no. o^-ofc wny p 7 2002 'jan 0 - dhcf · no. o^-ofc wny p 7 2002 'jan 0 supersedes...

Revision: HCFA-PM-86-20 (BERC) ATTACHMENT 3.1-BSEPTEMBER 1986

OMB No. 0938-0193

State/Territory: District of Columbia

AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDEDMEDICALLY NEEDY GROUP(S):

The following ambulatory services are provided.

Ambulatory services are provided to the medically needy in the same amount,duration and scope as are provided to the categorically needy. They are:

1. Inpatient hospital services

2. Outpatient hospital services

3 . Other laboratory and x-ray services

4 . Nursing facility services

5. Physician services

6. Medical care and other remedial care recognized under state law, furnished

by licensed practitioners within the scope of their practice, as defined by

state law.

7 . Home health services

8 . Private duty nursing services

9. Clinic services

i 10. Dental services

11. Physical therapy and related services

12. Prescribed drugs, dentures, and prosthetic devices; and eyeglasses

13. Other diagnostic, screening, preventive, and rehabilitative services

14. Services for individuals age 65 or older in institutions for mental diseases

15. Intermediate care facility services (other than for IMD services)

16. Inpatient psychiatric facility services (for individuals under 22 yrs.)

17. Nurse midwife services

18 . Hospice care

19. Case management services and Tuberculosis related services

20. Extended services to pregnant women

21. Ambulatory prenatal care for pregnant women furnished during a presumptive

eligibility period by an eligible provider

22. Respiratory care services

23. Nurse practitioner services

24. Other medical and remedial care, under state law specified by the Secretary

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1. Inpatient hospital services other than those provided in aninstitution for mental diseases.

X Provided: No limitations X With limitations*

a. Outpatient hospital services.


b. Rural health clinic services and other ambulatory servicesfurnished by a rural health clinic (which are otherwise coveredunder the plan).

Provided: No limitations With limitations*

X Not provided

c. Federally qualified health center (FQHC) services and otherambulatory services that are covered under the plan and furnishedby an FQHC in accordance with section 4231 of the State MedicaidManual (HCFA-Pub. 45-4) .

X Provided: No limitations With limitations

Other laboratory and X-ray services.


4. a. Nursing facility services (other than services in an institutionfor mental diseases) for individuals 21 years of age or older.


b. Early and periodic screening, diagnostic and treatment servicesfor individuals under 21 years of age, and treatment ofconditions found.*

X Provided

c. Family planning services and supplies for individuals ofchildbearing age.

X Provided: X No limitations With limitations*

*Description found in attachment /supplement.

.Supersedes Approval Dat$QV 2 T 2002 Ef £ective Date

TN No. 91-9

Revision: HCFA-PM-93-5 (MB) ATTACHMENT 3.1-BMay 1993 Page 2a

OMB NO:


AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDYGROUP(s):

5.a. Physicians' services, whether furnished in the office, thepatient's home, a hospital, a nursing facility, orelsewhere.


b. Medical and surgical services furnished by a dentist (inaccordance with section 1905(a)(5)(B) of the Act).

X Provided: No limitations X With limitations:

*Description provided on attachment.

rJAN 0TN NO. oi ~ WQV 9Supersedes Approval Date fe> , Effective DateTN No. 91-9 HCFA ID: 7986E

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OMB No. 0938-0193


AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDEDMEDICALLY NEEDY GROUP ( S ) :

6. Medical care and any other type of remedial care recognized underState law, furnished by licensed practitioners within the scope oftheir practice as defined by State law .

a. Podiatrists' Services


b. Optometrists' Services


c. Chiropractors' Services


X Not provided

d. Other Practitioners' Services


X Not provided

7 . Home Health Services

a. Intermittent or part-time nursing service provided by a homehealth agency or by a registered nurse when no home health agencyexists in the area.


b. Home health aide services provided by a home health agency.


c. Medical supplies, equipment, and appliances suitable for use inthe home .


d. Physical therapy, occupational therapy, or speech pathology andaudiology services provided by a home health agency or medicalrehabilitation facility.


Not provided

NOV 2 7 2002 JAN 0 1 200?E f f i e Datewnn v -1 £-u"t,Supersedes Approval Date _ Effective DateTN No. 95-03 HCFA ID: 7986E


OMB No. 0938-0193


AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDEDMEDICALLY NEEDY GROUP(S): All groups

8. Private duty nursing services.


9. Clinic services.


10. Dental services.


11. Physical therapy and related services.

a. Physical therapy.


b. Occupational therapy.


c. Services for individuals with speech, hearing, and languagedisorders (provided by or under supervision of a speechpathologist or audiologist).


12. Prescribed drugs, dentures, and prosthetic devices; and eyeglassesprescribed by a physician skilled in diseases of the eye or by anoptometrist.

a. Prescribed drugs.


b. Dentures.


*Description provided on attachment.

TN No .

