9501 APPLICATION, REDETERMINATION, AND RENEWAL

An individual may apply for Medicaid or other Insurance Affordability Programs (IAPs) using a single, streamlined application described at 42 C.F.R. Sections 435.907(b) and (c). The application and any required verification may be submitted:

Over the Internet;

By telephone;

By mail;

In person; and

Through other commonly available electronic means.

The application and any required verification may be submitted by:

The applicant;

An adult who is in the applicant’s household or family;

An authorized representative of the applicant, pursuant to Subsection 9501.33; or

An individual acting responsibly on behalf of the applicant, if the applicant is a minor or incapacitated.

Where the Department requires additional information to determine eligibility, the Department shall provide written notice that includes a statement of the specific information needed to determine eligibility; and the date by which an applicant or beneficiary shall provide the required information.

9501.4 The Department shall issue an eligibility determination, consistent with the timeframe described under § 9501.9 based on the receipt of an application that includes, at a minimum:

The applicant’s name;

The applicant’s District address; provided, that if the applicant is homeless and attests to their homelessness (consistent with § 9505.3), the applicant may select a mailing address provided from a list maintained by the Department of Human Services or provide an email address or phone number at which the Department may contact the applicant; and

A signature (wet, digital, or electronic, as appropriate) provided under penalty of perjury.

In order for the Department to determine whether an applicant meets the eligibility factors for Medicaid, the applicant shall complete the application process by providing a complete application, which shall consist of the:

The information and signature required by § 9501.4;

All information, including demographic information, citizenship/nationality or satisfactory immigration status, household composition, residency, and income, needed to determine eligibility; and

Required verifications for financial and non-financial eligibility factors.

The Department shall accept handwritten, telephonically recorded, and electronic signatures that conform to the requirements of federal and District law.

The Department may not require an in-person interview as part of the application process for Medicaid eligibility determinations.

The Department shall use the application filing date to determine the earliest date for which Medicaid can be effective. The filing date shall be the date that an application is received by the Department.

Application timeliness standards shall be as follows:

For an initial eligibility determination based on a disability, the Department shall inform the applicant of timeliness standards and determine eligibility within sixty (60) calendar days of the date that an application is received.

For an initial eligibility determination for all other applicants, the Department shall inform the applicant of timeliness standards and determine eligibility within forty-five (45) calendar days of the date that an application is received.

The Department may extend the sixty (60) day and forty-five (45) day periods when a delay is caused by unusual circumstances beyond the Department’s control such as:

Circumstances wholly within the applicant’s control;

Circumstances beyond the applicant’s control such as hospitalization or imprisonment; or

An administrative or other emergency that could not be reasonably controlled by the Department.

Eligibility for Medicaid shall begin three (3) months before the month of application if the individual was eligible and received covered services during that period.

The earliest possible date for retroactive eligibility shall be the first day of the third month preceding the month of application.

Retroactive eligibility, pursuant to Subsections 9501.10 and 9501.11, shall not apply to:

Qualified Medicare Beneficiaries (QMB);

Individuals without dependent children eligible for Medicaid under Section 1115 of the Social Security Act on or before December 31, 2014;

Individuals determined presumptively eligible by qualified hospitals; and

Individuals determined presumptively eligible based on pregnancy.

An applicant or the applicant’s authorized representative pursuant to § 9501.33 may withdraw an application upon request, through a signed statement, and prior to an eligibility determination through any means identified at Subsection 9501.1.

The Department shall renew eligibility every twelve (12) months for all beneficiaries, except for beneficiaries deemed eligible for less than one (1) year.

A beneficiary shall immediately notify the Department of any change in circumstances that directly affects the beneficiary’s eligibility to receive Medicaid, or affects the type of Medicaid for which the beneficiary is eligible.

The Department shall redetermine eligibility for beneficiaries identified at Subsection 9501.15 at the time the change is reported.

When renewing or redetermining eligibility, the Department shall, where possible, determine eligibility using available electronic information.

Where the Department can renew eligibility based on available electronic information, the Department shall issue written notice of the determination to renew eligibility and its basis to the beneficiary no later than sixty (60) days before the end of the certification period. The Department shall then renew eligibility for twelve (12) months.

A beneficiary shall not be required to sign and return the written notice identified at Subsection 9501.18 if the information provided in the notice is accurate.

Where the information in the written notice identified at Subsection 9501.18 is inaccurate, the beneficiary shall provide the Department with correct information, along with any necessary supplemental information through any means allowed under Subsection 9501.1.

A beneficiary may provide correct information and any necessary supplemental information pursuant Subsection 9501.20 without signature.

Where the Department cannot determine eligibility using available information, the Department shall provide a pre-populated renewal form with information available to the Department; a statement of the additional information needed to renew eligibility; and the date by which the beneficiary shall provide the requested information.

Where the Department provides a beneficiary with a pre-populated renewal form, to complete the renewal process, the beneficiary shall:

Complete and sign the form in accordance with Subsection 9501.6;

Submit the form via the Internet, telephone, mail, in person, or through other commonly available electronic means; and

Provide required information to the Department before the end of the beneficiary’s certification period.

The pre-populated renewal form shall be complete if it meets the requirements identified in Subsection 9501.5.

Where a beneficiary fails to return the pre-populated renewal form and the information necessary to renew eligibility, the Department shall issue a written notice of termination thirty (30) days preceding the end of a beneficiary’s certification period.

The Department shall terminate Medicaid eligibility when:

A beneficiary fails to submit the pre-populated renewal form and the necessary information by the end of certification period; or

The beneficiary no longer meets all eligibility factors.

For an individual who is terminated for failure to submit the pre-populated renewal form and necessary information, the Department shall determine eligibility without requiring a new application if the individual subsequently submits the pre-populated renewal form and necessary information within ninety (90) days after the date of termination.

The Department shall terminate eligibility upon a beneficiary’s request.

Upon receipt of a written request for termination of Medicaid eligibility by the beneficiary, the Department shall terminate the beneficiary’s eligibility on:

The last day of the month in which the Department receives the request where there are fifteen (15) or more days remaining in the month;

The last day of the following month in which the Department receives the request where there are fewer than fifteen (15) days remaining in the month; or

A date earlier than those referenced in Subsections 9501.29(a) through (b), upon request by the beneficiary.

A request to terminate Medicaid eligibility shall be complete if all of the following requirements are met:

The request is submitted by Internet, telephone, mail, in-person, or through other commonly available electronic means;

The request is signed and dated, under penalty of perjury, in accordance with Subsection 9501.6; and

The request includes all information necessary to determine the identity of the individual seeking termination.

The Department shall provide written notice of termination no later than fifteen (15) calendar days prior to termination, except as stated under Subsection 9508.5 through Subsection 9508.7.

An applicant or beneficiary determined to be ineligible for Medicaid shall receive an eligibility determination for other IAPs.

An individual may designate another individual or organization to be an authorized representative to act on their behalf to assist with an application, a redetermination of eligibility, and other on-going communications with the Department. The Department shall require the following:

The designation of an authorized representative shall be in writing and signed, pursuant to Subsection 9501.6, by the individual seeking representation. In the alternative, legal documentation of authority to act on behalf of an individual under District law, including a court order establishing legal guardianship or power of attorney, may serve in the place of a written authorization;

The authority of an authorized representative shall be valid until the represented individual or authorized representative notifies the Department that the representative is no longer authorized to act on the individual’s behalf; or there is a change in the legal document of authority to act on the individual’s behalf;

An authorized representative may be authorized to:

Sign an application on behalf of an applicant;

Receive copies of notices and other communications from the Department;

Act on behalf of an individual in all other matters with the Department; and

Complete and submit redetermination forms; and

An authorized representative shall agree to maintain, or be legally bound to maintain, the confidentiality of any information regarding the represented individual provided by the Department.

9501.34 Beginning on January 1, 2024, a twelve (12) month continuous eligibility period shall be given to individuals under age nineteen (19) (except for the individuals listed under § 9501.35) regardless of changes in circumstances, with certain exceptions, and pursuant to the provisions, set forth in 42 U.S.C. § 1396a(e)(12), 42 C.F.R.§ 435.926, and §§ 9501.35 through 9501.38.

9501.35 Continuous eligibility under § 9501.34 shall not apply to individuals who have only established eligibility as follows:

Through medically needy spend down, as described in § 9516 of this Chapter;

Through presumptive eligibility consistent with Section 1920A of the Social Security Act, but who have not yet received a determination of eligibility based on a regular application; and

Based on a transitional medical assistance determination, under § 9510 of this Chapter, upon renewal.

9501.36 Unless an exception under § 9501.37 applies, a continuous eligibility period begins as follows:

For new applicants, the continuous eligibility period shall begin on the first day of the month the application was submitted, consistent with 42 C.F.R. §435.915;

For current beneficiaries who are enrolled in Medicaid as of January 1, 2024 and whose eligibility is being renewed, the continuous eligibility period begins on the first day of the month following the end of the beneficiary’s last full eligibility period (which may include the initial eligibility period described in paragraph (a) or the last periodic renewal or redetermination, as applicable); and

For current beneficiaries who enrolled before January 1, 2024 and no longer meet eligibility requirements on or after January 1, 2024 and before the end of their certification date, the beneficiaries shall remain eligible under continuous eligibility until the end of their certification period.

9501.37 An individual’s eligibility may not be terminated during a continuous eligibility period, regardless of any changes in circumstances, unless:

The individual attains age nineteen (19);

The individual or individual’s representative requests a voluntary termination of eligibility, consistent with the requirements of § 9501.33;

The individual ceases to be a District resident;

The Department determines that eligibility was erroneously granted at the most recent determination, redetermination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual or the individual's representative; or

The individual dies.

9501.38 After the continuous eligibility period described under § 9501.36 ends, the Department shall re-evaluate the individual for eligibility. If the Department determines that the individual is no longer eligible for Medicaid, the Department shall begin the termination process described under § 9501.26.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015); as amended by Final Rulemaking published at 69 DCR 012065 (October 7, 2022); as amended by Final Rulemaking published at 72 DCR 008054 (July 18, 2025).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9501

9502 RESIDENCY

An individual shall be a resident of the District as a condition of Medicaid eligibility.

An individual shall be considered incapable of stating intent to reside in the District if one of the following applies to the individual:

Individual has an I.Q. of forty-nine (49) or less or a mental age of seven (7) or less, based on tests acceptable to the District Department on Disability Services;

Individual is judged legally incompetent; or

Individual is found incapable of indicating intent by a physician, psychologist, or other similarly individual licensed in accordance with the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201 et seq. (2012 Repl.)).

A resident of the District shall be any individual who:

Meets the conditions of Subsections 9502.4 through 9502.19; or

Meets the criteria specified in an interstate agreement under Subsection 9502.24.

9502.4 Subject to the exceptions identified in Subsections 9502.6, 9502.11, 9502.12, and 9502.14 below, an individual under age nineteen (19) who lives in the District shall be considered a resident of the District.

9502.5 Subject to the exceptions identified in Subsections 9502.6, 9502.11, 9502.12, and 9502.14 below, the state of residence of an individual who is age nineteen (19) through twenty (20) shall be where the individual resides or the state of residency of the parent or caretaker relative with whom the individual resides.

An individual who is under the age of twenty-one (21), who is capable of stating intent to reside; who is married or emancipated, and who does not reside in an institution, shall follow the residency rules applicable to individuals who are the age of twenty-one (21) and older.

An individual, who is the age of twenty-one (21) or older and who does not live in an institution, shall be considered a resident of the District if the individual is living in the District voluntarily and not for a temporary purpose; that is, an individual with no intention of presently leaving including individuals without a fixed address or who have entered the District with a job commitment or seeking employment, whether or not currently employed.

For purposes of determining eligibility for Medicaid, an individual may retain his or her status as a resident of the District of Columbia if the individual considers the District to be his or her fixed place of residence to which he or she will return with the intent to reside following a temporary absence, and:

(a) The individual is absent from the District for less than ninety (90) consecutive days; or

(b) The individual is absent from the District for more than ninety (90) consecutive days for good cause, as determined by DHCF, which may include, but not be limited to, the following:

(1) School attendance: an individual under the age of twenty-two (22) who is away from the District for the sole purpose of attending a boarding school, other educational facility, or in an educational placement as set forth in Title 5-E DCMR § 3013.6, if otherwise eligible, may retain Medicaid eligibility;

(2) Medical care: an otherwise eligible individual in need of medical care that temporarily resides outside of the District may retain Medicaid eligibility as long as the need for medical care continues; or

(3) U.S. Military service: an individual with full-time employment in the U.S. military service, if otherwise eligible, may retain Medicaid eligibility while away from the District due to a duty assignment.

Residence as defined for eligibility purposes shall not depend upon the reason for which the individual entered the District, except insofar as it may bear on whether the individual is there for a temporary purpose.

Unless an exception applies, the State of residence for an individual who is age twenty-one (21) and over, and who is not living in an institution, but who is incapable of stating intent to reside, shall be the State where the individual lives.

Where a District agency or designee arranges or makes an out-of-state placement for any individual aged eighteen (18) and older receiving diagnostic, treatment, or rehabilitative services related to intellectual or developmental disabilities, the District shall be the State of residence.

The State of residence for an individual placed by the District in an out-of-District institution shall be determined as follows:

An individual who is placed in an institution in another State by a District agency or designee is a District resident;

If a District agency or designee arranges or makes the placement, the District is considered as the individual's State of residence, regardless of the individual’s intent or ability to indicate intent;

Where a placement is initiated by a District agency or designee because the District lacks a sufficient number of appropriate facilities to provide services to its residents, the District, as the State making the placement is the individual's State of residence.

Any action by a District agency or designee beyond providing information to the individual and the individual’s family constitutes arranging, or making, an out-of-District placement in an institution.

The State of residence for an individual of any age who receives a State supplementary payment (SSP) shall be the State paying the SSP.

Except as provided in Subsections 9502.24 and 9502.25, the State of residence for individuals under the age of twenty-one (21) receiving adoption assistance, foster care, or guardianship care under title IV-E of the Social Security Act (the Act) shall be the State where the individual resides.

The State of residence for an institutionalized individual under the age of twenty-one (21), who is neither married nor emancipated, shall be the following:

The parent's or legal guardian's State of residence at the time of placement;

The current State of residence of the parent or legal guardian who files the application if the individual is institutionalized in that same State; or

(c) If the individual has been abandoned by his or her parents and has no legal guardian, the State of residence of the individual who files an application.

