4205.1 The grounds for disenrollment from the EPD Waiver program are limited to the following:

1. (a) The beneficiary no longer meets the financial eligibility criteria;
2. (b) The beneficiary no longer meets the required level of care as supported by the assessment tool;
3. (c) The beneficiary expires;
4. (d) The beneficiary has moved out of the District of Columbia;
5. (e) The beneficiary remains institutionalized for a period that is expected to exceed one hundred and twenty (120) consecutive days;
6. (f) The beneficiary or the beneficiary's authorized representative requests disenrollment, in writing, from the EPD Waiver; or
7. (g) The beneficiary has failed to provide the case management agency with recertification documents or cooperate with the case manager to ensure that level of care evaluation is completed.

4205.2 A case manager may coordinate the receipt and subsequent approval by DHCF or its designee for all program modification requests. These include requests to initiate, change, terminate, or suspend Waiver services, and to transfer or discharge from a service provider.

4205.3 The beneficiary, the beneficiary’s authorized representative, family member or a service provider may recommend to DHCF or its designee one or more of the following program modifications: the initiation of a new service; a change in approved services; a transfer; or a service termination.

4205.4 The beneficiary, the beneficiary’s authorized representative, a service provider or the beneficiary’s case manager may make requests to DHCF or its designee to authorize a discharge, transfer, or suspension.

4205.5 Conditions for authorization of a discharge or transfer consist of the following:

(a) A beneficiary is unsatisfied with the services delivered by a specific provider;

1. (b) A provider is unable to meet the needs of a beneficiary; if a service provider is requesting the discharge or transfer, the provider has demonstrated compliance with all requirements set forth in Subsection 4205.6;
2. (c) The behavior of a beneficiary poses an immediate threat to the safety and well-being of a waiver provider or provider's staff, in accordance with Subsection 4205.11; or
3. (d) A beneficiary fails to meet EPD Waiver eligibility criteria set forth at Subsection 4201.2.4205.6 A provider shall demonstrate the following before or at the time of a request to suspend, discharge, transfer, or terminate a beneficiary, except for a discharge based on a beneficiary's failure to meet EPD Waiver eligibility criteria:- (a) Appropriate steps were taken to attempt remediation of the situation that gave rise to the conditions necessitating the action as set forth in Subsection 4205.11, including a meeting with the beneficiary to resolve conflicts and provider staff training to resolve any staff complaints; and
4. (b) Compliance with provider requirements outlined in Subsection 4205.9 to ensure safe suspension, discharge, transfer, or termination of services.4205.7 DHCF, a case manager, or a provider may suspend the services of a beneficiary when:- (a) The beneficiary's behavior poses a risk to the staff, and interventions have not successfully addressed the behavior; or
5. (b) The beneficiary prohibits access to provider-related visits4205.8 In order to ensure that a beneficiary's health is not threatened during a discharge, transfer, suspension, or termination of services, except for a discharge based on a beneficiary's failure to meet EPD Waiver eligibility criteria, the provider shall:- (a) Assess the beneficiary's condition to ensure that discharge, transfer, suspension, or termination of services does not endanger the health and safety of the beneficiary;
6. (b) Document assessment findings in the beneficiary's record;
7. (c) Notify the physician;

(d) Ensure that the beneficiary's Medicaid eligibility is current;

(e) Refer the beneficiary to the Department of Behavioral Health or other agencies, as the case manager deems appropriate; and

(f) Document the actions taken to ensure that the beneficiary's discharge, transfer, suspension, or service termination will have no adverse effect on the beneficiary.

4205.9 In addition to the requirements specified in Subsection 4205.10, a provider shall take the following administrative actions before effectuating a discharge, transfer, suspension, or service termination, except for a discharge based on a beneficiary's failure to meet EPD Waiver eligibility criteria:

(a) Issue written notice pursuant to Subsections 4202.2 through 4202.4;

(b) Arrange for alternative services prior to effectuating the discharge, transfer, suspension, or service termination;

(c) Provide the beneficiary and DHCF with a copy of the plan identifying alternative services and include timelines describing when the alternative services will be put in place;

(d) Notify DHCF, the Department of Health's Health Regulation and Licensing Administration (HRLA), and Adult Protective Services if the provider believes that the beneficiary's health is at risk as a result of the discharge, transfer, suspension, or service termination; and

(e) In the case of transfers, including transfers to a new case management agency, ensure that an agreement between the transferring agency and receiving agency is executed before the transfer is executed.

4205.10 A case manager or case management agency shall notify DHCF or its designee of the need to send a written notice, pursuant to the grounds of disenrollment from the EPD Waiver program set forth in Subsections 4205.1(e) through (g), within five (5) business days of learning of the event in question.

4205.11 If the behavior of a beneficiary, or the environment in which services are being provided, poses an immediate threat to the safety or well-being of a provider or provider's staff, the provider must immediately review the threat and initiate an investigation.

(a) The provider has the right to immediately discharge the beneficiary or suspend the beneficiary's services for a period not to exceed thirty (30)

calendar days.

(b) A provider that discharges or suspends services for a beneficiary under this subsection remains subject to the requirements set forth at Subsection 4205.8.

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 72 DCR 004996 (April 25, 2025).