4201.1 Individuals shall be deemed eligible for the EPD Waiver prior to the receipt of the services described in this chapter.

4201.2 To be eligible for the EPD Waiver services described in this chapter, a beneficiary shall:

1. (a) Require the level of care furnished in a nursing facility as determined by DHCF's Long Term Care Services and Supports contractor using the standardized face-to-face assessment tool, in accordance with Subsections 4201.4 and 4201.5;
2. (b) Agree to participate in the waiver program by signing the Waiver Beneficiary Freedom of Choice form to elect to receive services in home and community-based settings rather than institutional settings;
3. (c) Be aged sixty-five (65) or older, or be aged eighteen (18) and older with one (1) or more physical disabilities;
4. (d) Not be an inpatient of a hospital, nursing facility, or intermediate care facility in accordance with Subsection 4201.3;
5. (e) Be financially eligible for long term care services and supports in accordance with the requirements set forth in Chapter 98 (Financial Eligibility for Long Term Care Services and Supports) of Title 29 DCMR;
6. (f) Reside in the District of Columbia in a community setting, such as a natural home or approved Community Residential Facility or EPD Waiver assisted living facility; and
7. (g) Not currently be a participant in the Program of All-Inclusive Care for the Elderly or any other 1915(c) HCBS waiver, including but not limited to the HCBS Waiver for Individuals with Intellectual and Developmental Disabilities under Chapter 19 of Title 29 DCMR.

4201.3 For purposes of eligibility, an inpatient shall be defined as a beneficiary who is institutionalized for a period greater than one hundred and twenty (120) consecutive days.

4201.4 A Registered Nurse (RN) or Licensed Independent Clinical Social Worker (LICSW) hired by, or under contract with, DHCF or its designee shall conduct a face-to-face assessment to determine if a beneficiary or applicant meets a nursing

facility level of care. The assessment shall utilize a standardized assessment tool which will also evaluate the individual's care and support needs across three (3) domains including:

(a) Functional - impairments including assistance with activities of daily living such as bathing, dressing, eating or feeding;

(b) Skilled Care - sensory impairments, other health diagnoses and the need for skilled nursing or other skilled care (e.g., wound care, infusions); and

(c) Behavioral - communications impairments including the ability to understand others, presence of behavioral symptoms such as hallucinations, or delusions.

4201.5 Completion of the assessment shall yield a final total score determined by adding up the individual scores from the three domains. To be eligible for EPD Waiver enrollment a Medicaid beneficiary or applicant must obtain a total numerical score of nine (9) or higher on the assessment, which equates to the need for a nursing home level of care.

4201.6 Eligibility for all EPD Waiver services shall be recertified on an annual basis in accordance with the procedures set forth in this chapter and 29 DCMR § 989.

SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 64 DCR 6784 (July 21, 2017); as amended by Final Rulemaking published at 68 DCR 3783 (April 9, 2021); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025).