{"data":{"id":"us-dc/d.c.-code-1-307.02","jurisdiction":"us-dc","citation":"D.C. Code § 1-307.02","heading":"District of Columbia medical assistance program.","body":"(a)\n(1)\nThe Mayor may submit, under title XIX of the Social Security Act (Title XIX) to the Secretary of the United States Department of Health and Human Services, a plan for medical assistance (and any modifications of the plan) to enable the District to receive federal financial assistance under Title XIX for a medical assistance program established by the Mayor under such plan.\n(2)\nRepealed.\n(3)\nReview and approval by the Council of the Fiscal Year 2010 Budget and Financial Plan shall constitute the Council review and approval required by paragraph 2 of this subsection of any modification or waiver to the state plan required to implement during fiscal year 2010 an initiative to:\n(A)\nUtilize Disproportionate Share Hospital funding to support the transition of individuals into health insurance programs through the modification of the Disproportionate Share Hospital qualification and distribution methodology;\n(B)\nChange service limit methodology for personal care aide services;\n(C)\nEnhance prescription drug utilization and review activities;\n(D)\nReduce reimbursement rates for prescription drugs to align pharmaceutical spending with national payment trends;\n(E)\nChange methodologies for recovering improper payments;\n(F)\nObtain available State Children’s Health Insurance Program funding for immigrant children and pregnant women;\n(G)\nShift coverage for unborn children of undocumented immigrants from the D.C. HealthCare Alliance to Medicaid;\n(H)\nImplement a new methodology for fee-for-service inpatient hospital reimbursement; and\n(I)\nReduce disallowances for public provider agencies.\n(4)\nReview and approval by the Council of the fiscal year 2011 budget and financial plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any waiver, modification to the state plan, or modification to a waiver required during fiscal year 2011 for purposes of implementing federal health care reform initiatives as set forth in the Patient Protection and Affordable Care Act, approved March 23, 2010 (124 Stat. 119; Pub. L. No. 111-148); provided, that the Department of Health Care Finance publishes a copy of any waiver, modification to the state plan, or modification to a waiver available on its website for at least 5 business days prior to submission to the Secretary of the United States Department of Health and Human Services.\n(5)\nReview and approval by the Council of the Fiscal Year 2012 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of:\n(A)\nAny modification or waiver to the state plan required to change the methodology used for the reimbursement for single source brand name drugs from the average wholesale price minus 10% to wholesale acquisition cost plus 3%; and\n(B)\nAny modification or waiver to the state plan required to change in whole or in part the level of personal-care services offered as a state plan benefit.\n(6)\nReview and approval by the Council of the Fiscal Year 2013 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any modification or waiver to the state plan required to:\n(A)\nUpdate the diagnosis-related group (“DRG”) grouper the agency uses to pay hospitals for inpatient care and other characteristics of the reimbursement system, such as base rates, DRG weights, outlier thresholds and transfer policy to adjust the average payment to cost ratio for inpatient care at DRG hospitals from 114% to 98%;\n(B)\nUpdate the reimbursement methodology model to one based on acuity for Intermediate Care Facilities for the Intellectually Disabled;\n(C)\nExclude the cost of therapies, including physical therapy, occupational therapy, and speech therapy, from the calculation of the nursing and resident care component of the nursing home rate; and\n(D)\nTransition beneficiaries to the replenishing pharmacy network for antiretroviral medications.\n(7)\nReview and approval by the Council of the Fiscal Year 2014 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:\n(A)\nEstablish a supplemental payment to rectify historic underpayments to District Medicaid hospitals for outpatient and emergency room services;\n(B)\nImplement Title II of the Patient Protection and Affordable Care Act, approved March 23, 2010 (Pub. L. No. 111-148; 124 Stat. 119), to:\n(i)\nProvide for new Modified Adjusted Gross Income eligibility methodologies;\n(ii)\nStreamline the application process;\n(iii)\nAlign Medicaid eligibility determinations, renewals, and appeals with eligibility determinations and appeals of cost sharing and advanced premium tax credits for the Health Benefit Exchange;\n(iv)\nSecure enhanced federal medical assistance percentages for newly eligible Medicaid beneficiaries and preventive services, including tobacco cessation;\n(v)\nProvide coverage for former foster care children through age 25;\n(vi)\nImplement presumptive eligibility by hospitals;\n(vii)\nExtend the District’s current Section 1115 demonstration for childless adults ages 21 through 64 years with incomes between 133% and up to 200% of the federal poverty level to provide stop-gap coverage for these beneficiaries until the District establishes the basic health plan; and\n(viii)\nCreate health homes for chronically ill District residents;\n(C)\nImplement needed reforms to Medicaid-funded, long-term care services and supports, including:\n(i)\nThe establishment of a single-point-of-entry system and a standardized, conflict-free assessment tool and process;\n(ii)\nClarification of eligibility requirements for institutional long-term care services; and\n(iii)\nThe creation of new programming, including adult day health services pursuant to Title XIX of the Social Security Act to ensure that District residents may be served in the most integrated setting appropriate to their needs; and\n(D)\nImplement an annual inflation rate adjustment for nursing facilities.