For any institutionalized individual who became incapable of indicating intent before age twenty-one (21), the State of residence shall be:

That of the parent applying for Medicaid on the individual's behalf, if the parents reside in separate States (if a legal guardian has been appointed and parental rights are terminated, the State of residence of the guardian is used instead of the parent's);

The parent's or legal guardian's State of residence at the time of placement (if a legal guardian has been appointed and parental rights are terminated, the State of residence of the guardian is used instead of the parent's);

The current State of residence of the parent or legal guardian who files the application if the individual is institutionalized in that State (if a legal guardian has been appointed and parental rights are terminated, the State of residence of the guardian is used instead of the parent's); or

The State of residence of the individual or party who files an application is used if the individual has been abandoned by their parent(s), does not have a legal guardian and is institutionalized in that State.

For any institutionalized individual (regardless of any type of guardianship) who became incapable of indicating intent at or after age twenty-one (21), the State of residence is the State in which the individual is physically present, except where another State makes a placement.

For any other institutionalized individual, the State of residence shall be the State where the individual is living and intends to reside.

The Department shall not deny eligibility for Medicaid because an individual has not resided in the District for a specified period.

The Department shall not deny eligibility for Medicaid to an individual in an institution, who satisfies the residency rules set forth in this section on the grounds that the individual did not establish residence in the District before entering the institution.

The Department shall not deny or terminate an individual’s eligibility for Medicaid because of the individual's temporary absence from the District if the individual intends to return when the purpose of the absence has been accomplished, unless another State has determined that the individual is a resident there for purposes of Medicaid.

The District may extend eligibility for Medicaid to individuals who would traditionally be considered residents of a State other than the District under an interstate agreement.

The Department may consider an individual under the age of twenty-one (21) who receives foster care assistance from the District under title IV-E of the Social Security Act and lives in an out-of-District foster home to be a resident of the District when:

The individual receives foster care as defined at 45 CFR § 1355.20;

The individual receives services from a provider screened and enrolled in the District Medicaid program pursuant to 29 DCMR §§ 9400 et seq.;

The District’s Child and Family Services Agency (CFSA) places the individual in an out-of-District foster home for reasons related to the safety, permanence, and well-being of abused and neglected children and their families; and

The District evaluates all factors affecting the best interests of the individual and determines that continued eligibility for and enrollment in the District Medicaid program is in the best interest of the individual.

The District may determine that continued eligibility for and enrollment in the District Medicaid program is not in the best interest of an individual described in Subsection 9502.24 for the following reasons:

The individual cannot obtain services from a provider enrolled in the District’s Medicaid program because of their geographic distance from the location where the services are provided;

The individual has special health needs that cannot be addressed by an available and accessible provider enrolled in the District’s Medicaid program;

The individual, or someone acting responsibly for the individual, requests that the individual be enrolled in the state’s Medicaid program where the individual is living; or

The District evaluates all factors affecting the best interests of the individual and determines that continued eligibility for and enrollment in the District Medicaid program is not in the best interest of the individual.

Where two or more States cannot resolve which State is the State of residence, and in the absence of an interstate agreement between the District and another State governing disputed residency, the State where the individual is physically located shall be the State of residence.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015); as amended by Final Rulemaking published at 64 DCR 7922 (August 11, 2017).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9502

9503 CITIZENSHIP OR SATISFACTORY IMMIGRATION STATUS

An individual shall meet applicable citizenship or satisfactory immigration status requirements as a condition of Medicaid eligibility.

The following groups of individuals satisfy citizenship or satisfactory immigration status requirements:

A U.S. citizen or national as described in Subsection 9503.8, including children born to a non-citizen in the U.S;

Lawful Permanent Residents (LPRs) pursuant to the Immigration and Nationality Act (INA);

Refugees admitted under Section 207 of INA including Afghan and Iraqi Special Immigrants (SIV's) as permitted under Pub. L. 111-118;

Aliens granted Asylum under Section 208 of INA;

Cuban or Haitian entrants as defined in Section 501(e) of the Refugee Education Assistance Act of 1980;

Aliens granted conditional entry prior to April 1, 1980;

Aliens who have been paroled into the U.S. in accordance with 8 U.S.C. § 1182(d)(5) for less than one (1) year;

Certain battered spouses, battered children or parents, or children of a battered individual with a petition approved or pending under Section 204(a)(1)(A) or (B) or Section 244(a)(3) of the INA;

An individual who has been granted withholding of Deportation;

American entrants pursuant to Section 584 of the Foreign Operations, Export Financing and Related Programs Appropriations Act of 1988 (as contained in Section 101(e) of Pub. L. 100-202 and amended by the 9th provision under Migration and Refugee Assistance in Title II of the Foreign Operations, Export Financing and Related Programs Appropriations Act, 1988, Pub. L. 100-461 as amended);

American Indians born outside the U.S. who were born in Canada and are at least fifty percent (50%) American Indian blood and to whom the provisions of Section 289 of the INA apply; and are members of a federally recognized tribe as defined in Section 4(e) of the Indian Self-Determination and Education Act; and

Lawfully residing aliens who are under the age of twenty-one (21) and pregnant women pursuant to Section 1903(v)(4) of the Social Security Act, including the following individuals who are:

Defined as qualified aliens in 8 U.S.C. Section 1641(b) and (c);

In a valid nonimmigrant status, as defined in 8 U.S.C. Section 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. Section 1101(a)(17))(includes worker visas, student visas, and citizens of Micronesia, the Marshall Islands, and Palau);

Paroled into the U.S. in accordance with 8 U.S.C. Section 1182(d)(5) for less than one (1) year, except for individuals paroled for prosecution, for deferred inspection or pending removal proceedings;

Granted temporary resident status in accordance with 8 U.S.C. Section 1160 or Section 1255a, respectively;

Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. § 1254a, and individuals with pending applications for TPS who have been granted employment authorization;

Granted employment authorization under 8 C.F.R Section 274a.12(c);

Family Unity beneficiaries in accordance with Section 301 of Pub. L. 101-649, as amended;

Under Deferred Enforced Departure (DED) in accordance with a decision made by the President;

Granted Deferred Action status;

Granted an administrative stay of removal under 8 C.F.R Section 241 (issued by the Department of Homeland Security);

The recipient of an approved visa petition or who has a pending application for adjustment to lawful permanent resident status;

The recipient of a pending application for asylum under 8 U.S.C. Section 1158, or for withholding of removal under 8 U.S.C. Section 1231, or under the Convention Against Torture who have been granted employment authorization; or are under the age of fourteen (14) and have had an application pending for at least one-hundred eighty (180) days;

Granted withholding of Deportation;

Children who have a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. Section 1101(a)(27)(J);

Lawfully present in American Samoa under the immigration laws of American Samoa; or

Victims of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, approved October 28, 2000 (Pub. L. 106-386, as amended; 22 U.S.C. Section 7105(b)).

Individuals with deferred action under the U.S. Department of Homeland Security’s Deferred Action for Childhood Arrivals (DACA) process, as described in the Secretary of Homeland Security’s June 15, 2012 memorandum, shall not meet citizenship or satisfactory immigration status requirements under Subsections 9503.2(c) through (l).

Unless exempt under 8 U.S.C. Section 1613(b), qualified aliens who are age nineteen (19) or older and entered the U.S. on or after August 22, 1996 shall be subject to a five (5) year period during which they are ineligible for full Medicaid.

The five (5) year period, described in 8 U.S.C. Section 1613, shall begin on the date the qualified alien entered the U.S., or the date a previously unqualified alien attained qualified alien status.

An alien who does not meet the citizenship or satisfactory immigration status requirements identified at Subsections 9503.1 through 9503.5 may be eligible to receive emergency services that are not related to an organ transplant procedure if:

The alien has a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in:

Placing health in serious jeopardy;

Serious impairment to bodily functions; or

Serious dysfunction of a bodily organ or part.

The alien meets all other eligibility requirements for Medicaid except the requirements concerning furnishing social security numbers and verification of alien status; and

The alien's need for the emergency service continues.

The Department shall discontinue Emergency Medicaid for aliens described at Subsection 9503.6 once the alien’s medical condition has been stabilized.

An individual shall qualify as a U.S. citizen if the individual was born in the fifty (50) states or the District of Columbia, Puerto Rico, Gram, U.S. Virgin Islands or Northern Mariana Islands. Nationals from American Samoa or Swain’s Island are regarded as U.S. citizens for purposes of Medicaid eligibility. A child of a U.S. citizen born outside the U.S. may automatically be eligible for a Certificate of Citizenship.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9503

9504 SOCIAL SECURITY NUMBER

An individual, except as otherwise provided in this section, shall provide his or her SSN as a condition of Medicaid eligibility pursuant to 42 C.F.R. Section 435.910.

An individual who cannot provide his or her SSN shall provide proof of an application for an SSN with the U.S. Social Security Administration (SSA).

The Department shall take the following actions when an individual cannot recall his or her SSN or has not been issued an SSN:

Assist with the completion of an application for an SSN;

Obtain evidence required under SSA regulations to establish the age, the citizenship or alien status, and the true identity of the individual; and

Send the application to SSA, or request SSA to furnish the number, if there is evidence that the individual has previously been issued a SSN.

The Department shall not deny or delay services to an otherwise eligible individual pending issuance or verification of the individual’s SSN by the SSA.

Individuals identified in Subsection 9504.3 shall be eligible for Medicaid on a temporary basis for ninety (90) days.

The Department shall verify each SSN of each individual with SSA, as prescribed by the U.S. Commissioner of Social Security, to ensure that each SSN furnished was issued to that individual, and to determine whether any others were issued.

The requirement to furnish an SSN shall not apply to the following individuals:

An individual who is applying for Medicaid due to the presence of an emergency medical condition defined at 42 C.F.R Section 440.255;

An individual who does not have an SSN and may only be issued an SSN for a valid non-work reason;

An individual who refuses to obtain an SSN because of well-established religious objections;

An individual who is an infant under the age of one (1);

An authorized representative;

Adult who is applying for Medicaid on a minor’s behalf; or

Any other individual member of an applicant or beneficiary’s household who is not applying for Medicaid.

9504.8 The Department may give a Medicaid identification number to an individual who, because of well-established religious objections, refuses to obtain an SSN. The identification number may be either an SSN obtained by the District on an individual's behalf or another unique identifier.

9504.9 The Department shall advise an individual of the uses the Department will make of each SSN, including its use for verifying income, eligibility, and amount of Medicaid payments.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9504

9505 VERIFICATION OF NON-FINANCIAL ELIGIBLITY FACTORS

The Department shall verify the non-financial eligibility factors necessary for a MAGI-based Medicaid eligibility determination at the time of application, at each renewal of eligibility, and at each redetermination of eligibility in accordance with the District Verification Plan pursuant to 42 C.F.R. Sections 435.940 through 435.965 and Section 457.380.

An applicant, adult who is in a minor applicant’s household, or an authorized representative, as identified in Subsection 9501.33, of an applicant shall attest to the following non-financial eligibility factors:

Household composition;

Residency;

Age;

SSN;

U.S. citizenship, nationality or satisfactory immigration status;

Pregnancy status;

Relationship of a caretaker relative to an applicant or eligible child; and

Eligibility for Medicare.

The Department shall accept attestation without verification, unless the attestation is not reasonably compatible with information available to the Department, for the following eligibility factors:

Household composition;

Residency for individuals age eighteen (18) and under;

Age;

Pregnancy (includes attestation of multiple gestation pregnancies, i.e., a woman pregnant with twins would be counted as three people);

Relationship of a caretaker relative to an applicant, beneficiary, or eligible child;

Homelessness; and

Eligibility for Medicare.

The Department shall require verification through one (1) or more federal and State electronic data sources for the following eligibility factors:

Residency for individuals age nineteen (19) and older;

SSN; and

U.S. citizenship/nationality or satisfactory immigration status.

The Department shall not require verification of U.S. citizenship or nationality and satisfactory immigration status pursuant to Subsection 9505.4(d) for the following:

Individuals receiving SSI;

Individuals receiving Social Security Disability (SSDI) based on their own disability;

Individuals who are entitled to or enrolled in Medicare;

Individuals who are eligible for Medicaid as a deemed newborn; and

Children in foster care or receiving adoption assistance payments.

The Department shall use a reasonable compatibility standard to match information obtained from federal and State electronic or other data sources with attested application information as further described in Subsection 9505.7 below.

Attestation and information from electronic or other data sources shall be considered reasonably compatible by the Department where the data sources match or do not significantly differ from attestation. Only discrepancies that affect eligibility shall be considered significant.

The Department may require individuals to provide supplemental information where electronic data is unavailable or application information is not reasonably compatible with information obtained from an electronic or other data source.

The Department may accept supplemental information in the following forms:

Paper, electronic, or telephonic documentation; or

If other documentation is not available, a statement which explains the discrepancy.

The Department shall provide a ninety (90) day period to provide supplementary information to verify SSN, U.S. citizenship or nationality, and satisfactory immigration status once per lifetime. Medicaid coverage may be provided during this period.

An applicant who makes a good faith effort to obtain the requested documentation may receive an additional ninety (90) day period to produce the documentation necessary to verify citizenship or immigration status once per lifetime.

Excepting citizenship, nationality, and satisfactory immigration status, the Department may waive its verification requirements for exceptional circumstances.

In accordance with the District Verification Plan, exceptional circumstances shall include:

Homelessness;

Domestic violence;

Instances where a noncustodial parent refuses to release documentation germane to verification of one (1) or more eligibility factors; and

Other circumstances as identified on a case-by-case basis and approved by the Department.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9505

9506 MODIFIED ADJUSTED GROSS INCOME (MAGI) ELIGIBILITY

This section shall establish the factors of District Medicaid eligibility for modified adjusted gross income (MAGI) eligibility groups, as identified in Section 9500.

9506.2 Beginning January 1, 2026, to be determined eligible for Medicaid as a parent or other caretaker relative, an individual shall:

Be a parent or other caretaker relative of a dependent child;

Have a household income that does not exceed one hundred thirty-three percent (133%) of the Federal Poverty Level (FPL) as determined in accordance with this section; and

(c) Meet all other applicable non-financial eligibility factors identified at Subsection 9506.9.

