Code of the District of Columbia

Subchapter IV. Medicaid Program Administration.


Part A. General.

§ 4–204.01. Monthly amount of income disregarded. [Repealed]

Repealed.


(Apr. 6, 1982, D.C. Law 4-101, § 401, 29 DCR 1060; Mar. 20, 1998, D.C. Law 12-60, § 701(d), 44 DCR 7378; Apr. 20, 1999, D.C. Law 12-241, § 2(g), 46 DCR 905.)

Prior Codifications

1981 Ed., § 3-204.1.

Emergency Legislation

For temporary repeal of §§ 4-204.01 through 4-204.04, see § 2(g) of the Self-Sufficiency Promotion Emergency Amendment Act of 1998 (D.C. Act 12-372, June 9, 1998, 45 DCR 4270), § 2(g) of the Self-Sufficiency Promotion Legislative Review Emergency Amendment Act of 1998 (D.C. Act 12-425, July 31, 1998, 45 DCR 5682),§ 2(g) of the Self-Sufficiency Promotion Congressional Review Emergency Amendment Act of 1998 (D.C. Act 12-552, December 24, 1998, 46 DCR 521), and § 2(g) of the Self-Sufficiency Promotion Congressional Review Emergency Amendment Act of 1999 (D.C. Act 13-19, February 17, 1999, 46 DCR 2492).

Temporary Legislation

For temporary (225 day) repeal of section, see § 2(g) of Self-Sufficiency Promotion Temporary Amendment Act of 1998 (D.C. Law 12-230, April 20, 1999, law notification 46 DCR 4143).


§ 4–204.02. Amount of federal payment disregarded. [Repealed]

Repealed.


(Apr. 6, 1982, D.C. Law 4-101, § 402, 29 DCR 1060; Apr. 20, 1999, D.C. Law 12-241, § 2(g), 46 DCR 905.)

Prior Codifications

1981 Ed., § 3-204.2.

Emergency Legislation

See notes to § 4-204.01.

Temporary Legislation

For temporary (225 day) repeal of section, see § 2(g) of Self-Sufficiency Promotion Temporary Amendment Act of 1998 (D.C. Law 12-230, April 20, 1999, law notification 46 DCR 4143).


§ 4–204.03. Ability of responsible relatives to contribute. [Repealed]

Repealed.


(Apr. 6, 1982, D.C. Law 4-101, § 403, 29 DCR 1060; Apr. 20, 1999, D.C. Law 12-241, § 2(g), 46 DCR 905.)

Prior Codifications

1981 Ed., § 3-204.3.

Emergency Legislation

See notes to § 4-204.01.

Temporary Legislation

For temporary (225 day) repeal of section, see § 2(g) of Self-Sufficiency Promotion Temporary Amendment Act of 1998 (D.C. Law 12-230, April 20, 1999, law notification 46 DCR 4143).


§ 4–204.04. Amount of training incentive payment disregarded. [Repealed]

Repealed.


(Apr. 6, 1982, D.C. Law 4-101, § 404, 29 DCR 1060; Apr. 20, 1999, D.C. Law 12-241, § 2(g), 46 DCR 905.)

Prior Codifications

1981 Ed., § 3-204.4.

Emergency Legislation

See notes to § 4-204.01.

Temporary Legislation

For temporary (225 day) repeal of section, see § 2(g) of Self-Sufficiency Promotion Temporary Amendment Act of 1998 (D.C. Law 12-230, April 20, 1999, law notification 46 DCR 4143).


§ 4–204.05. Medicaid benefits.

The District state plan required under title XIX of the Social Security Amendments of 1965 (42 U.S.C. § 1396 et seq.) shall provide that all persons in the following categories are eligible for full Medicaid benefits:

(1) All persons receiving Supplemental Security Income benefits;

(2) All persons categorically related to the Supplemental Security Income (“SSI”) program (that is, aged, blind, or persons with permanent disabilities) and receiving benefits under the Old Age and Survivors Disability Insurance (“OASDI”) program and who were eligible for SSI benefits (but for OASDI) cost-of-living increases received since April, 1977; and

(3) All persons categorically related to the SSI program (that is, aged, blind, or persons with permanent disabilities) whose monthly countable income, regardless of source, is equal to or less than the combined maximum monthly payment of SSI plus the District supplement for the person having no other income or resources.


(Apr. 6, 1982, D.C. Law 4-101, § 405, 29 DCR 1060; Apr. 24, 2007, D.C. Law 16-305, § 13(a), 53 DCR 6198.)

Prior Codifications

1981 Ed., § 3-204.5.

Section References

This section is referenced in § 1-307.02.

Effect of Amendments

D.C. Law 16-305 substituted “persons with permanent disabilities” for “permanently disabled”, throughout the section.

Cross References

Medical assistance program, see § 1-30


§ 4–204.05a. Extension of transitional Medicaid program.

(a) The Mayor shall extend the transitional Medicaid program to 24 months pursuant to the Family Support Act of 1988, approved October 13, 1988 (P.L. 100-485; 102 Stat. 2343), and the District of Columbia State Plan for Medicaid. The Mayor shall seek any waivers and exemptions from federal statutes and regulations necessary to make such an extension.

(b) Increased transitional medical assistance benefits shall be made available to all working families eligible under subsection (a) of this section.

(c) Earned income shall be disregarded under the extended Transitional Medicaid Program in accordance with § 4-205.11(a)(5)(B) [(a)(5) repealed].


(Apr. 6, 1982, D.C. Law 4-101, § 405a; as added Oct. 27, 1995, D.C. Law 11-72, § 301, 42 DCR 4728; Apr. 20, 1999, D.C. Law 12-241, § 4(a), 46 DCR 905.)

Prior Codifications

1981 Ed., § 3-204.5a.

Expiration of Law

Expiration of Law 11-72

Section 401 of D.C. Law 11-72 provided that the act shall expire 5 years from the date of implementation of an approved federal waiver and rules promulgated by the Mayor.

