I

State; ,Distric1 of Columbia Supplement I lo Attachment 3.1-A Page 19A

de~nding on the results of the Pharmacy and Therapeutics Committee r'.ecor:nme·ndations and Departmental review.

e. As specified in Sec.tion I 92-7{bX~XD) of the Act, not withs1.and'ing any other provisipns of law, rebate -infonnation disclQsed by a 1nanufacturer shall not b_e 8isclosed by the District for purposes otfier £Han rebate invoicing and verificat ion.

7) Afl anorexic drugs (amphetamine and amphetamine-like) are eliminnt.ed as reimbursable phamui:ceutlcals ex~~t,for dia_gnosed conditions of narcolepsy and minimal brain ciysfuncti6n in children.

~) Prio( aathorit..a'ti<!>n (PA.) is_ reqµir,ed. for the dispensing of the following prescribed drugs:

-a, }..ii I· p,re&cqg@tis for, Oxycodone WCL i nd, AsP.irin .(more ·c·om manly known as P.ercodariJ1.nnd Fl11r:azepam.(tn~l"re commonly known as'· Dalm'alle);

Q., •tnor,ex'ic ·drugs (amphe'.t.amino.ll!ld nmphetamine.,llJfo) m~y be dispensed with prior au:t.h'0t~tie)i'for the diagnosed conditiol'ls,qf norcolepsy-a.nd .miniintil'bl'ain ~ysfun~tioh itH,hildren; .arid

:tr. -kny 'fo)eet.ab'fe,drugs.,ori•4lJ'l-ambula.toFY b~is.

9--) P.nar:me.cy ~k-1i1 Program

a·. 'The Depruil)Jenlof,Hcalth:CD,re Finaneo{DJiCP), alung with the Dislric1 af Colt.intbla l?Jrug Utili7lltion .Review (DUR) Board, will rmplc.mcnt.a Pharmacy 1.:,ook.:Jn;Progrntn•lo safe~u,ard f!lc-nppropriatc uso of rncdlC8tions whon an individunl l!nn;illc.d in 'the Distrit:t of Columbia Medicaid Iiee-for.Scrvicc Pro_gram inlsusc$ dnfgs in d,tccss of the cusLbmll"r)' des.age for,tl:to ,pro~r lr~atmen·c of the given ,diaK!).o.s.is, ,or misuses,multi,lle drugs in a mw1oer•tlw:t -~ah be medically _hnrmful. aeheficiarics listed in section 9(k) .are ex,e_itJpt iroff! ti}~· Phanna'cy Lock-In

. P.rogran:i.

th O~trrw1_f1,usp tllo drug utillznti~n guidclines.ests.blcshco by the 0istrict of Cof.urrillia. Di,u~..,Utlljt.atl,oo R'c.llic.w (DUR) ·Bonrd in .s~pport of tJ1c restriction. btJ.R Bcml'tl1Guldellt1es require a monthly report from the· Mcdicaid ;MMIS to dct<1nni!l,i·~hel'i 11 boneftc1acy may bent risR of exceeding U1e· customnrily prerorJ~itJtmig~s,or 1,1ti1'ii.at1on. The rcport.wl'II id,cntify beneficiaries who meet cr1t~'ria, _sudh,is;

I. > 3 coh(roiled ·sobstance pre·scriptions ~r month

2. >3 pr.escribers for co"il.trolled sub-stances within the last 90 days

3. >IO prescriptions per month

TNNo. _ _ _ Approval oJJ_r_:_·, _ __ ':i_O~ Effective Oule I o cJotitl\... JO /0 Sur,c~cJc.'\ TN.Na. ·~:!.

•

s1.a·1e: District o[Cojumbla Supplement I to Attachment J . I-A Page 198

:rNNo. __ _ ~iiper=.tes TN'. No: 07--04

4. 3 or more phannades used pet man.th

c. DHCF shall notify the Me.dicaid ben~fi~iary ln writi.ng of the following at least fifteen (l5) days p~iortt:dhc effe<::tivc date of the restriction:

I. The Dcpartment :p.r]Iposes to.destgnate hitn bl' her as a rcst,r.i.cted Med ica.id; benefi~iii.cy;

2. The reason for the restrictipn; and

3. The beneficiary's r.ight to a.he-aring if he or -sh.e·disagrees with the designation.

d. The Me.dl.cai.d·ber1eficiary shall have fifteen ( I.$) days :fmm the date of. tlie notice to file a reifuest foi'a heru:ing-..Witli ttle Office ~f A.tlmini$frative i:Iearings (OAH.).

e. (f the ivfodieaid recipient requ~sts -s hearing, no furth·er- action shnll be taken on the restrioti6rr.designn.C_ioo ~n(ll th~-~eari[lg (s dismissed ·or a final .decision hos been ~ndeFCd~by OAH'J

f. 'A rcslriollen may-be required for n teaso)labjo omoUl}t of time, riot fo ex.eeed.twel\le ( 1-2:) months, •wlthtiot 11'rovfow b.)( t.hd Q):u_g Ullliz.alion Roviow (foard. Si16seqµcnt restrictions wrfr not be 'lmposcl:I ~nt.il .af}.-cr the. evlbW hn~,t~oluded.

$, $he D~parlfneut of'~iilth,E!are Fltnmco will .cnsu_r.c ~·(I.I when-a fo:ck-:i{i ~as ~n -iJJtposcd~-thc,beac'fil1i.n.ry w!ncontfol.m ta h:we reasonfib.l~:1fcc,ess :to Medicaid · ,;e_ri;ices· of ai:leq_uatt qoalit}'.

h. Wheh a r-estrietion is- ifTlf10Se:d ·u~n :a,~M"fitis.ry1 the b,,rt~fioi8{Y. may cheqsc the . ph·,u1r1acy of his er h~r choice, b'ase{! upon a Hst-efttire-o {3) pharmacy provi•oers .lctcntlfie~ by .tlie Oep;ntmei,it of ttealt.h Care 'Finance.

i. Whe11 a ~nefi,ciar:y fti1$·to r~uest -a h~n~wHh·<DAH or falls to,select a des·i~nnted.p~acy-{Uler a d.ec:Jsion h~-bcer, r~Jl(!erediby OA·tl upholding the -rcstri~t)on w.ltl;iinJhe~~1fied_t'iiTt'e·pol'io.d, the ~ -pru'trnenfdfflealth Care Finance, -on belialfofth:at ben~ficiary, will designate a phann·acy for pharmacy ser.vice$.

j. Restrictions will'not apply ,iii'•situatiol:is··wh~re emetgency ,s~rvi•cei; ate futnished to _a bencfidar:y: . . . . . . ··

k, Ben~ficiaries in skl_llea ,nursing facilities, long t~,rm care fac.ilities, and -intermediate care tscititics for the ine'ntally retirded.are not eligible for the Rharmacy Lock-In · Program. ·

Effective Dole/ O·ch belt J,6 /0 ti ,. ., ;I I; '· ;,

State: District oJ Columbi· Supplement 1 to AttachmenL 3.1-A Page 20

1. If a beneficiary, who is enrolled in the Medicaid Managed Care Organization (MCO) and is also required to participate in its Pharmacy Lock-In Program, subsequently becomes enrolled in the Medicaid Fee-For-Service Program, that beneficiary will be automati cally enrolled in the Medicaid Fee-For-Service Pharmacy Lock-In Program. The lock-in will remain in force for a period not to exceed the length of the initial lock-in period first imposed by the MCO, or twelve ( 12) months, whichever is less.

(10) Medication Assisted Treatment (MAT) under DUL Substance Abuse Rehabilitative Services (described in Supplement 6 to Attachment 3.1-A).

a. MAT is the use of pharmacotherapy as long-term treatment for opiate or other forms of dependence. A beneficiary who receives MAT must also receive SUD Counseling. Use of this service should be in accordance with ASAM service guidelines and practice guidelines issued by the Department of Behavioral Health.

b. Unil of Service: A beneficiary can be prescribed a maximum of one (I) docs/unit per day.

c. Limitations: An initial and second authorization cover a period of ninety (90) days each; subsequent authorizations must not exceed one hundred and eighty (180) days each. The maximum number o.f MAT services over a twelve ( 12) month period is two hundred-fifty (250) unit'i of medication and up to fifty-two units of administration, Any dosing over two hundred-fifty units will require DBH review and authorization.

d. .Location/Sett in g: Tn accordance with 42 CFR pait 8, Certification of Opioid Treatment Programs, MAT providers must also be certified by the U.S. Substance Abt.ise and Mental Health Services Administration (SAMHSA) and accredited by a national body that has been approved by SAMHSA.