To be determined eligible for Medicaid as a pregnant woman, an individual shall:

Be pregnant or in the post-partum period;

Have household income that does not exceed three hundred nineteen percent (319%) of the FPL as determined in accordance with this Section;

Not otherwise eligible or enrolled under the following mandatory groups:

Supplemental Security Income (SSI) and related groups,

Parent or Other Caretaker Relatives,

Infants and Children, or

Title IV-E Foster Children;

Not entitled to or enrolled in Medicare; and

Meet all other applicable non-financial eligibility factors identified at Subsection 9506.9.

The Department shall not require a pregnant woman to cooperate in establishing paternity in order to receive Medicaid.

A pregnant woman who is determined eligible for Medicaid shall retain eligibility throughout the pregnancy and the post-partum period regardless of changes in household income.

To be determined eligible for Medicaid as an infant and child under age nineteen (19), an individual shall:

Be age zero (0) through eighteen (18);

Have a household income that does not exceed three hundred nineteen percent (319%) of the FPL as determined in accordance with this section; and

Meet all other applicable non-financial eligibility factors identified at Subsection 9506.9.

To be determined eligible for Medicaid as a child age nineteen (19) or twenty (20), an individual shall:

Be age nineteen (19) or twenty (20);

Have household income that does not exceed two hundred sixteen percent (216%) of the FPL as determined in accordance with this section; and

Meet all other applicable non-financial eligibility factors identified at Subsection 9506.9.

To be eligible as an individual without a dependent child (childless adult), an individual shall:

Be age twenty-one (21) through sixty-four (64);

Have a household income that does not exceed hundred thirty-three percent (133%) of the FPL as determined in accordance with this section;

Without dependent children;

Not otherwise eligible or enrolled under the following mandatory groups:

SSI and related groups,

Parent or Caretaker Relative,

Pregnant Woman,

Former Foster Child, or

Not entitled to or enrolled in Medicare Part A or Part B; and

Meets all other applicable non-financial eligibility requirements identified at Subsection 9506.9.

All individuals applying for Medicaid, regardless of eligibility group, shall meet the following non-financial eligibility factors:

Be a District resident pursuant to 42 C.F.R. Section 435.403;

Provide an SSN or be exempt pursuant to 42 C.F.R. Section 435.910 and Subsection 9504.7; and

Be a U.S. citizen or national, or be in a satisfactory immigration status.

The Department shall employ MAGI methodologies (based on federal income tax rules) to determine household composition, family size, and how income is counted during eligibility determinations for MAGI eligibility groups.

For individuals who expect to file a federal income tax return or who expect to be claimed as a tax dependent by another tax filer for the taxable year in which an eligibility determination is made, household composition shall be determined as follows:

The household of an individual who expects to be a tax filer consists of the tax filer and all of the tax dependents the tax filer expects to claim;

The household of a tax dependent, except individuals identified in Subsection 9506.14, consists of the tax filer claiming the tax dependent and all other tax dependents expected to be claimed by that tax filer;

The household of a married individual who lives with their spouse consists of both spouses regardless of whether they expect to file a joint federal tax return or whether one or both spouses expect to be claimed as a tax dependent by another tax filer;

The household of a married individual who does not live with their spouse and files a joint federal tax return includes the married individual plus their spouse;

The household of a married individual who does not live with their spouse and is filing a federal tax return separately does not include the spouse; and

The household of a pregnant woman includes the pregnant woman plus the number of children she is expected to deliver. In determining the family size of the household of an individual that includes a pregnant woman, the pregnant woman is counted herself plus the number of children she is expected to deliver.

The Department shall consider an individual who expects to be both a tax filer and a tax dependent to be a tax dependent.

For individuals who do not expect to file a federal income tax return or be claimed as a tax dependent for the taxable year in which an eligibility determination is made, household composition shall be determined as follows:

The household of an individual who expects to be a non-filer consists of the non-filer and, if living with the non-filer:

The non-filer’s spouse;

The non-filer’s children under age nineteen (19); and

If the non-filer is under age nineteen (19), the non-filer’s parents and any siblings who are also under age nineteen (19).

Household composition shall be determined under Subsection 9506.13 for the following:

Individuals who expect to be claimed as a tax dependent by a tax filer who is not their spouse or biological, adoptive, or step parent, regardless of the individual’s age;

Individuals who are under age nineteen (19) living with both parents who do not expect to file a joint federal tax return, and who expect to be claimed as a tax dependent by one of their parents; or

Individuals who are under age nineteen (19) and expect to be claimed by a non-custodial parent.

MAGI-based income shall be determined using federal income tax rules for determining adjusted gross income except as otherwise provided in this Section. Countable income shall include the following:

Wages, salaries, tips, and other forms of earned income;

Taxable and tax-exempt interest;

Ordinary dividends;

Qualified dividends;

Taxable refunds, credits, or offsets of state and local income taxes;

Alimony received;

Business income or losses;

Capital gains or losses;

Other taxable gains or losses;

Taxable Individual Retirement Account (IRA) distributions;

Taxable pensions and annuities – taxable amount;

Rental real estate, royalties, income from partnerships, S corporations, trusts, etc.;

Farm income or losses;

Unemployment compensation;

Taxable and tax-exempt Social Security benefits except as provided in Subsection 9506.16(q) below;

Lump sum payments, which shall be counted as follows:

Qualified lottery winnings as defined under 42 U.S.C. § 1396a (e)(14)(K)(v), and qualified lump sum income as defined under § 1396a(e)(14)(K)(vi) (i.e., gambling winnings), shall be counted using the following formula (lottery winnings paid out in installments shall not be considered “qualified lottery winnings” and shall be considered unearned, recurring income that is counted in the month they are received):

Single payment winnings less than eighty thousand dollars ($80,000.00) shall be counted in the month received in their entirety;

Single payment winnings of eighty thousand dollars ($80,000.00) but less than ninety thousand dollars ($90,000.00) shall be counted as income over two (2) months, with an equal amount counted in each month only for the individual who received the winnings. For other household members, the winnings should be counted under subsection 9506.15(p)(2); and

For every additional ten thousand dollars ($10,000.00) of single payment winnings, one (1) month is added to the period over which total winnings are divided, in equal installments, and counted as income up to a maximum of one hundred twenty (120) months only for the individual who received the winnings (a table showing the amount of monthly income attributed to increasing amounts of winnings and the number of months over which the winnings are counted can also be found in the Centers for Medicare and Medicaid Services (CMS) State Health Official Letter # 19-003, Attachment B, pages 12 – 13, at https://www.medicaid.gov/federal-policy-guidance/downloads/sho19003.pdf (last visited on September 23, 2021)). For other household members, the winnings should be counted under subsection 9506.15(p)(2);

Other lump sum payments that are not qualified lottery winnings or qualified lump sum income described in Subsection 9506.15(p)(1) (including but not limited to backpay, a retroactive benefit payment, State tax refund, or an insurance settlement) shall be counted in the month(s) during which they are received; and

Any other income reported on Internal Revenue Service (IRS) Form 1040.

Countable income shall exclude the following:

Income scholarships, awards, or fellowship grants used for education purposes and not for living expenses;

American Indian/Alaska Native income as defined in 42 C.F.R Section 435.603(e);

Educator expenses;

Certain business expenses of reservists, performing artists, and fee-based government officials;

Health savings account deductions;

Moving expenses for active duty members of the military who are ordered to move or change duty stations. For individuals who are not active duty members of the military, moving expenses shall not be excluded from income through tax year 2025;

Deductible part of self-employment tax;

Self-employed Simplified Employee Pension (SEP), Savings Incentive Match Plan for Employees (SIMPLE), and qualified plans;

Self-employed health insurance deductions;

Penalty(ies) on early withdrawal of savings;

Alimony paid pursuant to separation or divorce agreements finalized on or before December 31, 2018, that has not been modified after December 31, 2018;

Alimony received pursuant to a separation or divorce agreement finalized on or after January 1, 2019, or pursuant to a pre-existing agreement modified on or after January 1, 2019;

Individual Retirement Account (IRA) deductions;

Student loan interest deductions;

Discharged student loan debt of a borrower if the debt is discharged due to the death or the permanent and total disability of the student, as described under section 11031 of the Tax Cuts and Jobs Act of 2017, approved on December 22, 2017 (Pub. L. No. 115-97, 131 Stat. 2054) (TCJA);

Public assistance benefits;

Domestic production activities deductions;

Supplemental Security Income (SSI) benefits under Title XVI of the Social Security Act; and

Compensation of a parent mentor, as defined under 42 U.S.C. § 1397mm (f)(5), that assists families with children that are eligible, but not enrolled, in Medicaid, in accordance with section 3004 of the Helping Ensure Access for Little Ones, Toddlers, and Hopeful Youth by Keeping Insurance Delivery Stable Act of 2017, approved on January 22, 2018 (Pub. L. No. 115-120, 132 Stat. 28) (HEALTHY KIDS Act).

Household income shall include the MAGI-based income of all individuals in a household except that:

The MAGI-based income of an individual who is included in the household of his or her natural, adopted, or step parent and is not expected to be required to file a federal tax return for the taxable year of an eligibility determination, shall not be included in household income, whether or not the individual files a federal tax return; and

The MAGI-based income of a tax dependent, other than a spouse or child under age nineteen (19), who is not expected to be required to file a separate federal tax return for the taxable year of an eligibility determination, is not included in the household income of the tax filer who expects to claim the tax dependent, whether or not such tax dependent files a federal tax return.

An amount equivalent to five percent (5%) of the Federal Poverty Level (FPL) for the applicable family size shall be deducted from household income only when determining the financial eligibility of an individual under the highest income standard available for an individual.

The Department shall base current financial eligibility for Medicaid on current monthly income.

Current monthly income shall be calculated as follows:

Income received on a yearly basis or less often than monthly, that is predictable in both amount and frequency, shall be converted to a monthly amount or prorated;

If the amount or frequency of regularly received income is known, the Department shall average the income over the period between payments; or

If neither the amount nor the frequency is predictable, the Department shall not average the income but count income only for the month in which it is received.

The Department shall verify financial eligibility for Medicaid at the time of application, at each renewal of eligibility, and at each redetermination of eligibility in accordance with the District Verification Plan, submitted to CMS pursuant to 42 C.F.R. Sections 435.940-435.965 and Section 457.380.

An applicant adult who is in a minor applicant’s household or family, or an authorized representative of an applicant, as identified in 42 C.F.R. Section 435.923, shall attest to household income.

The Department shall verify financial eligibility through one (1) or more federal or state electronic data sources, except for qualified lottery winnings and lump sum payments, for which the Department shall accept self-attestation, subject to post-eligibility verification using available electronic data sources.

The Department shall use a reasonable compatibility standard to match financial information obtained from federal and State electronic data sources with attested application information.

The reasonable compatibility standard for financial information shall be met when:

The attestation and data sources are both above the District Medicaid program’s applicable income standard;

The attestation and data sources are both below the District Medicaid program’s applicable income standard.

The attestation is below the District Medicaid program’s applicable income standard and the data sources are above the applicable income standard, when the difference between them is less than twenty percent (20%) of the amount given by data sources; and

The attestation is zero (0) income and no income data is available from electronic data sources.

The Department may require supplemental information where electronic data is unavailable or application information is not reasonably compatible with information obtained from an electronic data source.

The Department may accept supplemental information reflecting current monthly income in the following forms:

Paystubs;

Completed employer verification form;

Statement showing retirement income, disability income, Workers Compensation income, or a pension statement;

Bank and checking account statement;

Paper, electronic, or telephonic documentation; or

If other documentation is not available, a statement which explains the discrepancy.

The Department shall provide written notice to the applicant or beneficiary to provide supplementary information to verify financial eligibility and the date by which an applicant or beneficiary shall provide the required information, consistent with § 9501.3.

The Department may waive the verification required under this section for exceptional circumstances.

In accordance with the District Verification Plan, exceptional circumstances shall include:

Homelessness;

Domestic violence;

Employer moved to another state or country;

Business closed;

Employer will not release information;

Self-employed individuals who cannot produce documentation of income; or

Other circumstances as identified on a case-by-case basis and approved by the Department.

9506.31 An individual whose income exceeds the applicable limit due to the application of the formula for qualified lottery winnings and qualified lump sum income, as described in subsection 9506.15(p)(1), may continue to be eligible to the extent the Department determines that the denial of eligibility of the individual would cause an undue medical or financial hardship as determined on the basis of criteria as may be established by the Secretary of the U.S. Department of Health and Human Services.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015); as amended by Final Rulemaking published at 69 DCR 011768 (September 30, 2022); as amended by Final Rulemaking published at 69 DCR 012065 (October 7, 2022); as amended by Final Rulemaking published at 70 DCR 015109 (November 17, 2023); as amended by Final Rulemaking published at 73 DCR 006117 (April 17, 2026).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9506

9507 NON-MAGI ELIGIBILTY GROUP: DEEMED NEWBORNS

To be determined eligible for Medicaid as a deemed newborn, an individual shall be born to a woman eligible for and receiving Medicaid from the District at the time of birth.

The Department shall not require an application or income test for deemed newborns.

The Department shall not require deemed newborns to provide or apply for a SSN until age one (1).

The Department shall not require verification of U.S. citizenship/nationality or satisfactory immigration status for deemed newborns.

A deemed newborn who is determined eligible for Medicaid shall retain eligibility from date of birth until the end of the month in which the newborn turns age one (1) regardless of changes in household income or the mother’s eligibility for Medicaid; and provided the newborn remains a resident of the District.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9507

9508 NOTICE AND FAIR HEARING RIGHTS

The Department shall provide timely and adequate notice of eligibility and enrollment determinations and the right to appeal to Medicaid applicants and beneficiaries consistent with the requirements set forth in Federal and District law and rules.

The Department shall provide timely and adequate notice to Medicaid applicants and beneficiaries in cases of intended adverse action such as an action to deny, discontinue, terminate, or change the manner or form of Medicaid services.

An adequate notice shall include:

A statement of what action(s) are intended;

The reason(s) for the intended action(s);

Specific law and regulations supporting the action, or the change in federal or District law that requires the action(s);

An explanation of an applicant or beneficiary’s right to request an administrative or fair hearing; and

The circumstances under which Medicaid is provided during the pendency of a hearing.

