D.C. Mun. Regs. tit. 29, r. 29-808

Current through Register 71, No. 45, November 7, 2024

Rule 29-808 - REIMBURSEMENT

808.1

Since Medicaid cannot reimburse providers for services given without charge to the general public unless they are specifically exempted from charges by law, a participating FSMHC shall have an established fee schedule covering each of the services it provides from which a charge is made to each patient receiving the services.

808.2

A participating FSMHC shall agree to accept as payment in full the amount determined by the Department of Human Services as the fee for the authorized services provided to Medicaid patients. No additional charge may be made to the Medicaid patient, any member of the family, or to any other source.

808.3

A participating FSMHC shall agree to bill any and all other known third party payors prior to billing Medicaid.

808.4

A participating FSMHC shall understand that the payment and satisfaction of any Medicaid claim will be from federal and District funds, and that false claims, statements, documents, or concealment of material fact may be prosecuted under applicable federal and District laws.

808.5

The Department shall establish fees and reimburse for only those FSMHC services, as set forth in § 808.9, provided face-to- face by or under the direct supervision of a physician. Health Home services provided by a FSMHC shall be provided in accordance with the requirements set forth in 29 DCMR §§ 6900 , et seq. and 22-A DCMR §§ 2500, et seq.

808.6

Treatment-related services, such as information and referral services, charting, staffing of patients, co-therapy phone crisis intervention, case management, person and agency conferences, and similar services are not reimbursable under the FSMHC benefit. FSMHCs certified as a Health Home shall be reimbursed for the provision of Health Home services in accordance with the requirements set forth in 29 DCMR §§ 6900 , et seq. and 22-A DCMR §§ 2500, et seq.

808.7

Recreational therapy shall not be reimbursed under Medicaid.

808.8

Excluding Health Home services provided in accordance with requirements set forth in 29 DCMR §§ 6900 , et seq. and 22-A DCMR §§ 2500, et seq., Medicaid shall reimburse a participating FSMHC for only one (1) type of service for a Medicaid patient on a given day; provided, that if a full prescription visit, or medication assessment visit is indicated in addition to a therapy visit, and is accomplished on the same day, both services may be billed as long as no more than one (1) billing of this type occurs in a single month. Any additional billings of this type, shall be authorized by the Department prior to the FSMHC submitting a claim for payment.

808.9

The following services shall be reimbursable if the physician has certified that the services were medically necessary and a treatment plan for the services has been established by a physician or other qualified mental health professional which is periodically reviewed and approved by a physician:

(a) INDIVIDUAL PSYCHOTHERAPY - verbal, drug augmented, or other therapy methods provided by a mental health professional in a face-to-face involvement with one (1) patient to the exclusion of other patients and duties. A minimum of fifty (50) minutes shall be allotted to the patient's therapy hour;

(b) PRESCRIPTION VISITS - a visit with a physician for review and evaluation of the medication history of the patient and the writing or renewal of prescriptions as necessary. A minimum of fifteen (15) minutes shall be allotted to the visit;

(c) FAMILY THERAPY - therapy with the patient and one (1) or more family members present. Verbal or other therapy methods by a mental health professional in a personal involvement with the patient and family to the exclusion of other patients and duties. A minimum of sixty (60) minutes shall be allotted to the therapy hour. The clinic may bill Medicaid only for the Medicaid patient;

(d) FAMILY CONFERENCES - meeting with the family, or other significant persons (school, court, or other agency officials), to interpret or explain medical, psychiatric, or psychological examinations and procedures, other accumulated data and advice on how to assist the patient. A minimum of fifty (50) minutes shall be allotted to personal involvement with the family or other significant persons. The clinic may bill Medicaid only for the Medicaid patient;

(e) COMPLETE PSYCHOLOGICAL TESTING - up to five (5) hours of psychometric and projective tests with a written report done under the direction of a licensed clinical psychologist; and

(f) GROUP THERAPY - verbal or other therapy methods provided by a mental health professional in face-to-face involvement with three (3) or more patients with a maximum of twelve (12) patients. A minimum of sixty (60) minutes shall be allotted to the therapy hour.

D.C. Mun. Regs. tit. 29, r. 29-808

Final Rulemaking adopted at 29 DCR 264 (January 15, 1982); amended by Final Rulemaking published at 66 DCR 007941 (7/5/2019)