Supersedes Approval Date -^ AM /o / Effective Date / «*./.; / ff<TN No. -SS=«S- ff i~.C| / HCFA ID: 0140P/Oia/2A


OMB No. 0938-0193


AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDEDMEDICALLY NEEDY GROUP (S) :

c. Prosthetic devices.


d. Eyeglasses.


13. Other diagnostic, screening, preventive, and rehabilitative services,i.e., other than those provided elsewhere in this plan.

a. Diagnostic services.

X Provided: _ •• No limitations X With limitations*

b. Screening services.


c . Preventive services .


d. Rehabilitative services.

X Provided: No limitations X With limitati

14. Services for individuals age 65 or older in institutions for mentaldiseases .

a. Inpatient hospital services.


b. Skilled nursing facility services.


TTJ No ., /ig/, "-, // /Q-JJG//YMQOQ Effective Date 06/77Supersedes Approval Date

TN No. 86-fr- ' f HCFA ID: 0140P/0102A

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OMB No. 0938-0193


AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDEDMEDICALLY NEEDY GROUP(S): All groups

c. Intermediate care facility services.


15. a. Intermediate care facility services (other than such services inan institution for mental diseases) for persons determined inaccordance with section 1902(a)(31)(a) of the Act, to be in needof such care.


b. Including such services in a public institution (or distinct partthereof) for the mentally retarded or persons with relatedconditions.

\


16. Inpatient psychiatric facility services for individuals under 22years of age.


17. Nurse-midwife services.

X Provided: _ No limitations X With limitations*

18. Hospice care (in accordance with section 1905(o) of the Act).


*Description provided in attachment.

TN No.Supersedes Approval DateTN No. *3—05-

/ ~JQjfa //i Al-UL-j2LJJ Effective Date fv-QI

Revision:

22.

23.

24

HCFA-PM-87-4 (BERC)MARCH 1987

ATTACHMENT 3.1-BPage 8OMB No. 0938-0193



Respiratory care services (in accordance with section 1902(e)(9)(A)through (C) of the Act).

X Provided:Not provided.

No limitations X With limitations*

Nurse Practitioner services

X Provided: No limitationsNot provided.

X With limitations

Any other medical care and any other type of remedial carerecognized under State law, specified by the Secretary.

a.l. Transportation. (Please refer to Attachment 3.ID.)

X Provided: No limitations X With limitations*Not provided.

a.2. Brokered Transportation.

X Provided under section 1902 (a) (70)

The State assures it has established a non-emergency medical transportationprogram in order to more cost-effectively provide transportation, and candocument, upon request from CMS, that the transportation broker was procuredin compliance with the requirements of 45 CFR 92.36 (b)-(f).

A brief description of the District's transportation brokerage is included atthe end of this section.

(1) The State will operate the broker program without the requirements of thefollowing paragraphs of section 1902(a);

D statewideness (indicate areas of State that are covered)

D (10)(B) comparability (indicate participating beneficiary groups)

0 -(23) freedom of choice (indicate mandatory population groups)

(2) Transportation services provided will include:

0 wheelchair van

0 taxi

0 stretcher car

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Approval Date Effective DateHCFA ID: 1040P/0016P

/, £6 6 ft

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OMB No. 0938-0193


0 bus passes

D tickets

tU secured transportation

0 other transportation - Public transportation including the use of theMETRO rail and bus system

13 other transportation - Ambulatory van transportation subject to priorapproval based on medical necessity for recipients whose medicalcondition, behavioral condition, or age is such that other forms oftransportation are inappropriate.

As part of non-emergency transportation coverage, the state includescosts for lodging and meals where necessary for the recipient to haveaccess to a covered medical service. Where necessary, the costs for anattendant which may include transportation, lodging and meals are alsoincluded. MAA has the final decision as to coverage for lodging, mealsand attendants and the reimbursement for these.

(3) The State assures that transportation services will be provided under acontract with a broker who:

(i) is selected through a competitive bidding process based on the State'sevaluation of the broker's experience, performance, references,resources, qualifications, and costs;

(ii) has oversight procedures to monitor beneficiary access and complaintsand ensures that transport personnel are licensed, qualified,competent, and courteous;

(iii) is subject to regular auditing and oversight by the State in order toensure the quality of the transportation services provided and theadequacy of beneficiary access to medical care, and services;

(iv) complies with such requirements related to prohibitions on referralsand conflict of interest as the Secretary shall establish (based onprohibitions on physician referrals under section 1877 and such otherprohibitions and requirements as the Secretary determines to beappropriate);

(v) does not provide transportation services and is not a governmentalentity.