A timely notice shall be postmarked at least fifteen (15) calendar days before the date an action would become effective, except as permitted under Subsection 9508.5.

The Department may dispense with timely notice, but shall send adequate notice under the following circumstances:

The Department has factual information confirming the death of a beneficiary;

The Department receives a written and signed statement from a beneficiary:

Stating that Medicaid is no longer required; or

Providing information which requires termination or reduction of Medicaid and indicating, in writing, that a beneficiary understands the consequence of supplying the information;

A beneficiary has been admitted or committed to an institution, and no longer qualifies for Medicaid;

A beneficiary’s whereabouts are unknown and Department mailings, directed to the beneficiary, has been returned by the post office indicating no known forwarding address;

A beneficiary has been deemed eligible for Medicaid in another state and that fact has been established;

A change in level of medical care has been prescribed by a physician;

Presumptive eligibility granted for a specific period is terminated and the beneficiary has been informed in writing at the time of application that the eligibility automatically terminates at the end of the specified period;

The notice involves an adverse determination made with regard to the preadmission screening requirements of Section 1919(e)(7) of the Act; or

The date of action will occur in less than ten (10) days, in accordance with 42 C.F.R. Section 483.12(a)(5)(ii), which provides exceptions to the thirty (30) day notice requirements of 42 C.F.R. Section 483.12(a)(5)(i).

Under the circumstances identified in Subsection 9508.5, the Department shall issue notice no later than the effective date of action.

The Department may issue a notice no later than five (5) calendar days before the date of action if the Department has facts related to probable fraud by the beneficiary; and those facts have been verified, if possible, through secondary sources.

The Department shall automatically schedule an administrative review of an adverse action from the Department prior to the fair hearing. The scheduling of an administrative review shall not affect the individual’s right to request a fair hearing.

The Department shall grant an opportunity for a fair hearing when:

An application for Medicaid is denied;

Eligibility for Medicaid is suspended;

Eligibility for Medicaid is terminated;

An applicant or beneficiary believes the Department has taken an action which affects the receipt, termination, amount, kind, or conditions of Medicaid in error;

A beneficiary, who is a resident of a skilled nursing facility, believes the Department has wrongly determined that a transfer or discharge from the facility is required;

A beneficiary believes the Department made a wrong determination with regard to the preadmission and annual resident review requirements of Section 1919(e)(7) of the Social Security Act (the Act);

A beneficiary, who is an enrollee in a Managed Care Organization (MCO) or Pre-paid Inpatient Health Plan (PIHP), was denied coverage of or payment for medical services;

A beneficiary who is dissatisfied with the District’s determination that disenrollment from a MCO, PIHP, Pre-paid Ambulatory Health Plan, or Primary Care Case Management is appropriate; or

A Medicaid claim was denied or not acted upon with reasonable promptness pursuant to D.C. Official Code Section 4-210.02 and Subsection 9501.9.

The Department shall not be required to grant a hearing if the sole issue is a federal or District law requiring an automatic change that adversely affects some or all beneficiaries.

The Office of Administrative Hearings (OAH) may grant a hearing, or deny or dismiss a request for a hearing, in accordance with its rules under Chapter 28 of Title 1 of the DCMR.

An individual, an adult who is in the individual’s household, or an authorized representative shall submit a fair hearing request via:

Internet;

Telephone;

Mail;

In person; or

Through other commonly available electronic means.

An applicant or beneficiary seeking a fair hearing shall submit a fair hearing request no later than ninety (90) days following the date the notice of adverse action is mailed.

Where the Department provides notice as required under Subsections 9508.3 through 9508.7, and the beneficiary requests a fair hearing before the date of adverse action, the Department may not terminate or reduce services until a hearing decision is rendered unless:

It is determined at the hearing that the sole issue is one of Federal or District law or policy; and

The Department promptly informs the beneficiary in writing that Medicaid services will be terminated or reduced pending the hearing decision.

The Department shall reinstate and continue Medicaid services until a hearing decision is rendered if action was taken without timely notice, when timely notice is required by law, and the beneficiary requests a hearing within ten (10) days of the postmark of the written notice of the action.

Reinstated services shall continue until a hearing decision is reached unless, the hearing has determined that the sole issue is one of federal or District law or policy.

The Department shall reinstate and continue services until a decision is rendered after a hearing if:

Action is taken without the advance notice required under Subsections 9508.5 through 9508.7;

The beneficiary requests a hearing within ten (10) days from the date that the individual receives the notice of action. The date on which the notice is received is considered to be five (5) days after the date on the notice, unless the beneficiary shows that notice was not received within the five (5)-day period; or

The Department determines that the action resulted from other than the application of federal or District law or policy.

If a beneficiary's whereabouts are determined to be unknown, discontinued services shall be reinstated if the beneficiary’s whereabouts become known during the time the beneficiary is eligible for services.

The Department shall allow an applicant or beneficiary who requests a fair hearing decision no later than fifteen (15) days of the date that notice is mailed to decline receipt of Medicaid pending a fair hearing decision.

An appeal to the District Health Benefits Exchange Authority of a determination of eligibility for advanced payments of the premium tax credit or cost-sharing reduction shall trigger a request for a fair hearing under this section.

Fair hearings and appeals for the District Medicaid program shall be administered through the Office of Administrative Hearings in accordance with 42 C.F.R. Section 431.10(d) and 42 C.F.R. Sections 431.200 et seq., and amendments thereto, 1 DCMR Section 2970 through 1 DCMR Section 2978, and amendments thereto, and D.C. Official Code Sections 4-210.01 et seq., and amendments thereto.

This section shall apply to all eligibility determinations for Medicaid programs administered by the Department of Health Care Finance under Title XIX and Title XXI of the Act.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015); as amended by Final Rulemaking published at 69 DCR 012065 (October 7, 2022).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9508

9510 TRANSITIONAL MEDICAID

9510.1 Under Section 1925 of the Social Security Act (the Act), as amended, 42 U.S.C §§ 1396r-6, the Department of Health Care Finance (DCHF) may extend Transitional Medical Assistance (TMA) to certain families and dependent children with low-income who were: Medicaid eligible (includes retroactive eligibility) during at least three (3) of the six (6) months immediately preceding the month in which the family became ineligible.

9510.2 Twelve (12) months of full Medicaid coverage under TMA may be provided to families who no longer qualify under Section 1931 of the Act due to:

Increased earned income, or working hours, from a parent or other caretaker relative’s employment, or

The loss of a time-limited earned income disregard.

9510.3 TMA shall begin on the date of termination of Medicaid.

9510.99 DEFINITIONS

For the purposes of this section, the following terms shall have the meanings ascribed:

Disregard: means the amount(s) of income deducted in determining financial eligibility for Medicaid.

SOURCE: Final Rulemaking published at 62 DCR 8059 (June 5, 2015).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9510

9511 SUPPLEMENTAL SECURITY INCOME-BASED METHODOLOGY FOR CERTAIN NON-MAGI ELIGIBLITY GROUPS

9511.1 The Department shall determine financial eligibility for Medicaid using a Supplemental Security Income (SSI)-based methodology pursuant to 42 CFR Section 435.601 for the following non-modified adjusted gross income (non-MAGI) eligibility groups:

Individuals who are aged sixty-five (65) years or older, blind, or disabled (ABD); Individuals enrolled in the Qualified Medicare Beneficiary (QMB) program; Individuals enrolled in the QMB Plus program; Individuals with long-term medical needs; Individuals receiving Medicaid through the Katie Beckett eligibility group; and Individuals, described in Subsection 9500.15, who are medically needy. 9511.2 In order to receive Medicaid benefits, applicants and beneficiaries of the following non-MAGI eligibility groups set forth under Subsection 9511.1 shall be required to have the following income levels:

For ABD -income at or below one hundred percent (100%) of the federal poverty level (FPL); For the QMB program - income at or below one hundred percent (100%of the FPL. For applicants and beneficiaries that have income up to three hundred percent (300%) of the FPL, the Department shall disregard income in excess of one hundred percent (100%) of the FPL; For the QMB Plus program –income at or below one hundred percent (100%) of the FPL, and shall be entitled to full Medicaid coverage and benefits under the QMB program; For Long-term care - income at or below three hundred percent (300%) of the SSI Federal Benefit Rate (FBR); For the Katie Beckett eligibility group - income at or below three hundred percent (300%) of the SSI FBR; and For the Medically Needy – a medically needy (MN) spend-down process, in which the Department shall deduct the amount of medical expenses incurred by the individual or family or financially responsible relatives that are not subject to payment by a third party from countable income. The District shall disregard countable earned and unearned income in an amount equal to the difference between fifty percent (50%) of the FPL, and the District's medically needy income limit (MNIL) for a family of the same size, except the disregard for a family of one (1) will be equal to ninety-five percent (95%) of the disregard for a family of two (2). 9511.3 The SSI-based income methodology shall use monthly gross countable income to determine financial eligibility for Medicaid, which shall be calculated in accordance with Subsection 9511.11. The methodology under Subsection 9511.11 shall incorporate the following:

Countable earned income as set forth under Subsection 9511.4;

Countable unearned income as set forth under Subsection 9511.5;

Exclusions of gross countable income as set forth under Subsection 9511.6;

Deeming of income calculations as set forth under Subsection 9511.7; and

General income deductions and exclusions as set forth under Subsection 9511.10.

9511.4 An individual’s countable earned income shall include:

Wages, salaries, tips, overtime, and bonuses;

Net income from a business or self-employment;

Payments for services performed in a sheltered workshop or work activities center;

Royalties earned by an individual in connection with any publication of his or her work and any honoraria received for services rendered; and

Any other earnings from a job or work in which the individual receives payment.

9511.5 An individual’s countable unearned income shall be defined as all other income which does not coincide with income delineated under Subsection 9511.4 and which is not excluded under 20 C.F.R. § 416.1124, and shall include but not be limited to:

Social Security benefits;

Interest, dividends, and other income from investments;

(d) Department of Veterans Affairs benefits;

(e) Railroad retirement and civil service retirement benefits;

(f) Annuities and pensions from government or private sources;

(g) Workers’ compensation, unemployment insurance benefits, and black lung benefits;

(h) Prizes, settlements, and awards, including court-ordered awards;

(i) Proceeds of life insurance policies;

(j) Gifts and contributions;

(k) Child support and alimony payments;

(l) Inheritances in cash or property;

(m) Rental income; and

(n) Strike pay and other benefits from unions.

9511.6 An individual’s gross countable income shall exclude the following income or payments:

Children’s earnings (earnings from an unmarried child who is living with a person who provides care or supervision, or earnings from a child who is a student in college or vocational training);

Adoption subsidy;

AmeriCorps/VISTA income received under the National and Community Service Trust Act of 1993, effective September 21, 1993 (107 Stat. 787; 12 U.S.C. §§ 12501 et seq.), as amended by the Serve America Act of 2009, effective April 21, 2009 (123 Stat. 1463; 42 U.S.C. §§ 12501 et seq.);

Child nutrition payments;

Payments received under the Domestic Volunteer Service Act of 1973, effective October 1, 1973 (87 Stat. 396; 42 U.S.C. §§ 4950 et seq.), as amended by the Domestic Volunteer Service Act Amendments of 1984, effective May 21, 1984 (98 Stat. 189; 42 U.S.C. §§ 4951 et seq.), as amended by the National and Community Service Trust Act of 1993, effective September 21, 1993 (107 Stat. 899; 12 U.S.C. §§ 12501 et seq.), as amended by the Serve America Act of 2009, effective April 21, 2009 (123 Stat. 1581; 42 U.S.C. §§ 12501 et seq.);

Earned income tax credits;

Educational benefits (for example, Department of Education (DOE) Bureau of Indian Affairs Benefits, DOE Title IV Benefits, DOE Perkins Vocational and Applied Technology Education Act, DOE work study wages, and other any education benefits work study);

Energy assistance payments;

Foster care payments;

Housing assistance provided by the federal or District of Columbia government or non-profit organizations;

Incentive payments for prenatal and well-baby care, and from the work incentive programs for current or former recipients of Temporary Assistance for Needy Families (TANF) under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, effective August 22, 1996 (110 Stat. 2105; 42 U.S.C. §§ 1305 et seq.);

Non-cash benefits in the form of a voucher, commodity, or service;

Jury duty payments;

Money received by a third party for an applicant, beneficiary, or community spouse, unless an applicant, beneficiary, or community spouse has or will have access to the funds;

Money received by an applicant, beneficiary, or community spouse, on behalf of any third party;

Nutrition payments;

Rehabilitation Service Administration (RSA) payments received under the Rehabilitation Act of 1973, effective September 26, 1973 (87 Stat. 355; 29 U.S.C. §§ 701 et seq.);

Reimbursements received from an individual or organization to cover past, current, or future expenses, if all the following conditions are met:

(1) The reimbursement is for actual expenses;

(2) The reimbursement is earmarked to cover those expenses; and

(3) The reimbursement is paid or documented separately from any other payment such as wages;

Payments received from roommates to cover their share of household expenses such as rent and utilities and which are paid by the applicant or beneficiary to the landlord or utility company;

Senior Community Service Employment Program (SCSEP) income received under the Older Americans Act of 1965, approved July 14, 1965 (79 Stat. 218; 42 U.S.C. §§ 3001 et seq.), as amended by the Older Americans Act Amendments of 2000, approved November 13, 2000 (114 Stat. 2226; 42 U.S.C. §§ 3001 et seq.), as amended by the Older Americans Act Amendments of 2006, approved October 17, 2006 (120 Stat. 2522; 42 U.S.C. §§ 3001 et seq.);

TANF underpayments received;

Training income, such as training expense allowances and stipends;

Utility allowances received through a federal or District government housing assistance program; and

Other uncommon unearned income exclusions required under federal statute.

9511.7 With the exception of individuals with long-term medical needs and Katie Beckett eligibility group applicants and beneficiaries, the following deeming of countable earned and unearned income shall apply to the individual pursuant to Section 1614(f) of the Social Security Act (42 U.S.C. § 1382c(f)):

For an individual with a spouse who is ineligible for SSI benefits and is living with the individual, the income of an ineligible spouse shall be deemed to the individual and counted towards the individual’s gross countable income;

For a child under the age of eighteen (18) that lives with a parent(s), the income of the parent(s) is deemed to the child and counted towards the child’s gross countable income, unless deeming is determined to be inequitable pursuant to the circumstances described in Section 1614(f)(2)(B) of the Social Security Act (42 U.S.C. § 1382c(f)(2)(B)); and

For an individual who is an alien that meets citizenship requirements described under Subsection 9503.2, the individual’s income and resources shall be deemed to include the income and resources of the individual’s sponsor and the sponsor’s spouse.