Emergency Legislation

For temporary amendment of section, see § 4(a) of the Self-Sufficiency Promotion Emergency Amendment Act of 1998 (D.C. Act 12-372, June 9, 1998, 45 DCR 4270), § 4(a) of the Self-Sufficiency Promotion Legislative Review Emergency Amendment Act of 1998 (D.C. Act 12-425, July 31, 1998, 45 DCR 5682),§ 4(a) of the Self-Sufficiency Promotion Congressional Review Emergency Amendment Act of 1998 (D.C. Act 12-552, December 24, 1998, 46 DCR 521), and § 4(a) of the Self-Sufficiency Promotion Congressional Review Emergency Amendment Act of 1999 (D.C. Act 13-19, February 17, 1999, 46 DCR 2492).

Temporary Legislation

For temporary (225 day) amendment of section, see § 4(c) of Self-Sufficiency Promotion Temporary Amendment Act of 1998 (D.C. Law 12-230, April 20, 1999, law notification 46 DCR 4143).


§ 4–204.06. District supplement for Supplemental Security Income recipients.

Repealed.


(Apr. 6, 1982, D.C. Law 4-101, § 406; as added Sept. 14, 1982, D.C. Law 4-146, § 3, 29 DCR 3151; Mar. 10, 1983, D.C. Law 4-208, § 2(a), 30 DCR 202; Mar. 14, 1985, D.C. Law 5-159, § 17(b), 32 DCR 30; Apr. 30, 1988, D.C. Law 7-104, § 29, 35 DCR 147; Feb. 27, 1998, D.C. Law 12-53, § 2, 44 DCR 6228.)

Prior Codifications

1981 Ed., § 3-204.6.


§ 4–204.07. Interim Disability Assistance.

(a) The purpose of the Interim Disability Assistance (“IDA”) program is to provide temporary financial assistance to adults with disabilities while their application for Supplemental Security Income (“SSI”) is pending. The eligibility criteria are designed to qualify individuals who have a high likelihood of receiving SSI.

(b) Applications for IDA shall be approved or disapproved by the Mayor with reasonable promptness. Other aspects of the application process, including good-cause exceptions to the application-processing standard, shall be determined by rules established by the Mayor. The monthly grant amount shall be the same as that for a family size of one for an individual or 2 for a couple under the Temporary Assistance to Needy Families program, as determined under § 4-205.52.

(c) For the purposes of IDA, the term “disability” shall have the same meaning as that employed by the Social Security Administration (“SSA”);

(d)(1) An individual shall be eligible for IDA if the individual is:

(A) A United States citizen or an alien who meets the alien eligibility requirements for SSI under title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, approved August 22, 1996 (110 Stat. 2260; 8 U.S.C. §§ 1601-1646);

(B) A resident of the District of Columbia, as determined under § 4-205.03;

(C) Financially in need, as determined under the rules established by the Mayor;

(D) Ineligible for a category of cash assistance in which there is federal financial participation, except that an individual who has applied for Social Security Disability Insurance (“SSDI”) or Supplemental Security Income may be eligible during the period that the SSDI or SSI application is being processed; and

(E) Determined by the Department of Human Services (“DHS”) to meet the definition of disability.

(2) An otherwise eligible individual may not receive assistance unless the individual:

(A) Applies to the Social Security Administration for SSI benefits and maintains or pursues an active SSI application, motion for reconsideration, or request for hearing before an Administrative Law Judge, subject to the limitations of paragraph (3) of this subsection;

(B) Signs an Interim Assistance Reimbursement Authorization form in accordance with subsection (e)(2) of this section;

(C) Provides a social security number or verification of application for a social security number; and

(D) As a condition of eligibility, an applicant for or recipient of IDA shall cooperate with an entity designated by the Mayor to provide case management and legal advocacy in the SSI application and appeal process.

(3)(A) An otherwise qualified individual’s period of eligibility for IDA benefits shall begin in the month following the month in which his or her application for SSI was filed with the Social Security Administration.

(B) An otherwise qualified individual’s period of eligibility for IDA benefits shall end either at the end of the month in which the Social Security Administration begins payment of SSI benefits, or at the end of the month in which an Administrative Law Judge issues a decision denying the IDA recipient’s SSI application following a hearing pursuant to 20 C.F.R. § 416.1429.

(C) Repealed.

(D) If the decision of the Administrative Law Judge is a denial, the Department of Human Services shall immediately make a determination whether to refer the individual for appropriate vocational rehabilitation services.

(E) If an IDA recipient requests a fair hearing to contest the termination of his or her benefits, any IDA benefits paid pending the outcome of the fair hearing shall terminate as of the last month of the period of eligibility, as defined in this section, regardless of whether the fair hearing process is complete.

(4) If an applicant for IDA has previously been determined by the Social Security Administration (“SSA”) not to satisfy the disability requirements for SSI, DHS will evaluate disability in the same manner as under the Medicaid program, as provided in 42 C.F.R. § 435.541. The applicant shall be ineligible for IDA unless he or she:

(A) Alleges a disabling condition different from, or in addition to, that considered by SSA in making its determination;

(B) Alleges more than 12 months after the most recent SSA determination denying disability that his or her condition has changed or deteriorated since that SSA determination, alleges a new period of disability which meets the durational requirements of the Social Security Act, and has not applied to SSA for a determination with respect to these allegations; or

(C) Alleges less than 12 months after the most recent SSA determination denying disability that his or her condition has changed or deteriorated since that SSA determination, alleges a new period of disability which meets the durational requirements of the Social Security Act, and has applied to SSA for reconsideration or reopening of its disability decision.

(e)(1) For any month or period of months in which an IDA recipient receives both IDA and SSI, the IDA recipient shall repay to the District of Columbia:

(A) The entire amount of the IDA assistance payments received if the SSI benefits received for the same period equaled or exceeded the IDA payment; or

(B) That portion of the IDA assistance payments equal in amount to the SSI benefits received for the same period if the SSI benefits received were less than the IDA payment.

(2) To make repayment in accordance with paragraph (1) of this subsection, an IDA applicant shall sign an Interim Assistance Reimbursement Authorization which:

(A) Permits the Social Security Administration to send the individual’s past-due SSI benefit payment to the DHS; and

(B) Permits DHS to deduct from these payments an amount equal to the IDA benefits provided.