SUD treatment programs providing MAT with opioid replacement therapy shall comply with Federal; requirements for opioid treatment., as specified in 21 CFR, part 291, and shall comply with District and Federal regulations for maintaining controlled substances as specified in Chapter 10, Title 22 of the District of Columbia Municipal Regulations and 21 CFR, part 1300, respectively. Each MAT program shall submit applications to the District of Columbia Department of Behavioral Health and to the U.S. Food and Drug Administration (FDA), rcspective.ly, and shall require the approval of both agencies prior to its initial operation.

(c) Qual ified Pract itione rn : Qualified Physicians; APRNS; Physicians Assistants, supervised by Qualified Physicians; RNs; or LPNs, supervised by an MD, RN or APRN.

TN: 15-004

Supersedes TN: lHl.2

~ 'j'ro\5 Approval I l:llc - J \ \ \ .. _l.~ __

State: District of Columbia Supplement I to Attachment 3.IA Page 20A

B. Dentures and Other Removable Dental Prostheses

I. lriitfal placement or replnpcmentof-a removable prosth~is (any dentai :~evi:c~· o.r appliance replacing one or more missing t~dh, in~h1ding associated structures, if r.eq.uired, tb.~ is d<tSigned to be (emove.d and reinserted). once every five (5) years per beneficiary, unfoss the prosthesis:

2.

3.

a. was misplaced, stolen, or damaged due to circumstances beyond the beneficiary's control; or

b. cannot be modified or altered to meet the beneficiary's dental needs.

Denture reline and rebase, limited to one (1) over a five (5) year period unless additional services are prior authorized.

Denture replacements within the five (5) year frequency limitation require prior authorization from DHCF.

TN No. 16-004 Supersedes

Approval Date: I 0/04/20 I 6 Effective Date: 11/0I/2016

TN No. 07-02

S11ppkn1C:nt lo t\li,1ch11tl:~1 ). I 1\

l'agi: 7.00

C . f>t·o:,; t.: tv:.:: .i c oe v .l.c<:.!~ ..... --•·-·--. -··-·"""':'"'···----#-•~··~

l. Pc-o!ll;hf;!t i'c chivicf'.~i are 1:i.nlJ. t ed to items on the r>u rable Me.d.j.'c:al Equipment:/ Med.i.cal Supplies Pror:cdu 1~e Cb<'.le1.1 ;;ind Pr.ice. L°L!.lt: except where: pcior <1uthoc i.zed J:1y the St,1t.·~ Agency. ·

;,L Medical nuppl i.e.~, c111d f!c,ruipment in excess of 1Jped.t:ic J im:i,t:,,.ti-on~;. i.e., cost, r.ent:al oi:· lease equipment, , . or ccrt:;,v.r, pr-oc:etiu.c~ co(,ies rnuet: be ~rior ar.n:hor.ized by the ~tal:~ Agency. . .

1-,:r;..,·~-.-;i-;·.,;:(-- ,, __ .. ___ ., ____ - _ _, __ ·-•-·•--~-·.,--------·- ---· Ar,(l(('IV.tl Dille_______ f:[lcc1ivc();1/cl)_\•dt!.:-- 1, JOO',

supt.:r:,-c,,cs

TN Ncd.6 -6 11 tr· ,. ti ')WJ·7 ~L 1J~ •. : ) f_ !..,(

-:~•;,,~:•. :::l·r:i 1,~ ~t · 1r-1< h1t<l:HI , i ,•\

l',,g(: ~'.ilC

l. This item inc:lu :ic ,; l ,~ns!!. S r eq\ 1i. r ed i;o aid or tm[JrOve visi.on witl1 fr:a111e \•1he11 nece ;;sctry 1: h,:1t an:! rrcsccibcd by cl: phys,ic.: i ,rn sl· · llcct i_11 c.J .i. s easc.<; o f the aye. O t' by an optomet ci. f: t:. ,~t: • t:h<1: di.~cn~t: i.on _- of 1:h(~ patient:.

2. Eyeglasses a~c limiccd to one complete pair io a twe·nqr-foLtc {2•1) r11c101:h pct.tod, r~x:ceptions to thi.s policy an.~,

TN I-lo. 07-02 .'iurc1:;cdcs TI•/ /•! n f;f~: ~

b. Whenever ~here is a change in the pcesc~iption or nior::e than plu9. or rninu~ .·5 (one half) ~iopter, ..

· and

.: c. Br~ken.or lose eye~lasEes.

f:trc:cci,•cD;itc1~i'Y:1 /J .)001

State: District of Columpi~ Supplement I to Attachment 3.1-A Page 21

3) Special glasses such as sunglasses and tints must be justified in wrihng by the ophthalmologist or optometrist. Specia 1 tints and sunglasses are not allowed in addition to untintcd eyewear.

4) Contact lenses must be prior authorized by the State Agency.

13. Other Dial!.nOSLic. Scrco11il1g, Prevt:nlivc ·md RL:hr1b ilitaLivu Services. i.e., Other Than Those Prn_yided Elsewhere in This Plan include:

a. Diagnostic, Screening, and Preventive clinical services that are assigned a grade of. A or B (strongly recommended or recommended, respectively) by the United States Preventive Services Task Force; approved vaccines recommended by the Advisory Committee on Immunization Practices; preventive c.:Hre and screening of infants, children and adults recommend by the Health Resources nncl Services A(lministration's Bright Futures program; and additional preventive servkcs for women recommended by the Institute of Medicine. Preventive services shall he recommended by a physician or other licensed practitioner of the he,ding arts acting within the authorized scope of practice under the Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code§§ 3-1201.01 et seq.), or comparable law in the state where the provider is licensed.

b. Rehabilitative services must be prior authorized and arc covered for eligible Medicaid beneficiaries who are in need of mental health or substance abuse treatment, due to mental illness, serious emotional disturbance1 or substance use disorder. Covered services include: 1) Mental Health Rehabilitation Services (Ml-IRS); and 2) Adult Substance Abuse Rehabilitative Services (ASARS). These services are described in .fumvlement 6 to Atlnchment 3.1-A.

TNNo . . U-_ Supersedes TN No. 11-09

n.

b..

C

C • .fl. Prevent iv<> sorvioos must be pi ior n11ll1or i;:td.

/i!l!.-'.!.':!\!.!i.~! 1•i 1J1..L,~c:r-• ere liu,it.t.d tb ~c.rYicos urtifir.d u9 mcoicnJJy 11r.c;os~.:i1y by :._be (•,,~; Jt,:viow O,·r,,rn;~., linu. · · · - • S'i::illcrl nupiun ,facllll.y mviccs aro l~mi_l.id !o sc:rvi=s c::1<ifiCll as mc.di.:.1ll)'noccss.1ry by tlic !'t101' Roviow Ori,:nni7.a i.Jon. lrircrmcd illlC ca-,c facilit-/ SCr1'1G<l.t nrc limill\d lo SC,Jl'ir.cs culificd ;lf. ,nocli1:ally n:.t:r.~i:ury

b)' tho PM( Rovrow Ore-anizotion.

' . 15.a. tnreljlll!;l\lncc Corc.J.::!l~JIJ.lY SC"rvicc_f (ulhcr lh,\ll ,111..:.h .~orviu•; in ll[l in,Wlllirm for fllt/JIDI

16.

di:S"t:.!IS~) for pc:r:.o= ,lccerminc<l in accard.'.incc wich ,cction 190:!.(n)(J I)(~) aflho Acl, lo be im need ofsucl1 care ate provitlcd with no limi1ation~.

b. lncluillnc suoh sc.rvi.ce1 in II pub/lo irirtiLuuon (or dislinc;t µan lhorcol) for 1.hc nic:o.laJ.ly rolulliz,d ~r pcrrons with r.cl~rcd•coaditioru Uc provided. with !1" Jimil.o,.!rons. .. .,~ JnpaticntPw.ohj.1tJ'ic: fwilir:y Sordco~ fur in<1ividuals uqdcr 2.2 years pf ago are pr~ivide4 witlt Of>

.:, li·m!r11lloiu. ' • · • - 0 . __ · · -

TN/I !IA !\~ Supcrcodos 'fNI/ S.S.-.6

£.ffocrivo l),, ri: __ .

;,Ju: si.:.~ i-i~tk.tJ re~ ;_:;(:r"V1(: 1:•"; ,J(,;~, j:JL:(•l/i.:1 ~?·:·: ( ,. ,:i :. ~:t , · ·-j~:ti: ',!iUl il ,::.