9511.8 The Department shall only consider the income and assets of the child applying for or currently receiving Medicaid through the Katie Beckett eligibility group in calculating income under Subsection 9511.3. The parents’ income and resources shall not be deemed to be income and assets of the Katie Beckett eligibility group applicant or beneficiary.

9511.9 The Department shall determine the income and resources of individuals with long-term medical needs applying for or currently receiving Medicaid pursuant to Chapter 98 (Financial Eligibility for Long Term Care Services) of Title 29 DCMR.

9511.10 General income deductions and exclusions may apply as follows:

Individuals with unearned income may deduct up to twenty dollars ($20) as an unearned income deduction from their gross countable unearned income. If an individual has less than twenty dollars ($20) of unearned income in a month and also has earned income in that month, the remainder of the twenty dollar ($20) exclusion shall reduce the amount of the earned income;

An individual with earned income may deduct up to sixty-five dollars ($65) as an earned income deduction from their gross countable earned income;

One half of the remaining earned income in a month may be deducted; and

Exclusions from general earned income may include:

Earned income tax credit payments (effective January 1, 1991) and child tax credit payments;

Up to thirty dollars ($30) of earned income or sixty dollars ($60) of unearned income in a calendar quarter if it is infrequent or irregular;

Earned income of blind or disabled student children up to the student earned income exclusion (SEIE) monthly limit, but not more than the SEIE yearly limit as determined by the U.S. Social Security Administration;

Earned income of disabled individuals used to pay impairment-related work expenses;

Earned income of blind individuals used to meet work expenses; and

Any earned income used to fulfill an approved plan to achieve self-support (PASS).

9511.11 When applying SSI-based methodology to determine financial eligibility for Medicaid, an individual’s countable income shall be calculated as follows:

All countable unearned income sources, as determined under Subsection 9511.5, shall be added to deemed income, if any, as determined under Subsection 9511.7;

If the individual has up to twenty dollars ($20) of an unearned income deduction as determined under Subsection 9511.10(a), the amount of unearned income (up to twenty dollars ($20)) shall be deducted from the amount derived under paragraph (a) of this subsection. This derived amount shall be the net unearned income;

The individual’s countable gross earned income, as determined under Subsection 9511.4, shall be added to deemed income, if applicable, as determined under Subsection 9511.7;

If the household has earned income, the earned income deduction, if applicable as determined under Subsection 9511.10(b), shall be deducted from the amount calculated in paragraph (c) of this subsection. If a portion of the unearned income deduction was unused because the unearned income was less than twenty dollars ($20), as determined under Subsection 9511.10(a), the remaining amount shall be subtracted from paragraph (c) of this subsection;

Sixty-five dollars ($65) shall be deducted from the amount derived from paragraph (d) of this subsection. If paragraph (d) of this subsection is not applicable as determined under Subsection 9511.10(b), then sixty-five dollars ($65) shall be deducted from the amount derived in paragraph (c) of this subsection;

One half of the remaining earned income, as described under Subsection 9511.10(c), shall be deducted from the amount determined under paragraph (e) of this subsection. The exclusions to general earned income, delineated under Subsection 9511.10(d), shall then be applied. This amount shall be the net earned income; and

The household's total net unearned income derived in paragraph (b) of this Subsection shall be added to the total net earned income derived under paragraph (f) to determine the household's total gross income. This amount shall be the non-MAGI countable income.

9511.12 Each applicant described under Subsection 9511.1 shall report at the time of application all earned and unearned income, as described in this section, to the Department, including any income that the applicant receives periodically (less frequently than once a month) or anticipates receiving prior to the time of renewal. Each current Medicaid beneficiary described under Subsection 9511.1 shall continually report any new or significant changes of earned or unearned income to the Department.

9511.13 Recipients of SSI and state supplemental payments (SSP) are categorically eligible for Medicaid. The income of recipients of SSI and state supplemental payments (SSP) shall be determined pursuant to 20 C.F.R. Part 416 and in accordance with the District’s Section 1634 of the Social Security Act Agreement with the federal Social Security Administration (SSA). The methodology set forth in this section shall not be applied when determining income of recipients of SSI and SSP.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015); as amended by Final Rulemaking published at 63 DCR 13891 (November 11, 2016); as amended by Final Rulemaking published at 67 DCR 4033 (April 10, 2020).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9511

9512 NON-MAGI ELIGIBLITY GROUP: TEFRA/KATIE BECKETT

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:

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

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 TEFRA/Katie Beckett Application Form to be completed by the applicant;

A Care Plan to be completed by the applicant and the applicant’s physician, containing the prescribed or ordered services for the child; and

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:

Be age zero (0) through eighteen (18) years old;

Have individual income at or below three hundred percent (300%) of the Supplemental Security Income (“SSI”) federal benefit rate;

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);

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;

Have a LOC that is typically provided in one of the following settings:

A hospital, as described in 42 CFR § 440.10, pursuant to the criteria set forth under Subsection 9512.6;

An intermediate care facility, as described in 42 CFR § 440. 150, pursuant to the criteria set forth under Subsection 9512.7; or

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;

Be able to safely live at home;

Not otherwise be eligible for Medicaid;

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

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:

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;

The professional services needed are something other than intermediate care facility and nursing facility services, under Subsections 9512.7 and 9512.9, respectively;

The child’s condition is such that it requires treatment which is ordinarily furnished in an inpatient setting;

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 §§ 3-1201 et 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;

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

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:

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:

Mobility deficits;

Sensory deficits;

Chronic health problems;

Behavior problems;

Autism;

Cerebral Palsy;

Epilepsy;

Spina Bifida; or

Prader Willi;

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;

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:

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;

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;

The child requires ongoing care, either directly or on-call, by one or more of the following, as appropriate:

A physician who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;

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;

An advanced practice registered nurse who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;

A registered nurse who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;

A psychologist who is licensed to practice psychology in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;

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;

A physical therapist who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;

An occupational therapist who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished;

A speech pathologist who is licensed in accordance with HORA or the licensing requirements of the jurisdiction in which services are furnished; or

An audiologist who is licensed in accordance with HORA or in accordance with the licensing requirements of the jurisdiction in which services are furnished;

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;

The child requires more behavior modification than is provided in a six (6) hour school day; and

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:

Self-care;

Understanding the use of language;

Learning;

Mobility;

Self-direction; and

Capacity for independent living;

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

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:

Interventions that address age-appropriate limitations;

General supervision of children whose age is such that supervision is required for all children of the same age; or

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;

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:

Overall management and evaluation of a care plan for a child who is totally dependent in all activities of daily living;

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;

Intravenous or intramuscular injections or intravenous feeding;

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;

Nasopharyngeal or tracheostomy aspiration;

Insertion and sterile irrigation or replacement of suprapubic catheters;

Application of dressings involving prescription medications and aseptic techniques;

Treatment of extensive decubitus ulcers or other widespread skin disorder;

Heat treatments as part of active treatment which requires observation by nurses;

Initial phases of a regimen involving administration of medical gases; or

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:

Administration of routine medications, eye drops, and ointments;

General maintenance care of an ostomy;

General maintenance care in connection with a plaster cast;

Routine services to maintain satisfactory functioning of indwelling bladder catheters;

Changes of dressings for non-infected postoperative or chronic conditions;

Prophylactic and pain relief for skin care, including bathing and application of creams, or treatment of minor skin problems;

Routine care of an incontinent child, including use of diapers and protective sheets;

Use of heat as a pain relief and comfort measure (e.g., whirlpool and hydrocollator);

Routine evaluation of blood gases after a regimen of oxygen therapy has been established;

Assistance in dressing, eating, and toileting;

Periodic turning and positioning of the child; or

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:

Upon initial application, the Department shall:

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);

Estimate the annual cost of the services using the established Medicaid Fee Schedule, available at HYPERLINK "http://www.dc-medicaid.com" 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;

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

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:

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;

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

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:

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;

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

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:

If a child enrolls in a managed care plan contracted with the Department, the physician 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;

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

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:

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

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:

The child requires a service that is Medicaid-reimbursable pursuant to the District’s State Plan for Medical Assistance;

The service is medically necessary based on the submitted supporting documentation; and

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:

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;

The qualified professional shall submit a separate short application for a Single Case Agreement;

The qualified professional is screened by the Department pursuant to Chapter 94 of Title 29 DCMR; and

Claims are reimbursed pursuant to the Department’s fee schedule, available at HYPERLINK "http://www.dc-medicaid.com" www.dc-medicaid.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:

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

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 completed and signed renewal form;

A new Care Plan as described in Subsection 9512.3(b);

A new LOC form with documentation as described in Subsection 9512.3(c); and

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.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015); as amended by Final Rulemaking published at 66 DCR 15228 (November 15, 2019).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9512

9513 NON-MAGI ELIGIBILITY GROUP: OPTIONAL AGED, BLIND, AND DISABLED

This section shall govern eligibility determinations pursuant to Sections 1902(a)(10)(A)(ii)(X), 1902(m)(1), 1902(a)(10)(A)(ii)(I), and 1905(a)(iv) of the Social Security Act, 42 CFR §§ 435.201(a)(1) - (3) for the optional Aged, Blind, and Disabled (ABD) eligibility group.

The Department of Health Care Finance (“Department”) may provide Medicaid reimbursement under the optional Aged, Blind, and Disabled (ABD) eligibility group to individuals who:

(a) Are aged sixty-five (65) years or older or who are determined blind or disabled in accordance with the criteria set forth under 42 USC § 1382c, by either the U.S. Social Security Administration (SSA) or by the Department of Human Services, Economic Security Administration (ESA) Medical Review Team (MRT):

(b) Have a household income at or below one hundred percent (100%) of Federal Poverty Level;

Meet the following non-financial eligibility factors in accordance with Section 9506:

(1) Are District residents pursuant to 42 CFR Section 435.403;

(2) Have Social Security Number s (SSNs) or are exempt pursuant to 42 CFR Section 435.910 and Section 9504; and

(3) Are U.S. citizens or nationals, or in satisfactory immigration status; and

Have resources at or below the Supplemental Security Income (SSI) resource levels of four thousand dollars ($4,000) for individuals or six thousand dollars ($6,000) for couples.

The Department shall determine whether an applicant meets the eligibility factors for Medicaid reimbursement under the optional ABD eligibility group based upon the submission of:

(a) A complete application for Medicaid in accordance with Section 9501 of this chapter. The date of application shall be the date that a complete application is received by the Department; and

(b) A document containing verification from the Social Security Administration (SSA) if the Department cannot verify an applicant’s blindness or disability through electronic data sources, or a completed medical review form in accordance with Subsection 9513.5, if applicable.

9513.4 If an applicant is applying for Medicaid based on age, the Department shall accept self-attestation of aged sixty-five (65) or older unless the attestation is not reasonably compatible with other available information.

9513.5 If an applicant is applying for Medicaid based on blindness or a disability and does not have a blindness or disability determination issued by the SSA, the Department shall immediately provide the applicant (by mail, in person, or other commonly available electronic means) a medical review form that must be completed by a physician to document blindness or disability and be submitted to the Department by the applicant or beneficiary to determine eligibility.

9513.6 All application and renewal materials, including the medical review form, may be submitted to the Department through the following means:

Mail;

In person; or

Other commonly available electronic means.

9513.7 Where the Department determines that an applicant is not at least aged sixty-five (65) or is not blind or disabled based on a review of the submitted medical review form and supporting medical documentation, the applicant shall be ineligible for Medicaid under the optional ABD eligibility group and the Department shall submit a notice to the applicant in accordance with Section 9508 of this chapter.

9513.8 Application timeliness standards for the Department to determine eligibility set forth under Section 9501 of this chapter shall apply.

9513.9 A beneficiary shall immediately notify the Department of any change in circumstances that directly affects the beneficiary’s eligibility to receive Medicaid under the optional ABD eligibility group.

9513.10 For continued Medicaid coverage under the optional ABD eligibility group, each beneficiary shall complete and submit (by mail, in person, or through commonly available electronic means) the following renewal documents every twelve (12) months:

Completed and signed pre-populated renewal forms, as described under Section 9501;

If the individual was determined blind or disabled initially by the MRT or no longer has a disability determination from SSA, a new medical review form that is completed by the beneficiary’s physician or verification of disability; and

Documents that may be required in order to verify financial and non-financial eligibility factors set forth under Subsection 9513.2.

9513.12 If an individual’s benefits have been terminated for failure to submit the pre-populated renewal form and necessary information, then the Department shall determine eligibility without requiring a new application if the individual subsequently submits the pre-populated renewal form and necessary information within thirty (30) days after the date of termination.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015); as amended by Final Rulemaking published at 67 DCR 4033 (April 10, 2020).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9513

9514 NON-MAGI ELIGIBILITY GROUPS: SUPPLEMENTAL SECURITY INCOME AND OPTIONAL STATE SUPPLEMENTAL PAYMENT

9514.1 This section shall govern eligibility requirements for the following:

(a) The Supplemental Security Income (SSI) eligibility group pursuant to 42 CFR § 435.120; and

(b) The Optional State Supplemental Payment (OSP) eligibility group pursuant to § 1902(a)(10)(A)(ii)(IV) of the Social Security Act (the Act) and 42 CFR § 435.232.

9514.2 Consistent with the requirements of 42 CFR § 435.120, the SSI eligibility group shall include aged, blind, and disabled individuals or couples who are receiving or are deemed to be receiving SSI by the U.S. Social Security Administration (SSA), which includes individuals who are:

Receiving SSI pending a final determination of blindness or disability;

Receiving SSI under an agreement with SSA to dispose of resources that exceed the SSI dollar limits on resources; or

(c) Receiving benefits under § 1619(a) of the Act or in § 1619(b) status (blind individuals or those with disabling impairments whose income equals or exceeds a specific Supplemental Security Income limit), and those qualified severely impaired individuals defined in § 1905(q) of the Act.