(4) The broker contract will provide transportation to the followingcategorically needy mandatory populations:

0 Low-income families with children (section 1931)

0 Low-income pregnant women

0 Low-income infants

0 Low-income children 1 through 5

TN No. . -Supersedes Approval Date10 s_^-Jl_£JiJuO Effective Date P A N / cMtf 6TN No. 01-04 HCFA ID: 1040P/0016P'

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OMB No. 0938-0193


0 Low-income children 6 - 1 9

0 Qualified pregnant women

0 Qualified children

0 IV-E Federal foster care and adoption assistance children

0 TMA recipients (due to employment)

0 TMA recipients (due to child support)

0 SSI recipients

(5) The broker contract will provide transportation to the followingcategorically needy optional populations:

D Optional low-income pregnant women

D Optional low-income infants

0 Optional targeted low-income children

0 Individuals under 21 who are under State adoption assistance agreements__ th

tij Individuals under age 21 who were in foster care on their 18 birthday

0 Individuals who meet income and resource requirements of AFDC or SSI

D Individuals who would meet the income & resource requirements of AFDCif -child care costs were paid from earnings rather than by a Stateagency

0 Individuals who would be eligible for AFDC if State plan had been asbroad as allowed under Federal law

0 Individuals who would be eligible for AFDC or SSI if they were not in amedical institution

0 Individuals infected with TB

0 Individuals screened for breast or cervical cancer by CDC program

D Individuals receiving COBRA continuation benefits

0 Individuals in special income level group, in a medical institution forat least 30 consecutive days, with gross income not exceeding 300% ofSSI income standard

0 Individuals receiving home and community based waiver services whowould only be eligible under State plan if in a medical institution

0 Individuals terminally ill if in a medical institution and will receivehospice care

Individuals aged or disabled with income not above 100% FPL

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OMB No. 0938-0193


0 Individuals receiving only an optional State supplement in a 209(b)State

D Individuals working disabled who buy into Medicaid (BBA workingdisabled group)

13 Individuals working disabled who buy into Medicaid (TWWIIA workingdisabled group)

D Employed medically improved individuals who buy into Medicaid underTWWIIA Medical Improvement Group

D Individuals disabled age 18 or younger who would require aninstitutional level of care (TEFRA 134 kids)

(6) The State will pay the contracted broker by the following method:

0 risk capitation

D non-risk capitation

D other (e.g., brokerage fee and direct payment to providers)

The broker is paid on a monthly capitation basis. Payment is on a per-member-per-month basis. Actuarial analysis was conducted on Medicaid fee-for-service transportation data to establish the rates paid to the broker.The broker in-turn makes payments to the transportation provider on a fee-for-service basis.

Description of the District of Columbia's Transportation Brokerage:

The Medical Assistance Administration (MAA) initiated a non-emergencytransportation broker contract in July 2007. The non-emergency brokerprovides services to Medicaid and SCHIP enrollees that are not enrolled inmanaged care. Thus, all Medicaid and SCHIP enrollees that are in the fee-for-service program receive transportation services through the non-emergencytransportation broker.

Recipients contact the broker when in need of transportation to a Medicaid .covered service. The broker verifies enrollment in Medicaid or SCHIP, thatthe trip is to a covered service, arranges for the transportation, andreimburses the transportation provider. The broker has contracts withnumerous transportation providers and assures that transportation isavailable throughout the Metro DC area.

The broker ensures that a Transportation Provider Service Agreement (TPSA) isexecuted with each transportation provider selected by the broker as a memberof the broker's transportation network prior to the delivery of services.The broker may not establish or maintain transportation provider serviceagreements with transportation providers that have committed fraud againstthe District, Medicaid Assistance Administration, or any Federal agency orhas been terminated from the District Medicaid program.

TN No.Supersedes Approval Date WW _ • « Effective DateTN No. 01-04 HCFA ID: 1040P/0016P

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OMB No. 0938-0193


The Broker provides oversight and monitoring of the day-to-day operationsnecessary for the delivery of NET services, the maintenance of appropriaterecords, systems, and support services for reporting to MAA's Chief ofProgram Operations and maintaining compliance with the terms of the contract.Monitor the overall delivery of transportation services including vehicle,driver, and attendant requirements and performance to ensure the consistentdelivery of quality NET services allowing recipients timely access to healthcare services.

The current contract with the broker was awarded in July 2007, with theoption of 4 one-year extensions. Future year increases will be based on thetransportation portion of the Washington-Baltimore Consumer Price Index.

24. b. Services of Christian Science nurses.

Provided: No limitations With limitations*X Not provided

c. Care and services provided in Christian Science sanitaria.

Provided: No limitations With limitations*X Not provided

d. Skilled nursing facility services provided for patients under21 years of age.

X Provided: X No limitations With limitations*Not provided.

e. Emergency hospital services.


f. Personal care services, prescribed in accordance with a plan oftreatment and furnished by a qualified person under supervisionof a registered nurse.


*If there is additional information it can be found in the supplements.

T N N O - " • / /I IIIH "TSupersedes Approval Date uu ' -"• * OJUUEffective Date Of tN / x

TN No. 01-04 HCFA ID: 1040P/0016P

no. o^-ofc wny p 7 2002 'jan 0 - dhcf · no. o^-ofc wny p 7 2002 'jan 0 supersedes...

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