La·,: ]0-2•17

if.i. 1/o.sp;;cc::_Care (in c.c:cordarcce wit:.r1 ~;ecc;.ion .l.90'i(cl of the Acl).

A !io •·ptcc pco9.tams 111· 11• . i. I, · fJ.'1 l l · , 11 • v-•· , c11:-~ ::ind ·co,ins~lir~g <;e c v 1.C ia!S l:o cccrni.11,\l ly i J I 1 11 1"!1 Ji, l•.r,d ~:; in ; , 1: c:-0Ldc'tr1ce: , .. ith a. wri·t.r::m pl'• 11 of: 1,;1:(• 1111 c:,H· il t:h.!1 •.·idu~l. 1'h,: init:ial Ho,.p i e el ~c ti.o r: pt::, 1.ud ,,!,n: J I,,. l H ' ri.i no Ly ( 90 l d,\y!i, f;c,J l o ,,,eci tiv .1 ser:und ·1i 11,,: 1· y ( 1Hl J d,.,, period, <1 Lhii:-d pe iod o( ·i, c t: y ( J(J ) rf, t \•:1. ,t11 ol 1. ll~c ,1 oi1c or:- ·moce thirty 1·10 1 d,l,, l~X e nded cd ·t:: t 1 1.11 1 1°• · 1 •rd: : , '• lonl) ;H: the

J)l OV I tit• 1. of t.,J L ll !i ,I ''" I I r !;! II C. • • :· t j f I•• rl t: j llJl ; ea tCntG::n.:: t.hd C

l· I • t't;,C:ip,., .• ri · ., m ·d' c ,1l p,· ogno ~·i s js F.,ol: c1 li fe · ;cp1!ct<lnr;y of $i>e rnonL h t;; or l a!>s . 'l'h i.s' cert.iEic:at.i.on

sh. J I be obt:1ir. d n o .l.o.cec .:h c1 11 t•,ro ( ii c,:1lemJ,1;1r days .:iLL.:cr t: h,~ I 1i9j 1111Jn o f eac h p·e r ..i. o cl.

t3. An elect;ion to rN:ei •, c ho:.•pi cc c,.ii:e ,\S considered to continue t:h.rough th,_ i. n .i. tia I l·. ).e<:l ion pcr.i.orl a nd t hrough any subseq:uent e :t et:'Lion per .i ocl • wi "IH)u t:. a break .i.n cai:e as long llS the r,~cip.i.en t: ) " el\111 ) 11 5 . 11 l:h$ care Ot t he hospice· and does nf> · c~vc,ke 1; h t; ""J "ct·io11..

C. If a recipient has both Medicare and Medic~id coverage, the hospice benefit shall be elected si~ultaneously as well as revoked simultaneously _under both programs.·

D. J:f the re<;:ipient revoke6 t.:he hospice election. his o;r h~r waiver. .of othe~ Medicaid coverage expires.

E . 'l'he :r:ecipient ma.y revoke t.he ho~pice elect.ion ducing any period.

r. The recipient may designate a Gew provider of hospice care no moi;-e than once during ,m election period:

Tl'J No. •j7 (I!,

s~J(lec~ ~~.i~-;­TN No . . 22:_9~

Appcova l oar.e 71 15/"J}

o: ::iic:, ,~11.i{.ftl.lt">fl oi l ,l:c t~l!:':.:f J!!;, ~j, !1:.: .. ;·,iJ1: .. :: .;1.:•.; J:.1;

:;~~('\Jl(::'} ~; 1r.!i:.~ch Ui::.? \~~~rvi•.:-~'1.J~•tt i..t,, ~, hL- :;::··:•A/1:·~·~. i0 C: -•:.:!-{:(i

uft(:J(., r: Ule Hedi.Cd(\! :'c..:-,:;i-t..:1HI, A[ li!C' llc;--.;p L(:,, ,:; 1,:cL ! ()It.

MP.tlicf.u .d pc1 ;'rnent: sh.:ii I. ho:~ m<1dc i:or sucv1c<.>s i:hc1L ar~, ('rj=.,·2recl \.1(ld~1 L:hc ~;,~ar:e 9 t,Hl 1 L c.hnsf: 1.:ef-., !..Ct.::"\ "~ rl; n<,r.

,::c.w:::,,:,~c! by Mc.d~c.-ire .

.St·t r v l Ct~!:~ ('> cov i.dr:d by :.·. h=:..: t·!t::-:; i.. -~!nd t. ~:,....I ;~n.-:;p l c.:•: f •-= i ;: , , •• .- ;­

d L C'cct: l y ot: und,:r <1t't.-,'l:"l',):i,i, .. 0 nt:.l,

~:riL-.,..ir:c,s pt·ov.id<:d l,f t:lit, c~'<:li•:unt:::' ,1l.l:er:c:tnt;i t.tl1y,;ician if l".hc1t: fihy~;:t.:l'"ln ls nu1· .. ,1 e,11;)! ,:;y,:·,'! r,f !ill:­

·dt-!~ignf.Jt~!d !\ospi~~r; or c•:r:.i.:":i.\_;i&'\q C(.1mpcrL~;UtLoo tr.om che hos0ic~ for thosB socv~ca~; anu

)_ Qualit.:.y of li.fe pce.scci:.pt.:i_on dcugs.

H. Coveced hospice· sei..-Jices inclt1de:

l. Nu.rs ing ca.ce proy:ided by or undei. the supecv is ion o E a registered n~rse;

2. Medical social services provided by a licensed social worker under the direction of a physician: -

) . Services µ,~r.l'oCTned by a doct.pr of medicine, of dental . surgery o:r. dcnr:.:il medicine ( Eor persons; under 21 years of age}, c>f r,,odi.d t:.cic medicine, oc of· Of?tomet:ry. ex:cept that t:.he se.ir-vicci.: of: c.he hospice. medi.cal di.recto, or the phys:ici.aii 1ncmbe:c f 1:h-e int:ecdisciplinary group. muse. be pecfornw:c by a doctoi: of. medic:, ne_

'1. Counseling sc~t:"v.i.c.es, including hec~,:iv,~ment. and if: app.cop1.·iate, sricitua1. _.and dietbcy;

5. Short-c.ecm inpati.eni; care pco'l.i.ded in a Medi.ca.id certified hospit~ inpatient unit. oc a Medicaid certifie~ hospital oc nursing home that ~co~ides supervision.and management of the hospice team:

6 Durable medical i;quipnieni.: Mid sup;dies ;

·-·- - ' - ·- - .... _ l'N I-lo :! ~--:~OS° ~<J!)ac~c~~s Appcov~l Oate G/29!9) ••p.--- · ·rr, 1•:o

"f"N i"lo

:)'upr:. · "floj i·/:,

~·~::c.-!~C!. L[-''-!.Dfi diug~ \-.:(1\(; , .:.~l· t, ~ ·If:•:. ~: 1:

((?¼ i..·'.:f of. [>ain .1:1d .~-;y'TT1pl om cuntc~·)i_ , .- :.;~! ,! .:n tnc t'2'.C .t()i. e.,1t:'s tecm Lno1l i l. 111ess ;

9. Home he,.ilth aide, personal can~ di.d,~. l.l lld homemu.ker services; and

10 . Chernot:herapy and r adiat i.on ther:1py to pr.r.,v idc pa.ln control or symptom relief

I . Cont:inuous Home Care can~ tc, nia i. nt.a L!"t ,:1 ,·1.) c j pient.: a.t hem~ rluc i ng a brief period of ccisis is cnver~d foe :

L. Nursing care, provided by e ithec a registered nurte or d li~ensed practical nurse. and ~ccouncing for more t.han ha lf of the pei:-iod oE ca.re:

2 . A minirnwn of ~ight. (f:! I hours o f cace, not necessarily consecutive, provided during a t.wenty­four (24) hour day whicti b egins and ends at midnight; and

J . Homemaker, home health, and per5onal .ca("e aide services if needed, to supplement tthe nur6ing care.

