4210.1 Case management services shall be reimbursed on a per member per month (PMPM) basis.

4210.2 Reimbursement for case management services at the PMPM rate shall be contingent on the performance of the monthly and ongoing care coordination activities outlined in Section 4224.

4210.3 Reimbursement for transitional case management services provided during an institutional (e.g., hospital or nursing facility) stay shall not exceed one hundred twenty (120) days. Reimbursement shall be contingent on the case manager's performance of activities during the institutional stay that facilitates the transition to the community, consistent with the reimbursement standards for transitional case management set forth in Subsection 4224.9.

4210.4 Reimbursement for transitional case management services shall be made only after the beneficiary returns to the home or community setting and not during the beneficiary's institutional stay.

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).