10205 MY HEALTH GPS PROVIDER REQUIREMENTS

10205.1 Each My Health GPS provider shall contain an approved interdisciplinary team of practitioners, as described within this Section, embedded within the primary care setting of an organization described in § 10204.1.

10205.2 Each My Health GPS provider shall be adequately staffed, consistent with the requirements set forth in this section, by healthcare professionals who meet all applicable licensure and certification requirements of the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01 et seq. (2012 Repl. & 2016 Supp.)) and attendant regulations contained in Title 17 DCMR.

10205.3 Each My Health GPS provider shall comprise, at a minimum, the following practitioners, or comparable practitioners, as approved by DHCF on a case-by-case basis, as set forth below:

(a) A Health Home Director, who has a Master’s level education in a health-related field;

(b) A Nurse Care Manager, who has an advanced practice nursing license or a Bachelor of Nursing degree with appropriate care management experience;

(c) A Social Worker (Care Coordinator), who has a Bachelor’s degree in social work or has a Bachelor’s degree in a health-related field with at least three (3) years’ experience in a healthcare or human services field; and

(d) A Peer Navigator, who is a health educator capable of linking beneficiaries with the health and social services they need to achieve wellness. This individual has either completed at least forty (40) hours of training, or has at least six (6) months of experience, in community health.

10205.4 For My Health GPS providers, the following minimum staffing ratios are required per 400 beneficiaries:

(a) Health Home Director: One half (0.5) full-time employee;

(b) Nurse Care Manager: Two (2) full-time employees;

(c) Social Worker (Care Coordinator): One (1) full-time employee; and

(d) Peer Navigator: One (1) full-time employee.

10205.5 Each My Health GPS entity shall demonstrate that all its My Health GPS providers comply with the minimum staffing ratios set forth in § 10205.4 no later than the end of the second quarter following the effective date of the entity's enrollment in the My Health GPS program. A My Health GPS entity shall continue to comply with all minimum staffing ratios for the duration of the entity's enrollment in the program.

10205.6 If a My Health GPS provider fails to comply with the minimum staffing ratio set forth in § 10205.4, the entity shall only be allowed to retain the beneficiaries who were enrolled with the provider before the provider's staffing ratio exceeded the maximum permitted ratio. Any remaining beneficiaries shall be re-assigned to another My Health GPS provider.

10205.7 If all My Health GPS providers within a My Health GPS entity have maximized capacity to serve the entity's enrolled beneficiaries in accordance with the staffing ratio outlined in § 10205.4 and the entity is contacted by a beneficiary who wishes to receive My Health GPS services from any of its My Health GPS providers, the entity shall notify DHCF within one (1) business day of receiving the beneficiary's request. DHCF will reassign the beneficiary to a My Health GPS provider that has capacity.

10205.8 If beneficiaries are re-assigned to another My Health GPS entity pursuant to § 10205.6, DHCF shall notify the entity to which the beneficiaries were previously assigned of the re-assignment in writing consistent with the requirements set forth in § 10202.11.

10205.9 If DHCF re-assigns a beneficiary to a new My Health GPS entity, DHCF shall inform the beneficiary of the re-assignment in accordance with § 10202.10.

10205.10 Each My Health GPS provider shall conduct outreach to each beneficiary in accordance with the following timeframes:

(a) The provider shall conduct outreach by the end of the third quarter following the effective date of the entity's enrollment for all beneficiaries initially assigned to the entity as described in § 10202.3; and

(b) The provider shall conduct outreach by the end of the third quarter following the effective date of the beneficiary's assignment for all beneficiaries subsequently assigned to the entity as described in § 10202.3.

10205.11 Each My Health GPS provider shall document the outreach activity performed pursuant to § 10205.10 by including the following information in each beneficiary's EHR or use the tools approved by DHCF:

(a) The date and time the activity was performed;

(b) The identity of the My Health GPS provider staff member who performed the activity;

(c) A description of the setting in which the activity was performed; and

(d) A description of the activity, including mode of communication.

10205.12 In order to maintain enrollment as a My Health GPS entity, each organization described in § 10204.1 shall:

(a) Participate in all activities scheduled by DHCF to support the successful implementation of the My Health GPS program, including:

(1) Trainings to foster professional competency and development of best practices related to person-centered planning, chronic disease self-management, and related topics;

(2) Continuous quality improvement tasks, monitoring, and performance reporting;

(3) District-wide initiatives to support the exchange of health information; and

(4) Evaluation required by the Centers for Medicare and Medicaid Services (CMS), DHCF, or its agent;

(b) Maintain compliance with all requirements set forth in this chapter; and

(c) Maintain compliance with all terms and conditions set forth in the entity's DC Medicaid provider agreement including all modifications, as well as with all applicable federal and District laws.

10205.13 Each My Health GPS entity shall enter into a Memorandum of Agreement (MOA) or delegation agreement with each D.C. Medicaid Managed Care Plan (MCP). The MOA shall set forth the division of responsibilities between the MCP and the My Health GPS entity.

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 72 DCR 010392 (September 26, 2025).