(3) Upon receipt of an IDA recipient’s past-due SSI benefit, DHS shall calculate, in accordance with paragraph (1) of this subsection, the amount of the benefit due to DHS as repayment and the amount, if any, due the IDA recipient. DHS shall then provide the IDA recipient with a written explanation of this calculation and shall pay any amount due the IDA recipient, in accordance with section 1631 of the Social Security Act, approved October 30, 1972 (86 Stat. 1475; 42 U.S.C. § 1383(g)) and SSA Interim Assistance regulations, 20 C.F.R. §§ 416.1901 to 416.1922.

(4) Because having a pending SSI application is an eligibility requirement for IDA, if an IDA recipient is determined by the Social Security Administration to meet the disability requirements for purposes of SSI eligibility but withdraws the SSI application prior to payment of past-due SSI benefits, the IDA benefits received by that individual shall be considered an overpayment and that individual shall be liable to the District for repayment of all IDA benefits received.

(e-1)(1) The amount of a recipient’s past-due SSI benefit payment that is due DHS as repayment under subsection (e) of this section shall be deposited into the Interim Disability Assistance Fund established by § 4-204.09.

(2) The amount of an overpayment of IDA benefits that is received from an IDA recipient pursuant to subsection (e)(4) of this section shall be deposited into the Interim Disability Assistance Fund established by § 4-204.09.

(f) The Mayor shall submit to the Council by March 15 of each year a report on the operation of the program for the previous calendar year. The report shall include:

(1) The total number of IDA applicants, the number approved, and the number denied;

(2) The number and percentage of IDA applicants approved for SSI. To the extent possible, the information should be provided for each of the four levels of adjudication (original application, reconsidered application, Administrative Law Judge decision, and Appeals Council of the Office of Hearings and Appeals;

(3) An analysis of the approvals and denials at each level, why the approval percentage is what it is, and what needs to be done to ensure a better match between SSI approvals and DHS approvals; and

(4) Observations on the best practices in other states.

(g) The payment of benefits under this section shall be subject to the availability of appropriations.

(h) The Department of Human Services shall establish eligibility criteria for participants in the Interim Disability Assistance program.


(Apr. 6, 1982, D.C. Law 4-101, § 407; as added Apr. 3, 2001, D.C. Law 13-252, § 2(b), 48 DCR 673; Oct. 1, 2002, D.C. Law 14-190, § 1902(a), 49 DCR 6968; May 18, 2004, D.C. Law 15-156, § 2, 51 DCR 3393; Sept. 14, 2011, D.C. Law 19-21, § 5092, 58 DCR 6226; Dec. 24, 2013, D.C. Law 20-61, § 5162, 60 DCR 12472.)

Section References

This section is referenced in § 4-204.09.

Effect of Amendments

D.C. Law 14-190 added subsec. (e-1).

D.C. Law 15-156 rewrote subsec. (b); and in subsec. (d), substituted “established by the Mayor” for “applicable to the TANF program” in subpar. (1)(C), made nonsubstantive changes to subpars. (2)(B) and (2)(C), and added subpar. (2)(D). Prior to amendment, subsec. (b) had read as follows: “(b) The application and financial eligibility processes shall be administered in accordance with the rules for the Temporary Assistance to Needy Families (‘TANF’) program. The monthly grant amount shall be the same as that for a family size of one under the TANF program, as determined under § 4-205.52.”

D.C. Law 19-21 added subsec. (h).

The 2013 amendment by D.C. Law 20-61 rewrote (d)(2)(A) and (d)(3).

Emergency Legislation

For temporary (90 day) amendment of section, see § 2 of Interim Disability Assistance Emergency Amendment Act of 2002 (D.C. Act 14-285, February 25, 2002, 49 DCR 2315).

For temporary (90 day) amendment of section, see § 1902(a) of Fiscal Year 2003 Budget Support Emergency Act of 2002 (D.C. Act 14-453, July 23, 2002, 49 DCR 8026).

For temporary (90 day) amendment of section, see § 2 of Interim Disability Assistance Emergency Amendment Act of 2003 (D.C. Act 15-2, January 22, 2003, 50 DCR 1424).

For temporary (90 day) amendment of section, see § 2 of Interim Disability Assistance Congressional Review Emergency Amendment Act of 2003 (D.C. Act 15-48, March 24, 2003, 50 DCR 2820).

For temporary (90 day) amendment of section, see § 2 of Interim Disability Assistance Second Emergency Amendment Act of 2003 (D.C. Act 15-278, December 18, 2003, 51 DCR 58).

For temporary (90 day) amendment of section, see § 2 of Interim Disability Assistance Congressional Review Emergency Amendment Act of 2004 (D.C. Act 15-402, March 18, 2004, 51 DCR 3643).

For temporary (90 days) amendment of this section, see §§ 5162 and 5163 of the Fiscal Year 2014 Budget Support Emergency Act of 2013 (D.C. Act 20-130, July 30, 2013, 60 DCR 11384, 20 DCSTAT 1827).

For temporary (90 days) amendment of this section, see §§ 5162 and 5163 of the Fiscal Year 2014 Budget Support Congressional Review Emergency Act of 2013 (D.C. Act 20-204, October 17, 2013, 60 DCR 15341, 20 DCSTAT 2311).

Temporary Legislation

For temporary (225 day) amendment of section, see § 2 of Interim Disability Assistance Temporary Amendment Act of 2002 (D.C. Law 14-141, 200, law notification 49 DCR 5058).

For temporary (225 day) amendment of section, see § 2 of Interim Disability Assistance Temporary Amendment Act of 2003 (D.C. Law 15-1, May 3, 2003, law notification 50 DCR 3781).

For temporary (225 day) amendment of section, see § 2 of Interim Disability Assistance Temporary Amendment Act of 2004 (D.C. Law 15-116, March 30, 2004, law notification 51 DCR 3803).

Short Title

Short title of title XIX of Law 14-190: Section 1901 of D.C. Law 14-190 provided that title XIX of the act may be cited as the Interim Disability Assistance Fund Establishment Amendment Act of 2002.

Short title: Section 5091 of D.C. Law 19-21 provided that subtitle J of title V of the act may be cited as “Interim Disability Assistance Amendment Act of 2011”.