9514.3 Aged, blind, and disabled shall have the same meanings as set forth under § 1614 of the Act.

9514.4 In order to be eligible for Medicaid under the OSP eligibility group, individuals and couples shall meet the following requirements:

Be deemed eligible for SSI by SSA or meet SSI disability standards set forth by SSA, consistent with 20 CFR §§ 416.2101 through 416.2176; and

Reside in an adult foster care setting, as described in 20 CFR § 416.1143(a)(1), that is located in the District of Columbia.

9514.5 SSA shall be responsible for conducting renewals and redeterminations in accordance with SSA’s requirements for beneficiaries’ continued receipt of SSI and OSP payments from SSA. The Department shall continue to deem beneficiaries with continued eligibility for SSI and OSP payments eligible for Medicaid.

9514.6 The Department shall make eligibility for Medicaid for SSI and OSP applicants effective no later than the third month before the month of application if the following requirements are met:

(a) The applicant received Medicaid services, at any time during that period, of a type covered under the District of Columbia’s Medicaid State Plan; and

(b) The applicant would have been eligible for Medicaid at the time the applicant received the services if the applicant had applied (or someone had applied for the applicant), regardless of whether the individual is alive when application for Medicaid is made.

9514.7 The earliest possible date for retroactive eligibility shall be the first day of the third month preceding the month of application.

9514.8 Eligibility for Medicaid shall include meeting all financial, non-financial, and medical factors (as applicable).

SOURCE: Final Rulemaking published at 65 DCR 6841 (June 22, 2018).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9514

9515 MEDICALLY NEEDY

9515.1 This section establishes the conditions of medically needy eligibility for individuals, identified in Subsection 9515.3, who have income in excess of District Medicaid or Medicaid Waiver standards at the time of application, renewal, or redetermination.

9515.2 The medically needy eligibility category shall be subject to the spend down provisions of Section 9516 and all other requirements applicable to District of Columbia Medicaid or Medicaid Waiver programs, including but not limited to, application requirements set forth under Section 9501, and Chapters 19 and 42 (as applicable) of Title 29 DCMR, and DHCF policy.

9515.3 The following Modified Adjusted Gross Income (MAGI) eligibility coverage groups may be eligible for District Medicaid under this Section:

Parents and caretaker relatives with household income above the amount determined in accordance with Subsection 9506.2;

Individuals under age nineteen (19) with household income above the amount determined in accordance with Subsection 9506.6;

Individuals aged nineteen (19) or twenty (20) with household income above the amount determined in accordance with Subsection 9506.7; and

Pregnant women with household income above the amount determined in accordance with Subsection 9506.3.

9515.4 Individuals that are sixty-five (65) or older, blind or disabled with household income above the amounts determined in accordance with Section 9511 of this chapter and have resources at or below four thousand dollars ($4,000) for an individual and six thousand dollars ($6,000) for a couple may be eligible for District Medicaid under this section. This eligibility coverage group includes individuals applying for or receiving long-term services and supports.

9515.5 MAGI and non-MAGI eligibility coverage groups identified at Subsections 9515.3 and 9515.4 shall meet the following non-financial eligibility criteria, where applicable, as a condition of medically needy Medicaid or Medicaid Waiver eligibility:

Non-financial categorial requirements as identified at Subsection 9506.9, which are as follows:

District residency pursuant to 42 CFR § 435.403;

Provision of a Social Security Number (SSN) or proof of exemption pursuant to 42 CFR § 435.910 and Subsection 9504.7; and

U.S. citizenship or nationality, or satisfactory immigration status;

Non-financial technical requirements for long-term care services, waiver services, or to establish medical or functional level of need as follows:

Federal requirements set forth under 42 USC § 1382c for individuals that are aged sixty-five (65) or older, blind, or disabled;

Non-financial requirements set forth under Chapter 19 for individuals applying for services under the Home and Community Based Services (HCBS) Waiver for Individuals with Intellectual and Developmental Disabilities (ID/DD);

Non-financial requirements set forth under Section 989 for individuals applying for services in nursing facilities;

Non-financial requirements set forth under Chapter 41 for individuals applying for services in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID); and

Non-financial requirements set forth under Chapter 42 for individuals applying for services under the HCBS Waiver for Persons Who Are Elderly and Individuals with Physical Disabilities (EPD).

9515.6 When applying for Medicaid, applicants shall comply with the application requirements set forth under Section 9501 of this chapter, and individuals applying for or enrolled in the HCBS Waiver programs under Subsection 9515.4 shall also comply with the application requirements set forth under Chapters 19 and 42 (as applicable for the HCBS Waivers for ID/DD and EPD, respectively) of Title 29 DCMR, and DHCF policy.

9515.7 After the Department determines that an individual meets all non-financial and medical or functional (if applicable) eligibility factors as described in this section but is over the applicable income limit, the individual may become eligible for medically needy Medicaid through the spend down process, pursuant to the requirements set forth under Section 9516.

SOURCE: Final Rulemaking published at 69 DCR 012069 (October 7, 2022).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9515

9516 SPEND DOWN FOR MEDICALLY NEEDY COVERAGE

9516.1 This section establishes the calculation of spend down and eligibility determination process for medically needy individuals who have income above the income limit for their respective eligibility coverage group, pursuant to the requirements set forth under 42 CFR § 435.831.

9516.2 The spend down process shall not apply to individuals that have resources above the resource limit for their respective eligibility coverage group.

9516.3 Individuals in eligibility groups described in Subsections 9515.3 through 9515.4 with household incomes that exceed the income limit but otherwise meet the eligibility requirements for their coverage group shall submit qualifying incurred medical and remedial expenses in order to qualify for medically needy coverage through spend down. The individual shall submit expenses that may be used as follows:

To fulfill the individual’s spend down obligation during a retroactive budget period or prospective budget period, as described in Subsections 9516.8 and 9516.13; or

To be carried forward to fulfill a spend down obligation in a future budget period if any unpaid amount submitted for a previous budget period was unused, subject to the requirements set forth under Subsections 9516.15.

9516.4 The Department shall use budget periods in accordance with Subsection 9516.6 to compute the spend down obligation that an individual must meet in order to be eligible for medically needy Medicaid through spend down. Except for computing the spend down obligation(s) for retroactive medically needy Medicaid coverage as described in Subsections 9516.5 and 9516.8, the initial budget period begins on the first day of the first month an individual applies for Medicaid.

9516.5 An individual may request a separate budget period for retroactive medically needy coverage through spend down for up to three (3) calendar months immediately before the month of application, subject to the requirements set forth under Subsection 9516.8.

9516.6 The Department shall use the following budget periods for individuals who have been determined eligible for medically needy coverage through spend down:

(a) For eligibility groups described in Subsections 9515.3 and 9515.4 who are not applying for or receiving long term care services and supports, the Department shall use a one (1) month period to budget the individual’s spend down obligation; and

(b) For the eligibility groups described in Subsection 9515.4 who are applying for or receiving long term care services and supports, the Department shall use a six (6) month period to budget the individual’s spend down obligation.

9516.7 The Department shall use the following process to calculate the spend down obligation for medically needy coverage for an individual who meets one (1) of the eligibility groups under Subsections 9515.3 and 9515.4:

Determine countable income by subtracting allowable deductions from the applicant’s or beneficiary’s gross income, as appropriate, as follows:

For eligibility groups under Subsection 9515.3, subtract allowable deductions in accordance with Section 9506 of this chapter and 42 CFR § 435.831(b)(1)(ii); and

For eligibility groups under Subsection 9515.4, subtract allowable deductions in accordance with the requirements set forth in Section 9511 of this chapter and 42 CFR § 435.831(b)(2); or

Determine the dollar amount of the medically needy income limit (MNIL), as described in Supplement 8a to Attachment 2.6-A, page 2 of the Medicaid State Plan (also found at: HYPERLINK "https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DHCFStatePlanAttach2-6aSup8a.pdf" https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DHCFStatePlanAttach2-6aSup8a.pdf), that applies to the applicant’s or beneficiary’s household size for each month of the budget period as follows:

(1) The MNIL for a household of two (2) or more individuals shall be fifty percent (50%) of the annual Federal Poverty Level (FPL); and

(2) The MNIL for a household of one (1) shall be ninety five percent (95%) of the MNIL for a household of two (2).;

Verify that the applicant’s or beneficiary’s countable income, as determined under Section 9516.7(a), exceeds the Medically Needy Income Level (MNIL) in accordance with the methodology described in 42 C.F.R. §§ 435.831(b)(1)(ii) or (b)(2);

Calculate the applicant’s or beneficiary’s spend down obligation as follows:

For individuals using a one (1) month budget period:

Countable income – MNIL = Individual’s spend down obligation for the one (1) month budget period; and

For individuals using a six (6) month budget period:

(Countable income – MNIL) × 6 = Individual’s spend down obligation for the six (6) month budget period; and

Use documentation of qualifying medical or remedial expenses to determine whether the documented expenses meet the conditions of a qualifying medical or remedial expense pursuant to the requirements set forth in Subsections 9516.10 and 9516.12.

9516.8 If an individual requests retroactive Medicaid coverage pursuant to Subsection 9516.5, the Department shall calculate the retroactive budget period, which shall be considered separately from the prospective budget period, as follows:

(a) Determine the individual’s countable income, consistent with the process described in Subsection 9516.7(a). The Department shall only consider the income available to the individual in the month(s) that the individual requests retroactive coverage;

(b) Determine the individual’s MNIL using the process described in Subsection 9516.7(b). The Department shall base the MNIL on the month(s) requested for retroactive coverage;

(c) Verify that the applicant’s or beneficiary’s countable income exceeds the MNIL in accordance with the methodology described in 42 CFR §§ 435.831(b)(1)(ii) or (b)(2);

(d) If the requested months of retroactive coverage are consecutive, the individual shall have a choice to either:

Consider each month of retroactive coverage separately to determine a spend down amount for each month using the calculation described in Subsection 9516.7(d)(1); or

Combine the excess income for each month to obtain one (1) spend down amount for the retroactive period using the calculation described in Subsection 9516.7(d)(1). For example, if an individual requests retroactive coverage for two (2) consecutive months and chooses to combine the excess income for each month, the calculation shall be as follows:

(Countable income for month one (1) – MNIL) + (countable income for month two (2) – MNIL) = Individual’s spend down obligation for the two (2) month retroactive period;

(e) If the requested months of retroactive coverage are not consecutive, consider each month separately and determine a spend down amount for each month using the calculation described in Subsection 9516.7(d)(1); and

(f) The individual shall have a choice to apply a specific qualifying incurred medical or remedial expense towards a spend down amount for a retroactive budget period, prospective budget period, or both, as long as the expense meets the requirement in Subsection 9516.10(d).

9516.9 The Department shall deduct the following types of qualifying incurred medical or remedial expenses that meet the requirements of Subsections 9516.10 and 9516.12, once the spend down amount is determined:

(a) Medicare and other health insurance deductibles, coinsurance charges, enrollment fees, copayments and premiums;

(b) Medical or remedial expenses for necessary medical or remedial services not included in the Medicaid State Plan or HCBS Waivers;

(c) Medical or remedial expenses for necessary medical or remedial services included in the Medicaid State Plan or HCBS Waivers, which exceed the Department’s limitations on amount, duration, or scope of services, as described in Section 3 of the District’s Medicaid State Plan, Appendix C of the HCBS Waivers, and corresponding rules; and

(d) Medical or remedial expenses for necessary medical or remedial services included in the Medicaid State Plan or HCBS Waivers which are within the Department’s limitations on amount, duration, or scope of services, as described in Section 3 of the District’s Medicaid State Plan, Appendix C of the HCBS Waivers, and corresponding rules.

9516.10 To be determined a qualifying incurred medical expense, an expense shall meet the following requirements:

Be a necessary cost incurred by an individual for medical goods or services that meets one (1) of the types of expenses outlined in Subsections 9516.9(a)-(d), and may include, the following types of medical goods and services:

Inpatient hospital services;

Outpatient hospital services;

Laboratory and x-ray services;

Nursing facility services;

Physician services;

Clinic services;

Dental services;

Rehabilitation services;

Durable Medical Equipment (DME); and

Home health services;

Be an incurred expense for which the individual, the individual’s family, or the individual’s financially responsible relatives, as described in 42 CFR § 436.602, is financially liable;

Not be subject to payment by a third party unless the third party is a State or territory’s public program financed by the State or territory, other than the Medicaid program;

Not already be used to meet a spend down obligation for a previous budget period, unless an unused and unpaid portion of an expense is being carried forward consistent with Subsection 9516.3(b); and

Be verified by a prescription, referral, bill, receipt, or written statement regarding the goods or services provided, or through other means of documentation required in DHCF policy.

9516.11 Only applicants and beneficiaries of institutional services described in Subsection 9515.4(a) may use medical institutional expenses (other than expenses in acute care facilities) projected to the end of the budget period at the Medicaid reimbursement rate to meet their spend down obligation, subject to the following conditions:

Only medical expenses that are not subject to payment by a third party may be counted;

Medical expenses shall include expenses that the individual or family or financially responsible relatives, as described in 42 CFR § 436.602, are projected to incur within the six (6) month budget period;

Only medical expenses related to institutional care may be projected; and

Projected medical institutional expenses applied towards an individual’s spend down obligation shall be subject to the six (6) month periodic reconciliation of expenses to determine whether spend down was met in accordance with 42 CFR § 435.831(i)(2).

9516.12 To be determined a qualifying incurred remedial expense, an expense shall meet the following requirements:

Be a nonmedical support service cost, that does not pertain, relate, or belong to the study and practice of medicine, or the science and art of the investigation, prevention, cure, and alleviation of disease;

Be a cost that is made necessary by the individual’s medical or functional condition and that is directly related to the individual’s medical or functional care;

Be a necessary cost for a good or service, consistent with the descriptions in subparagraphs (a)-(b) of this subsection, that meets one (1) of the types of expenses outlined in Subsections 9516.9(a)-(d), and may include, but not be limited to:

(1) Travel costs incurred in order to obtain medical services or supplies; and

(2) Home or vehicle modifications that provide a direct medical or functional benefit and is necessary due to the individual’s medical or functional condition;

Be an incurred expense for which the individual, the individual’s family, or the individual’s financially responsible relatives, as described in 42 CFR § 436.602, is financially liable;

Not be subject to payment by a third party unless the third party is a State or territory’s public program financed by the State or territory, other than the Medicaid program;

Not have been used to meet a spend down obligation for a previous budget period, unless Subsection 9516.3(b) applies; and

Be verified by a prescription, referral, bill, receipt, or written statement regarding the goods or services provided, or through other means documented in DHCF policy.