A . Ca s e ·11.:111agement Services as Defined in. and to The Gr.oup Specified in, Sup p lemen t 2 to Attachmen t J. lA (in acc:oz:d n ee wi th s ection 1905 (a) (19) or secc. .ion 19 1.5 (g) o f t he AcCl ace ~rovided wi th l i mi tations . • 1

~•\.~~,{IW fl. Tubercu l osis Related Services

l Covered servi.ces shall be defined a s t.!1 0 .<se ~ervi.ces --· listed in Section 1360-J o f 1:he Omn.i.bu s

Reconcil i ation Ac t of 1J9J ~s being related to the treatment of those persons with a diagnosis of tuberculosis disease_ In accocdance with Section

c·•·d n ! .,~r;-~) .,:,{{

1) 60). room and board are not a coveced service for pa t.ienl:s comple t ing tccatmerct unde::- obser;v<1Llon

These services shall be pr.ei;ccibed by <1 physician ein d shal 1 be p art o E a vJ!"i l lcn p l..;;,n of car. e ai;;,pi:oved by the Bureau of 'l'ubeccu.los1~ Control of: the Departmen t oE Health

1:,:.q1~~rJ.:•cj ~crvi.c:~::-.: ~b -::il i be di. -:eccly ond s;?i'.!C~!:~c".1i !y

,>:-: 1 ~1 t: r:·:d t •:; <' p .l ... ) n o ( ca-::..-.~ ~-, c i. t:ten by a. pt;1,..:, i c i. ,:L .. : .-1r1-..! c111,;r:·Y,'(!r.l ti 1 t:.hc riuC,~01u o[ 'rut.1ecculosis Conr.co 1.:

:'h:~ ::•'!{·;i ~- •~·-~: :-..;!id ti b~ ,_-~f '-·~ .. :l~:.')f°!-<.:d:Jl::' ,~tnO:il~L--: cl:ir..-,~ •tn;

•.)n:'j t 1 :.~r;u•.:11<: ·:·• ,,nd td,r:, ! L i·;c t;p,:;~c i. f Le and ;>cr.v i..d-.~ eii\:r:r ,v,-. ,:!4 !; .-:lt:rn~nt: f.o,~ c.hc: 9a.L:ienc·s ~":tndi. !:i.on i:1 l~:.· · : 1 ,·~! 1r·:r.:-.· .' i. t.h_ 1·-,cc,_:p~:\~:d ~~: t:-(ln(lri£:d:; (' (· u,~:cJ i C:•~\ i i,11·,=;ct It ·( .·~

r·,:t~-·· t!)/?;·•=~'.:fr:-~rnr 1 n:;. ~~r.i/i Cl~~ C:01: tubr~rc:u 1or.; ls p~l: l ~()l:s :.: .. ~; ! .i.., p: ,:.:;: ,:.uLho!'':.,:t~d h\/ r.hr: [Ju(•~·-=i,., u( "i':d:,,:•;~··. ConLr..vJ..,

2. · Docu111encati.on Hequi.cements

Trr .;th) I •

Oocum~n~atioD of tuberculosis-~elated services shall at a m.1.nimum:

a. rnclude the diag~osis and describ~ t'.he clinical signs and symptoms' of the. patient's condition;

b Include e1 complete an.d accurate description of 1:he patient's clinical course and treatments;

c . Oocumen·c. c.hat a pla.-1.1. of C@ t·e baaed spec.i E.:i.ca.lly on a cornp•cehensi ve ai.sessment: of the 'patient' .s needs has been developed foJ.' toe patien t: arid revie,-Jed and <'ipr, r. oved D)' i.:he flucea1..1 of '!'uberculosio Conc.r:-o1 of t,:i.e Com1r. i:~.si. c,n o[ 2ubl.i.c Me~lt:.h;

ct Jr·,cludl.; :J copy oE ,~he pt<'\n oE care c1nd L:he phy'.-,i.<:i.un·s ,;,rdeu;:

e, 'fnr.lud~ all r:reat:ment cendered l:o t:he pc:1.tient .i.n ~cco~dance with the pl6n of care, ptoviding in Eot:"ma t. i."n on the l:n~quenC)', d11t:a I.. Lon. mocla l i 1:y ,:ind ,:respor.sc, cud ident.: i. fy •,1!10 provided t.:h.-) c.:ar.~: by (,_, ll nc:;.rne c1 nd t i 1.: Le ;

De~cc it,t:! clwnges i.n t:he p,,tienl.: ·.;; C0!1di,t:i on i.n i:e.~~pons,~ ti> tne zeC'V-lce,,,: pc:-ovided t!ir.ough che pliln or c,;i, '": ,=,n,d,

' -· ',;:-·,•!· .. , (:,}.- ·. ,:;_.: :..' '

,,

Include t.he 1:une [i:ames necc~;sc1r.y l.0 crnaplcL,: U;,~ t:c,~atrne111.:. c1nd th£? pat:i.ent·s discha.r9~~ cl{!.';t:.i.n,:.r,i.c;r,

s~cvices pi:ovided to pa~ients without an approved plan of c;:;,·e ~hcil l not: be ceimbursed.

,1 ')ec:vi.ce. l imi.tations: The Eoll o ,11ing gef\cnll. r.eq1.lit:<?m~11t~ !;hall c,pply_ to all re1.mbur.sabl,~ t:.ubc rculo:,;i,, .. ccU1c ;,,d St!t-\/ iC:E' !': ;

;,_ P,1c .1. e1•1,.s must· b e uncle.1.· t:h.e Cell:" of a physici~n who .ts ieq .11 l:,r .=.rnthc.c u red tr:• pr.ar.t i ce and ,,,t,a i.s c1ctin0 unrtc~ th~ M~ope of hLs/her l1cRnse.

b. Services sh•>ll be h11· 111.sh-•t1 , 11 ,d, · 1 " w,· i t:t·n i:,! . n pf car-e th"'t .1.s (:!;t:11b i shi::.d ,:u,d 1.c•vi,~w•.!d p,:11orl1.c,1J ly by a p hy!':i.cilln . . The =s , v ·cl!S or i em:: f-,c whi.ch .r:eimbursetn1:?Ylt · s souyh · mu t:r-. b,'! 1,ci c.:t;::a, y Lo c:ac-ry out the plu n , ( c:a,· e ~ n d mut.; · be ,·r~J ,:i l: t!~J to t:l1C:! p~tien ~ •s con&ifion.

c . fl, phy.·icic1n·~ 1:e·-ce.rc:i.f:'c<11.· o ,1 of, pJ;:,n shuil be ,:equicetl pl'!J:i ilical y ; sh.'.IJl b<- ~:ic-nicd · nd dated by th r hy~; -; ·,n 1.o,ho c vjcws 1: ) 11. pJ .-111 or c: ,:s ·u: .c.h.al.1 i.nclir.a · r:! t~ln': ct111l: .i.n11ing n ,, rl f ., c li e iH:rvi.ce and es •imot,_ hm,1 .1 0 11 ,J St? . vlce .. wi.1, l 1,v 1,e •ded; nnd. mvst be .ivui.l.ttbl,~- wh"411 ·he r,l.:u, o f. car-,~ i.s r -eviewed· by the Merli~a · d pr:o L~m o icn anent.

ct. 'f'Ji. phy~ician's 01·d rs ur ~~~1:vj . ,~s shal.J inc;lud. the ,peci fjc: l:rec1tn_1e t.o b· 1 rovi<lcd c'lnd shall ·inr:ticcit.:<: th tL"Cc.:f\1, .ncy c1 11d cf11r:.:.1t:ior, of t:<: ·vices.

e. Ut.i lization . vu;i.,, s li c1 l 11 •. ,-; 1,chu:1. . . c! hy the MedicaicJ pcogram or i1 :: .'.lqnu 1. o d1d. , .. 1.,11i nr~ ,.Jl,ethr:r: services are appropri,\Jt.Ply p,vv1-CIP.<I 11•1 t. ·• ~:r}; u,· e thuc 't:he ~·cr:vjces ace: 111 di1. :1tl;• 11<• r •r! ~ ::,,1: y 1•d .c1pi;i,opr..ia1:e. $ei:-vices not: s 1. ~ • . il'1 ;oily dr.,,. ,1t111•11t ( I 1 n r.hc patien1:'s mP.di c: a.l r:e<.:c;rd ;1s lv,v1.nq 1,,. 1i:n r •'-: 11 l•·11~d nhcll.l be deew d not. t 1i~,v.._. l.:n.,,., ,· ,•nrJt:, 1•0 ;,-.i,rl ., l1nl1 not: oe re.i. ,nbui:-se<l_ ,1t1·1 ::er-,i c .-!: f•,11111! ,,,., 1. 1.1 be rn<!cllcall'y necl:'!ssar:y a:;,, i1·:.u!t ,·,i ut· iJi:,.1, 1.i.on revie1-J shall 11ot b~ tei.mb1Jr.sed.

20. Ex1c.11dcd Scrvicc!i frl!Prcgna_nt Won11::n

Suprlcmcnt l to Auachmcnl ]. t-/\ Page 27

A. Pregnancy-related and poslparium services for 60 clays after the pregnam:y ends arc provillcd wi1h 11()

limitations. The Dcparlmcnl of Health will provide lht! J'ull range of scrvicl'.':; .ivailal>lc under the Dislrict of Columbia Medicaid Stale Plan. as long as the re4uircd medical service is pregnancy related.