Section 5161 of D.C. Law 20-61 provided that Subtitle O of Title V of the act may be cited as the “Interim Disability Assistance Emergency Amendment Act of 2013”.

Editor's Notes

Sections 3 and 4 of D.C. Law 13-252 provided:

“Sec. 3. The Interim Disability Assistance Amendment Act of 2000 shall be applicable beginning October 1, 2001, unless funds are made available by reprogramming for implementation during the fourth quarter of fiscal year 2001.

“Sec. 4. The Mayor shall provide the Council, no later than November 15, 2001, a report on how to implement a computer system that, at a minimum, would enable the District’s Interim Disability Assistance program to interface and directly exchange information with the computer systems of the federal Social Security Disability Insurance and Supplemental Security Income programs. The report shall include a description of at least one proposed computer system, its capabilities and limitations, preliminary cost estimates to obtain the system, and timetables for acquisition and implementation.”

Section 5163 of D.C. Law 20-61 provided that § 5162 of the act shall not be construed as affecting the eligibility of an otherwise qualified individual who has a Social Security application pending on Dec. 24, 2013.

Applicability of D.C. Law 20-61: Section 11001 of D.C. Law 20-61 provided that, except as otherwise provided, the act shall apply as of October 1, 2013.


§ 4–204.08. Pilot program for Interim Disability Assistance.

(a) The Mayor shall establish a pilot program for providing Interim Disability Assistance, beginning no later than February 1, 2002. Eligibility for assistance under the program shall be based on a minimum appropriation of no less than $2,150,000, and assistance shall continue to be provided if additional funds in excess of the $2,150,000 become available. During any period in which eligibility for assistance is capped due to the unavailability of funds, the Mayor shall establish and maintain a waiting list of likely eligible applicants.

(b) The Department of Human Services, Income Maintenance Administration (“IMA”) shall conduct a study to determine the size of the eligible population for assistance. The report shall be completed in time for the IMA to recommend to the Mayor the appropriate funding level for the program in Fiscal Year 2003.

(c) Based on an analysis of the available data, including the size of the eligible population determined pursuant to subsection (b) of this section, the IMA shall recommend to the Mayor the appropriate funding level to fully fund the Interim Disability Assistance program for Fiscal Year 2003.

(d) The Mayor shall fully fund the Interim Disability Assistance program for Fiscal Year 2003 by including a line item for that purpose in the Fiscal Year 2003 base budget and operational plan.


(Apr. 6, 1982, D.C. Law 4-101, § 408; as added Oct. 3, 2001, D.C. Law 14-28, § 5002, 48 DCR 6981; Mar. 13, 2004, D.C. Law 15-105, § 29, 51 DCR 881.)

Effect of Amendments

D.C. Law 15-105 validated a previously made technical correction.

Emergency Legislation

For temporary (90 day) addition of section, see § 4502 of Fiscal Year 2002 Budget Support Emergency Act of 2001 (D.C. Act 14-124, August 3, 2001, 48 DCR 7861).

For temporary (90 day) addition of §§ 4-204.11 to 4-204.16, see §§ 1501 to 1506 of Fiscal Year 2003 Budget Support Emergency Act of 2002 (D.C. Act 14-453, July 23, 2002, 49 DCR 8026).

For temporary (90 day) addition of §§ 4-204.51 to 4-204.56, see §§ 1551 to 1556 of Fiscal Year 2003 Budget Support Emergency Act of 2002 (D.C. Act 14-453, July 23, 2002, 49 DCR 8026).

For temporary (90 day) addition of § 4-204.09, see § 1902(b) of Fiscal Year 2003 Budget Support Emergency Act of 2002 (D.C. Act 14-453, July 23, 2002, 49 DCR 8026).


§ 4–204.09. Interim Disability Assistance Fund.

(a) There is established as a nonlapsing, revolving fund the Interim Disability Assistance Fund (“Fund”) which shall be separate from the General Fund and into which shall be deposited funds to be used solely for the purpose of implementing the Interim Disability Assistance program established by § 4-204.07.

(b) All funds shall be deposited into the Fund without regard to fiscal year limitation pursuant to an act of Congress. All funds deposited into the Fund shall not revert to the General Fund at the end of any fiscal year or at any other time, but shall be continually available for the purpose of funding the Interim Disability Act program, subject to authorization by Congress in an appropriations act.


(Apr. 6, 1982, D.C. Law 4-101, § 409; as added Oct. 1, 2002, D.C. Law 14-190, § 1902(b), 49 DCR 6968.)

Section References

This section is referenced in § 4-204.07.


Part B. Office of Medicaid Operations Reform.

§ 4–204.11. Short title.

This part may be cited as the “Office of Medicaid Operations Reform Establishment Act of 2002”.


(Oct. 1, 2002, D.C. Law 14-190, § 1501, 49 DCR 6968; Nov. 13, 2003, D.C. Law 15-39, § 1502(a), 50 DCR 5668.)

Effect of Amendments

D.C. Law 15-39 deleted “Public Provider” following “Medicaid”.

Emergency Legislation

For temporary (90 day) approval of proposed amendments to the District of Columbia State Plan for Medical Assistance, see § 1902 of Fiscal Year 2003 Budget Support Amendment Emergency Act of 2002 (D.C. Act 14-544, December 4, 2002, 49 DCR 11700).

For the temporary (90 day) Medicaid State Plan Amendment Approval provisions, see § 1902 of the Fiscal Year 2003 Budget Support Amendment Congressional Review Emergency Act of 2003 (D.C. Act 15-27, February 24, 2003, 50 DCR 2151).

For temporary (90 day) amendment of section, see § 1502(a) of Fiscal Year 2004 Budget Support Emergency Act of 2003 (D.C. Act 15-105, June 20, 2003, 50 DCR 5613).

For temporary (90 day) amendment of section, see § 1502(a) of Fiscal Year 2004 Budget Support Congressional Review Emergency Act of 2003 (D.C. Act 15-149, September 22, 2003, 50 DCR 8360).

For the temporary (90 day) Medicaid State Plan Amendment Approval provisions, see § 1902 of the Fiscal Year 2003 Budget Support Amendment Second Congressional Review Emergency Act of 2003 (D.C. Act 15-103, June 20, 2003, 50 DCR 5499).

