D.C. Mun. Regs. tit. 29, r. 29-5003
Except as provided in Subsection 5003.11, in order to be reimbursed by Medicaid, PCA services shall not be initiated or provided on a continuing basis by a Provider without a PCA Service Authorization from DHCF or its designated agent that, for each beneficiary, identifies the amount, duration and scope of PCA services authorized and the number of hours authorized.
A Medicaid beneficiary who is seeking PCA services for the first time shall submit a request for a PCA Service Authorization to DHCF or its designated agent in writing, accompanied by a copy of the physician's or Advanced Practice Registered Nurse's (APRN) written order for PCA services that complies with the requirements set forth under this chapter. The request may be submitted by the beneficiary, the beneficiary's representative, family member, physician or APRN.
DHCF or its designated agent shall be responsible for conducting a face-to-face assessment of each beneficiary using a standardized assessment tool to determine each beneficiary's need for assistance with activities of daily living that the beneficiary is unable to perform. The assessment shall:
Based upon the results of the face-to-face assessment conducted in accordance with Subsection 5003.3, DHCF or its authorized agent shall issue to the beneficiary a PCA Service Authorization that specifies the amount, duration, and scope of PCA services authorized to be provided to the beneficiary.
Payment shall not exceed the maximum authorized units specified in the PCA Service Authorization and must be consistent with the plan of care in accordance with Section 5015.
If authorized, PCA services may be provided up to eight (8) hours per day seven (7) days per week. Additional hours may be authorized if a person is deemed eligible under the Elderly or Individuals with Physical Disabilities (EPD Waiver) or Individuals with Intellectual and Developmental Disabilities Waiver (IDD Waiver).
PCA services shall be provided in a manner consistent with the requirements of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. A beneficiary under the age of twenty-one (21) shall have access to all medically necessary Medicaid services, including PCA services, provided by any willing and qualified Medicaid provider of the beneficiary's choice.
When total DHCF reimbursement for PCA services, in addition to other home care services, for a beneficiary exceeds the cost of institutional care over a six (6) month period, DHCF may limit or deny PCA services for the beneficiary on a prospective basis. If DHCF limits or denies prospective PCA services for a beneficiary on this basis, a notice meeting all requirements of Subsection 5003.14 shall be issued to the beneficiary and the beneficiary will have the rights of appeal outlined in Subsection 5003.14.
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 once every twelve (12) months or upon a significant change in the beneficiary's health status, and submit requests for face-to- face reassessments, in accordance with the requirements set forth in 29 DCMR 989.16.
Requests to conduct a face-to-face re-assessment based upon a significant change in the beneficiary's health status may be made at any time by the beneficiary, the beneficiary's representative, family member, physician or APRN and shall be made in accordance with the requirements of Subsection 5003.2.
An R.N. or Licensed Independent Clinical Social Worker (LICSW) employed by DHCF or its agent shall conduct a face-to- face reassessment, in accordance with the requirements of Subsection 5003.3, of each beneficiary referred by the supervisory nurse as described in Subsection 5003.9 and for whom a reassessment is requested pursuant to Subsection 5003.10 to determine PCA service needs.
Through December 31, 2017, DHCF may authorize the face -to-face reassessment for a period not to exceed eighteen (18) months, if necessary, to align the assessment date with the Medicaid renewal date.
If, based upon the assessment conducted pursuant to this section, a beneficiary is found to be eligible for PCA services, DHCF or its agent shall issue a Beneficiary Approval Letter informing the beneficiary of the assessment score, the amount, duration and scope of authorized PCA services, and the dates of the authorization period, as well as confirming the provider selected by the beneficiary during the assessment.
If, based upon the assessment conducted pursuant to this section or due to a determination made under Subsection 5003.8 that six-month cost of home care services may exceed the cost of institutional care, a beneficiary is found to be ineligible for PCA services, or the amount, duration or scope of PCA services is reduced or limited, DHCF or its agent shall issue a Beneficiary Denial, Termination or Reduction of Services Letter informing the beneficiary of the reasons for the intended action, the specific law and regulations supporting the action, his or her right to appeal the denial, termination, or reduction of services in accordance with federal and District law and regulations, and the circumstances under which PCA services will be continued if a hearing is requested (See 42 CFR §§ 431.200et seq., D.C. Official Code § 4-205.55 ).
D.C. Mun. Regs. tit. 29, r. 29-5003