9512.1 A child below the age of nineteen (19) years old that applies for Medicaid eligibility under the "TEFRA/Katie Beckett eligibility group" shall comply with the following requirements:
(a) Submit a complete application for Medicaid, in accordance with Section 9501 of this chapter, which shall include but not be limited to supplying information on household income; and(b) Be evaluated for Medicaid eligibility based on Modified Adjusted Gross Income ("MAGI Medicaid") pursuant to the requirements set forth under Section 9506 of this chapter.9512.2 The District of Columbia (District) shall provide Medicaid benefits under the TEFRA/Katie Beckett eligibility group to eligible children with disabilities who do not qualify for MAGI Medicaid because their income is over the MAGI Medicaid income threshold for children in the District set forth in this section.
9512.3 If an applicant is deemed to be ineligible for MAGI Medicaid because his or her income is over the income threshold set forth in Section 9506, then the Department shall submit notice to the applicant of the applicant's ineligibility for MAGI Medicaid and the applicant's opportunity to be evaluated for Medicaid through the TEFRA/Katie Beckett eligibility group. The Department shall also submit the following documents to the applicant for the applicant's completion to determine the applicant's eligibility for Medicaid under the TEFRA/Katie Beckett eligibility group :
(a) A TEFRA/Katie Beckett Application Form to be completed by the applicant;(b) A Care Plan to be completed by the applicant and the applicant's physician, containing the prescribed or ordered services for the child; and(c) Level of Care ("LOC") forms to be completed by the applicant's physician which must be accompanied with documentation that supports a LOC in accordance with Subsection 9512.4(e).9512.4 In order to be eligible for Medicaid through the TEFRA/Katie Beckett eligibility group, a child shall meet the following non-financial and financial requirements:
(a) Be age zero (0) through eighteen (18) years old;(b) Have individual income at or below three hundred percent (300%) of the Supplemental Security Income ("SSI") federal benefit rate;(c) Have individual resources equal to or less than two thousand and six hundred dollars ($2,600) after application of a disregard of all countable resources between two thousand and six hundred dollars ($2,600) and four thousand dollars ($4,000);(d) Have a disability which can be expected to result in death or to last for at least twelve (12) months in accordance with Section 1614(a) of the Social Security Act;(e) Have a LOC that is typically provided in one of the following settings:(1) A hospital, as described in 42 CFR § 440.10, pursuant to the criteria set forth under Subsection 9512.6;(2) An intermediate care facility, as described in 42 CFR § 440. 150, pursuant to the criteria set forth under Subsection 9512.7; or(3) A nursing facility, as described in the "Health Care and Community Residence License Act of 1983, approved October 28, 1983 (D.C. Law 5-48; D.C. Official Code § 44-501) , pursuant to the criteria set forth under Subsection 9512.9;(f) Be able to safely live at home;(g) Not otherwise be eligible for Medicaid;(h) Have estimated Medicaid costs of care received at home that do not exceed the estimated Medicaid costs of care received in an institution pursuant to the cost effectiveness methodology set forth in Subsection 9512.13; and(i) Meet non- financial eligibility factors in accordance with Section 9506. 9512.5 Only the income and assets of the child shall be considered in determining financial eligibility under Subsection 9512.4. The parents' income and assets shall not be deemed to be income and assets of the child.
