10205.1 Each My Health GPS provider shall contain an approved interdisciplinary team of practitioners, as described within this Section, embedded within the primary care setting of an organization described in § 10204.1.
10205.2 Each My Health GPS provider shall be adequately staffed, consistent with the requirements set forth in this section, by healthcare professionals who meet all applicable licensure and certification requirements of the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01et seq. (2012 Repl. & 2016 Supp.)) and attendant regulations contained in Title 17 DCMR.
10205.3 Each My Health GPS provider serving lower-acuity (Group One) beneficiaries, as determined using the criteria set forth in § 10207.4, shall be comprised, at a minimum, of the following practitioners, or comparable practitioners as approved by DHCF on a case-by-case basis as set forth below:
(a) A Health Home Director, who has a Master's level education in a health-related field;(b) A Nurse Care Manager, who has an advanced practice nursing license or a Bachelor of Nursing degree with appropriate care management experience; and(c) A Peer Navigator, who is a health educator capable of linking beneficiaries with the health and social services they need to achieve wellness, who has either completed at least forty (40) hours of training in, or has at least six (6) months of experience in, community health.10205.4In addition to the practitioners described in § 10205.3, each My Health GPS provider serving higher-acuity (Group Two) beneficiaries, as determined using the criteria set forth in § 10207.4, shall also include the following practitioners, or practitioners with comparable qualifications as approved by DHCF on a case-by-case basis:
(a) A Care Coordinator, who has a Bachelor's degree in social work or has a Bachelor's degree in a health-related field with at least three (3) years' experience in a healthcare or human services field; and(b) A licensed Clinical Pharmacist, who is a Doctor of Pharmacy with experience in direct patient care environments, including but not limited to experience providing services in medical centers and clinics.10205.5 The minimum staffing ratios for providers are as follows:
(a) For My Health GPS providers serving lower-acuity (Group One) beneficiaries, the following minimum staffing ratios are required: (1) Health Home Director: One half (0.5) full- time employee per four hundred (400) beneficiaries;(2) Nurse Care Manager: One (1) full-time employee per four hundred (400) beneficiaries; and(3) Peer Navigator: One (1) full- time employee per four hundred (400) beneficiaries;(b) For My Health GPS providers serving higher-acuity (Group Two) beneficiaries, the following minimum staffing ratios are required: (1) Health Home Director: The equivalent of one-half (0.5) of a fulltime employee's hours worked per four hundred (400) beneficiaries;(2) Nurse Care Manager: Two (2) full- time employees per four hundred (400) beneficiaries;(3) Peer Navigator: The equivalent of three and one-half (3.5) of the hours a full-time employee works per four hundred (400) beneficiaries;(4) Care Coordinator: Two (2) full-time employees per four hundred (400) beneficiaries; and(5) Clinical Pharmacist: The equivalent of one- half (0.5) of the hours full-time employee works per four hundred (400) beneficiaries.10205.6Each My Health GPS entity shall demonstrate that all its My Health GPS providers comply with the minimum staffing ratios set forth in § 10205.5 no later than the end of the second quarter following the effective date of the entity's enrollment in the My Health GPS program. A My Health GPS entity shall continue to comply with all minimum staffing ratios for the duration of the entity's enrollment in the program.
10205.7 If a My Health GPS entity fails to comply with the requirements set forth in § 10205.6, the entity may only be allowed to retain the number of beneficiaries whose needs are met by the entity's current My Health GPS providers. Any remaining beneficiaries may be re-assigned to another My Health GPS entity.
10205.8 If all My Health GPS providers within a My Health GPS entity have maximized capacity to serve the entity's enrolled beneficiaries in accordance with the staffing ratios outlined in § 10205.5 and the entity is contacted by a beneficiary who wishes to receive My Health GPS services from any of its My Health GPS providers, the entity shall notify DHCF within one (1) business day of receiving a beneficiary's request for services.
10205.9 If beneficiaries are re-assigned to another My Health GPS entity pursuant to § 10205.7, DHCF shall notify the entity to which the beneficiaries were previously assigned of the re-assignment in writing consistent with the requirements set forth in § 10202.11.
10205.10 If DHCF re-assigns a beneficiary to a new My Health GPS entity, DHCF shall inform the beneficiary of the re-assignment in accordance with § 10202.10.
10205.11 Each My Health GPS provider shall conduct outreach to each beneficiary in accordance with the following timeframes:
(a) The provider shall conduct outreach by the end of the second quarter following the effective date of the entity's enrollment for all beneficiaries initially assigned to the entity as described in § 10202.3; and(b) The provider shall conduct outreach by the end of the second quarter following the effective date of the beneficiary's assignment for all beneficiaries subsequently assigned to the entity as described in § 10202.3.10205.12 Each My Health GPS provider shall document the outreach activity performed pursuant to § 10205.11 by including the following information in each beneficiary's EHR:
(a) The date and time the activity was performed;(b) The identity of the My Health GPS provider staff member who performed the activity;(c) A description of the setting in which the activity was performed; and(d) A description of the activity, including mode of communication.10205.13 In order to maintain enrollment as a My Health GPS entity, each organization described in § 10204.1 shall:
(a) Participate in activities supporting the successful implementation of the My Health GPS program, including, but not limited to:(1) Trainings to foster professional competency and development of best practices related to person-centered planning, chronic disease self- management, and related topics;(2) Continuous quality improvement tasks, monitoring and performance reporting;(3) District-wide initiatives to support the exchange of health information; and(4) Evaluations required by the Centers for Medicare and Medicaid Services (CMS), DHCF or its agent;(b) Maintain compliance with all requirements set forth in this chapter; and(c) Maintain compliance with all terms and conditions set forth in the entity's DC Medicaid provider agreement including all modifications, as well as with all applicable federal and District laws.10205.14 Each My Health GPS entity shall enter into a Memorandum of Agreement (MOA) with each D.C. Medicaid Managed Care Organization (MCO). The MOA shall set forth the division of responsibilities between the MCO and the My Health GPS entity.
D.C. Mun. Regs. Tit. 29, § 10205
Final Rulemaking published at 64 DCR 636 (1/26/2018); amended by Final Rulemaking published at 66 DCR 005382 (4/26/2019)