995.1 Effective April 25, 2009, Medicaid reimbursement rates for fee-for-service physician and specialist services shall be consistent with 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 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.

SOURCE: Final Rulemaking published at 44 DCR 5497 (September 26, 1997); as Final Rulemaking published at 50 DCR 3473(May 2, 2003); as Final Rulemaking published at 50 DCR 9253(October 31, 2003); as Final Rulemaking published at 52 DCR 7021(July 29, 2005); as Final Rulemaking published at 55 DCR 338 (January 11, 2008). 56 DCR 005928 (July 24, 2009).