9512.6 A child's needs shall meet a hospital LOC if a child meets all of the following criteria:
(a) The child has a condition for which room, board, and professional services furnished under the direction of a physician is expected to be medically necessary for a period of forty-eight (48) hours or longer;(b) The professional services needed are something other than intermediate care facility and nursing facility services, under Subsections 9512.7 and 9512.9, respectively;(c) The child's condition is such that it requires treatment which is ordinarily furnished in an inpatient setting;(d) The service that the child needs has been ordered by a physician who is licensed in accordance with District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code Sections §§ 3-1201et seq. (2016 Repl. & 2019 Supp.)) ("HORA") or the licensing requirements of the jurisdiction in which services are furnished, and complies with screening and enrollment requirements set forth under Subsection 9512.17;(e) The service that the child receives is furnished either directly by, or under the supervision of, a physician who is licensed pursuant to HORA or the licensing requirements of the jurisdiction in which services are furnished, and is in compliance with screening and enrollment requirements set forth under Subsection 9512.18; and(f) The service that the child receives is ordinarily furnished, as a practical matter, in a hospital, certified by the Health Regulation and Licensing Administration ("HRLA") in the Department of Health pursuant to Sections 2000 - 2099 of Title 22- B of the District of Columbia Municipal Regulations (DCMR), for the care and treatment of individuals with disorders other than mental diseases. 9512.7 A child's needs shall meet an intermediate care facility's LOC if a child's needs meet all of the following criteria:
(a) If the child is age two (2) years or older, the child has the diagnosis of an intellectual disability that meets one of the level of care criteria set forth under Section 1902 of Title 29 DCMR. If the child is under the age of two (2), the child shall be diagnosed with either one (1) of the following deficits or diagnoses: (3) Chronic health problems;(b) The child is referred for an Intermediate Care Facility for Individuals with Intellectual Disabilities ("ICF/IID") LOC based on a medical evaluation by a physician who is licensed pursuant to HORA or the licensing requirements of the jurisdiction in which services are furnished, and who complies with screening and enrollment requirements set forth under Subsection 9512.17;(c) The child requires active treatment that is designed to prevent or decelerate the regression or loss of current optimal functional status and address a child's need for a combination and sequence of interdisciplinary supports that are individually planned, coordinated, and are of lifelong or extended duration. The child shall be deemed to require active treatment by meeting the following requirements: (1) The child's needs have not been met with the child's current plan of treatment, i.e., wraparound services in school and in the community;(2) The child requires twenty- four (24) hour supervision by a licensed practical nurse or nursing assistive personnel, as appropriate, who are acting within the scope of practice authorized under HORA or the licensing requirements of the jurisdiction in which services are furnished;(3) The child requires ongoing care, either directly or on-call, by one or more of the following, as appropriate: (A) A physician who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;(B) A psychiatrist who is licensed by a Board of Medicine in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;(C) An advanced practice registered nurse who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;(D) A registered nurse who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;(E) A psychologist who is licensed to practice psychology in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;(F) A social worker who is a licensed independent social worker, a licensed graduate social worker, or a licensed independent clinical social worker, in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;(G) A physical therapist who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;(H) An occupational therapist who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;(I) A speech pathologist who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished; or(J) An audiologist who is licensed in accordance with HORA or in accordance with the licensing requirements of the jurisdiction in which services are furnished;(4) Subject to limitations under Subsection 9512.8 of this chapter, the child requires specialized services through an integrated program of therapies and other activities that are developed and supervised by medical and rehabilitative professionals, as appropriate, in order to improve the child's ability to function at a higher, less dependent level;(5) The child requires more behavior modification than is provided in a six (6) hour school day; and(6) If the child is age two (2) years or older, the child has severe functional limitations in three (3) or more of the following areas of major life activities: (B) Understanding the use of language;(F) Capacity for independent living;(d) The services that the child requires will be furnished either directly by, or under the supervision of, appropriately qualified professionals that are licensed and practicing within the scope of their license pursuant to HORA or the licensing requirements of the jurisdiction in which services are furnished, and in compliance with screening and enrollment requirements set forth under Subsection 9512.18; and(e) The services that the child requires would have ordinarily been provided in an intermediate care facility, licensed by HRLA pursuant to Sections 3100 - 3199 of Title 22-B DCMR (Public Health and Medicine), in the absence of community services.9512.8 Specialized services under Subsection 9512.7(c)(4) shall not include:
