995 MEDICAID PHYSICIAN AND SPECIALTY SERVICES RATE METHODOLOGY

995.1 For services rendered on or after January 1, 2011, Medicaid reimbursement rates for fee-for-service physician and specialist services shall be eighty percent (80%) of the rates paid by the Medicare Program as set forth in this section.

995.2 For services where the physician and specialist service procedure code falls within the Medicare (Title XVIII) fee schedule, payment shall be the lesser of the Medicare rate established pursuant to subsection 995.1 or the providers' actual charges to the general public.

995.3 For services where the procedure code does not fall within the Medicare fee schedule, an alternative method, as set forth in § 995.4, shall be used to establish the Medicaid reimbursement rate.

995.4 When making a determination to establish the Medicaid reimbursement rate using an alternative method for physician and specialty services, in addition to using professional judgment, the following factors may be considered:

(a) Practitioner fees;

(b) Fee schedules from other states;

(c) Similar procedures with established fees; or

(d) Private insurance payments.

995.5 Beginning Fiscal Year 2010, and annually thereafter, all rates for physician and specialty services shall be updated on January 1st pursuant to the rate schedules in effect on the first day of the District of Columbia fiscal year or October 1st.

995.6 All physician and specialty services reimbursement rates shall be located on the Department of Health Care Finance website.

995.7 The Department of Health Care Finance (DHCF) shall provide a supplemental payment to participating providers of physician and specialty services in accordance with the requirements set forth in Section 995.4 through 995.7.

995.8 To qualify for a supplemental payment, a provider must have participated in the Medicaid program and have paid claims for physician and specialty services between the period January 1, 2011 and February 29, 2012.

995.9 For each provider who qualifies for payment in accordance with Section 995.4,

DHCF shall:

(a) Establish a fund that shall be equal to and shall not exceed the difference between one hundred percent (100%) of the Medicare rate in effect for the period referenced in Section 995.4 and eighty percent (80%) of the Medicare rate in effect for the period referenced in Section 995.4 (Medicaid payment rate) for all claims paid to that provider between January 1, 2011 and February 29, 2012;

(b) Pay a provider-specific supplemental payment based on the claims submitted to DHCF during the three (3) month period beginning May 1, 2013; and

(c) Make certain that the total amount paid to each provider shall not exceed the amount set forth in Section 995.5(a).

995.10 The supplemental payment shall be calculated as the total of each provider's fund, divided by the paid claims submitted for the payment period by each provider and added proportionally to the fee-for-service rate paid to that provider during the payment period.

995.11 All payments shall be made as a lump sum adjustment at the end of the defined three month payment period.

SOURCE: Final Rulemaking published at 44 DCR 5497 (September 26, 1997); as amended by Final Rulemaking published at 50 DCR 3473 (May 2, 2003); as amended by Final Rulemaking published at 50 DCR 9253 (October 31, 2003); as amended by Final Rulemaking published at 52 DCR 7021 (July 29, 2005); as amended by Final Rulemaking published at 55 DCR 338 (January 11, 2008); as amended by Final Rulemaking published at 56 DCR 5928 (July 24, 2009); as amended by Emergency and Proposed Rulemaking published at 57 DCR 950 (October 8, 2010)[EXPIRED]; as amended by Final Rulemaking published at 59 DCR 147 (January 13, 2012); as amended by Final Rulemaking published at 60 DCR 11955 (August 16, 2013).