5015 REIMBURSEMENT

5015.1 Each provider shall comply with the Living Wage Act of 2006, effective June 8, 2006 (D.C. Law 16-118; D.C. Official Code §§ 2-220.01 et seq.).5015.2 The current reimbursement rate for covered PCA services is 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 the reimbursement rate.5015.3 Each Provider shall maintain adequate documentation substantiating the delivery of allowable services provided, in accordance with § 5013.1, the PCA service authorization, and the beneficiary's plan of care, for each unit of service submitted on every claim.5015.4 Reimbursement for PCA services provided as a benefit under the District's Medicaid State Plan shall not exceed eight (8) hours per day, seven (7) days a week, and shall be limited to the amount, duration, and scope of services set forth in the PCA service authorization and the plan of care, as described in Section 5003.5015.5 Claims for PCA services submitted by a provider for any period during which the beneficiary is an inpatient at a health care facility, including a hospital, nursing home, psychiatric facility, or rehabilitation program, shall be denied except on the day a beneficiary is admitted or discharged.5015.6 When a beneficiary is discharged from a health care facility to the beneficiary's home and requires PCA services on the date of discharge, the number of PCA hours on that day shall be authorized in accordance with the beneficiary's discharge plan.5015.7 Claims for PCA services submitted by a provider for any hour in which the beneficiary was receiving 1915(i) State Plan ADHP services, or other similar service in which PCA services are provided concurrently to the beneficiary, shall be denied.5015.8 Each provider shall agree to accept as payment in full the amount determined by DHCF as Medicaid reimbursement for the authorized services provided to beneficiaries. Providers shall not bill the beneficiary or any member of the beneficiary's family for PCA services.5015.9 Each provider shall agree to bill any and all known third-party payers prior to billing Medicaid.5015.10 All reimbursable claims for PCA services shall include the NPI numbers for the:

(a) Billing provider;

(b) Physician or Advanced Practice Registered Nurse (APRN) who ordered the PCA services;

(c) Staffing agency, if applicable; and

(d) PCA who provided the PCA services, regardless of whether the PCA is an employee of the provider or is from another staffing agency.

5015.11 Pursuant to 42 CFR § 424.22(d), DHCF shall deny PCA service claims, or recoup paid claims, when provider records or other evidence indicate that the primary care physician or APRN ordering a beneficiary's treatment has a direct or indirect financial relationship, compensation, ownership or investment interest as defined in 42 CFR § 411.354, with the provider billing for the services, unless the financial relationship, compensation, ownership or investment interest meets an exception set forth in 42 CFR § 411.355.

5015.12 Claims resulting from marketing by a staffing agency (including face-to-face solicitation at doctors' offices, home visits, requests for beneficiary Medicaid numbers, or otherwise directing beneficiaries to any Medicaid provider) shall be denied.

SOURCE: Final Rulemaking published at 60 DCR 15537 (November 8, 2013); as amended by Final Rulemaking published at 61 DCR 6818 (July 4, 2014); as amended by Final Rulemaking published at 62 DCR 3940 (April 3, 2015); as amended by Final Rulemaking published at 63 DCR 4455 (March 25, 2016); as amended by Final Rulemaking published at 63 DCR 14134 (November 18, 2016); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025); as amended by Final Rulemaking published at 73 DCR 007348 (May 15, 2026).