(a) Interventions that address age-appropriate limitations;(b) General supervision of children whose age is such that supervision is required for all children of the same age; or(c) Physical assistance for children who are unable to physically perform tasks but who understand the process needed to do them.9512.9 A child's needs shall meet a nursing facility LOC if a child's needs meet all of the following criteria:
(a) The child requires service that is inherently complex based on clinical indications due to a physical disability (e.g., treatment for cystic fibrosis, osteogenesis imperfecta, sickle cell, spina bifida, etc.) and can only be safely and effectively performed by, or under the supervision of, professional personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, licensed clinical social workers, and speech pathologists or audiologists, who are licensed pursuant to HORA or the licensing requirements of the jurisdiction in which services are furnished, and in compliance with screening and enrollment requirements set forth under Subsection 9512.18;(b) The child requires one (1) of the following three (3) categories of services : (1) Extensive treatment as set forth under Subsection 9512.10;(2) High- intermediate treatment as set forth under Subsection 9512.11; or(3) Intermediate treatment as set forth under Subsection 9512.12;(c) The service needed has been ordered by a physician who is licensed pursuant to HORA or the licensing requirements of the jurisdiction in which services are furnished, and complies with screening and enrollment requirements set forth under Subsection 9512.17;(d) The service is furnished either directly by, or under the supervision of, qualified professionals who are licensed pursuant to HORA or the licensing requirements of the jurisdiction in which services are furnished, and in compliance with screening and enrollment requirements set forth under Subsection 9512.18; and(e) The beneficiary requires skilled nursing or skilled rehabilitation services, or both, at a minimum of five (5) days per week.9512.10 Extensive treatment, described under Subsection 9512.9(b)(1), shall mean the child requires a service seven (7) days per week and involves, or is similar to, one (1) or more of the following:
(a) Overall management and evaluation of a care plan for a child who is totally dependent in all activities of daily living;(b) Observation and assessment of a child's changing condition when the documented instability of his or her medical condition is likely to result in complications, or when the documented instability of his or her mental condition is likely to result in suicidal or hostile behavior;(c) Intravenous or intramuscular injections or intravenous feeding;(d) Enteral feeding that comprises at least twenty-six (26) percent of daily calorie requirements and provides at least five hundred and one (501) milliliters of fluid per day;(e) Nasopharyngeal or tracheostomy aspiration;(f) Insertion and sterile irrigation or replacement of suprapubic catheters;(g) Application of dressings involving prescription medications and aseptic techniques;(h) Treatment of extensive decubitus ulcers or other widespread skin disorder;(i) Heat treatments as part of active treatment which requires observation by nurses; (j) Initial phases of a regimen involving administration of medical gases; or(k) Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing that are part of active treatment.9512.11 High- intermediate treatment, described under Subsection 9512.9(b)(2), shall mean the child requires a service five (5) days per week and involves, or is similar to, one (1) or more of the following services:
(a) Ongoing assessment of physical rehabilitation needs and potential services concurrent with the management of a patient care plan;(b) Therapeutic exercises and activities performed by physical therapy or occupational therapy;(c) Gait evaluation and training to restore function to a child whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality;(d) Range of motion exercises which are part of active treatment of a specific condition that has resulted in a loss of or restriction of mobility;(e) Maintenance therapy when specialized knowledge and judgment is needed to design a program based on initial evaluation;(f) Ultrasound, short-wave, and microwave therapy treatment;(g) Hot pack, hydrocollator, infrared treatments, paraffin baths, and whirlpool treatment when the child's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, etc. and specialized knowledge and judgment is required; or(h) Services of a speech pathologist or audiologist when necessary for the restoration of function in speech or hearing;9512.12 Intermediate treatment, described under Subsection 9512.9(b)(3), shall mean the child, due to an additional medical complication, requires one (1) of the following services, which is performed or supervised by professional personnel:
