D.C. Mun. Regs. tit. 29, § 4209
Reimbursement:general
Effective Jul 21, 201764 DCR 6784Authority: Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6)), An Act To enable the District of Columbia to receive Federal financial assistance under title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02), and Mayor’s Order 2024-115, dated July 1, 2024. 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).District of Columbia, Office of the Secretary
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 For purposes of this chapter, the effective dates of EPD Waiver Year Five (5) are January 4, 2016 through April 3, 2017.
4209.5 For purposes of this chapter, the effective dates of EPD Waiver Year One (1) of the Renewal are April 4, 2017 through January 3, 2018.
4209.6 In accordance with CMS’ cost neutrality requirements, DHCF may limit or deny Waiver services if the cost of the services in addition to other home care services, exceeds the estimated cost of institutional care.
4209.7 Subsequent changes to any of the reimbursement rate(s) published herein shall be posted on the Medicaid fee schedule at www.dc-medicaid.com. DHCF shall also publish a notice in the D.C. Register which reflects the change in the reimbursement rate(s) at least thirty (30) days before a change is made to the 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).