9516.13 Pursuant to 42 CFR § 435.831(f), the Department shall deduct incurred medical and remedial expenses that have not been previously applied in establishing eligibility, based on age of bills as follows:

For the retroactive budget period, paid or unpaid expenses incurred during such period;

For the first prospective budget period that also includes any of the three (3) preceding months, paid or unpaid expenses incurred during such period;

(c) For the first prospective budget period that does not include any of the months preceding the month of application, paid or unpaid expenses incurred during such budget period and any of the three (3) preceding months;

(d) For any of the three (3) months preceding the month of application that are not includable under Subparagraph (b) of this subsection, expenses incurred in the three (3) month period that were a current liability of the individual in any such month for which a spend down calculation is made;

(e) Current payments made in the current budget period on other expenses incurred before the beginning of the budget period; and

(f) If the individual's eligibility for medical assistance was established in each such preceding period, expenses incurred before the current budget period, to the extent that such expenses are unpaid and are:

(1) Described in Subsection 9516.9; and

(2) Carried over from the preceding budget period or periods because the individual had a spend down obligation in each such preceding period that was met without deducting all such incurred, unpaid expenses.

9516.14 Pursuant to 42 CFR § 435.831(h)(2), the Department shall deduct incurred medical and remedial expenses in chronological order by the date each service is furnished, or in the case of insurance premiums, coinsurance or deductible charges, the date such amounts are due. Expenses for services furnished on the same day shall be deducted in the following order:

(a) Medical or remedial care expenses for necessary medical or remedial care not included in the Medicaid State Plan;

(b) Medical or remedial care expenses for necessary medical or remedial care included in the Medicaid State Plan, which exceed the Department’s limitations on amount, duration, or scope of services; and

(c) Medical or remedial care expenses for necessary medical or remedial care included in the Medicaid State Plan, which are within the Department’s limitations on amount, duration, or scope of services.

9516.15 The Department shall not apply medical and remedial expenses towards an individual’s initial spend down obligation if the expenses were incurred more than three (3) months before the month of application, subject to Subsection 9516.13(e).

9516.16 Once the applicant has submitted medical and remedial expenses to the Department to meet the spend down obligation and has met all other Medicaid eligibility factors, as appropriate, the Department shall make an eligibility determination and provide notice in accordance with Subsection 9516.24.

9516.17 For individuals described in Subsections 9515.3 and 9515.4, the Department shall determine the start of the eligibility period as follows:

(a) If the individual’s spend down obligation is met on a date within the budget period, eligibility shall begin on the date the spend down obligation is met (which shall be the latest date of service of an expense submitted and approved to meet the spend down obligation for that budget period) and end on the last day of the individual’s budget period, unless Subsection 9516.18 applies; and

(b) If the individual’s spend down obligation is met using only expenses for services received on a date prior to the budget period, eligibility shall begin on the first day of the first month of the budget period and end on the last day of the individual’s budget period.

9516.18 For individuals who are required to contribute a portion of income towards the costs of institutional care or HCBS Waiver services pursuant to the requirements set forth under Section 9804 of Title 29 of the District of Columbia Municipal Regulations, the eligibility start date shall be the first day of the budget period if:

The individual’s spend down obligation is met after the first day of the budget period; and

Beginning eligibility after the first day of the budget period makes the individual’s share of health care expenses under the post eligibility treatment of income rules, as determined under Section 9804 of Title 29 DCMR, greater than the individual has in contributable income.

9516.19 Pursuant to 42 CFR § 435.831(i)(5), expenses used to meet a spend down obligation shall not be reimbursed under Medicaid.

9516.20 In order to obtain Medicaid reimbursement for any remaining portion of an expense that was not used to meet a previous spend down, the expense shall meet the applicable requirements set forth under the District’s Medicaid State Plan and applicable laws and regulations.

9516.21 For beneficiaries using a six (6) month budget period, if the individual meets his or her spend down obligation for the first budget period and becomes eligible for medically needy Medicaid, the following shall occur:

The Department shall automatically determine that the beneficiary is eligible to qualify for medically needy Medicaid by meeting spend down in accordance with Subsection 9516.7 for a second six (6) month budget period;

The Department shall send a notice that otherwise complies with Section 9508 to the beneficiary sixty (60) days in advance of the end of the first budget period to inform the beneficiary that the beneficiary’s medically needy Medicaid eligibility will expire at the end of the current budget period, and the individual must inform the Department of any changes in circumstances that would affect his or her Medicaid eligibility. The Department may also include additional information in the notice as follows:

(1) The beginning and ending dates of his or her next budget period;

The amount of his or her spend down obligation for the next budget period; and

(3) Notice that the individual must submit sufficient qualifying incurred medical and remedial expenses to meet spend down for the next budget period before he or she will regain medically needy Medicaid eligibility.

9516.22 Upon renewal, the Department shall calculate an individual’s six (6) month spend down obligation in accordance with the methodology described in Subsection 9516.7, and shall take into account any submitted but unused expenses that can be carried over from a previous budget period, if applicable.

9516.23 For continued medically needy Medicaid coverage through spend down, the following shall occur:

For beneficiaries with a six (6) month budget period:

(1) The Department shall send the beneficiary a notice consistent with Subsection 9516.21(b); and

(2) The Department shall send the beneficiary a renewal form for the beneficiary’s completion no later than ninety (90) days prior to the end of the beneficiary’s twelfth (12th) month of Medicaid eligibility, as long as the beneficiary has met his or her spend down obligation for both six (6) month budget periods; and

For beneficiaries with a one (1) month budget period, the beneficiary shall continue to meet his or her spend down obligation for each budget period. By the twelfth (12th) month following the first prospective budget period, the beneficiary shall submit a new application to the Department, consistent with Subsection 9515.7, in order for the Department to re-determine the beneficiary’s Medicaid eligibility.

9516.24 The Department shall provide timely and adequate notice of eligibility and enrollment determinations and the right to appeal to applicants and beneficiaries consistent with the requirements set forth in Section 9508, 42 CFR § 435.917 and other applicable rules.

9516.25 The Department may include additional information in the notice described in Subsection 9516.24 that is not required under federal or District law, which may include but is not limited to the following:

(a) The beginning and end dates of the individual’s budget period, as described in Subsection 9516.6;

(b) The beginning and end dates of the individual’s eligibility period, which shall be the time period during which spend down has been met (consistent with the requirements set forth under Subsection 9516.17) and the individual is fully eligible for Medicaid;

The individual’s spend down obligation, as determined in accordance with Subsection 9516.7, for the individual’s corresponding budget period;

(d) Instructions for submitting documentation of expenses consistent with the requirements set forth under Subsections 9516.10(e) and 9516.12(g);

Instructions that the individual may submit documentation for a twelve (12) month period;

The total amount of the acceptable qualifying incurred medical and remedial expenses that the individual has already submitted, if any;

Description of expenses that were submitted but are not acceptable towards the individual’s spend down obligation;

An explanation of why any documentation was not acceptable pursuant to the requirements of Subsections 9516.10 and 9516.12, if applicable;

The remaining amount of incurred medical and remedial expenses that is required to meet the individual’s spend down obligation; and

The amount of unpaid expenses that may be carried over towards the next budget period.

SOURCE: Final Rulemaking published at 69 DCR 012069 (October 7, 2022).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9516

9599 DEFINITIONS

For the purposes of this chapter, the following terms shall have the meanings ascribed:

Active treatment - A continuous program, which includes consistent implementation of training, therapies, health and related services designed to address the child's social, intellectual, and behavioral deficits and, further, that are directed toward the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible.

Activities of Daily Living - Activities including eating, bathing, toileting, grooming, dressing, undressing, mobility, and in place transfers.

Acuity level - The intensity of services required for an applicant or beneficiary. An applicant or beneficiary with a high acuity level requires more care those with lower acuity levels require less care.

Alien - An individual who is not a Citizen or National of the United States pursuant to 8 U.S.C.A. § 1641 and § 101(a) of the Immigration and Nationality Act, 8 U.S.C.A. § 1101(a).

AmeriCorps/VISTA income - income given to volunteers in the Volunteers in Service to America (VISTA) program.

Applicant - An individual who is seeking an eligibility determination for Medicaid through an application submission or a transfer from another insurance affordability program.

Application - The single streamlined form that is used by the District of Columbia in accordance with 42 C.F.R. § 435.907(b) or an application described in § 435.907(c)(2) of this chapter submitted on behalf of an individual.

Authorized Representative - Legally authorized individual or entity able to consent on behalf of a prospective applicant.

Beneficiary - An individual who has been determined eligible and is currently receiving Medicaid.

Budget Period - The timeframe over which the individual's income is calculated to determine medically needy Medicaid eligibility.

Carry Over Expense – An unpaid, incurred medical and remedial care expense that may be applied towards a spend down obligation in a future budget period(s) if it was incurred within a previous budget period (or up to three (3) months preceding the month of application) in which spenddown eligibility was established, remains the liability of the individual, and was not fully counted in any previous budget period in which eligibility was met.

Certification Period - Medicaid eligibility is determined for a twelve-month period. This period is called a certification period.

Cost Sharing - When patients pay out-of-pocket for a portion of health care costs not covered by health insurance, including but are not limited to, copays, deductibles, and coinsurance.

Custodial Parent - A court order or binding separation, divorce, or custody agreement establishing physical custody controls; or if there is no such order or agreement or in the event of a shared custody agreement, the custodial parent is the parent with whom the child spends most nights pursuant to 42 C.F.R § 435.603 (iii)(A)-(B).

Deduction - income that is subtracted from countable earned and unearned income.

Deemed income - the amount of another person’s income that is considered to belong to the applicant/recipient.

Deemed Newborn - A child under the age of one (1) who is automatically eligible for Medicaid pursuant to 42 C.F.R. § 435.117.

Deferred Action for Childhood Arrivals (DACA) - Certain individuals who were brought to the U.S. as children are as described pursuant to the Memorandum from Janet Napolitano, Secretary of Homeland Security, to David V. Aguliar, Acting Commissioner, U.S. Customs and Border Protection; Alejandro Mayorkas, Director, U.S., Citizenship and Immigration Services; John Mortan, Director, U.S. Immigration and Customs Enforcement (June 15, 2012) (on file with the U.S. Department of Homeland Security.

Department - For the purposes of this chapter, the term “the Department” shall refer to the Department of Health Care Finance (DHCF) or its designee.

Dependent Child - A natural or biological, adopted or step-child who is under the age of eighteen (18), or is age eighteen (18) and a full-time student in secondary school (or equivalent vocational or technical training).

Earned Income Tax Credit (EITC) - a federal tax credit for working individuals who have low to moderate income.

Eligibility determination - An approval or denial of eligibility in accordance with 42 C.F.R. § 435.911 as well as a renewal or termination of eligibility in accordance with 42 C.F.R. § 435.916.

Emergency medical condition - A medical condition, including emergency labor and delivery, manifesting itself by acute symptoms of sufficient severity including severe pain so that the absence of immediate medical attention could reasonably be expected to result in one of the following: (1) placing the patient's health in serious jeopardy, (2) serious impairment to bodily functions, (3) serious dysfunction of a bodily organ or part.

Exclusion - income that is not counted when determining gross countable income.

Fair Hearings - an administrative procedure that gives applicants and beneficiaries the opportunity to contest adverse decisions regarding eligibility and benefit determinations.

Family - The individuals for whom a tax filer claims a deduction for a personal exemption under § 151 of the Code for the taxable year, which may include the tax filer, the tax filer’s spouse, and dependents. 26 U.S.C. § 36B(d)(1)(2012).

Family size - The number of persons counted as members of an individual's household for purposes of MAGI Medicaid eligibility. When counting a household that includes a pregnant woman, the pregnant woman is counted as herself plus the number of children she is expected to deliver.

Federal Benefit Rate - The share of the Supplemental Security Income grant paid by the federal government, which does not include any applicable State supplement.

Federal Poverty Level (FPL) - A measure of income levels updated periodically in the Federal Register by the Secretary of Health and Human Services under the authority of 42 U.S.C. Section 9902(2), as in effect for the applicable budget period used to determine an individual's eligibility in accordance with 42 C.F.R. § 435.603(h).

Home and Community-Based Services Waiver (HCBS Waiver) Programs – Shall be consistent with the definition set forth under 42 CFR § 440.180.

Household Composition - Determined by individuals living together and their relationships to one another. The composition of the household determines an individual’s family size.

Household Income - The MAGI-based income of every individual included in an applicant or beneficiary’s household.

Incurred expense – An expense for which the individual, the individual’s family, or the individual’s financially responsible relative is currently financially liable.

Indian - Means any individual who is a member of any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688; 43 U.S.C. §§ 1601 et seq.), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.

Institution - Means Institution and Medical institution, as defined in 42 C.F.R. § 435.1010.

Lawfully Present - Aliens described at 42 C.F.R. Section 152.2 (1),(3)-(7); aliens in a valid nonimmigrant status, as defined in 8 U.S.C. § 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. § 1101(a)(17)); aliens granted an administrative stay of removal under 8 C.F.R. Section 241; aliens lawfully present in American Samoa under the immigration laws of American Samoa; and aliens who are victims of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, approved October 28, 2000 (Pub. L. 106-386, as amended; 22 U.S.C. § 7105(b)).

Limited or no-English proficiency - As defined by D.C. Official Code § 2-193 (2012 Repl.) as the inability to adequately understand or to express oneself in the spoken or written English language.

Long-term services and supports - Nursing facility services, a level of care in any institution equivalent to nursing facility services; home and community-based services furnished under a waiver or State plan under Sections 1915 or 1115 of the Act; home health services as described in § 1905(a)(7) of the Act and personal care services described in § 1905(a)(24) of the Act.

Lawful Permanent Resident (LPR) - One who was lawfully admitted for permanent residence in accordance with the immigration laws of the United States, such status not having changed since admission. A legalized alien under IRCA whose status has been adjusted from LTR to LPR by INS.

Medicaid - Means the program established under Title XIX and Title XXI of the Social Security Act, 42 U.S.C. §§ 1396 et seq. and Title 29 DCMR, Chapter 9.