Short Title

Short title of title XV of Law 15-39: Section 1501 of D.C. Law 15-39 provided that title XV of the act may be cited as the Medicaid and Tobacco Funding Amendment Act of 2003.

Editor's Notes

Section 1902 of D.C. Law 14-307 provided: “Pursuant to section 1(a)(2) of An Act To enable the District of Columbia to receive Federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02(a)(2)), the Council of the District of Columbia approves the proposed amendments to the District of Columbia State Plan for Medical Assistance to authorize the Medicaid Program to remove the requirement that requires that rates paid to hospitals, nursing facilities, and intermediate care facilities for persons with mental retardation be adjusted annually for inflation; to add provisions that require that payments made to hospitals, nursing facilities, and intermediate care facilities for persons with mental retardation for inflation adjustments in subsequent fiscal years be contingent upon the availability of funds; to increase the pharmacy dispensing fee effective April 1, 2003; and to remove provisions authorizing payment exceptions to the cost ceilings applicable to nursing facilities; and to approve a waiver to the District of Columbia State Plan for Medical Assistance to expand coverage of its Medicaid Program to childless adults 50 to 64 years of age.” Establishment of the Office of Medicaid Public Provider Operations Reform, see Mayor’s Order 2002-101, June 28, 2002 ( 49 DCR 5997).


§ 4–204.12. Definitions.

For the purposes of this part, the term:

(1) “Director” means the Director of the Office of Medicaid Operations Reform.

(1A) “Foster Care and Adoption Assistance” means the programs authorized by Part E of Title IV of the Social Security Act, approved June 17, 1980 (94 Stat. 501; 42 U.S.C. § 670 et seq.).

(2) “Medicaid” means the medical assistance programs authorized by title XIX of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396 et seq.), or by § 1-307.02, and administered by the Department of Health.

(2A) “Medicare” means the health insurance programs authorized by Title XVIII of the Social Security Act, approved July 30, 1965 (79 Stat. 290; 42 U.S.C. § 1395 et seq.).

(3) “Office” means the Office of Medicaid Operations Reform.


(Oct. 1, 2002, D.C. Law 14-190, § 1502, 49 DCR 6968; Nov. 13, 2003, D.C. Law 15-39, § 1502(b), 50 DCR 5668.)

Effect of Amendments

D.C. Law 15-39, in pars. (1) and (3), deleted “Public Provider” following “Medicaid”; added pars. (1A) and (2A); and in par. (2), substituted “or by” for “and by”.

Emergency Legislation

For temporary (90 day) amendment of section, see § 1502(b) of Fiscal Year 2004 Budget Support Emergency Act of 2003 (D.C. Act 15-105, June 20, 2003, 50 DCR 5613).

For temporary (90 day) amendment of section, see § 1502(b) of Fiscal Year 2004 Budget Support Congressional Review Emergency Act of 2003 (D.C. Act 15-149, September 22, 2003, 50 DCR 8360).


§ 4–204.13. Establishment of the Office of Medicaid Operations Reform.

(a) There is established an Office of Medicaid Operations Reform.

(b) The Mayor shall appoint a Director of the Office who shall be responsible for the management and operations of the Office and serve at the pleasure of the Mayor.

(c) The Mayor shall establish an External Medicaid Task Force to advise the Director.

(d) The Mayor shall fix the compensation of the Director pursuant to subchapter IX of Chapter 6 of Title 1.

(e) The Director is authorized to hire staff in the Career Service, consistent with budgetary authorization, as he or she deems necessary to perform the functions of the Office. The Director may engage qualified volunteers in accordance with District of Columbia law.

(f) If spending pressures generated by the Medicaid, Medicare, and Foster Care and Adoption Assistance programs make it necessary that funds from the Medicaid and Special Education Reform Fund be made available for expenditure by the Department of Human Services, the Child and Family Services Agency, the Department of Mental Health, or the Department of Health, the Director, in accordance with § 4-204.55(a)(2)(A), shall submit to the Mayor either a plan to generate savings comparable to the funds allocated or a performance plan to ensure future reduction of costs and maximization of third-party revenues.

(g) The Director shall have the authority to delegate to other employees of the Office any of the Director’s powers and duties.


(Oct. 1, 2002, D.C. Law 14-190, § 1503, 49 DCR 6968; Nov. 13, 2003, D.C. Law 15-39, § 1502(c), 50 DCR 5668.)

Effect of Amendments

D.C. Law 15-39, in subsec. (a), deleted “Public Provider” following “Medicaid”; rewrote subsec. (f) which had read as follows: “(f) If spending pressures generated by the Medicaid program make it necessary that funds from the Tobacco Settlement Trust Fund be made available for expenditure by the Department of Human Services or the Child and Family Services Agency, the Director shall submit to the Mayor a plan to generate savings comparable to the funds allocated in accordance with § 7-1811.03(b)(5)(A)(i).”

Emergency Legislation

For temporary (90 day) amendment of section, see § 1502(c) of Fiscal Year 2004 Budget Support Emergency Act of 2003 (D.C. Act 15-105, June 20, 2003, 50 DCR 5613).

For temporary (90 day) amendment of section, see § 1502(c) of Fiscal Year 2004 Budget Support Congressional Review Emergency Act of 2003 (D.C. Act 15-149, September 22, 2003, 50 DCR 8360).


§ 4–204.14. Purposes, powers, and duties of the Office.

The primary purpose of the Office is to redesign the District of Columbia’s Medicaid, Medicare, and Foster Care and Adoption Assistance infrastructure to improve the operational management of Medicaid, Medicare, and Foster Care and Adoption Assistance programs on an agency level. The Office shall:

(1) Provide technical assistance and support to District of Columbia agencies for the purpose of documenting and processing Medicaid, Medicare, and Foster Care and Adoption Assistance claims, and maximizing Medicaid, Medicare, and Foster Care and Adoption Assistance reimbursements, where not duplicative of assistance already provided to District of Columbia agencies by the State Medicaid Office;

(2) Manage Medicaid, Medicare, and Foster Care and Adoption Assistance costs and project revenues in liaison with the State Medicaid, Medicare, and Foster Care and Adoption Assistance Office and the Chief Financial Officer;

(3) Review and support legislation ensuring service expansion for all entitled residents in collaboration with the Mayor and the State Medicaid Office;

(4) Oversee the implementation of Medicaid, Medicare, and Foster Care and Adoption Assistance reforms within District of Columbia agencies to fulfill statutory requirements;

(5) Prepare an annual report for the Mayor and the Council on the Office’s activities and recommendations; and

(6) Engage in other activities as needed to carry out the purposes of this part.


