5015.1 Each Provider shall be reimbursed four dollars and thirty-five cents ($4.35) per fifteen minutes for services rendered by a PCA, of which three dollars and forty cents ($3.40) per fifteen minutes shall be paid to the PCA to 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. (2012 Repl.)).

5015.2 Reimbursement for PCA services, when provided through the DC Medicaid program's State Plan PCA benefit, shall not exceed eight (8) hours per day and shall be limited to the amount, duration, and scope of services set forth in the PCA Service Authorization described in Section 5003.

5015.3 Claims for PCA services submitted by a Provider in any period during which the beneficiary has been admitted to another health care facility including a hospital, nursing home, psychiatric facility or rehabilitation program shall be denied.

5015.4 Claims for PCA service submitted by a Provider for any hours in which the beneficiary was receiving adult day health or other similar service in which PCA services are provided to the beneficiary shall be denied.

5015.5 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.

5015.6 Each Provider shall agree to bill any and all known third-party payers prior to billing Medicaid.

5015.7 All reimbursable claims for PCA services shall include the NPI numbers for the:

(a) Provider;

(b) Physician who ordered the personal care services;

(c) The staffing agency, if applicable; and

(d) Personal care aide who provided the personal care services, regardless of whether the personal care aide is an employee of the Provider or is from another staffing agency.

5015.8 Pursuant to 42 C.F.R. § 424.22(d), the Department shall deny PCA service claims or recoup paid claims when Provider records or other evidence indicate that the primary care physician ordering a beneficiary's treatment has a direct or indirect

financial relationship, compensation, ownership or investment interest as defined in 42 CFR § 411.354 in the Provider billing for the services, unless the financial relationship, compensation, ownership or investment interest meets an exception as defined in 42 CFR § 411.355.

5015.9 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 not be reimbursed.

SOURCE: Final Rulemaking published at 60 DCR 15537 (November 8, 2013); as amended by Final Rulemaking published at 61 DCR 6818 (July 4, 2014).