10207.1 DHCF shall reimburse My Health GPS entities for the provision of covered My Health GPS services described in § 10206 using a per-member-per-quarter (PMPQ) payment structure that aligns with the quarters of the calendar year.10207.2 A My Health GPS entity shall be eligible to receive only one of the following two (2) rates, per quarter, for each beneficiary enrolled in the My Health GPS program:- (a) A PMPQ reimbursement rate for the initial comprehensive assessment and the development of the person-entered care plan. The rate also applies to the annual reassessment and care plan revision. Following the initial assessment, this PMPQ shall be available no earlier than the quarter in which the beneficiary's annual reassessment falls; and - (b) A PMPQ reimbursement rate for the three (3) quarters in which an initial assessment or annual reassessment is not performed.10207.3 The PMPQ rate set forth in § 10207.2(a) shall be higher than the PMPQ rate set forth in § 10207.2(b), reflecting the additional My Health GPS provider staff and resources required to complete the needs assessment and care plan update.10207.4 DHCF shall use a nationally recognized risk adjustment tool to identify the acuity level of each beneficiary in accordance with guidance published on the DHCF website. Based upon the results of the analysis, DHCF shall provide the data for each beneficiary to the assigned My Health GPS provider. The identified acuity levels are not related to the PMPQ rates but shall be used by the providers to stratify their population and develop priority and engagement strategies.10207.5 DHCF shall publish guidance on the methodology used to identify the acuity level of each beneficiary on the DHCF website at dhcf.dc.gov.10207.6 DHCF will update and provide the beneficiaries' revised acuity level, annually, to the My Health GPS provider, consistent with the procedure set forth in §10207.4.10207.7 The base PMPQ rates for the rates set forth in § 10207.2 shall be established based on the staffing model described in §§ 10205.3 and 10205.4, and adjusted to take into account regional salaries, including fringe benefits. The rates shall also take into account the average expected service intensity for beneficiaries and shall be determined in accordance with the requirements of 42 USC § 1396a(a)(30)(A).10207.8 Two (2) payment enhancements shall be added to each PMPQ rate set forth in § 10207.2 to:

(a) Reflect the My Health GPS provider's overhead or administrative costs; and

(b) Support the My Health GPS provider in procuring, using, or modifying health information technology.

10207.9 DHCF shall review the PMPQ rates set forth in § 10207.2 on an annual basis to ensure that the rates are consistent with requirements set forth in 42 USC § 1396a(a)(30)(A).

10207.10 The PMPQ rates set forth in § 10207.2 shall be established and listed in the D.C. Medicaid fee schedule, available at: https://dc-medicaid.com

10207.11 In order to receive the first PMPQ payment for an eligible beneficiary, a My Health GPS provider shall:

(a) Outreach and inform the beneficiary about available My Health GPS program services;

(b) Obtain the beneficiary's informed consent to receive My Health GPS program services in writing; and

(c) Complete the following components of the person-centered care plan in accordance with the standards for Comprehensive Care Management set forth in § 10206.3(a)(2):

(1) Conduct an in-person needs assessment in accordance with § 10206.3(a);

(2) Enter available clinical information and information gathered at the in-person needs assessment into the person-centered care plan, which shall include individualized goals pursuant to § 10206.3(a)(2)(iv); and

(3) Retain documentation demonstrating the delivery of each of the activities described in (1) and (2) above.

10207.12 In order to receive a subsequent PMPQ payment for an eligible beneficiary, a My Health GPS provider shall review the completed person-centered care plan in accordance with the standards set forth in § 10206.3, provide a copy of the completed plan of care to the beneficiary, and provide a My Health GPS service as follows:

(a) Deliver at least one (1) My Health GPS program service to the beneficiary within the calendar quarter; and

(b) Complete the annual reevaluation of the care plan no earlier than the anniversary quarter of the last assessment and care plan update performed.

10207.13 For the initial and annual evaluation of the assessment and care plan PMPQ payments set forth in § 10207.2(a), a maximum of one (1) initial and annual PMPQ payment is claimable annually per beneficiary, regardless of whether the beneficiary elects to receive additional services from a different My Health GPS entity or withdraws from the program and later re-enrolls.

10207.14 Each My Health GPS provider shall document each program service and activity provided in each beneficiary's EHR. Any Medicaid claim for program services shall be supported by written documentation in the EHR that clearly identifies the following:

(a) The specific service(s) rendered and descriptions of each identified service sufficient to document that each service was provided in accordance with the requirements set forth in § 10206;

(b) The date and time the service(s) were rendered;

(c) The My Health GPS provider staff member who provided the service(s);

(d) The setting in which the service(s) were rendered;

(e) The beneficiary's person-centered care plan provisions related to the service(s) provided; and

(f) Documentation of any further action required for the beneficiary's well-being as a result of the service(s) provided.

10207.15 Each claim for a My Health GPS service shall meet the requirements of § 10206 and shall be documented in accordance with § 10207.14 in order to be reimbursed.

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).