\n(8)\nReview and approval by the Council of the Fiscal Year 2015 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:\n(A)\nImplement needed amendments to the Elderly and Individuals with Physical Disabilities waiver to ensure compliance with federal law and promote best practices;\n(B)\nEstablish new payment rates for Federally-Qualified Health Centers;\n(C)\nEstablish a new payment method and make other improvements to the payment methodology for hospital inpatient treatment;\n(D)\nEstablish a new payment method and make other improvements to the payment methodology for hospital outpatient services;\n(E)\nImplement needed amendments to the Intellectual Disabilities/Developmental Disabilities waiver to ensure compliance with federal law and promote best practices;\n(F)\nAlign specialty hospital payments with the complexity of their patient mixes and national best practices and to describe payment standards for sub-acute services for children who are inpatients in private psychiatric specialty hospitals; and\n(G)\nUpdate transplantation coverage standards and provide coverage for lung transplantation and autologous bone marrow transplantation.\n(9)\nReview and approval by the Council of the Fiscal Year 2016 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:\n(A)\nUpdate the reimbursement methodology model for intermediate care facilities for persons with developmental disabilities to ensure compliance with federal law;\n(B)\nUpdate the payment methodology for hospital services;\n(C)\nUpdate the payment methodology for Federally-Qualified Health Centers;\n(D)\nUpdate the payment methodology and program standards for Home Health Agencies;\n(E)\nCreate health homes for chronically ill District residents;\n(F)\nEstablish a provider fee on District Medicaid hospitals for in-patient services; and\n(G)\nEstablish a supplemental payment to District Medicaid hospitals for outpatient services.\n(10)\nReview and approval by the Council of the Fiscal Year 2017 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:\n(A)\nImplement needed amendments to:\n(i)\nThe Intermediate Care Facilities for Individuals with Developmental Disabilities reimbursement methodology;\n(ii)\nThe payment methodology for hospital services;\n(iii)\nThe payment methodology for nursing homes;\n(iv)\nThe payment methodology for the Disproportionate Share Hospital program;\n(v)\nThe health homes program;\n(vi)\nRenew and update the Elderly and Individuals with Physical Disabilities waiver program and make conforming changes to the state plan; and\n(vii)\nThe payment methodology for prescription drugs; and\n(B)\nIncrease the number of participants in the Home and Community-Based Services Waiver for Persons with Intellectual and Developmental Disabilities program.\n(11)\nReview and approval by the Council of the Fiscal Year 2018 Budget and Financial Plan shall constitute the Council review and approval required by paragraph (2) of this subsection of any amendment, modification, or waiver of the state plan required to:\n(A)\nContinue a provider fee on District Medicaid hospitals for in-patient services;\n(B)\nContinue a supplemental payment to District Medicaid hospitals for outpatient services;\n(C)\nUpdate the payment methodology and rates for fee-for-service providers;\n(D)\nRenew and amend the Intellectual and Developmental Disabilities waiver;\n(E)\nMake changes to the health homes program; and\n(F)\nMake changes to mental health rehabilitation services.\n\n(b)\n(1)\nNotwithstanding any other provision of law, the Mayor may take such action as may be necessary to submit such plan to the Secretary and to establish and carry out such medical assistance program, except that in prescribing the standards for determining eligibility for and the extent of medical assistance under the District of Columbia’s plan for medical assistance, the Mayor may not (except to the extent required by Title XIX of the Social Security Act):\n(A)\nPrescribe maximum income levels for recipients of medical assistance under such plan which exceed:\n(i)\nThe Title XIX maximum income levels if such levels are in effect; or\n(ii)\nThe Mayor’s maximum income levels for the local medical assistance program if there are no Title XIX maximum income levels in effect; or\n(B)\nPrescribe criteria which would permit an individual or family to be eligible for such assistance if such individual or family would be ineligible, solely by reason of his or its resources, for medical assistance both under the plan of the State of Maryland approved under Title XIX of the Social Security Act and under the plan of the State of Virginia approved under such title.\n(2)\nFor purposes of subparagraph (A) of paragraph (1) of this subsection:\n(A)\nThe term “Title XIX maximum income levels” means any maximum income levels which may be specified by Title XIX of the Social Security Act for recipients of medical assistance under state plans approved under that title;\n(B)\nThe term “the Mayor’s maximum income levels for the local medical assistance program” means the maximum income levels prescribed for recipients of medical assistance under the District of Columbia’s medical assistance program in effect in the fiscal year ending June 30, 1967; and\n(C)\nDuring any of the first 4 calendar quarters in which medical assistance is provided under such plan there shall be deemed to be no Title XIX maximum income levels in effect if the Title XIX maximum income levels in effect during such quarter are higher than the Mayor’s maximum income levels for the local medical assistance program.