D.C. Mun. Regs. tit. 29, r. 29-4112

Current through Register Vol. 71, No. 43, October 25, 2024

Rule 29-4112 - DENIAL OF PAYMENT

4112.1

Pursuant to Section 1902(i) of the Act and 42 C.F.R. § 442.118, and in lieu of termination in situations where residents are not in immediate jeopardy, DHCF may initiate a one-time denial of payment for claims associated with new admissions at ICFs/IID that fail to comply with one (1) or more of the CoPs for Medicaid enrollment.

4112.2

The denial of payment term shall be eleven (11) months in duration, beginning on the first day of the month after DHCF imposes the denial of payments.

4112.3

DHCF shall also deny payment to ICFs/IID if DOH previously initiated enforcement actions due to immediate jeopardy, and the facility has failed to mitigate the circumstances that caused immediate jeopardy.

4112.4

DHCF, in coordination with DOH, shall notify the ICF/IID that it is subject to denial of payment. The written notification shall indicate the following:

(a) The ICF/IID has up to sixty (60) days to correct the cited deficiencies; and

(b) The procedures that shall commence once the sixty (60) days have lapsed, pursuant to§ 4112.5.

4112.5

If the ICF/IID does not correct the violations within the sixty (60) day timeframe, DHCF shall notify the facility of its intention to deny payment. This written notification shall include:

(a) Reasons for denial of payment;

(b) Information on the right to request a hearing though OAH, pursuant to 29 DCMR§§ 1300 et seq.;

(c) Details of public notice; and

(d) The effective date for denial of payments.

4112.6

If an ICF/IID appeals DHCF's decision to deny payment, DHCF shall notify the provider that the effective date of the sanction, established in § 4112.2, shall be suspended until the appeal is resolved.

4112.7

If denial of payment is upheld at the appeal, the DHCF shall notify the facility and the public at least thirty (30) days before the newly established effective date of the sanction.

4112.8

DHCF, in coordination with other District agencies, shall monitor the facility's progress in improving cited violation(s) throughout the eleven (11) month period.

4112.9

The Director of DHCF shall consider modifying or rescinding denial of payment upon the occurrence of one of the following:

(a) Circumstances have changed and resulted in alterations of the CoPs violation(s) in such a manner as to immediately jeopardize patient health and safety; or

(b) The ICF/IID achieves full compliance with the CoPs in fewer than eleven (11) months; or

(c) The ICF/IID makes significant progress in achieving compliance with the CoPs through good faith efforts.

4112.10

DHCF shall terminate the provider agreement of an ICF/IID that has been unable to achieve compliance with the CoPs during the full eleven (11) month period of denial of payment. Termination shall be effective on the first day following the last day of the denial payment period.

4112.11

An ICF/IID provider agreement that is subject to denial of payment shall be automatically extended for the eleven (11) month period if the provider agreement does not lapse on or before the effective date of denial of payments.

4112.12

ICF/IID provider agreements that are subject to denial of payment may only be renewed when the denial period expires or is rescinded.

D.C. Mun. Regs. tit. 29, r. 29-4112

Final Rulemaking published at 60 DCR 11590 (August 9, 2013); as Amended by Final Rulemaking published at 61 DCR 12231 (November 28, 2014); amended by Final Rulemaking published at 63 DCR 297 (1/8/2016)

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. 744; D.C. Official Code § 1-307.02 (2006 Repl. & 2012 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.).