(a) Administration of routine medications, eye drops, and ointments;(b) General maintenance care of an ostomy;(c) General maintenance care in connection with a plaster cast;(d) Routine services to maintain satisfactory functioning of indwelling bladder catheters;(e) Changes of dressings for non- infected postoperative or chronic conditions;(f) Prophylactic and pain relief for skin care, including bathing and application of creams, or treatment of minor skin problems;(g) Routine care of an incontinent child, including use of diapers and protective sheets;(h) Use of heat as a pain relief and comfort measure (e.g., whirlpool and hydrocollator);(i) Routine evaluation of blood gases after a regimen of oxygen therapy has been established; (j) Assistance in dressing, eating, and toileting;(k) Periodic turning and positioning of the child; or(l) General supervision of exercises that were taught to the child and can be safely performed by the child including the actual carrying out of maintenance programs. 9512.13 The Department, or its agent, shall determine whether the estimated Medicaid cost of caring for the child outside of an institution exceeds the estimated cost of appropriate institutional care based on the following methodologies:
(a) Upon initial application, the Department shall:(1) Identify the services that the child is prescribed or ordered to receive based on forms submitted by the applicant under Subsections 9512.3(b) - (c);(2) Estimate the annual cost of the services using the established Medicaid Fee Schedule, available at http://www.dc-medicaid.com. The beneficiary's acuity level and severity of illness, as supported in the beneficiary's Care Plan and LOC forms, shall be factored into the estimation;(3) Estimate the annual costs of services if services were provided in an institution by multiplying the current institutional per diem reimbursement rate, in accordance with Subsection 9512.13(b), with the number of days in one year. The beneficiary's acuity level, severity of illness, and length of stay, as supported in the beneficiary's Care Plan and LOC forms, shall be factored into the estimation. This estimate shall be the maximum allowable costs; and(4) Compare the annual costs identified in Subsection 9512.13(a)(2) with the maximum allowable costs identified in Subsection 9512.13(a)(3). If the annual cost is more than the maximum allowable costs, the applicant will be ineligible for Medicaid under the TEFRA/Katie Beckett eligibility group, and the Department shall provide timely and adequate notice of ineligibility to the applicant consistent with the requirements set forth in Section 9508. (b) The institutional per diem reimbursement rate of services, described in Subsection 9512.13(a)(3), shall be determined as follows: (1) If the Department determines that the child has a hospital LOC pursuant to Subsection 9512.6, the Department shall use the applicable per- diem reimbursement rates of a specialty hospital provider that most closely meets the medical needs of the child, in accordance with Chapter 48 of Title 29 DCMR, and is enrolled with the Department pursuant to Chapter 94 of Title 29 DCMR;(2) If the Department determines that the child has an intermediate care facility LOC pursuant to Subsection 9512.7, the Department shall use applicable per-diem reimbursement rates in accordance with the ICF/IID fee schedule, set forth under Subsection 4102.15 of Title 29 DCMR; or(3) If the Department determines that the child has a nursing facility LOC pursuant to Subsection 9512.9, the Department shall use the applicable per-diem reimbursement rates of the pediatric nursing facility that most closely meets the medical needs of the child, pursuant to Chapter 65 of Title 29 DCMR or pursuant to the Medicaid rates of the jurisdiction in which the facility is located, and is enrolled with the Department pursuant to Chapter 94 of Title 29 DCMR.(c) The Department shall employ the following methodology during annual renewals, unless Subsection 9512.22 applies: (1) Calculate the actual or estimated annual costs of care incurred for the child in the preceding year by aggregating the actual monthly costs of care;(2) Compare actual or estimated annual costs determined under Subsection 9512.13(c)(1) with the maximum allowable costs that was previously determined under Subsection 9512.13(a)(3); and(3) If the actual or estimated annual cost is more than the maximum allowable costs, the applicant will be ineligible for renewed Medicaid under the TEFRA/Katie Beckett eligibility group.9512.14 If an applicant is found eligible for Medicaid through the TEFRA/Katie Beckett eligibility group, the Department shall notify the applicant within sixty (60) calendar days of receipt of completed documents set forth in Subsection 9512.3, in accordance with Section 9501 of this chapter. The applicant shall be automatically enrolled in fee- for-service Medicaid. However, the applicant shall have the option to transition his or her enrollment to a managed care plan, subject to the Department's approval.