B. Servict!S for any other meilical condition Lhal may complicate pregnancy are provided with no limitations. The Dcpar!menl of Hcallh will pnividc 1hc full range of.services available under the;:

. Di.strh:1 or Columbia Medicaid Stme Plan, as long as 1he required medical service is pregnancy rclalcd.

C. Tobacco Ccs:-;ation Scrvic.:cs include fare-to-face counseling and Lob11cco cessation pharmacolherapy, :L~ n.!commcndcd in Treating Tohm:co Use anti Depcm.lcnce: 2008 Update: A Clinical Practice Guidelini!'', published by Puhlic He;1Jth Scrvic:e in May 2008, or any suhsc.4uen1 modification of this Guideline. Tobaci.:o cessation services arc provided by a Medicaid-cinrollcd physician or an Advanced Praclicc Registered Nurse (APRN) under lhe supervision of a Mcdi~nid-cnrolletl physicilln. A physician or APRN, licensed or certified pursuaiil lo Districl or Columbia Heallh Occupa1ions Revisions Act of 1985. effective Mnrch 25, 1986 (D.C. Law 6-99; D.C. Official Code§§ 3-1201 ct seq. (2007 Repl.; 2011 Supp.)), shall prescribe product~ used for IQbacco Cl'.'iSalion pharmacothcrnpy. Cost Sharing is not imposed for Tnbacrn Ccssn1ion Services for pregnant wnn1en.

2J. Ambula111ry Prcnat11I Q in.! l'or Pregnant Women Furnished During A l'rc.sum~Iillg,ihilitv Period by A Ou.1lilicu Pmv}dcr (in acc1~rdance with :m:1ion 1920 of the At:l) is provided.

22. Respi rn tm,, Carn Services (in ;1ccordance wifh scclion 1902(c)(9)(A) through (C) of the Act) 11re

001 provided fo r vc11li laj1) r d~cndc1H imli idlli~-

23. Nurse ~mu:tiliiincr lil!rVit:cs arc provide,! in accordance with D.C. Law 10-247.

A. The services of the nurst: prnc1iti1>11cr art.' subsum1:xl _under the hroad calegory, Adv:1nccd Pra1:1icc Rcgisll!n:d Nur.;ing which inclucks. but is not limited to, nurse mi~wifc, nurse ancs1hc1is1, nurse prac1i1i,rner anti clinical nurse spcdillist.

B. The ~crvil'e:-; of the at!va11ccd 1m11:1icc rcg.istcrctl nurse iirc lo be carried ou1 in general collaboration with a liL:en:;cd he.allh care provider.

24. Any Other Mcdit-dj Care anti An,, Other 'fypc 11r R11mt:uiaf (arc Rccugni;,;cd under St;ilc L1~ ~cci fit:d b~tlt: rcl.ill.Y.

A. Jrans[?l)tlal ipn scrvi9:.li ;lrc not discussed umjcr I his section of lhc slalc plan. See Allachmcnt 3. 1-D.

B. Scrvin:s of Chrisliiln Scicm.:e Nu r:--c!i arc nnt provided.

C. (m:cand_ 'i.:r/ t:c:; Provided in Christi;i n Si:icnti: S:rni!fil.in arc not pnwidcd.

TN No, B-18 Supersecfes

TN No. !1.7:92

District of Columbia Supplement I to Attachrnenl J.1-A Page 28

24, Any Olhcr Medical C·trc and Any Other Type of Rt:mcdinl Care Recognized Under Stace; LHw, Specilied by the Secretary (cont'd )

D. Nursin, Fac ili~~-r:rvice~1•ovidcd for P:1licn ts under 21 Ycnrs of Age are provided with no limitations ,

E. Emergency l lospital Services

nJ No. l!:.Ql Su r~_rscdcs IN No. 97-05

I. The emergency room clinic physician encounter must be authenticated in the medical record by the signature of a licensed physician to be considered for reimbursement by the program.

2. Reimbursement by the State Agency is restricted to one encounter when the same patient is seen in both the emergency room and/or outpatient clinic department on the same day.

3. Reimbursement for induced abortions is provided only in ca.ses where the life ohhe moth~r would be endangered if t!ie fetus were carri•ed to term, or the pregnancy occurred as a result.of rape or incest, and when the claim is accompanied by the fo llowing documentation:

a. Documentation that services were performed by a provider licensed to provide such services; and

b. Written documentation from the treating physician that the life of the mother would be endangered if the fetus were carried to tenn; or

c. Documentation that the pregnancy occurred as a result of rape or incest. For purposes of this requirement, documentation may consist of official reports; a written certification from the patient that the pregnancy occurred as a result of rape or incest; certification from the physician that the patient de.clared the pregnancy occurred as a result of rape or incest; or certification from the physician that in his or her professional opinion, the pregnancy resulted from rape or incest.

Reimbursement shall be made according to the fee schedule amount and shall cover all services related to the procedure including physician fee(s), laboratory fee(s) and counseling fcc(s) .

Approval 0,\1~ CT ·11 2011 EfTt ctiv~ Dnl~ \ l _ / )

District of Columbia Supplement 1 to Attachment 3.lA Page 29

(continued). Any other medical care and any other types ofremedial care recognized under State law, specifically by the Secretary.

f. Per onal Care ervices. Presc ribed io Accord ance wit11 a Plan of Treatment and Furnished bv OualiJied Persons Under Supervision of a Reeistere.d Nurse are covered wiLh Jim irations

a. Covered Services

1. Personal Care Aide (PCA) services are services provided to individuals who require assistance with activities of daily living. Covered services include cuemg, hands-on assistance, and safety monitoring related to activities of daily living including bathing, dressing, toileting, transferring and ambulation.

2. Section 1905(a)(24) of the Social Security Act authorizes the provision of PCA services in a person's home or, at the State's option, in another location.

3. Under Section l 905(a)(24) of the Social Security Act, PCA services shall not be provided to individuals who are inpatients or residents of a hospital, nursing facility, intermediate care facility for the developmentally disabled, or institution for mental disease. Additionally, PCA services must not be provided in any other living arrangement which includes personal care as a reimbursed service under the Medicaid program.

b. Service Authorization

1. All PCA services must be prior authorized. To be eligible for PCA services, a person must:

(a) Be in receipt of a written order for PCA services, signed by a physician or Advanced Practice Registered Nurse (A.P.R.N) who: (1) is enrolled in Medicaid; and (2) has had a prior professional relationship with the person that included an examination(s) provided in a hospital, primary care physician's office, nursing facility, or at the person's home prior to the prescription of the personal care services.

(b) Be unable to independently perform one or more activities of daily living for which personal care services are needed as established by the face-to face assessment conducted by DHCF or its agent.

(c) Be in receipt of a PCA Service Authorization, which serves as the service plan approved by the state required by 42 C.F.R. § 440.167(a)(l), that authorizes the hours for which the individual is eligible.

2. For new beneficiaries, a request for an assessment shall be made to DHCF by the person seeking services, the person's representative, family member, or health care professional.

3. An R.N. or Licensed Independent Clinical Social Worker (LICSW) employed by DHCF or its designated agent shall conduct the initial face-to-face assessment following the receipt of a request for an assessment.

1N No. 19-001 Supercedes TN No. 17-004 Approval Date: May _ I.20 19 Effective Date: /\.pr il I.2019

District of Columbia Supplement 1 to Attachment 3.IA Page 30

4 . The face-to-face assessment will utilize a standardized assessment tool, adopted by DHCF, to determine each person's level of need for Long Term Care Suppo1ts Services (LTCSS).

5 . DHCF shall issue an assessment determination (PCA Service Authorization) that specifies the amount, frequency, duration, and scope of PCA services authorized to be provided to the person.

6. The supervisory nurse employed by the home health agency shall conduct an evaluation of each beneficiary's need for the continued receipt of State Plan PCA services at least every twelve (12) months or upon a significant change in the beneficiary's health status, as follows:

TN No. 19-001 Supercedes TN No. 17-004

(a) The evaluation shall determine whether there 1s a significant change m the beneficiary's health status;

(b) Prior to August 1, 2019, regardless of whether the evaluation results in a determination that there is or is no significant change, the supervisory nurse shall request that a face-to-face reassessment be conducted in accordance with the requirements of this section.

