4209.1 DHCF shall not reimburse any provider of Waiver services who:

(a) Fails to comply with any applicable regulation in this chapter;

(b) Fails to comply with all applicable federal and District of Columbia laws, and regulations;

(c) Fails to comply with all applicable transmittals, rules, manuals and other requirements for payment issued by DHCF;

(d) Provides services in the absence of an approved prior authorization from DHCF or its designee for payment identifying the authorized service, number of hours or units authorized, duration, and scope of service; and

(e) Fails to comply with the terms of the Medicaid Provider Agreement.

4209.2 Each provider of Waiver services shall agree to accept as payment in full the amount determined by DHCF as reimbursement for the authorized waiver services provided to beneficiaries.

4209.3 Each provider shall agree to bill any and all known third-party payers prior to billing Medicaid.

4209.4 In accordance with federal cost neutrality requirements, DHCF may limit or deny waiver services if the combined cost of waiver services and other home care services exceeds the estimated cost of institutional care.

4209.5 Current reimbursement rates for all services covered under this chapter are listed in the District Medicaid fee schedule at www.dc-medicaid.com. DHCF shall also publish a notice in the District of Columbia Register at least thirty (30) days before implementing a change to any reimbursement rate.

SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 53 DCR 1696 (March 10, 2006); as amended by Final Rulemaking published at 61 DCR 6817 (July 4, 2014); as amended by Final Rulemaking published at 62 DCR 3939 (April 3, 2015); as amended by Final Rulemaking published at 63 DCR 6144 (April 22, 2016); 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).