\n\n(c)\nThe District state plan required under Title XIX of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396 et seq.), shall provide that all persons in the following categories are eligible for Medicaid benefits:\n(1)\nA pregnant woman or an infant under 1 year of age with an income up to 185% of the federal poverty line, as authorized by § 1902(a)(1) of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396a(a)(1));\n(2)\nA child born after September 30, 1983, who has not attained the age of 8 years and whose family income is not more than 100% of the federal poverty line, as authorized by § 1902 of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396a); and\n(3)\nA pregnant woman or a child during a presumptive eligibility period as authorized by § 1902(a) of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396a(a)).\n\n(d)\n(1)\nFor purposes of this subsection, the term:\n(A)\n“TANF-related Medicaid recipient” means a family that has dependent children under 21 years of age in the home and whose income is not low enough to qualify for financial assistance, but is low enough to qualify for medical assistance.\n(B)\n“Health maintenance organization” means a public or private organization, operating in the District of Columbia, which contracts with the District government to provide comprehensive health maintenance, preventive and treatment services emphasizing access to primary care for enrolled members of the plan through its own network of physicians and hospitals for a fixed prepaid premium.\n(C)\n“Managed care provider” means either a primary care provider or a health maintenance organization.\n(D)\n“Primary care provider” means a physician, clinic, hospital, or neighborhood health center that is responsible for providing primary care and coordinating referrals, when necessary, to other health care providers.\n(E)\n“Restricted recipient” means a person who has been restricted to one designated primary care provider for a minimum of one year after a finding of abuse or misuse of Medicaid services by the Commission on Health Care Financing.\n(2)\nThe Mayor shall establish a plan to mandate enrollment of TANF and TANF-related Medicaid recipients in a managed care program for the purpose of providing access to comprehensive and coordinated health care in an efficient and cost effective manner. The plan shall provide the following:\n(A)\nTANF and TANF-related Medicaid recipients shall select any health maintenance organization with a current contract with the District of Columbia to provide managed care services to TANF and TANF-related Medicaid recipients on a capitated method of payment;\n(B)\nThe Mayor shall exclude TANF and TANF-related Medicaid recipients from the managed care program who are:\n(i)\nResidents in a nursing facility or intermediate care facility for persons with intellectual or developmental disabilities;\n(ii)\nRepealed.\n(iii)\nEligible for Medicaid for a period that is less than 3 months;\n(iv)\nEligible for a period that is retroactive;\n(v)\nFoster children residing outside the District of Columbia; or\n(vi)\nRestricted recipients.\n(C)\nThe Mayor shall assign any TANF and TANF-related Medicaid recipient who does not choose a provider within a reasonable time to a health maintenance organization described in subparagraph (A) of this paragraph.\n(D)\nRepealed.\n(E)\nTANF and TANF-related Medicaid recipients enrolled in a managed care program shall be exempted from any additional co-payment requirements other than those imposed by the Medicaid program.\n(F)\nThe Mayor shall develop an education program to fully inform TANF and TANF-related Medicaid recipients about the various managed care programs to ensure better care for recipients while avoiding unnecessary and inappropriate use of hospital based services for preventive and primary care.\n(3)\nIn order to participate in the managed care plan, a provider must:\n(A)\nBe a Medicaid qualified provider and be accessible to enrollees on a 24 hours per day, 7 days per week basis. The Mayor shall establish a monitoring system to ensure that recipients have 24 hours per day, 7 days per week access to their managed care providers and that treatment is provided in a timely manner; and\n(B)\nHave a written contract with the District government which provides detailed information regarding the responsibilities of the managed care provider and the District government for providing or arranging for the provision of, and making payment for all services to which the TANF and TANF-related Medicaid recipient is entitled under the District state Medicaid plan.\n(4)\nThe Mayor shall maintain a grievance and appeal process for TANF and TANF-related Medicaid recipients enrolled in a managed care program.\n(5)\nThe Mayor shall require that managed care providers, which receive a capitated method of payment, submit adequate assurances to protect the District government against risk in case a provider becomes insolvent.\n(6)\nTo implement the requirements of this subsection the Mayor shall:\n(A)\nAmend the District state Medicaid plan pursuant to § 4-204.05; and\n(B)\nSeek and obtain all necessary waivers of federal Medicaid statutes, rules and regulations.\n(7)\nThe Mayor shall submit to the Council on an annual basis an assessment of the cost effectiveness of the managed care plan and its impact on the TANF and TANF-related Medicaid recipient’s access to care of adequate quality.\n\n(e)\n(1)\nThe District state plan required under Title XIX of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396 et seq.), may provide for reimbursement of chiropractic services.\n(2)\nThe Mayor may develop and implement a reimbursement methodology for chiropractic services.\n\n(f)\n[Not funded].","path":["Title 1. Government Organization.","Chapter 3. Specified Governmental Authority.","Subchapter IV. Special Programs.","Part A. General."],"source_url":"https://code.dccouncil.gov/us/dc/council/code/sections/1-307.02","current_through":"2026-08-20 (D.C. Law 26-175)","vintage":"","retrieved_at":"2026-08-29T05:44:07Z","sha256":"34b64daf91311431f93a1d8bc5ac9a9a7ebd413ef045b794d3c9dc2ce1378a1d","source_id":"us-dc","stale":false,"prev":"us-dc/d.c.-code-1-307.01","next":"us-dc/d.c.-code-1-307.02a"},"notice":"GroundRules: Original legal text. Not legal advice."}