10201 ELIGIBILITY CRITERIA

10201.1 Except as set forth in § 10201.2, a Medicaid beneficiary shall be eligible to participate in the My Health GPS program if the beneficiary has current diagnoses of three (3) or more of the following chronic conditions:

1. (a) Asthma;
2. (b) Body mass index higher than thirty-five (35);
3. (c) Cerebrovascular disease;
4. (d) Chronic obstructive pulmonary disease;
5. (e) Chronic renal failure, indicated by dialysis treatment;
6. (f) Diabetes;
7. (g) Heart disease including:
8. (1) Cardiac dysrhythmias;
9. (2) Conduction disorders;
10. (3) Congestive heart failure;
11. (4) Myocardial infarction; and
12. (5) Pulmonary heart disease;
13. (h) Hepatitis;
14. (i) Human Immunodeficiency Virus;
15. (j) Hyperlipidemia;
16. (k) Hypertension;
17. (l) Malignancies;
18. (m) Mental health conditions including:
19. (1) Depression;

(2) Bipolar disorder;

(3) Manic disorder;

(4) Schizophrenia; and

(5) Personality disorders;

(n) Paralysis;

(o) Peripheral atherosclerosis;

(p) Sickle cell anemia; and

(q) Substance use disorder.

10201.2 The following categories of beneficiaries shall not be eligible for the My Health GPS program:

(a) 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 District of Columbia Municipal Regulations (DCMR);

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

(c) Beneficiaries enrolled in the HCBS Waiver for Individual and Family Support, as described in Chapter 90 of Title 29 of the DCMR;

(d) Beneficiaries residing in a nursing facility;

(e) Beneficiaries residing in an Intermediate Care Facility for Individuals with Intellectual Disabilities;

(f) Beneficiaries enrolled in the My DC Health Home program, as described in Chapter 25 of Title 22-A DCMR;

(g) Beneficiaries enrolled in a Dual-Eligible Special Needs Plan (D-SNP) under the District Dual Choice program; and

(h) Beneficiaries enrolled in other case management programs that would be duplicative of the My Health GPS program.

10201.3 A beneficiary who is eligible for more than one Health Home program in the District of Columbia may choose to enroll in one of the programs but may not be concurrently enrolled in more than one Health Home program.

10201.4 A beneficiary may be concurrently enrolled in a D.C. Medicaid risk-based managed care organization and the My Health GPS program.

10201.5 A Medicaid beneficiary is considered enrolled in the My Health GPS program when the following conditions are met:

(a) The beneficiary has completed an initial assessment; and

(b) The My Health GPS provider has submitted a claim and has received payment for this assessment.

SOURCE: Final Rulemaking published at 65 DCR 0636 (January 26, 2018); as amended by Final Rulemaking published at 66 DCR 5381 (April 26, 2019); as amended by Final Rulemaking published at 69 DCR 011758 (September 30, 2022); as amended by Final Rulemaking published at 72 DCR 010392 (September 26, 2025).