10207.1 DHCF shall reimburse My Health GPS entities for services described in § 10206 using a per member per month (PMPM) payment structure.10207.2 DHCF shall establish two (2) distinct PMPM rates. The PMPM rate for higher acuity (Group Two) beneficiaries shall be higher than the PMPM rate for lower acuity (Group One) beneficiaries, reflecting the greater anticipated needs of Group Two beneficiaries for My Health GPS services and the additional My Health GPS provider staff required to serve Group Two beneficiaries.10207.3 DHCF shall use a nationally-recognized risk adjustment tool to determine the acuity level of each beneficiary. Based upon the results of the analysis, DHCF shall place the beneficiary into the appropriate acuity group.10207.4 A My Health GPS entity may request re-determination of a beneficiary's assigned acuity level as follows:- (a) If re-determination is requested, a My Health GPS entity shall submit clinical documentation of a significant change in the beneficiary's health status to DHCF in the manner specified in the My Health GPS manual; and - (b) If the documentation submitted in accordance with the My Health GPS manual by the My Health GPS entity is complete, DHCF shall re-determine the beneficiary's acuity level in accordance with the procedure set forth in § 10207.3.10207.5 DHCF shall provide the My Health GPS entity with written notification of the results of the re-determination described in § 10207.4, including a copy of the re-determination analysis.10207.6 The base PMPM rates for both Group One and Group Two beneficiaries shall be established based on the staffing model described in §§ 10205.3 through 10205.5, 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).10207.7 Two (2) payment enhancements shall be added to the base PMPM rates for both Group One and Group Two beneficiaries 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.

10207.8 DHCF shall review the PMPM rates for both Group One and Group Two beneficiaries on an annual basis to ensure that both rates are consistent with requirements set forth in 42 USC § 1396a(a)(30)(A).

10207.9 The PMPM rates for both Group One and Group Two beneficiaries shall be listed in the D.C. Medicaid fee schedule, available at: www.dc-medicaid.com.

10207.10 In order to receive an initial PMPM payment for an eligible beneficiary, a My Health GPS provider shall:

(a) 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 plan of care in accordance with the standards for Comprehensive Care Management set forth in § 10206.3:

(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 plan of care which shall include individualized goals pursuant to § 10206.3(b)(4); and

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

10207.11 In order to receive a subsequent PMPM payment for an eligible beneficiary, a My Health GPS provider shall complete the person-centered plan of care in accordance with the standards set forth in § 10206.3, provide a copy of the completed plan of care to the beneficiary, and deliver at least one (1) My Health GPS program service to the beneficiary within the calendar month as follows:

(a) For Group One beneficiaries, the service(s) provided during the month may be delivered face to face or remotely; and

(b) For Group Two beneficiaries, at least one (1) service provided during the

month shall be delivered face to face.

10207.12 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 which 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 services;

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

(e) The beneficiary's person-centered plan of care 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.

10207.13 Each claim for a My Health GPS service shall meet the requirements of § 10206 and shall be documented in accordance with § 10207.12 in order to be reimbursed.

SOURCE: Final Rulemaking published at 65 DCR 0636 (January 26, 2018).