(c) Effective August 1, 2019, the following shall apply:

(1) If the evaluation results in a determination that there is no significant change, the supervisory nurse shall attest that a face-to-face reassessment is not required, and services shall continue to be provi ded at the level set forth in the current assessment determination; and

(2) If the evaluation results in a determination that there is a significant change, the supervisory nurse shall request that a face-to-face reassessment be conducted in accordance with the requirements of this section.

Approval Date: May 21, 2019 Effective Date: April 1. 2019

Distric or Colu mbia Supplement I to Attachment 3.IA Page JOA

c.

TN No. 17-004 Supen;edes TN No.NEW

7. Reque-sts to conduct a re-assessment based upon a significant change in the benefi c iary's l1ea lth status may be made at any ti me by Lhe beneficia ry, the beneficiary's representative, fami ly member, or hea lthcare professional.

8. All beneficiaries receiving PCA services shall receive a face-to-face re-assessment at least once every thirty-six (36) months, regardless of whether a significant change in health status has been identified.

9. Through December 31, 2017, DHCF may authorize the validity of the face-to-face re-assessment for a period not to exceed e ighteen ( 1'8) months to align the level of need assessment date with the Medicaid renewal date.

IO. Any re-assessment based upon a significant change in the person's condition shall be acco·mpanied by an o rder for services signed by the person 's physician or APRN.

I l. DH.CF, or its agent, wi.ll make a referral for services to the person' s choice of qual ifi ed provider upon completion of the initial assessment determination that auth orizes 'PCA services (PCA Service Authorization).

Scope of Services

1. PCA services are provided to individuals who require assistance with activities of daily living.

2. In order to receive Medicaid reimbursement, PCA services shall include, but not be limited to, the following:

(a) Cueing or hands-on assistance with performance of routine activities of daily living (such as, bathing, t.ransferring, toileting, dressing, feeding, and maintaining bowel and bladder control);

(b) Assisting with incontinence, including bed pan use, changing urinary drainage bags, changing protective underwear, and monitoring urine input and output;

(c) Assisting persons with transfer, ambulation and range of motion exercises;

Approval Date: 8/4/2017 EtTec:.tive Date: ].Ll.LWJ1

District of Columbia Supplement 1 to Attachment 3.lA

TN No.15-007 Supercedes TN No. NEW

Page 31b

( I) Ensuring that the planning process includes individuals chosen by the person;

(2) Ensuri.ng (hat the planning process incorporates the person's needs, strengths, preferences, and goals for receiving PCA services;

(3) Providing sufficient information to the person to ensure that he/she can db·cct the process to the maximum extent possible;

(4) Reflecting cultural consklcrntions of the pcn:on and is conducted by providing oil infom111tfon in plain langungc or consistent with any Limited English Proficient (LEP) considerations;

(5) Strategies for solving conflicts or disagreements; and

( 6) A method for the person to request updates to the plan.

3. After an initial plan of care i$ dtivclopcd, all subsequent u1111u 11 1.1pd11tcs and modi:fic-alions to plans of cu:re shall be submitted to DHCF or its ngcnl for opproval in accordnnce wiih Section c.2 (Plan of Core), except the signnlurc rcquircoienrs prescribed under e,2 (e).

4. The Provider shall initiate services ao later than twenty-four (24) ho1:11s after completing the plan ·of co.re unless the person's health ·or safety warrants the need for more immediate service initiation or the person and his/her rcprese11tntive agree that services should start at a later date. ·

5. The R.N. nt mi.niruurn, shall visit each bcnc.ficia1y within forty-eight (•I 8) hours of initialing p1,1rsonul care services, and no less than every sixty (60) duys thcrenfter, to monitor tho i111plcmcn1ation of the plun of cure n11d thu quality of l'CA services provided to the beneficiary.

6. The R.N. shall notify the person's physician of any significant change in the person's condition.

7. The R.N. shall provide additional supervisory vlsits to each person if the situation warrunts add_itiooal visits, such as in the case of an assignment of a new personal care aide or change in the person's cohdition.

8. Lf an l1pdn1c or modification to n person's plru.1 of ciuc requires ru1 inc1 ·a.S<= or dccrc-usc ii, th~ 11umbcr of hours of PCA st.:rvices provided to the person, the Provider 11111s1 obtain an updated PCA Scrvicc Authoriwtiun from lJI-ICF or its <lesignntcd ugent, subs~qucm to the request for rc,isscssmcnt for services.

9. Each Provider shall i;oordinalc a beneficiary's co.re by sharing information with all other henltJ1 care BJld service providers, as applicable, to ensure that the benellciary's care is organi7.ed nnd to achicve safer and more effective health outcomes.

ApprovalDate:8/2/2016 Effective Date:_ November 1.4, 2015

District of Columbia Supplement 1 to Attachment 3.lA

Page 31c

10. If a beneficiary is receiving Adult Day Health Program .(ADHP) services under the 1915 (i) State Plan Option and PCA services, a provider shall coordinate the delivery of PCA services to promote continuity and avoid the duplication of care.

f. :Provider Qualifications

g.

TN No. 15-007 Supercedes TN No. NEW

I. A provider of PCA services must be a D.C. Medicaid enrolled home care agency licensed in accordance with Health Care and Community Residence Facility, Hospice and Home Care Licensure Act ofl 983, effective February 24, 1984 ( D.C. Law 5-48; D.C. Official .Code, §§ 44~501 et seq. (2005 Rep!. & 2012 Supp.)), and implementing rules, and be enrolled as a Medicare home health agency qualified to offer skilled services as set forth in Sections 1861(0) and 1891.(e) of the Social Security Act ·and 42 CFR § 484.

2. A Provider may contract with a licensed staffing agency to secure staff to deliver PCA services.

PC.A Regn'irements

1, In order to receive Medicaid reimbursement for the delivery of PCA services, each PCA hired by the home care agency m~t have the following qualifications:

(a) Obtain or have an existing Home Health Aide certification in accordance with Chapter 93 of Title 17 of the District of Columbia Municipal Regulations;

(b) Confirm, on an annual basis, that he or she is free from communicable diseases including tuberculosis' and hepatitis, by undergoing .an annual purified protein derivative (PPD) te~ and receiving a hepatitis vaccine during physical examination by a physician, and obtaining written and signed documentation from the examining physician confirming freedom from commwricable diseese;

(c) Provide evidence, of current cardio pulmonary resuscitation and first aid certification;

(d) Pass a criminal background check pursuant to the Licensed Health Professional Criminal Backgrmmd Check Amendment Act of 2006, effective March 6, 2007 (D.C. Law 16-222; D.C. Official Code § 3-1205.22) andl7 DCMR. § 9303;

( e) Pass a reference check and a verification of prior employment;

ApprovalDate:8/2/2016 Effective Date: November 14, 2015

District of Columbia Supplement 1 to Attachment 3.1A Page 31d

(f)

(g)

(h)

Have an individual National Provider [dentification (NPl) nwnber obtained from National Plan and Provider Enumeration System (NPPES);

Obtain at least twelve (l2J hours of continuing education or in-service training annually in accordance with the Department of Health's Home Care Agency training requirem~nts under 22-B DCMR§ 3915;

Meet all of the qualillca.tions for Home Health Aide trnlnees in accordance with Chapter 93 ofTitle 17, which includes the followfog:

(1) Be ab)e to un~erstand, speak, read, and write English at a fifth (5 th)

grade level;

(2) Be knowledgeable about infection control procedures; and

(3) Possess b.isis safety skills including being able to recognize an emergency and be knowledgeable about emergency procedures.

h- Sen,ice Limifntions

TN No. 15-007 Supercedes TN No. NEW

1. The reimbqrsement ofrela:tives other than the person's spouse, a parent of a minor child, or any other legally responsible relative or court-appointed guardian may provide PCA services. Legally responsible relatives do not include parents of adult children.

2. Family n;iembers providing PCA services must meet the PCA Requirements described un~er Section g.

ApprovalDate:8/2/2016 Effective Date : November 111, 2015

State: District of Columbia Supplement 1 to Attachment 3.1-A Page 32

25(i). Licensed or Otherwise State-Approved Freestanding Birth Centers

Provided: approved

No limitations X Provided With limitations None licensed or

Please describe any limitations: See below

(A) Facilities must:

(1) Be lice~sed by the Department of Health (DOH) urider Chapter 26 of Title 22 of the

District of_ Columbia Municipal Regulations (DOVfR); \

(2) Be specifically approved by DOH to provider birth center/maternity center services; and

(3) Maintain standards of care required by DOH for licensure.