9512.15 Retroactive eligibility, pursuant to Section 9501, shall apply to TEFRA/Katie Beckett eligibility group applicants if the applicant was eligible in accordance with the requirements set forth under Subsection 9512.4 and received covered services during that period.
9512.16 Pursuant to Section 9501, each beneficiary shall notify the Department within ten (10) calendar days of any change in circumstances that directly affects the beneficiary's eligibility to receive Medicaid pursuant to Subsection 9512.4. Once changes are reported, the Department shall review the beneficiary's eligibility in accordance with the requirements of this chapter to determine if the beneficiary remains eligible for Medicaid under the TEFRA/Katie Beckett eligibility group.
9512.17 The physician that orders or refers services for a child that meets a LOC criteria set forth under Subsections 9512.6, 9512.7, or 9512.9 and is found eligible through the TEFRA/Katie Beckett eligibility group shall be subject to the following screening and enrollment criteria:
(a) If a child enrolls in a managed care plan contracted with the Department, the physicia n that continues to order or refer services for the child shall be subject to the managed care plan's screening and enrollment requirements pursuant to the managed care contract;(b) If a child enrolls in fee- for-service Medicaid, the physician that continues to order or refer services for the child shall be subject to screening and enrollment requirements set forth under Chapter 94 of Title 29 DCMR; and(c) If a physician, who is not already enrolled with the Department, orders or refers services for a child that requires services to be furnished by a qualified professional who must to enter into a Single Case Agreement with the Department pursuant to Subsection 9512.20, the physician shall submit a streamlined application for enrollment to the Department.9512.18 The qualified professionals that furnish services to a child that meets a LOC criteria set forth under Subsections 9512.6, 9512.7, or 9512.9 and is found eligible through the TEFRA/Katie Beckett eligibility group shall be subject to the following screening and enrollment criteria:
(a) If a child enrolls in a managed care plan contracted with the Department, the qualified professionals that continue to furnish services for the child shall be subject to the managed care plan's screening and enrollment requirements, unless a Single Case Agreement has been approved subject to Subsection 9512.19; and (b) If a child enrolls in fee-for-service Medicaid, the qualified professionals that continue to furnish services to the child shall be subject to screening and enrollment requirements set forth under Chapter 94 of Title 29 DCMR, unless a Single Case Agreement has been approved subject to Subsection 9512.20.9512.19 If a child that is enrolled in a managed care plan requires service(s) from a qualified professional that is not within the managed care plan's network, the managed care plan may enforce conditions under which it will engage in Single Case Agreements with qualified professionals that are reflective of the conditions set forth in Subsection 9512.20 (a) - (b), in addition to any other conditions set forth in the managed care contract with the Department.
9512.20 Services may be delivered to a beneficiary pursuant to a Single Case Agreement between a qualified professional and the Department if all of the following conditions are met:
(a) The child requires a service that is Medicaid-reimbursable pursuant to the District's State Plan for Medical Assistance;(b) The service is medically necessary based on the submitted supporting documentation; and(c) The service cannot be delivered by providers that are currently enrolled with the Department pursuant to Chapter 94 of Title 29 DCMR.9512.21 If a qualified professional is interested in entering into a Single Case Agreement with the Department, the following requirements shall be met:
(a) An ordering, referring, or prescribing physician who is enrolled with the Department pursuant to Chapter 94 of Title 29 DCMR shall submit a request for a Single Case Agreement with supporting clinical documentation of the required service to be furnished by a non-enrolled qualified professional;(b) The qualified professional shall submit a separate short application for a Single Case Agreement;(c) The qualified professional is screened by the Department pursuant to Chapter 94 of Title 29 DCMR; and(d) Claims are reimbursed pursuant to the Department's fee schedule, available at www.dcmedicaid.com.9512.22 If upon annual renewal there is a significant change to the services prescribed or ordered for a child in the Care Plan, described in Subsection 9512.3(b), the Department shall conduct a cost effectiveness review using the methodology set forth under Subsection 9512.13(a). A significant change shall include, but not be limited to, a change in the child's condition that would require additional resources or services for the child.