(Oct. 1, 2002, D.C. Law 14-190, § 1504, 49 DCR 6968; Nov. 13, 2003, D.C. Law 15-39, § 1502(d), 50 DCR 5668; Mar. 13, 2004, D.C. Law 15-105, § 30(a), 51 DCR 881.)

Effect of Amendments

D.C. Law 15-39, in the introductory paragraph, substituted “Medicaid, Medicare, and Foster Care and Adoption Assistance infrastructure” for “Medicaid infrastructure” and substituted “Medicaid, Medicare, and Foster Care and Adoption Assistance Programs” for “Medicaid programs”; in par. (1), substituted “Medicaid, Medicare, and Foster Care and Adoption Assistance claims, and maximizing Medicaid, Medicare, and Foster Care and Adoption Assistance reimbursements,” for “Medicaid claims, and maximizing Medicaid reimbursements,”; and in pars. (2) and (4), substituted “Medicaid, Medicare, and Foster Care and Adoption Assistance” for Medicaid“.

D.C. Law 15-105, in par. (6), validated a previously made technical correction.

Emergency Legislation

For temporary (90 day) amendment of section, see § 1502(d) of Fiscal Year 2004 Budget Support Emergency Act of 2003 (D.C. Act 15-105, June 20, 2003, 50 DCR 5613).

For temporary (90 day) amendment of section, see § 1502(d) of Fiscal Year 2004 Budget Support Congressional Review Emergency Act of 2003 (D.C. Act 15-149, September 22, 2003, 50 DCR 8360).


§ 4–204.15. Rules.

The Mayor, pursuant to Chapter 5 of Title 2, may issue rules to implement the provisions of this part.


(Oct. 1, 2002, D.C. Law 14-190, § 1505, 49 DCR 6968.)


§ 4–204.16. Applicability.

This part shall apply as of October 1, 2002.


(Oct. 1, 2002, D.C. Law 14-190, § 1506, 49 DCR 6968; Mar. 13, 2004, D.C. Law 15-105, § 30(b), 51 DCR 881.)

Effect of Amendments

D.C. Law 15-105 validated a previously made technical correction.


Part C. Medicaid and Special Education Reform Fund.

§ 4–204.51. Short title.

This part may be cited as the “Medicaid and Special Education Reform Fund Establishment Act of 2002”.


(Oct. 1, 2002, D.C. Law 14-190, § 1551, 49 DCR 6968.)

Editor's Notes

Section 1506 of D.C. Law 14-190 provided that this part shall apply as of October 1, 2002.


§ 4–204.52. Definitions.

For the purposes of this part, the term:

(1) “District” shall mean the District of Columbia.

(1A) “Foster care and adoption assistance” means the programs authorized by Part E of Title IV of the Social Security Act, approved June 17, 1980 (94 Stat. 501; 42 U.S.C. § 670 et seq.).

(2) “Fund” shall mean the Medicaid and Special Education Reform Fund established by § 4-204.53

(3) “Medicaid” means the medical assistance programs authorized by title XIX of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396 et seq.), or by § 1-307.02, and administered by the Department of Health.

(4) “Medicare” means the health insurance programs authorized by title XVIII of the Social Security Act, approved July 30, 1965 (79 Stat. 290; 42 U.S.C. § 1395 et seq.).

(5) “Special Education” means services provided under § 38-2501 to students who are classified as having a disability, as defined in section 101(a)(1) of the Individuals with Disabilities Education Act, approved April 13, 1970 (84 Stat. 175; 20 U.S.C. § 1401(a)(1)), or in section 7(8) of the Rehabilitation Act of 1973, approved September 26, 1973 (87 Stat. 359; 29 U. S.C. § 706(8)).


(Oct. 1, 2002, D.C. Law 14-190, § 1552, 49 DCR 6968; Nov. 13, 2003, D.C. Law 15-39, § 1503(a), 50 DCR 5668.)

Effect of Amendments

D.C. Law 15-39, added pars. (1A), (4), and (5); and in par. (3), substituted “or by” for “and by”.

Emergency Legislation

For temporary (90 day) amendment of section, see § 1503(a) of Fiscal Year 2004 Budget Support Emergency Act of 2003 (D.C. Act 15-105, June 20, 2003, 50 DCR 5613).

For temporary (90 day) amendment of section, see § 1503(a) of Fiscal Year 2004 Budget Support Congressional Review Emergency Act of 2003 (D.C. Act 15-149, September 22, 2003, 50 DCR 8360).


§ 4–204.53. Establishment of the Medicaid and Special Education Reform Fund.

(a) There is established as a nonlapsing, revolving fund the Medicaid and Special Education Reform Fund into which shall be deposited funds made available for the purposes of Medicaid, Medicare, Foster Care and Adoption Assistance, and Special Education reform described in § 4-204.54. The Fund shall be administered by the Chief Financial Officer.

(b) All amounts deposited in the Fund shall be appropriated without fiscal year limitation pursuant to an act of Congress. All amounts deposited in the Fund shall not revert to the General Fund at the end of any fiscal year or at any other time, but shall be continually available for the purposes of Medicaid, Medicare, Foster Care and Adoption Assistance, and Special Education reform described in § 4-204.54, subject to authorization by Congress in an appropriations act.


(Oct. 1, 2002, D.C. Law 14-190, § 1553, 49 DCR 6968; Nov. 13, 2003, D.C. Law 15-39, § 1503(b), 50 DCR 5668.)

Section References

This section is referenced in § 4-204.52 and § 7-1811.03.