(B) Birth Centers shall cover services relating to three main components of care:

(1) Routine ante-partum care in any trimester shall include the following:

(a) Initial and subsequent history;

TN No.12-08 Supersedes TN No. NEW

(b) Physical Examination;

( c) Recording of weight and blood pressure;

( d) Recording of fetal heart tones;

(e) Routine chemical urinalysis;

(f) Maternity C(!\!,DSeling, such as risk factor assessment and referrals;

(g) Limitations on services for billing related to a nonnal, uncomplicated pregnancy

(approximately fourteen (14) ante-partum visits include:

(i) Monthly visits up to 28 weeks gestation;

(ii) Thereafter, biweekly visits up to 36 weeks gestation;

(iii) Thereafter, weekly visits until delivery; and

(iv) Additional v.isits for increased monitoring during the ante-partum period beyond

the fourteen (14) routine visits must be medically necessary to qualify for

payments.

Approval oaSEP 1 6 2013 Effective Date April 13, 2013

State: District of Columbia Supplement 1 to Attachment 3.1-A Page 33

(2) Delivery services shall include:

(a) Admission history and physical examination;

(b) Management of uncomplicated labor;

(c) Vaginal delivery.

(3) Postpartum care

(a) Mother's Postpartum check within six (6) weeks of birth;

(b) Newborn screening test. Screening panel inc]udes but is not limited to the fo1lowing:

(i) PKU;

(ii) CAH;

(iii) Congenital hypothyroidism;

(iv) Hemogobinopathies;

(v) Biotinidase deficiency;

(vi) MSUD;

(vii) MCAD deficiency;

(viii)Homocystinuria; and

(ix) Galactosemisa.

(c) Limitations of services for 11 Well Baby Check (newborn assessment) include:

(i) One· postpartum check per beneficiary;

(ii) Two tests per new born for screening on two separate dates of service; and

(iii) Two Well Baby Checks/assessments per newborn.

(ii) Licensed or Otherwise State-Recognized covered professionals providing services in the Freestanding Birth Center

Provided: No limitations X Provided with limitations (please describe below) Not Applicable (there are no licensed or State approved Freestanding Birth Centers)

Please describe any limitations: Professionals will be reimbursed for those services included under Birth Center Services under 25 (i).

TN No.12-08 Supersedes TN No. NEW Approval Dato SEP 1 0 2 0 1 lffective Date April 13, 2013

State: District of Columbia Supplement 1 to Attachment 3.1-A Page 34

Please check all that apply: _

X (a) Practitioners furnishing mandatory services described in another benefit category

and otherwise covered under the State plan (i.e., physicians and certified nurse

midwives).

The following practitioners may provide birth center services and must be

licensed. in the District of Columbia as a:

(a) Physician under Chapter 46 of Title 17 of the DCMR

(b) Pediatric nurse practitioner under Chapter 56 of Title 17 of the DC:rv1R

(c) Family nurse practitione~ under Cbapter 56 of Title 17 of the DCMR

(d) Nurse midwife under Chapter 56 of Title 17 of the DCMR

X (b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum care in a freestanding birth center within the scope of practice under State law whose services are otherwise covered under 42 CFR 440.60 (e.g., lay midwives, certified professional midwives (CPMs), and any other type of licensed midwife). *

(i) Licensed certified professional midwives

(c) Other health care professionals licensed or otherwise recognized by the State to provide these birth attend.ant services (e.g., doulas, lactation consultant, etc.).* NIA

*For (b) and ( c) above, please li,st and identify below each type of professional who will be providing birth center services: (see b (i) above).

TN No,12-08 Supersedes TN No. NEW Approval Dat~EP 1 6 2013 Effective Date April 13, 2013

State: District of olu111bia Supplemen t I lo Attach ment 3.1-A Page 35

A. Rural Health Cl in ic Services

The District of Columbia does not have any rural areas.

B. federally Qualified Health Centers

Federa lly Qualified Health Centers (FQHCs). serv ices, as described in 26.8.2 through 5 of.t!iis seclron, are included in the reimbursement melhoq ology described in Attachment 4. 19-B, Part l , beginn ing page 6f, ccl ion 12 .b.

l. General Provisions:

a. Prior to seeking Medicaid reimbursement, each FQHC must:

1. Be approved by the fc~cral Health Resources Services Adm inistration (HRSA) and meet 1he requ irements se forth ih the applicable provisions of Title XVJIJ of the Social Security Act and artendarit regulations;

ii. Be screened and enrolled in the District of Columbia Medicaid program;

iii.. Obtain a NaLion.ai-Provider Identifier (NPI). The NPI shall be obtained for each site operated by an FQHC; and

iv. Submit the fQHC's Scope of Proje<::t approved by the Health Resources Services Administra'tion (HRSA).

b. Medicaid reimbursab le sc.rviccs provided by"an FQHC shall be cpnsistent with the Section l 9O5(a)(2) of the Soci,11 cct1rity Act and furnished in accordairce with section 423 l of the State Med ic:,id Manual.

c. Services may be·providcd at other siles including mobile vans, intenn iltcnl sites such as ·a homeless shelter, seasonal s ites and a bcncfi!,:iary~s place o [ rcsitlcnce, prov ided the cla ims for rc:imborsemenl arc consistent with the serv ices descri bed covereo un der Section I 905(a)(2) oflhe Social Securi ty AcJ and in Section 26.B.2 through 5.

d_ All services provided by an FQHC shall be subject to qua li ty .srandarps, measures and guidelines estab lished by National Committee for Qua lity Assurnnce (NCQA), HRSA, MS and the Depa rtment of Hea lth Care Finance (DHCF) .

e. Serv ices for 'wh ich an F H C seeks Med icaid reimbursement pursuant to th is Section and Attachment 4_f 9-B, Part I, beginning page 6f, SecLion 12.b sha ll be de livered in acc0Tda11ce wi lh the correspondi ng standards for serv ice delivery, as

TN r~o 16-009 ~;uper :-;c.~de.::: TN No. _ Nt:N_.

Approval Dale 09/J0/2017Effective Dale. Soplernbcr l, .201G

Slate: Dis trict of Columbia Supplement I to Attachment 3.1-A Page 36

described in relevant sectiol)s of the District of Columbia State Plan for Medical Assistance and implementing regulations.

2. Primary Care Services

~)ui.)cr. ::-;i:~de::> TN ·r-10 NF:h'

a. Covered Pri_mary Care services provided by the FQHC shall be limited to the following services:

1. Health services related to family medicine, internal medicine, pediatrics, obstetrics (excluding services related to birth and delivery), and gynecology which include but are not limited to:

(1) Health management services and treatment for illness, injuries or chronic cc;mditions ( examples of chronic • conditions include diabetes, high blood pressure, etc.) including, but not limited to, health education and self­management training;

(2) Services provi<;ied pursuant to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for Medk:aid eligible children under *e age of twenty-one (21);

(3) Preventive fluoride varnish for chHdre~, provid~d the service is furnished during a well-child visit by a physician or p_ediatrician who is acting within the District of Columbia's authorized scope of practice, or in accordance with the applicable professional practices act within the jurisdiction where services are provided ;

( 4) Preventive and .diagnostic services including but not limited to the following:

1. Prenatal and postpartum care rendered at an FQHC, excluding labor and delivery; ,

11. Lactation consultation, education and support services if provided by a ce1tified nurse mid-wife, who shall be licensed in accordance with the District of.Columbia's statutory requirements on scope of practice orthe applicable professional practices act within the jurisdiction where services are provided, and certified by the lnlernational Board of Lactation Consultant Examiners (IBLCE) or a registered lactation consultant certified by JBLCE;

0 ~/ 2G/2Ul1sffective -- .

State: Dis1ric1 of Cor1m1bia Supplement l lo_ Anachment 3. I-A Page 37

T~; :-Jo. ~ (:, i~U} ~:,. UJ.i-:~ t ~; :• )c ':'

·:-,-. ;-_'.,) - m:;:-:

iii.

iv.

V.

vi.

vii.

viii.

Physical exams;

Family planning services;

Sc:recn ings and assessments, including but not limited to, visual acu ity and hearing screenings, and nutritional assessments and referrals;

Risk assessments and initial counseling regarding risks for clinical services;

PAP smears, breast exams and mammography referrals when provldcd as part of an office visit; and

Preventive health education.

