10299.1 When used in this chapter, the following terms shall have the meanings ascribed:

Assigned Beneficiary – An individual who is eligible based on the My Health GPS eligibility criteria and has been designated to a My Health GPS provider.

Beneficiary – An individual deemed eligible for and in receipt of services provided through the District Medicaid program.

Best Practice Protocols – Documented policy and procedure that outlines how the My Health GPS provider team shall provide care coordination services, using clinical methods, processes, and interventions that will improve the quality of care delivered.

Care Plan – A living document developed in conjunction with the beneficiary and the My Health GPS team that contains the beneficiary’s goals, wants, and needs along with objectives and interventions that will assist in meeting the goals. This document guides the delivery of My Health GPS services.

Chronic Conditions – Health conditions or diseases that are long-lasting but manageable with proper care and coordination. DHCF has identified the chronic conditions eligible for the My Health GPS program in § 10201.1.

Comprehensive Biopsychosocial Assessment (Needs Assessment) – The collection and documentation of beneficiary information gathered through an assessment by a qualified clinician that identifies the beneficiary’s strengths, weaknesses, risk, and needs.

Corporate Entity – An organization that holds a single Employer Identification Number, as defined in 26 CFR § 301.7701-12.

Corrective Action Plan (CAP) – Sanction issued with the purpose of identifying, addressing, and notifying providers of their non-compliance with the program.

Disenrollment – The process by which DHCF removes previously eligible beneficiaries from the My Health GPS program due to the loss of their eligibility for the program.

Fair Hearing – A procedure whereby the District provides an opportunity for a hearing to any person whose claim for assistance is denied consistent with

the requirements set forth in 42 CFR § 431.200 et seq.

Federally Qualified Health Center (FQHC) – An organization that meets the definition set forth in Section 1905(l)(2)(B) of the Social Security Act (42 USC § 1396d(1)(2)(B)).

Hybrid Data – A combination of administrative data (i.e. claims, encounters, and vital records) and clinical data contained in medical records.

My Health GPS Entity – A primary care clinical individual practice, primary care clinical group practice, or Federally Qualified Health Center currently enrolled as a District Medicaid provider that incorporates a My Health GPS provider into its primary care service delivery structure.

My Health GPS Provider – An approved interdisciplinary team that delivers My Health GPS services within a My Health GPS entity.

Opt Out – The process by which an eligible beneficiary chooses not to participate in the My Health GPS program.

Outreach – Active and progressive attempts at beneficiary engagement, including direct communication (i.e. face-to-face, mail, email, telephone) with the beneficiary or the beneficiary’s designated representative.

Per-Member-Per-Quarter (PMPQ) – The reimbursement rate cadence paid to the My Health GPS program-approved providers for completing My Health GPS services based on the program requirements.

Primary Care Practice (individual and group) – Located within a primary care setting, medical practitioners that provide holistic, preventative medical care to beneficiaries.

Primary Care Setting – Entry point for beneficiaries that focuses on the overall health needs of the beneficiaries.

Provider Change – The process by which a My Health GPS beneficiary chooses to move from their currently assigned My Health GPS provider to another My Health GPS provider of their choice.

Sentinel Event – Any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient and which is not related to the natural course of the patient’s illness.

Withdrawal – The process by which a My Health GPS enrolled beneficiary

chooses not to continue to participate in the My Health GPS program.

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).