D.C. Mun. Regs. tit. 29, r. 29-5501

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-5501 - ENROLLMENT

5501.1 The Department shall enroll certain Medicaid eligibility groups, as described in § 5501. 2, into either DC Health Families managed care program or an alternative delivery system (e.g. fee-for-service (FFS), Program for All-Inclusive Care for the Elderly, Children & Adolescents Supplemental Security Income Program (CASSIP)) using one of the following three (3) designations:

(a)Mandatory managed care, which means the beneficiary shall only be enrolled in a DC Healthy Families managed care organization (MCO) and receive services through the MCO in accordance with its contract with the Department;

(b)Voluntary managed care, which means the beneficiary may choose to enrollin a DC Healthy Families MCO or to continue to receive services through an alternative delivery system; or

(c)Excluded, which means the beneficiary shall not enroll in a DC Healthy Families MCO and may only receive services through an alternative delivery system.

5501.2 The Department shall enroll the following Medicaid eligibility groups into a DC Families MCO on a mandatory basis, as described under § 5501.1(a) (except for certain children with special health care needs and adults who will become eligible for Medicare within ninety (90) days of assignment to a mandatory managed care eligibility group, who shall have the ability to opt out of the DC Healthy Families MCO by contacting the Department, consistent with DHCF guidance published at dhcf.dc.gov):

(a) Parents and other Caretaker Relatives, as described under 42 CFR § 435.110, that have household income above the amount determined in accordance with § 9506 of Title 29 DCMR;

(b) Pregnant Women, as described under 42 CFR § 435.116 and §§ 9506.39506.5 of Title 29 DCMR;

(c) Children under Age Nineteen (19) (inclusive of Deemed Newborns under 42 CFR § 435.117) , as described under § 435.118, that have household income above the amount determined in accordance with § 9506 of Title 29 DCMR;

(d) Former Foster Care Youth (under age twenty-six [26]), as described under 42 CFR § 435.150 and referenced at § 9506.8(d)(4) of Title 29 DCMR;

(e) Individuals without a Dependent Child (Childless Adults), as described under 42 CFR § 435.119, that have household income below the amount determined in accordance with § 9506 of Title 29 DCMR;

(f) Individuals eligible for Transitional Medical Assistance, as described under §§ 1902(a)(52), 1902(e)(1), 1925, and 1931(c)(2) of the Act; and subject to the requirements set forth under § 9510 of Title 29 DCMR;

(g) Individuals receiving extended Medicaid due to Spousal Support Collections, as described under 42 CFR § 435.115;

(h) Individuals receiving Supplemental Security Income (SSI) age nineteen (19) and over, as described under 42 CFR § 435.120 and pursuant to the requirements of § 9511 of Title 29 DCMR;

(1) Individuals receiving SSI who are age twenty-one (21) or over, as well as those individuals identified in §§ 5501.2(j), 5501.2(l), 5501.2(m) and 5501.2(p), who are enrolled in CASSIP (the District's managed care program for children who are under age twenty-six [26] and receiving SSI) prior to October 1, 2021 may voluntarily remain in CASSIP until age twenty-six (26); and

(2) Individuals age twenty-one (21) or older receiving SSI, as well as those individuals identified in §§ 5501.2(j), 5501.2(l), 5501.2(m) and 5501.2(p), who are not enrolled in CASSIP prior to their twenty-first (21st) birthday will be mandatorily enrolled into a managed care plan other than CASSIP;

(i) Individuals who became ineligible for cash assistance as a result of Old-Age, Survivors, and Disability Insurance (OASDI) cost-of-living increases received after April 1977, as described under 42 CFR § 435.135;

(j) Disabled Widows and Widowers Ineligible for SSI due to an increase of OASDI, as described under 42 CFR § 435.137;

(k) Disabled Widows and Widowers Ineligible for SSI due to Early Receipt of Social Security, as described under 42 CFR § 435.138;

(l) Working Individuals with a Disability under § 1619(b) of the Act, as described under §§ 1619(b), 1902(a)(10)(A)(i)(II), and 1905(q) of the Act;

(m) Adult Children with a Disability, as described under § 1634(c) of the Act;

(n) Childless Adults Under Age Sixty-Five (65) with Income Above One Hundred Thirty Three Percent (133%) of the Federal Poverty Level (FPL), as described under 42 CFR § 435.218;

(o) Children Ages Nineteen (19) and Twenty (20), as described under 42 CFR § 435.222, and with household income above the amount determined in accordance with § 9506 of Title 29 DCMR;

(p) Aged, Blind, or Disabled (ABD) Individuals eligible for but not receiving Cash Assistance, as described under 42 CFR §§ 435.210 and 435.230;

(q) Optional State Supplement Payment Recipients, as described under 42 CFR § 435.232 and pursuant to the requirements set forth under § 9514 of Title 29 DCMR; and

(r) Optional Aged or Disabled Individuals, as described under §§ 1902(a)(10)(A)(ii) (X) and 1902(m)(1) of the Act and subject to the household income and resources requirements set forth under § 9513 of Title 29 DCMR.