Effect of Amendments

D.C. Law 15-39, in subsecs. (a) and (b), substituted “Medicaid, Medicare, Foster Care and Adoption Assistance, and Special Education reform” for “Medicaid and Special Education reform”.

Emergency Legislation

For temporary (90 day) amendment of section, see § 1503(b) of Fiscal Year 2004 Budget Support Emergency Act of 2003 (D.C. Act 15-105, June 20, 2003, 50 DCR 5613).

For temporary (90 day) amendment of section, see § 1503(b) of Fiscal Year 2004 Budget Support Congressional Review Emergency Act of 2003 (D.C. Act 15-149, September 22, 2003, 50 DCR 8360).

For temporary (90 day) addition of section, see § 5142 of Fiscal Year 2013 Budget Support Emergency Act of 2012 (D.C. Act 19-383, June 19, 2012, 59 DCR 7764).

For temporary (90 day) addition of section, see § 5142 of Fiscal Year 2013 Budget Support Congressional Review Emergency Act of 2012 (D.C. Act 19-413, July 25, 2012, 59 DCR 9290).

Editor's Notes

Section 5142 of D.C. Law 19-168 provided:

“(a) Beginning on June 1, 2012, unspent funds from Medicaid underenrollment, calculated on a fiscal year basis, shall be set aside in a fund to offset the costs to implement the South Capitol Street Memorial Amendment Act of 2012 effective June 7, 2012 (D.C. Law 19-141; 59 DCR 3083) (‘South Capitol Street Memorial Amendment Act’).

“(b) This section shall not apply if the South Capitol Street Memorial Amendment Act is fully funded, as certified by the Chief Financial Officer, either by the terms of this section or pursuant to section 10002(3) of the Revised Revenue Estimate Contingency Priority List Act of 2012, passed on 2nd reading on June 5, 2012 (Enrolled version of Bill 19-743).”


§ 4–204.54. Purposes of the Fund.

The Fund shall be used for the following purposes:

(1) Ensuring adequate resources are available to support District-wide Medicaid costs and revenue shortfalls;

(1A) Ensuring adequate resources are available to support District-wide Medicare costs and revenue shortfalls;

(1B) Ensuring adequate resources are available to support District-wide Foster Care and Adoption Assistance costs and revenue shortfalls;

(2) Ensuring adequate resources are available to support District-wide Special Education costs and revenue shortfalls;

(3) Supporting Medicaid, Medicare, and Foster Care and Adoption Assistance reform activities designed to establish cost-effective, agency-based Medicaid, Medicare, and Foster Care and Adoption Assistance operations; and

(4) Optimizing Medicaid, Medicare, Foster Care and Adoption Assistance and other third-party revenues.


(Oct. 1, 2002, D.C. Law 14-190, § 1554, 49 DCR 6968; Nov. 13, 2003, D.C. Law 15-39, § 1503(c), 50 DCR 5668.)

Section References

This section is referenced in § 4-204.53 and § 4-204.55.

Effect of Amendments

D.C. Law 15-39, in the introductory language, substituted “The Fund shall be used for the following purposes:” for “The purposes of the Fund shall include:”; added pars. (1A) and (1B); in par. (3), substituted “Medicaid, Medicare, and Foster Care and Adoption Assistance” for “Medicaid” in two places; and in par. (4), substituted “Medicaid, Medicare, Foster Care and Adoption Assistance” for “Medicaid”.

Emergency Legislation

For temporary (90 day) amendment of section, see § 1503(c) of Fiscal Year 2004 Budget Support Emergency Act of 2003 (D.C. Act 15-105, June 20, 2003, 50 DCR 5613).

For temporary (90 day) amendment of section, see § 1503(c) of Fiscal Year 2004 Budget Support Congressional Review Emergency Act of 2003 (D.C. Act 15-149, September 22, 2003, 50 DCR 8360).

For temporary (90 day) addition of section, see § 5142 of Fiscal Year 2013 Budget Support Emergency Act of 2012 (D.C. Act 19-383, June 19, 2012, 59 DCR 7764).

For temporary (90 day) addition of section, see § 5142 of Fiscal Year 2013 Budget Support Congressional Review Emergency Act of 2012 (D.C. Act 19-413, July 25, 2012, 59 DCR 9290).


§ 4–204.55. Distribution of funds.

(a) The Chief Financial Officer shall distribute funds from the Fund only after:

(1) Certifying that the funds are needed by the District of Columbia Public Schools, the Child and Family Services Agency, the Department of Human Services, the Department of Mental Health, or the Department of Health for the purposes described in § 4-204.54;

(2)(A) Certifying either that:

(i) A savings plan to be submitted by the Director of the Office of Medicaid Operations Reform to the Mayor will generate savings for the Child and Family Services Agency, the Department of Human Services, the Department of Mental Health, or the Department of Health, respectively, comparable to the funds to be allocated to the agency during Fiscal Year 2003 or Fiscal Year 2004; or

(ii) If a savings plan that will generate savings comparable to the funds allocated is not possible, a performance plan to be submitted by the Director of the Office of Medicaid Operations Reform to the Mayor will ensure that the agency to which the requested funds are to be allocated will implement policies and procedures and develop the infrastructure necessary to enable the agency to reduce costs and maximize third-party revenues by no later than October 1, 2004; or

(B) Certifying that a savings plan to be submitted by the District of Columbia Public Schools will generate savings comparable to the funds allocated to the agency during Fiscal Year 2003 or Fiscal Year 2004; and

(3) Providing notification of the distribution to the Mayor and Council.

(a-1) A savings plan required under subsection (a)(2)(A)(i) of this section that pertains to the allocation of funds to an agency in Fiscal Year 2003 shall be submitted no later than December 31, 2002. The plan shall commence no later than October 1, 2003, and shall generate savings comparable to the funds allocated to the agency from the Fund in Fiscal Year 2003.

(a-2) A savings plan required under subsection (a)(2)(A)(i) of this section that pertains to the allocation of funds to an agency in Fiscal Year 2004 shall be submitted no later than December 31, 2003. The plan shall commence no later than October 1, 2004, and shall generate savings comparable to the funds allocated to the agency from the Fund in Fiscal Year 2004.