9512.23 If additional or a change of services are prescribed or ordered for the child before the end of the child's certification period, the following shall occur:
(1) If a child is enrolled in fee- for-service Medicaid, the child's physician shall submit a new Care Plan to the Department, and the Department shall conduct a new cost effectiveness review using the methodology set forth under Subsection 9512.13(a); and(2) If the child is enrolled in a managed care plan, the child's physician shall submit the new Care Plan to the managed care plan in which the child is enrolled. The managed care plan shall submit the Care Plan to the Department, and the Department shall conduct a new cost effectiveness review using the methodology set forth under Subsection 9512.13(a).9512.24 Each applicant and beneficiary shall be subject to the provisions of Chapter 14 of Title 29 DCMR, including but not limited to providing the Department with written notice of any known or suspected third-party liability at the time the child applies for Medicaid and at all times the beneficiary is receiving Medicaid through the TEFRA/Katie Beckett eligibility group.
9512.25 In addition to the requirements set forth under Subsection 9512.24, if an applicant or beneficiary requires a service that is covered within the applicant's or beneficiary's primary health insurance plan, each applicant or beneficiary shall follow the rules and requirements of the primary health insurance before seeking reimbursement from the Department or managed care plan for the service.
9512.26 For continued Medicaid coverage through the TEFRA/Katie Beckett eligibility group, each beneficiary shall complete and submit the following documents every twelve (12) months in order for the Department to determine all of the eligibility requirements set forth under Subsection 9512.4:
(a) A completed and signed renewal form;(b) A new Care Plan as described in Subsection 9512.3(b);(c) A new LOC form with documentation as described in Subsection 9512.3(c); and(d) Supporting documentation to verify other financial and non- financial eligibility factors described in Subsection 9512.4.9512.27 The Department shall send a renewal package, containing the documents described in Subsection 9512.26(a) - (c) for the beneficiary's completion, no later than ninety (90) days prior to the end of the eligibility period.
9512.28 If the beneficiary's annual renewal documents reveal that the beneficiary no longer meets all of the eligibility factors set forth under Subsection 9512.4, the beneficiary's Medicaid coverage under the TEFRA/Katie Beckett eligibility group shall be terminated and the Department shall evaluate the beneficiary's eligibility for Medicaid under other eligibility groups pursuant to 42 CFR § 435.916. The Department shall provide notice to the beneficiary or the beneficiary's authorized representative prior to termination in accordance with the provisions under Section 9508 of this chapter. The Department shall also provide notice to the beneficiary of its eligibility determination under other eligibility groups.
9512.29 If a cost effectiveness review conducted pursuant to Subsection 9512.23 reveals that a beneficiary's estimated Medicaid costs of care received at home exceed the estimated Medicaid costs if care is received in an institution, the beneficiary's Medicaid coverage under the TEFRA/Katie Beckett eligibility group shall be terminated. The Department shall provide notice to the beneficiary prior to termination in accordance with the provisions under Section 9508 of this chapter.
9512.30 At all times during the beneficiary's enrollment in Medicaid through the TEFRA/Katie Beckett eligibility group, the beneficiary shall meet all eligibility factors described in Subsection 9512.4.
9512.31 Eligibility through the TEFRA/Katie Beckett eligibility group shall not continue once a beneficiary turns nineteen (19) years old. Prior to the beneficiary's nineteenth (19th) birthday, the Department shall re-evaluate the beneficiary's eligibility for Medicaid under another eligibility category.
D.C. Mun. Regs. tit. 29, r. 29-9512
Reserved by Final Rulemaking published at 62 DCR 11142 (8/14/2015); amended by Final Rulemaking published at 66 DCR 15228 (11/15/2019)