5501.3 The Department shall enroll the following Medicaid eligibility groups into a DC Healthy Families MCO on a voluntary basis, as described under § 5501.1(b):

(a) Title IV-E Children, as described under 42 CFR § 435.145 and § 9506 of Title 29 DCMR;

(b) Non-Title IV-E Adoption Assistance Under Age Twenty-one (21), as described under 42 CFR § 435.227;

(c) Independent Foster Care Adolescents Under Age Twenty-One (21), as described under 42 CFR § 435.226;

(d) American Indian/Alaskan Native, as described under 42 CFR § 438.14; and

(e) Individuals who are Dual Eligible for Medicaid and Medicare, but notenrolled in the Medicare Savings Program (under §§ 1902(a)(10)(E), 1905(p), or1905(s) of the Act) with dependent children.

5501.4 The Department shall exclude the following Medicaid eligibility groups from DC Healthy Families MCO, consistent with § 5501.1(c):

(a) Individuals Eligible for Cash except for Institutionalized Status, as described under 42 CFR § 435.211;

(b) Individuals Receiving Home- and Community-Based Services (HCBS) Waiver under Institutional Rules, as described under 42 CFR § 435.217 that are subject to the non-financial requirements set forth under Chapter 42 and the financial requirements set forth under Chapter 98 of Title 29 DCMR;

(c) Individuals Participating in a Home and Community Based Service Waiver pursuant to § 1915(c) of the Social Security Act that are subject to the nonfinancial requirements set forth under Chapter 42 and the financial requirements set forth under Chapter 98 of Title 29 DCMR,

(d) Individuals Participating in a Program of All-Inclusive Care for the Elderly (PACE) Program under Institutional Rules, as described under § 1934 of the Act that are subject to the requirements set forth under Chapter 88 of Title 29 DCMR;

(e) Individuals Needing Treatment for Breast or Cervical Cancer (under age sixty-five (65)), as described under 42 CFR § 435.213 that are subject to the requirements set forth under Chapter 43 of Title 29 DCMR;

(f) Medically Needy Eligibility Group Eligible to Spend Down, as described under 42 CFR §§ 435.301(b)(1)(i) and (iii), 435.301(b)(1)(ii), 435.308, 435.310, 435.320, 435.322, 435.324;

(g) Medicare Savings Program, including Qualified Medicare Beneficiaries (QMBs) and Qualified Disabled Working Individuals (QDWIs), as described under §§ 1902(a)(10)(E), 1905(p), and 1905(s) of the Act;

(h) Children Under the TEFRA/Katie Beckett Eligibility Group, as described under 42 CFR § 435.145 that are subject to the requirements of § 9512 of Title 29 DCMR;

(i) Individuals Residing in Nursing Facilities or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), subject to the nonfinancial eligibility requirements set forth under § 989 and Chapter 41 of Title 29 DCMR (respectively), and the financial eligibility requirements set forth under Chapter 98 of Title 29 DCMR;

(j) Individuals Enrolled in Another Managed Care Plan, which may include individuals in eligibility groups described under §§ 5501.2 and 5501.3; and

(k) Individuals Receiving Retroactive Medicaid, pursuant to the requirements of 42 CFR § 435.915 and § 9501 of Title 29 DCMR.

5501.5 For beneficiaries that are enrolled on a mandatory or voluntary basis, as described under §§ 5501.1(a)-(b), the Department shall send a notice within thirty (30) days of the Department's determination of the beneficiary's Medicaid eligibility informing the beneficiary of his or her enrollment status.

5501.6 For a beneficiary that is enrolled on a mandatory basis as described under § 5501.1(a) , the Department shall include the following information in the notice described under § 5501.5:

(a) The beneficiary's right to choose to enroll in available DC Healthy Families MCOs contracted with the Department;

(b) The timeframe for which the beneficiary may choose a DC Healthy Families MCO to enroll;

(c) An explanation that if the beneficiary does not choose a DC Healthy Families MCO within the timeframe given under subparagraph (b), a DC Healthy Families MCO shall be auto-assigned to the beneficiary in accordance with the process described under §§ 5501.8(a)-(b); and

(d) A list of available DC Healthy Families MCOs that are contracted with the Department.

5501.7 A beneficiary enrolled on a mandatory managed care basis shall have thirty (30) days from the date of the notice, described under § 5501.5, to select a DC Healthy Families MCO and to submit his or her selection to the Department through the following means of communication:

(a) Over the internet;

(b) By telephone;

(c) By mail; or

(d) Through other commonly available electronic means.

5501.8 If a beneficiary does not choose a DC Healthy Families MCO within the timeframe specified in § 5501.7 and is auto-assigned to a DC Healthy Families MCO in accordance with § 5501.6(c), auto-assignment shall occur in accordance with the following requirements:

(a) The Department shall use a process where each DC Healthy Families MCO's position in the assignment order is stored in an electronic system that remembers the next DC Healthy Families MCO in order for the purpose of automated, sequential beneficiary assignment;

(b) The Department shall enroll all members of the same household into the same DC Healthy Families MCO as other members of the same household unless a family member has requested another DC Healthy Families MCO; and

(c) Auto-assignment and enrollment into an DC Healthy Families MCO shall be completed within sixty (60) days of the end of the initial thirty (30) day DC Healthy Families MCO enrollment selection period identified in § 5501.6.

