D.C. Mun. Regs. tit. 29, r. 29-6902

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

Rule 29-6902 - REIMBURSEMENT

6902.1

Medicaid reimbursement for Health Home services is on a per member per month (PMPM) reimbursement schedule. The month time period shall begin on the first (1^st) of the month and end on the last day of the month.

6902.2

Health Homes are required to provide services in accordance with § 6901.4, and document the delivery of these services in DBH's approved electronic record system, in order to receive the PMPM reimbursement rate.

6902.3

In order to qualify for the monthly rate, Health Homes shall document Health Home services provided as set forth in 22-A DCMR § 2515.3 and §§ 2516.3 - 4.

6902.4

Health Homes shall not bill the beneficiary or any member of the beneficiary's family for Health Home services. Health Homes shall bill all known third-party payors prior to billing the Medicaid Program.

6902.5

Medicaid reimbursement for Health Home services for dates of service prior to February 1, 2019 shall be determined as follows:

SERVICE	CODE	BILLABLE UNIT OF SERVICE	RATE EFFECTIVE JAN. 1, 2016
Health Home Services: High-Acuity	S0281U1	Month	$481.00
Health Home Services: Low-Acuity	S0281U2	Month	$349.00

6902.6

Effective February 1, 2019, Medicaid reimbursement for Health Home services shall be determined as follows:

SERVICE	CODE	BILLABLE UNIT OF SERVICE	RATE EFFECTIVE FEBRUARY 1, 2019
Health Home Services	S0281U4	Month	$125.75

6902.7

DBH shall be responsible for payment of the District's share or the local match for Health Home services. DHCF shall claim the federal share of financial participation for Health Home services.

6902.8

Medicaid reimbursement for Health Home services is not available for:

(a) Room and board costs;

(b) Inpatient services (including hospital, nursing facility services. Intermediate Care Facilities for Individuals with Intellectual Disabilities, and Institutions for Mental Diseases services);

(c) Transportation services;

(d) Vocational services;

(e) School and educational services;

(f) Socialization services;

(g) Services which are not provided and documented in accordance with DBH-established Health Home service-specific standards;

(h) A person who is receiving Assertive Community Treatment (ACT) services;

(i) Medicaid beneficiaries enrolled in the Home and Community- Based Services (HCBS) Waiver for the Elderly and Individuals with Physical Disabilities, as described in Chapter 42 of Title 29 of the DCMR;

(j) Medicaid beneficiaries enrolled in the HCBS Waiver for Persons with Intellectual and Developmental Disabilities, as described in Chapter 19 of Title 29 of the DCMR; and

(k) Medicaid beneficiaries enrolled in the My Health GPS program, as described in Chapter 102 of Title 29 of the DCMR.

6902.9

Only one Health Home will receive payment for delivering Health Home services to a beneficiary in a particular month.

6902.10

Effective February 1, 2018, an entity enrolled as Health Home may bill Medicaid separately for the provision of MHRS Community Support services provided to a beneficiary enrolled in a Health Home.

6902.11

DHCF shall not reimburse other Medicaid claims submitted by Health Homes that duplicate Health Home services, as described in 22-A DCMR §§ 2506 - 2511.

D.C. Mun. Regs. tit. 29, r. 29-6902

Final Rulemaking published at 65 DCR 7933 (7/5/2019)