D.C. Mun. Regs. r. 29-4501
Medicaid reimbursement for primary care, behavioral health, and dental services furnished by an FQHC shall be made under:
Each FQHC that is geographically located in the District of Columbia and enrolled in the District's Medicaid program as of the effective date of the corresponding State Plan Amendment (SPA) that elects to be reimbursed for services under an APM shall sign an agreement with the DHCF.
The APM referenced in Subsection 4501.2 shall become effective on or after the date of an executed agreement between DHCF and the FQHC, or the effective date of the corresponding State Plan amendment, whichever is later.
The APM shall comply with Section 1902(bb)(6) of the Social Security Act .
Any FQHC that elects not to be reimbursed under an APM shall be reimbursed under the PPS methodology described in Section 4502.
An FQHC may only be reimbursed at the PPS or APM rate for services that are within the scope of services described in Sections 4502, 4505, 4506, 4507, and 4508, in accordance with Section 1905(a)(2) of the Social Security Act.
If an FQHC seeks Medicaid reimbursement for services covered under the DC Medicaid State Plan, in accordance with Section 1905(a)(2)(B) and (C) of the Social Security Act, that are outside the scope of services described in Sections 4502, 4505, 4506, 4507, and 4508, the FQHC shall be reimbursed at the fee-for-service rate if it meets the following conditions:
Each encounter for a Medicaid enrollee who is enrolled in Medicare or another form of insurance (or both) shall be paid an amount that is equal to the difference between the payment received from Medicare and any other payers and the FQHC's payment rate calculated pursuant to these rules.
Each encounter for a qualified Medicare beneficiary for whom Medicaid is responsible for only cost-sharing payments shall be paid the amount that is equal to the difference between the payment the FQHC received from Medicare and the FQHCs' Medicare prospective payment rate.
The payment received by an FQHC from Medicare, any other payor and Medicaid shall not exceed the Medicaid reimbursement rate.
Each FQHC shall ensure that a service that requires multiple procedures, and which may be performed as part of a single course of treatment under general standards of care, shall be completed as a single encounter unless multiple visits are medically required to complete the treatment plan and the medical necessity is documented in the clinical record.
At the end of each fiscal year, DHCF will review and reconcile the total payments made to each FQHC that elects the APM rate to ensure that the overall per encounter rate is at least equal to the PPS rate for that FQHC for the fiscal year. If the payments are less than the total amount that would be paid under the PPS rate methodology for that FQHC, DHCF will pay the FQHC the difference between the amount paid and the amount the FQHC would have been due under the APM rate methodology for the total number of encounters provided.
Payments related to yearly reconciliations will be made in accordance with the two-year payment requirement at 42 CFR § 447.45 and 45 CFR § 95, Subpart A.
D.C. Mun. Regs. r. 29-4501