5501.9 On the date of the beneficiary's auto-assignment to a DC Healthy Families MCO in accordance with § 5501.8, the Department shall send an additional notice to the beneficiary that contains the following information:

(a) An explanation that the beneficiary has been automatically enrolled into a DC Healthy Families MCO, including the name and contact information for the selected DC Healthy Families MCO; and

(b) A description of the beneficiary's rights under auto-assignment, including to the beneficiary's right to disenrollment, as described under § 5502.

5501.10 For a beneficiary that is enrolled on a voluntary basis in accordance with § 5501.1(b) , the Department shall include the following information in the notice described under § 5501.5:

(a) The beneficiary's right to choose to enroll in a DC Healthy Families MCO or to receive services through an alternative delivery system;

(b) The timeframe during which the beneficiary may choose to enroll in a DC Healthy Families MCO or receive services through an alternative delivery system, as described under § 5501.11;

(c) A list of available DC Healthy Families MCOs that are contracted with the Department, including contact information and website links; and

(d) For beneficiaries in eligibility groups described under § 5501.3(a) - (c), an explanation that if the beneficiary does not make an election within the timeframe specified in § 5501.11, the Department shall enroll the beneficiary into an alternative delivery system. For beneficiaries in eligibility groups described under §§ 5501.3(d) - (e), an explanation that if the beneficiary does not make an election within the timeframe specified in § 5501.11, the Department shall enroll the beneficiary into a DC Healthy Families MCO.

5501.11 Beneficiaries enrolled on a voluntary basis (in accordance with § 5501.1(b)) shall have thirty (30) days from the date of the notice described under § 5501.5 to choose to enroll in either a DC Healthy Families MCO or receive services through an alternative delivery system and to send the selection to the Department through the following means:

(a) Over the internet;

(b) By telephone;

(c) By mail; or

(d) Through other commonly available electronic means.

5501.12 Except for eligibility groups described under §§ 5501.3(d) - (e), if a beneficiary does not make an election within thirty (30) days and submit his or her election to the Department in accordance with § 5501.11, the Department shall automatically enroll the beneficiary in a FFS delivery system. For eligibility groups described under §§ 5501.3(d) - (e), if the beneficiary does not elect to remain in a FFS delivery system within thirty (30) days of the notice, the Department shall automatically enroll the beneficiary in a DC Healthy Families MCO, described under 5501.15. Following enrollment in managed care, the Department shall additionally provide beneficiaries in eligibility groups described under §§ 5501.3(d) - (e) an additional thirty (30) days to disenroll from managed care, as described under § 5502, and return to a FFS delivery system.

5501.13 If the Department approves a beneficiary's enrollment into a DC Healthy Families MCO by the fifteenth (15th) of the month, the beneficiary's enrollment in a DC Healthy Families MCO shall be effective on the first (1st) day of the following month.

5501.14 If the Department approves a beneficiary's enrollment into a DC Healthy Families MCO care after the fifteenth (15th) of the month, the beneficiary's enrollment in an DC Healthy Families MCO shall be effective on the first (1st) day of the second (2nd) month after the month in which the Department approves the enrollment.

5501.15 Beneficiaries enrolled in a DC Healthy Families MCO (either on a mandatory or voluntary basis as described under §§ 5501.1(a) or (b)) may opt to enroll in a different DC Healthy Families MCO for any reason within ninety (90) days of enrollment or during an annual open enrollment period, which shall be from November 1 through January 31 each year. Beneficiaries may also opt to enroll in a different DC Healthy Families MCO during special open enrollment periods identified by DHCF and specified in guidance published on the DHCF website. For beneficiaries in eligibility groups described under §§ 5501.3(d) - (e) who are automatically enrolled in managed care as described under § 5501.12, the beneficiary shall additionally have the option to elect to enroll in an alternative delivery system during the open enrollment period.

5501.16 Thirty (30) days in advance of the open enrollment period, the Department shall send a notice to all currently enrolled DC Healthy Families MCO beneficiaries to inform the beneficiary of the open enrollment period and the process and required timeframes for selection of a DC Healthy Families MCO for the upcoming plan year.

5501.17 If the beneficiary chooses to change the DC Healthy Families MCO in which the beneficiary is currently enrolled, in accordance with § 5501.15, the beneficiary may submit his or her new election to the Department through the following means:

(a) Over the internet;

(b) By telephone;

(c) By mail; or

(d) Through other commonly available electronic means.

D.C. Mun. Regs. tit. 29, r. 29-5501

Final Rulemaking published at 42 DCR 1566, 1597 (March 31, 1995); amended by Final Rulemaking published at 69 DCR 2149 (3/18/2022)