D.C. Mun. Regs. tit. 29, r. 29-5799

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

Rule 29-5799 - DEFINITIONS

For the purposes of this chapter, the following terms shall have the meanings ascribed:

Applicant -- shall have the same meaning as set forth in § 9599.1 of Chapter 95 of Title 29 DCMR.

Beneficiary -- an individual who has been determined eligible and is currently receiving Medicaid.

Department -- the Department of Health Care Finance (DHCF) or its designee or agent.

Dependent child -- a biological, adopted, or step-child who is under the age of eighteen (18), or is age eighteen (18) and a full-time student in secondary school (or equivalent vocational or technical training).

Disenrollment -- discontinuation of a Medicaid beneficiary's enrollment with a specific D-SNP that provides Medicaid services to District Medicaid beneficiaries.

Dual Special Needs Plan (D-SNP) - a specialized Medicare Advantage plan for special needs individuals who are entitled to medical assistance under a State plan under title XIX of the Social Security Act, as described at 42 CFR § 422.2.

Intermediate sanction - suspension of all new enrollment, including default enrollment, after the date the Secretary or the Department notifies the D-SNP of a determination of a violation of any requirement under sections 42 U.S.C. §§ 1396b(m) or 1396u-2.

Medicaid -- the program established under Title XIX and Title XXI of the Social Security Act, 42 USC §§ 1396et seq., and Chapter 9 of Title 29 DCMR.

Medicare -- the health insurance program for the aged and disabled under Title XVIII of the Social Security Act.

Medicare Advantage plan -- a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. 1395w-28(b)(1), which includes:

(1) Coordinated care plans which provide health care services, including but not limited to health maintenance organization plans (with or without a point-of-service option), plans offered by provider-sponsored organizations, and preferred provider organization plans;

(2) Medical savings account plans coupled with a contribution into a Medicare Advantage plan medical savings account; and

(3) Medicare Advantage private fee-for-service plans.

Medicare supplement policy -- a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical services associations or health maintenance organizations, other than a policy issued pursuant to a contract under 42 U.S.C § 1395mm or an issued policy under a demonstration project specified in 42 U.S.C. § 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare. The term "Medicare supplement policy" does not include Medicare Advantage plans established under Medicare Part C, Outpatient Prescription Drug plans established under Medicare Part D, or any Health Care Prepayment Plan (HCPP) that provides benefits pursuant to an agreement under 42 U.S.C. § 1395l(a)(1)(A).

D.C. Mun. Regs. tit. 29, r. 29-5799

Final Rulemaking published at 43 DCR 4833, 4857 (September 6, 1996); repealed by Final Rulemaking published at 69 DCR 2149 (3/18/2022); amended by Final Rulemaking published at 69 DCR 11758 (9/30/2022)