D.C. Mun. Regs. tit. 29, r. 29-10202

Current through Register Vol. 71, No. 44, November 1, 2024

Rule 29-10202 - BENEFICIARY ASSIGNMENT AND ENROLLMENT

10202.1

All beneficiaries who meet the eligibility criteria set forth in § 10201 may participate in the My Health GPS program.

10202.2

A beneficiary shall only be assigned to a single My Health GPS entity at any time in accordance with the process set forth below:

(a) An eligible beneficiary shall be assigned to the My Health GPS entity that currently provides the beneficiary's primary care services or to a My Health GPS entity that is part of a corporate entity that currently provides the beneficiary's primary care services;

(b) If the beneficiary has a relationship with more than one (1) My Health GPS entity, as determined by the Department of Health Care Finance (DHCF) through a review of Medicaid claims submitted during the past twelve (12) months, the beneficiary shall be assigned to the My Health GPS entity seen most frequently during the review period;

(c) If a beneficiary who meets the criteria described in (b) has seen multiple My Health GPS entities with equal frequency during the review period, the beneficiary shall be assigned to the entity seen most recently during the review period; and

(d) If the beneficiary does not have a prior relationship with any My Health GPS entity, as determined by DHCF through a review of Medicaid claims submitted during the past twelve (12) months, the beneficiary shall be assigned to a My Health GPS entity based on the entity's capacity to serve additional beneficiaries and the geographic proximity of the beneficiary to the entity.

10202.3

The initial assignment of eligible beneficiaries shall occur after the initial application period described in § 10204.4(a) and shall be effective on the program implementation date. Eligible beneficiaries who enter the program after the initial assignment period shall be assigned on a time-basis established in accordance with guidance published to the DHCF website or within thirty (30) days of receipt of a referral.

10202.4

After an assignment is made, DHCF shall provide the beneficiary with the following information in writing:

(a) A clear statement that the beneficiary has been identified as eligible to participate in the My Health GPS program;

(b) A clear explanation of the benefits of the My Health GPS program and the services provided;

(c) Information regarding the My Health GPS entity to which the beneficiary has been assigned;

(d) A clear explanation of the beneficiary's right to select a different My Health GPS entity or to opt out of the My Health GPS program; and

(e) Instructions on selecting a different My Health GPS entity and opting out of the My Health GPS program.

10202.5

DHCF shall inform any other provider furnishing primary care services to an eligible beneficiary of the assignment, in writing, of the following:

(a) A statement that the beneficiary served by the provider has been determined eligible for the My Health GPS program and assigned to a My Health GPS entity;

(b) A clear explanation of the benefits of the My Health GPS program and the services provided; and

(c) Information regarding the My Health GPS entity to which each beneficiary has been assigned.

10202.6

A beneficiary who has been assigned to a My Health GPS entity shall have the right to select a different entity or to opt out of the My Health GPS program.

10202.7

A beneficiary may notify DHCF at any time that the beneficiary wishes to select a different My Health GPS entity or opt out of the program.

10202.8

A beneficiary who has been assigned to a My Health GPS entity and wishes to be assigned to a different entity shall notify DHCF. The assignment to the new entity shall occur as follows:

(a) If the beneficiary notifies DHCF of the new selection prior to the twentieth (20^th) day of the mont h, the beneficiary shall be re-assigned to the new entity effective the first (1^st) day of the month following the month in which the beneficiary notified DHCF of the new selection;

(b) If the beneficiary notifies DHCF on or after the twentieth (20^th) day of the month, the beneficiary shall be re-assigned to the new entity effective the first (1^st) day of the second (2^nd) month following the month in which the beneficiary notified DHCF of the new selection; and

(c) The beneficiary shall remain eligible to receive My Health GPS services from the beneficiary's current My Health GPS entity until the effective date of the beneficiary's assignment to the new entity.

10202.9

Any beneficiary assigned to a My Health GPS entity for whom the entity has not submitted an initial claim for a person-centered care plan in accordance with § 10207.12 within the first two (2) quarters following the effective date of the beneficiary assignment, as described in § 10202.3, may be re-assigned to another My Health GPS entity in accordance with the process described in § 10202.2.

10202.10

If DHCF re-assigns a beneficiary to a new My Health GPS entity, DHCF shall provide the beneficiary the following information in writing:

(a) A statement that the beneficiary remains eligible to participate in the My Health GPS program but has been re-assigned to a new My Health GPS entity;

(b) A clear explanation of the benefits of the My Health GPS program and the services provided;

(c) The reason the beneficiary has been re-assigned to a ne w My Health GPS entity;

(d) Information regarding the new My Health GPS entity to which the beneficiary has been assigned;

(e) A clear explanation of the beneficiary's right to select a different My Health GPS entity or to opt out of the My Health GPS program; and

(f) Instructions on selecting a different My Health GPS entity and opting out of the My Health GPS program.

10202.11

If DHCF re-assigns a beneficiary to a new My Health GPS entity, DHCF shall notify the entity to which the beneficiary was previously assigned of the reassignment in writing, including the following information:

(a) A clear statement explaining why the beneficiary has been re-assigned;

(b) Specific reference to the applicable sections of the rules, statute or provider manual; and

(c) The effective date of the re-assignment.

10202.12

The effective date of a beneficiary's enrollment in the My Health GPS program shall be the date on which the My Health GPS provider completes the components of the beneficiary's person-centered plan of care in accordance with § 10207.12.

D.C. Mun. Regs. tit. 29, r. 29-10202

Final Rulemaking published at 64 DCR 636 (1/26/2018); amended by Final Rulemaking published at 66 DCR 005382 (4/26/2019)