9709.1 ADHP services shall not be initiated or provided on a continuing basis by a provider without an approved assessment determination and an authorization for the receipt of ADHP services from DHCF, DHCF's designated agent to authorize the receipt of ADHP services, or a Dual Eligible Special Needs Plan under the District Dual Choice Program.

9709.2 A Medicaid beneficiary who is seeking ADHP services for the first time shall submit his or her request for an assessment and a certification from the beneficiary's physician or advance practice registered nurse that he or she has a chronic medical condition in accordance with Subsection 9710.2 to DHCF or its designated agent in writing.

9709.3 DHCF or its designated agent shall be responsible for conducting a face-to-face assessment of each beneficiary using a standardized needs-based assessment tool to determine each beneficiary's need for ADHP services. The assessment shall:

(a) Confirm and document the beneficiary's functional limitations, behavioral and medical support needs and personal goals with respect to long-term care services and supports;

(b) Be conducted in consultation with the beneficiary and/or the beneficiary's representative and/or support team;

(c) Document the beneficiary's unmet need for services taking into account the contribution of informal supports and other resources in meeting the beneficiary's needs for assistance; and

(d) Document the amount, frequency, duration, and scope of long-term care services and support services needed.

9709.4 DHCF or its designated agent shall conduct the initial face-to-face assessment following the receipt of a request for an assessment and shall conduct a reassessment at least every twelve (12) months or upon significant change in the participant's condition. A request for a reassessment or a change in acuity level may be made by a Medicaid beneficiary, the beneficiary's representative, or a provider.

9709.5 Based upon the results of the face-to-face assessment conducted in accordance with Subsection 9709.3, DHCF or its authorized agent shall issue an assessment determination that specifies the beneficiary's acuity level.

9709.6 If the beneficiary meets the acuity level for ADHP services and chooses to participate in an ADHP program, DHCF or its authorized agent shall refer the

beneficiary to the Aging and Disability Resource Center (ADRC) which shall be responsible for developing the person-centered service plan in accordance with federal regulations under 42 C.F.R. § 441.725.

9709.7 Consistent with 42 C.F.R. § 441.725(c), the person-centered service plan must be reviewed, and revised upon reassessment of functional need as required in § 441.720, at least every twelve (12) months, and/or when the beneficiary's circumstances or needs change significantly in accordance with Subsection 9709.4.

9709.8 The ADRC shall assist the beneficiary to select an ADHP provider, and shall refer the beneficiary to other available services of his or her choice.

9709.9 If, based upon the assessment or reassessment conducted pursuant to this section, a beneficiary is found to be ineligible for ADHP services, DHCF or its agent shall issue a letter informing the beneficiary of his or her ineligibility, or change in acuity for ADHP services, including information about his or her right to appeal the denial, reduction or termination of services in accordance with federal and District of Columbia law and regulations consistent with D.C. Official Code § 4-205.55. The notice shall also contain information regarding the beneficiary's right to request DHCF to reconsider its decision and the timeframes for making a request for reconsideration.

9709.10 If a beneficiary is enrolled in a dual eligible special needs plan (D-SNP) under Chapter 57 of this title:

(a) The D-SNP shall be responsible for developing the person-centered service plan for the beneficiary in accordance with 42 C.F.R. § 441.725;

(b) The D-SNP shall submit the person-centered service plan to DHCF for DHCF's review and approval; and

(c) The provider selection process for DHCF approved services provided under the D-SNP shall be facilitated by the District's third-party long-term care services (LTCS) contractor.

SOURCE: Final Rulemaking published at 63 DCR 1031 (January 29, 2016); as amended by Final Rulemaking published at 69 DCR 011758 (September 30, 2022); as amended by Final Rulemaking published at 73 DCR 007348 (May 15, 2026).