D.C. Mun. Regs. tit. 29, r. 29-995

Current through Register Vol. 72, No. 2, January 10, 2025

Rule 29-995 - MEDICAID PHYSICIAN AND SPECIALTY SERVICES RATE METHODOLOGY

995.1

Medicaid reimbursement rates for fee-for-service physician and specialist services shall be eighty percent (80%) of the rates paid by the Medicare Program as set forth in this section, except for physician-administered chemotherapy drugs administered on or after May 1, 2016. Medicaid reimbursement for chemotherapy drugs that are administered on or after May 1, 2016 shall be one hundred percent (100%) of the Medicare fee schedule. The reimbursement rates for physician administered chemotherapy drugs shall be posted on DHCF's website at www.dc-medicaid.com and updated annually.

995.2

For services where the physician and specialist service procedure code falls within the Medicare (Title XVIII) fee schedule, payment shall be the lesser of the Medicare rate established pursuant to subsection 995.1 or the providers' actual charges to the general public.

995.3

For services where the procedure code does not fall within the Medicare fee schedule, an alternative method, as set forth in §§995.4, shall be used to establish the Medicaid reimbursement rate.

995.4

When making a determination to establish the Medicaid reimbursement rate using an alternative method for physician and specialty services, in addition to using professional judgment, the following factors may be considered:

(a) Practitioner fees;

(b) Fee schedules from other states;

(c) Similar procedures with established fees; or

(d) Private insurance payments.

995.5

All updates to the Medicaid fee schedule governing reimbursement rates for physician and specialty services shall comply with the requirements set forth under Section 988 (Medicaid Fee Schedule) of this chapter.

995.6

All physician and specialty services reimbursement rates shall be located on the Department of Health Care Finance website.

995.7

The Department of Health Care Finance (DHCF) shall provide a supplemental payment to participating providers of physician and specialty services in accordance with the requirements set forth in Section 995.4 through 995.7.

995.8

For services rendered between October 1, 2024, through June 30, 2025, supplemental payments in the amount described in §§ 995.10 shall be equally distributed among physician groups that meet the criteria described in §§ 995.9.

995.9

To receive a supplemental payment, a physician group shall meet all of the following requirements:

(a) Be a group practice, consistent with the conditions set forth under 42 CFR §§ 411.352, and have at least five hundred (500) physicians that are members of the group (whether employees or direct or indirect owners) as defined at 42 CFR §§ 411.351;

(b) Be screened and enrolled with the Department of Health Care Finance (DHCF) in accordance with the requirements set forth under Chapter 94 of Title 29 of this title; and

(c) Contract with a public general hospital, as defined under 22-B DCMR §§ 2099, located in an economically underserved area of the District of Columbia to provide at least one (1) of the following services to Medicaid beneficiaries:

(1) Inpatient services, as described in Supplement 1 to Attachment 3.1A, Section 1.B, page 2, and Supplement 1 to Attachment 3.1B, Section 1.B, page 2 of the District's State Plan for Medical Assistance (State Plan) (available at https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Amount%2C%20Duration%20and%20Scope%20of%20Services%20Attachment%203.1A%20Supplement%201_2.pdf;

https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Amount%2C%20Duration%20and%20Scope%20of%20Services%20Attachment%203.1B%20Supplement%201%20%28P.17-49%29.pdf; and

https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Payment%20for%20Services%20Attachment%204.19B%20Part%201%20%28p.%206aa-40%29_2.pdf) and defined in 42 CFR §§ 440.10;

(2) Emergency hospital services, as described in Supplement 1 to Attachment 3.1A, Section 24.E, page 28; Supplement 1 to Attachment 3.1B, Section 24.E, page 27; and Attachment 4.19B, Part 1, Section 20.a, page 11 of the State Plan (available at the websites listed in subparagraph (c)(1)); or

(3) Intensive care physician services, as authorized under Supplement 1 to Attachment 3.1A, Section 5, pages 6b-7, and Supplement 1 to Attachment 3.1B, Section 5, pages 5b-6 of the State Plan (available at the websites listed in subparagraph (c)(1)).

995.10

Supplemental payments made in accordance with §§ 995.8 shall equal four million five hundred thousand dollars ($4,500,000) for Fiscal Year 2025.

995.11

Payments shall be made in three (3) installments, aligning with the end of the first (1^st), second (2^nd), and third (3^rd) quarters of the federal fiscal year. All payments shall be made by June 30, 2025.

D.C. Mun. Regs. tit. 29, r. 29-995

Final Rulemaking published at 44 DCR 5497 (September 26, 1997); as amended by Final Rulemaking published at 50 DCR 3473 (May 2, 2003); as amended by Final Rulemaking published at 50 DCR 9253 (October 31, 2003); as amended by Final Rulemaking published at 52 DCR 7021 (July 29, 2005); as amended by Final Rulemaking published at 55 DCR 338 (January 11, 2008); as amended by Final Rulemaking published at 56 DCR 5928 (July 24, 2009); as amended by Emergency and Proposed Rulemaking published at 57 DCR 950 (October 8, 2010)[EXPIRED]; as amended by Final Rulemaking published at 59 DCR 147 (January 13, 2012); as amended by Final Rulemaking published at 60 DCR 11955 (August 16, 2013); amended by Final Rulemaking published at 63 DCR 10443 (8/12/2016); amended by Final Rulemaking published at 67 DCR 3713 (4/3/2020); amended by Final Rulemaking published at 69 DCR 2147 (3/18/2022); amended by Final Rulemaking published at 69 DCR 14963 (12/9/2022); amended by Final Rulemaking published at 70 DCR 15107 (11/17/2023); amended by Final Rulemaking published at 71 DCR 16344 (12/27/2024)

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.774; D.C. Official Code § 1-307.02 (2011 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.).