District experienced an unprecedented growth in unemployment from five and seven tenths percent (5.7%) to eleven percent (11%). During this period, the Medicaid program has experienced huge pressures in enrollment and service delivery. Emergency action is required to preserve the health, welfare and safety of District residents during this crisis, since DHCF must reduce spending to pay for the health care needs of District residents.
DHCF is also amending the District of Columbia State Plan for Medical Assistance (State Plan) to reflect these changes. The State Plan amendment will be submitted to CMS for approval. The Council of the District of Columbia approved the reduction in hours for PCA services in the Fiscal Year 2010 Budget Support Act of 2009, effective March 3, 2010 (D.C. Law 18-111; 57 DCR 181). These rules shall become effective for services rendered on or after January 1, 2011, if the corresponding State Plan amendment has been approved by CMS with an effective date of January 1, 2011 or the effective date established by CMS in its approval of the corresponding State Plan amendment, whichever is later. If approved, DHCF will publish a notice which sets forth the effective date of the rules.
The emergency rulemaking was adopted on December 20, 2010, and shall become effective for services rendered on or after January 1, 2011 subject to CMS approval. The emergency rules shall remain in effect for one hundred and twenty (120) days or until April 18, 2011, unless superseded by publication of a Notice of Final Rulemaking in the D.C. Register. The Director also gives notice of the intent to adopt this proposed rule not less than thirty (30) days from the date of publication of this notice in the D.C. Register.
Chapter 50, MEDICAID REIMBURSEMENT FOR PERSONAL CARE SERVICES, of Title 29, PUBLIC WELFARE of the DCMR is amended as follows:
Section 5004, PROGRAM SERVICES, is amended as follows:
Subsection 5004.1 is deleted in its entirety and replaced to read as follows:
5004.1 Personal care services shall be prescribed by a physician or advanced practice registered nurse who established a patient-provider relationship prior to the prescription of the personal care services and has examined the beneficiary in a hospital, provider’s office or at the beneficiary’s home in accordance with the beneficiary’s plan of treatment.
Section 5004.3 is deleted in its entirety and replaced to read as follows:
5004.3 An individual or family member other than a spouse, parent of a minor recipient or any other legally responsible relative may provide personal care services. Each individual providing personal care services shall meet the requirements set forth in section 5003 of these rules.
A new subsection 5004.9 is added to read as follows:
5004.9 Each prescription for personal care services shall include the prescriber’s NPI number obtained from NPPES.
Section 5009, REIMBURSEMENT, is deleted in its entirety and replaced to read as follows:
5009 REIMBURSEMENT
5009.1 Each Provider shall be reimbursed sixteen dollars and thirty cents ($16.30) per hour for services rendered by a personal care aide.
5009.2 Reimbursement for personal care services shall not exceed eight (8) hours of service per day per beneficiary. Reimbursement for services shall not exceed five hundred and twenty (520) hours during a calendar year.
5009.3 Each Provider shall agree to accept as payment in full the amount determined by the Department of Health Care Finance as reimbursement of the authorized services provided to beneficiaries. Providers shall not bill the beneficiary or any member of the beneficiary’s family for personal care services.
5009.4 Each Provider shall agree to bill any and all known third-party payers prior to billing Medicaid.
5009.5 All claims for PCA services submitted for reimbursement shall include the NPI numbers for:
(a) the Provider; and
(b) the personal care staffing agency, if staff who performed personal care services were obtained from a personal care staffing agency.
All persons desiring to comment on the subject matter of this proposed rulemaking should file comments, in writing, no later than thirty (30) days after the date of publication of this notice in the D.C. Register. Comments should be submitted, in writing, to Julie Hudman, Director, Department of Health Care Finance, 899 North Capitol Street, N.E., 6th Floor, Washington, D.C. 20002. Copies of these rules may be obtained from the same address.