11. In cidental services and supplies that Ort! iJ1tcgral. although lnci<lcntal, lo the diagnostic or treatment cornponcllls of l'JH\ services described in 26.B. I .a of this Section and included iJ, allowable 1.:osls as dc.scribtt.l in Allaclimcnt 4.19-B, Part 1, page 6q, Sect ion 12.b.viii. Incidental services and supplies include, but arc not limitc:;d to, the folJowing:

(I) Lactalion consultation, education and support services that are prov ided by health care professionals described in 26.B.2 ofthis Section;

(2) · Medical ser:vices ordinarily rendered by an FQHC staff pei:son such as takin•g pa_tient history, blood pressure measurement or temperatures, and changing dressi11gs;

(3) Medfcal supplies, equipment or other disposable products such as gauze, bandages, and wrist b'races;

(4) Administration of drugs or medication treatments, including administration of contraceptive treatments, that are delivered during a Primary Care visit, not including the cost of the drugs and medications;

(5) Immunizations;

(6) Electrocardiograms;

State: District of Columbia

(7)

(8)

Supplement I to Attachment 3. l-A Page 38

Office-based laboratory screenings or tests performed by FQHC employees in conjunction with an encounter, which shall not include lab work performed by an external laboratory or x-ray provider. These ~ervices include, but are not limited to, stool testing for o~cult blood, dipstick urinalysis, cholesterol screening, and tuberculosis testing for high-risk beneficiaries; and

Hardware and softwar~ systems used to facilitate patient record-keeping.

11 1. Enabling services are those services that support an individual's management of their health and social service needs or improve the FQH(;:'s ability to treat the individual and shall include the following:

(1) Health education and promotion service_s including assisting the individual in developing a self-management plan, executing the plan through self-monitoring.and management ·skills, educating the individual on accessing Gare in appropriate settings and making healthy lifestyle and wellness choices; connecting the individual to peer and/or recovery supports· including self-help and advocacy groups; and providing support for improving an individual's social network. These services shall· be -' provided by health educators, with or witho1,1t specific degrees in this area, family planning special-ists, I-iIV specialists, or other professionals who provide information about health conditions and guidance about appropriate use of health services;

(2) Trar:islation ;md interpretation services during an encounter. These services are provided by staff whose foll time or dedicated time is devoted to translation and/or interpretation services or by an outside licensed translation and interpretation service provider. Any portion of the time of a physician, nurse, medical assistant, or other support and administrative staff who provides interpretation or translation during the course of his or her other billable activities sbaJI not be included;

(3) Referrals to providers of medical services (including specialty referral when medically indicated) and other health-related services (including substance abuse and mental health services). Such services shall not be reimbursed separately as enabling services where such

Stale: Distric_t of Co lumbia Supplement to Attachment 3.1-A Page 39

referrals are provided during the course of other billable treatment activities;;

(4) Eligibility assistance services designed to assist individuals in establishing eligibility for and gaining access to Federal, State and District programs that provide or financially suppo11 the provision of medical related services;

(5) J:Icalth literacy;

(6) Outreach services to identify potential patients and clients and/or facilitate access or refenal of potential health center patients to avaiJable health center services, including reminders for upcoming events, brochures and social service!>; and

(7) Care coordination, which consists of services designed to 9rganize person-centered care activities and information sharing a,no.i;ig those involved in the clinical and social aspects of an individual's care to achieve safer and .more effe~tiv.e healthcare and improved health outcomes. These services shall be provided by individuals trained as, and with-specific titles of care cootdinators, case managers, referral coarc;l inators, or other-titles such as nurses, social workers, and other profe~sional staff who are specificaJJy allocated to care coordination during assigned hours but not when these serviGes are an:integral part of their other duties such as providing direct t,atient care.

b. Primary Care services as set fotth in this 26.B. l of this Section shall be delivered by the fo llowing health care profess_ionals, wh0 shall be liceris ed in accordance wit.h the District of Colu mbia ' s statuto_ry requ irements on scope of practice or the applicable professional practices act within the jurisdiction where services are provided:

1. A physician; 11 . An Advanced Practiced Registered Nurse (APRN);

iii. A physician assistant working under the supervision of physician; or

iv. A nurse-mid-wife. ·

3. Behavioral Health Services

::~ilf.•&r ~:t::dei;:

'J',·1 ''iC. N[(·l

a. Covered Behavioral Health services provided by an FQHC shall be limited to ambulatory mental health and substance abuse evaluation, l'reatment and management services identified by specific Current Procedural

State: Di.slri o.t o l Col umbia Supplement I lo Attachment 3.1-/\ Page 40

Terminology (CPT) codes. Such codes include psychiatric diagnosis, health and behavioral health assessment and treatment, individt1al psychotherapy, family therapy an d pharmacologic management. OHCF shall issue a transmittal to lhe FQHCs which sha ll inclu de the specific CPT codes including any billing requi rem ents for covered Behaviora l Health services. FQHCs that deliver substance abuse services must be certified by the Department of Behavioral Health.

b. Covered Behavioral Health services as set forth in this section shall be delivered by the following health care professionals, who shall be licensed in accordance with the District of Columbia's statutory requirements on scope of practice or the applicable professional practices act within the jurisdictjon where services are p_rovided:

1. A physician, including a psychiatrist; 11. An APRN;

iii. A psychologist; iv. A licensed independent clinical soci8:l worker; v. A licensed independent social worker (LISW);

vi. A graduate social worker, working under the supervision of a LISW;

vii . A licensed pr9fessfonal counselor; viii. A certified addiction counselor;

ix. A lice(lsed marriage and family therapist; and x. A licensed psychologist associate, working .under the supervision

of a psychologist or psychiatrist. .

4. P_reventive and Diagnostic Dental Services

a. Covered Preventive and Diagnostk Dental services may include the following procedures:

b.

C.

TN No . .lfi ·-009

1. Diagnostic procedures- clinical oral examinations, radiographs, diagnostic imaging, tests and examinations; and

11. Preventive procedures- dental prophylaxis, topical fluoride treatment (office procedure), space maintenarice (passive applianc_es and sealants.

All Preventive and Diagnostic Dental services shall be provided in accordance with the requirements, including any limitations, as set forth in Supplement 1 to Attachment 3.1 -A, page 12, Section i0; Supplement I to A Llachment 3 .1-B,· page I I, Sec tion 10 . .

Each provider of Preventive. and Diagnostic Dental services, with the exception of children's flu oride varnish treatments, sha II be a dentist or dental hyg ien ist, working under the supervision of a dentist, w ho provide

State: District of Columbia Supplement I to Attachment 3.1 -A Page 41

services consistent with the District of Columbia's statutory requirements on authorized scope of practice, or consistent with th e a,ppl icable professional practices act wi thi n the jurisdiction where ~ervice~ are provided.

5. Comprehensive Dental Services

a. Covered Comprehensive Dental services provided by the FQHC shall

include the ·following procedures:

r. Restorative procedures - amalgam restoration, resin-based composite restorations, crowns (single restorations only), and additional restorative services;

ii. Endodontie procedures- pulp capping, pulpotomies, endodontic therapy of primary and permanent teeth, endodontic retreatment, a pex1fication/reca lei ii cation procedures, apjcoectomy/perirad icu lar services, and 9ther eododontic services; ·

111 . Peridontic procedures - surgical services, including usual postoperativ~ care), nonsurgical periodontal servict:s, and other peri0dontal services;

iv. Prosthodontic procedw-es- complete and partial dentures treatme11t including repairs and rebasing, interim prosthesis, and other removable prosthetic services; · · ·

v. MaxiJJofacial Prosthetics procedures- the surgical stent procedure; vi . Implants. Sef\lices - Pre-surgical and surgi03l services, implant­

supported prosth~tics, and other implant services; vii '. Oral and Mroci!Jofacial Surgery~ treatment and care ~elated to

extractions, alveoJoplasty, vestibuloplasty, surgical treatment of lesions, treatment of-fractures, repair traumatic wounds including complicated suturing;

v111. Orthodontics - 01thodontic treatments and services; and ix. Adjunc6ve Genera) Services~ unclassified treatment, anesthesia,

pr'ofessional consultation, professional visits, drugs and miscellaneous.

b. All Comprehensive Dental !iervices shall be provi ded in accordance wi th the requirements, incl.uding any limitations as set fort h in Supplement 1 to Attac,;hmenl 3. 1-A, page 12, Section 10; and Supplement 1 to Attachm ent 3.1-B, page 11, Section 10

c. Each provider of Comprehensive Dental services, with the exception of children,.s fluoride varnish trearm ents, shall be a dentist or dental hygi enist, working under the supervision ~f a dentist, who provide services consistent with the District of Columbia':,; statutory requiremenls on authorized scope of practice, or consistent with the applicable

State: District of Columbia Supplement I ro Allachmc11t 3.1-A Page 42

rH F•·, . • (, 1.'•, •

c:r. t~' ... ;a·lt ·• :·r-: l~... l t L'

professional practices act within thcjurisdicrion where services are provided.