(a-3) A performance plan required under subsection (a)(2)(A)(ii) of this section shall be submitted no later than December 31, 2003, and shall commence no later than October 1, 2004.

(a-4) The savings plan required under subsection (a)(2)(B) of this section that pertains to the allocation of funds to the District of Columbia Public Schools in Fiscal Year 2003 shall be submitted, no later than December 31, 2002, by the District of Columbia Public Schools to the Special Education Task Force established by Chapter 25A of Title 38. The plan shall commence no later than October 1, 2003, and generate savings comparable to the funds allocated to the agency from the Fund in Fiscal Year 2003.

(a-5) The savings plan required under subsection (a)(2)(B) of this section that pertains to the allocation of funds to the District of Columbia Public Schools in Fiscal Year 2004 shall be submitted, no later than December 31, 2003, by the District of Columbia Public Schools to the Special Education Task Force established by Chapter 25A of Title 38. The plan shall commence no later than October 1, 2004, and generate savings comparable to the funds allocated to the agency from the Fund in Fiscal Year 2004.

(a-6) Beginning 3 months following the commencement of any plan submitted pursuant to subsection (a)(2) of this section, or no later than January 2, 2004, the Mayor and the Special Education Task Force shall provide the Council with quarterly reports on the progress made by the Department of Human Services, the Child and Family Services Agency, the Department of Mental Health, the Department of Health, and the District of Columbia Public Schools, in reducing costs associated with the Medicaid, Medicare, Foster Care and Adoption Assistance, and Special Education programs.

(b) Total distribution of funds from the Fund to the District of Columbia Public Schools, the Child and Family Services Agency, the Department of Human Services, the Department of Mental Health, or the Department of Health in any given fiscal year shall not exceed the amount appropriated for that agency in that fiscal year for the purposes of § 7-1811.03(b).


(Oct. 1, 2002, D.C. Law 14-190, § 1555, 49 DCR 6968; Nov. 13, 2003, D.C. Law 15-39, § 1503(d), 50 DCR 5668; Apr. 13, 2005, D.C. Law 15-354, §§ 12, 84(g), 52 DCR 2638.)

Section References

This section is referenced in § 4-204.13 and § 7-1811.03.

Effect of Amendments

D.C. Law 15-39, in subsec. (a), substituted “the Department of Human Services, the Department of Mental Health, or the Department of Health” for “or the Department of Human Services” in par. (1), and rewrote par. (2); added subsecs. (a-1), (a-2), (a-3), (a-4), (a-5), and (a-6); and in subsec. (b), substituted “the Department of Human Services, the Department of Mental Health, or the Department of Health” for “or the Department of Human Services”. Prior to amendment, par. (2) of subsec. (a) had read as follows: “(2) Certifying that a savings plan to be submitted by the Director of the Office of Medicaid Public Provider Operations Reform to the Mayor in accordance with § 7-1811.03(b)(5)(A)(i), will generate savings comparable to the funds allocated; and”

D.C. Law 15-354, in subsecs. (a-4) and (a-5), validated previously made technical corrections.

Emergency Legislation

For temporary (90 day) amendment of section, see § 1503(d) of Fiscal Year 2004 Budget Support Emergency Act of 2003 (D.C. Act 15-105, June 20, 2003, 50 DCR 5613).

For temporary (90 day) amendment of section, see § 1503(d) of Fiscal Year 2004 Budget Support Congressional Review Emergency Act of 2003 (D.C. Act 15-149, September 22, 2003, 50 DCR 8360).


§ 4–204.56. Annual report.

The Mayor shall report annually to the Council on the revenues and activities of the Fund.


(Oct. 1, 2002, D.C. Law 14-190, § 1556, 49 DCR 6968.)


Part D. Nursing Facilities Medicaid Reimbursement.

§ 4–204.61. Definitions.

For the purposes of this part, the term:

(1) “Case mix reimbursement methodology” means a prospective Medicaid payment rate system for nursing facilities that includes:

(A) A point-of-sale prescription system;

(B) A resident classification system based on resident acuity and needs; and

(C) The following 3 peer groupings for rate purposes:

(i) All freestanding nursing facilities, except those owned by the District of Columbia;

(ii) All hospital-based nursing facilities; and

(iii) All nursing facilities owned by the District of Columbia.

(2) “Medicaid” means the medical assistance programs authorized by title XIX of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396 et seq.), and by § 1-307.02, and administered by the Department of Health.

(3) “Nursing facility” means a health care facility as defined in § 44-501(a)(3), but does not include a health care facility operated by the federal government.


(Dec. 7, 2004, D.C. Law 15-205, § 5211, 51 DCR 8441; Mar. 2, 2007, D.C. Law 16-191, § 19, 53 DCR 6794.)

Effect of Amendments

D.C. Law 16-191, in par. (3), validated a previously made technical correction.

Emergency Legislation

For temporary (90 day) addition, see § 5211 of Fiscal Year 2005 Budget Support Emergency Act of 2004 (D.C. Act 15-486, August 2, 2004, 51 DCR 8236).

For temporary (90 day) addition, see § 5211 of Fiscal Year 2005 Budget Support Congressional Review Emergency Act of 2004 (D.C. Act 15-594, October 26, 2004, 51 DCR 11725).


§ 4–204.62. Medicaid reimbursement system for nursing facilities.

(a) The Department of Health shall develop and implement a case mix reimbursement methodology for nursing facilities. The case mix reimbursement methodology shall be effective no earlier than April 1, 2005.

(b) The Mayor, pursuant to subchapter I of Chapter 5 of Title 2, shall issue rules to implement this section.


(Dec. 7, 2004, D.C. Law 15-205, § 5212, 51 DCR 8441.)

Section References

This section is referenced in § 47-1269.

Cross References

Child support enforcement, “dependent child” and “public assistance” defined, see § 46-201.

Emergency Legislation

For temporary (90 day) addition, see § 5212 of Fiscal Year 2005 Budget Support Emergency Act of 2004 (D.C. Act 15-486, August 2, 2004, 51 DCR 8236).

For temporary (90 day) addition, see § 5212 of Fiscal Year 2005 Budget Support Congressional Review Emergency Act of 2004 (D.C. Act 15-594, October 26, 2004, 51 DCR 11725).