Medically Needy - Individuals, as described in 42 U.S.C. § 1396a(a)(10)(A)(ii), who meet non-financial eligibility determination factors but who have incomes over the Medicaid threshold.

Medically Needy Income Level (MNIL) – Fifty percent (50%) of the Federal Poverty Level (FPL) for a household of two (2) or larger; the MNIL for a household of one (1) is ninety-five percent (95%) of that for a household of two, as described in Supplement 8a to Attachment 2.6-A, page 2 of the Medicaid State Plan (also found at: HYPERLINK "https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DHCFStatePlanAttach2-6aSup8a.pdf" https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DHCFStatePlanAttach2-6aSup8a.pdf).

Modified adjusted gross income (MAGI) - Income calculated using the financial methodologies used to determine modified adjusted gross income as defined in 26 U.S.C. § 36B(d)(2)(B) and 42 C.F.R. § 435.603.

Non-MAGI - Eligibility Groups described at 42 C.F.R. § 435.603 for which MAGI–based methods do not apply.

Nursing assistive personnel - Unlicensed personnel of assigned patient care tasks that do not require professional skill or judgment within a health care, residential, or community support setting; provided, that the patient care tasks are performed under the general supervision of a licensed health care professional.

Parent - A person who has a natural or biological, adopted, or step-child.

Pregnant woman - an individual during pregnancy and the postpartum period, which begins on the date the pregnancy ends, extends twelve (12) months, and ends on the last day of the month in which the twelve (12) month period ends.

Prospective budget period – The timeframe over which an individual’s income is calculated that does not include the retroactive months for which an individual requests retroactive Medicaid coverage.

Qualified Alien - An alien described in Section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. § 1641, as amended (PRWORA), and non-citizens required to be eligible by § 402(b) of the PRWORA, as amended, and non-citizens not prohibited by § 403 of PRWORA, as amended including qualified non-citizens subject to the five (5) year bar identified in 8 U.S.C. § 1613.

Qualified Plan - Profit-sharing, money purchase, defined benefit plans, 401K, and other retirement plans that allow a tax-favored way to save for retirement. Employers may deduct contributions made to the plan on behalf of their employees. Earnings on these contributions are generally tax free until distributed at retirement.

Renewal - Annual review to evaluate continued eligibility for Medicaid.

Retroactive budget period – The timeframe of up to three (3) months preceding the month of application for which an individual’s income is calculated.

Satisfactory Immigration Status - An immigration status which does not make the alien ineligible for benefits under the applicable program (See § 121(d)(1)(B)(i)(III)) of IRCA, 42 U.S.C.A. § 1320b-7, note).

Self-employed Simplified Employee Pension (SEP) - A written plan that allows individuals to make contributions toward their own retirement and their employees’ retirement without getting involved in a more complex qualified plan.

Sibling - Each of two or more children or offspring having one or both natural, biological, adopted, or step-parents in common.

SIMPLE - An employer sponsored retirement plan offered for small businesses that have 100 employees or less.

Single Case Agreement - An agreement between a non-enrolled Medicaid provider and the Department for Medicaid reimbursement of covered services that are furnished to an eligible D.C. Medicaid beneficiary.

Skilled Nursing- Medical and educational services that address healthcare needs related to prevention and primary healthcare activities.

Skilled Rehabilitation Services - Services delivered in an inpatient or outpatient setting that assists with retention, regaining, or improving skills and functioning for daily living that are lost or impaired due to a new medical condition, an acute exacerbation of a chronic medical condition, sickness, injury, or disability. Services that require the judgment, knowledge and skill of a qualified therapist and may include, but are not limited to, physical and occupational therapy, speech pathology, and audiology.

Spend Down – Spend down is the process by which an individual may use medical or remedial expenses to reduce countable income to the MNIL to meet financial eligibility requirements for Medicaid coverage.

Spend Down Obligation – The monthly amount of the individual’s gross countable income which is over the MNIL multiplied by the number of months in the budget period.

State - Includes any of the fifty (50) constituent political entities of the United States and the District of Columbia.

Streamlined Application for Provider Enrollment - An enrollment application available for providers whose relationship with the Medicaid program is ordering, referring, and/or prescribing services to Medicaid-eligible beneficiaries.

TANF underpayments - TANF payments to a recipient that are lower than the TANF payments the recipient is eligible to receive.

Tax dependent - Tax dependent has the same meaning as the term “dependent” under Section 152 of the Internal Revenue Code, as an individual for whom another individual claims a deduction for a personal exemption under § 151 of the Internal Revenue Code for a taxable year.

TEFRA/Katie Beckett eligibility group - An eligibility group that provides Medicaid benefits for eligible children with disabilities, who would not ordinarily qualify for Medicaid because their income would be above the Medicaid income threshold for children in the District.

U.S. National - A person who is a citizen of the U.S. or a person who, though not a citizen of the U.S., owes permanent allegiance to the U.S.

Verification plan - the plan describing the verification policies and procedures adopted by the Department in accordance with 42 C.F.R. §§ 435.940-435.965, and § 457.380.

Well-established religious objections - The applicant is a member of a recognized religious sect or division of the sect and adheres to the tenets or teachings of the sect or division and for that reason is conscientiously opposed to applying for or using a national identification number.

SOURCE: Final Rulemaking published at 62 DCR 11142 (August 14, 2015); as amended by Final Rulemaking published at 63 DCR 13891 (November 11, 2016); as amended by Final Rulemaking published at 66 DCR 15228 (November 15, 2019); as amended by Final Rulemaking published at 69 DCR 010036 (August 5, 2022); as amended by Final Rulemaking published at 69 DCR 012069 (October 7, 2022).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9599

9800 GENERAL PROVISIONS

9800.1 This chapter establishes standards governing financial eligibility determinations and post-eligibility treatment of income for long term care services and supports (LTCSS), which include health-related care and services provided in a nursing facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or in a home or community setting through a Home and Community-Based Services Waiver (HCBS Waiver) program.

9800.2 Applicants and beneficiaries shall consist of the following three (3) eligibility groups:

(a) Individuals who have been determined eligible for Social Security Income (SSI) by the U.S. Social Security Administration (SSA);

(b) Individuals who meet the income and resource requirements under the Special Income Standard (SIS), which is equal to three hundred percent (300%) of the SSI federal benefit rate (FBR); and

(c) Individuals whose gross countable income exceeds the SIS and who elect to spend their excess income down to the Medically Needy Income Level (MNIL) to become financially eligible for LTCSS.

9800.3 The Department of Health Care Finance (the Department) shall establish an applicant or beneficiary’s financial eligibility for LTCSS after evaluating the applicant’s or beneficiary’s non-financial eligibility for LTCSS.

9800.4 A determination of non-financial eligibility for LTCSS shall include consideration of the following five (5) components:

(a) District of Columbia residency, determined in accordance with Section 9502 of Title 29 DCMR;

(b) U.S. citizenship or satisfactory immigration status, determined in accordance with Section 9503 of Title 29 DCMR;

(c) Social Security number, determined in accordance with Section 9504 of Title 29 DCMR;

(d) Age (eighteen (18) years or older for all LTCSS applicants and beneficiaries, and sixty five (65) years or older for applicants and beneficiaries seeking LTCSS under the Elderly and Persons with Physical Disabilities (EPD) waiver program on the basis of advanced age); and

(e) Clinical determination that the applicant or beneficiary requires an institutional level of care.

9800.5 Determinations of financial eligibility for LTCSS shall include those determinations made at the initial application, annual renewals, and periodic redeterminations.

9800.6 A determination of financial eligibility for LTCSS shall include the following:

(a) An income test, as described at Subsection 9801.1; and

(b) A resource test, as described at Subsection 9802.1.

9800.7 In calculating gross countable income and gross countable resources, the Department shall only count the income and resources available to the applicant or the applicant’s spouse at the time of the initial eligibility determination.

9800.8 The Department shall redetermine financial eligibility for LTCSS every twelve (12) months, except for individuals referenced in Subsection 9800.2(c). Financial eligibility for these individuals shall be redetermined every six (6) months.

9800.9 A beneficiary shall immediately notify the Department of any change in circumstances that directly affects financial eligibility for LTCSS.

9800.10 The Department shall redetermine eligibility for beneficiaries identified at Subsection 9800.9 at the time the change is reported.

9800.11 After an applicant or beneficiary is determined financially eligible for LTCSS, the Department shall determine how much that individual shall contribute to the cost of care.

SOURCE: Final Rulemaking published at 63 DCR 1605 (February 12, 2016).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9800

9801 INCOME TEST

9801.1 In order to be eligible for LTCSS, an applicant or beneficiary shall have gross countable income at or below the Special Income Standard (SIS), which is equal to three hundred percent (300%) of the SSI federal benefit rate (FBR), except as identified at Subsection 9801.6.

9801.2 Individuals identified at Subsection 9800.2(a) shall be exempt from the income test in Subsection 9801.1.

9801.3 If an applicant or beneficiary has a community spouse, gross countable income shall be determined after spousal impoverishment protections for income have been applied.

9801.4 Gross countable income shall include the following:

(a) Taxable income received from employment;

(b) Income received from sources other than employment; and

(c) Income from self-employment.

9801.5 Gross countable income shall exclude the following:

(a) Earnings from an unmarried minor child who is living with an individual who provides care or supervision;

(b) Adoption subsidies;

(c) AmeriCorps/VISTA Income received under the National and Community Service Trust Act of 1993, effective September 21, 1993 (Pub.L. 103-82, 107 Stat. 787), as amended by the Serve America Act of 2009, effective April 21, 2009 (Pub.L. 111-13, 123 Stat. 1463; 42 U.S.C. §§ 12501 et seq.);

(d) Child Nutrition Payments;

(e) Payments received under the Domestic Volunteer Service Act of 1973, effective October 1, 1973 (Pub.L. 93-113, 87 Stat. 396), as amended by the Domestic Volunteer Service Act Amendments of 1984, effective May 21, 1984 (Pub.L. 98-288, 98 Stat. 189), as amended by the National and Community Service Trust Act of 1993, effective September 21, 1993 (Pub.L. 103-82, 107 Stat. 899), as amended by the Serve America Act of 2009, effective April 21, 2009 (Pub.L. No. 111-13, 123 Stat. 1581; 42 U.S.C. §§ 12501 et seq.);

(f) Earned Income Tax Credits;

(g) Educational benefits;

(h) Energy assistance;

(i) Foster care payments;

(j) Housing assistance provided by the federal or District of Columbia government or non-profit organizations;

(k) Incentive payments for Prenatal & Well-Baby Care and from the Work Incentive programs for current or former recipients of Temporary Aid to Needy Families (TANF) under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, effective August 22, 1996 (Pub. L. 104-193, 110 Stat. 2105; 42 U.S.C. §§ 1305 et seq.);

(l) Non-cash benefits in the form of voucher, commodity or service;

(m) Jury duty payments;

(n) Money received by a third party for an applicant, beneficiary, or community spouse, unless an applicant, beneficiary, or community spouse has or will have access to the funds;

(o) Money received by an applicant, beneficiary, or community spouse, on behalf of any third party;

(p) Nutrition payments;

(q) Rehabilitation Services Administration (RSA) Payments received under the Rehabilitation Act of 1973, effective September 26, 1973 (Pub.L. 93-112, 87 Stat. 355);

(r) Reimbursements received from an individual or organization to cover past, current, or future expenses, if all the following conditions are met:

(1) The reimbursement is for actual expenses;

(2) The reimbursement is earmarked to cover those expenses; and

(3) The reimbursement is paid or documented separately from any other payment such as wages;

(s) Payments received from roommates to cover their share of household expenses such as rent and utilities and which are paid by the applicant or beneficiary to the landlord or utility company;

(t) Senior Community Service Employment Program (SCSEP) Income received under the Older Americans Act of 1965, approved July 14, 1965 (Pub.L. 89-73, 79 Stat. 218), as amended by the Older Americans Act Amendments of 2000, approved November 13, 2000 (Pub.L. 106-501, 114 Stat. 2226), as amended by the Older Americans Act Amendments of 2006, approved October 17, 2006 (Pub.L. 109-365, 120 Stat. 2522);

(u) TANF underpayments;

(v) Training income, such as Training Expense Allowances/Stipends; and

(w) Utility allowances received through a federal or District government housing assistance program.

9801.6 An applicant or beneficiary who has gross countable income exceeding the SIS shall be permitted to spend down the excess income to the MNIL, in accordance with 42 C.F.R. § 435.831, to become financially eligible for LTCSS.

9801.7 The following standards shall apply in determining the income allocated to an applicant or beneficiary with a spouse:

(a) If there is no trust or other legally enforceable document establishing ownership of the income, one half (1/2) of the income shall be considered available to each spouse;

(b) If payment of income is provided for in a trust or other legally enforceable document, the income shall be considered available to each spouse in accordance with the allocation made in the document;

(c) If there is no trust or other legally enforceable document establishing ownership of the income and payment of income is made in the names of both spouses, one half (1/2) of the income shall be considered available to each spouse;

(d) If there is no trust or other legally enforceable document establishing ownership of the income and payment of income is made solely in the name of one spouse, the income shall be considered available only to that spouse; and

(e) If there is no trust or other legally enforceable document establishing ownership of the income and payment of income is made in the names of either spouse, or both, and to another individual or individuals, the income shall be considered available to each spouse in the proportion to the spouse’s interest. If payment is made to both spouses and no other interest is specified, one half (1/2) of the joint interest shall be considered available to each spouse.

9801.8 Following an initial eligibility determination, no income of a community spouse shall be considered available to a beneficiary during any month in which the beneficiary receives LTCSS.

9801.9 A community spouse shall be entitled to retain a Community Spouse Allowance.

9801.10 A Community Spouse Allowance shall equal the minimum monthly maintenance needs allowance (MMMNA) plus any excess shelter allowance.

9801.11 A community spouse may retain an amount higher than the Community Spouse Allowance if either spouse demonstrates at a fair hearing that a higher amount is necessary due to exceptional circumstances resulting in severe financial duress. Exceptional circumstances may include but are not limited to:

Recurring or extraordinary non-covered medical expenses;

Amounts to preserve, maintain, or make major repairs to a home;

Transportation costs; and

Amounts necessary to preserve an income-producing resource.

9801.12 In accordance with Section 2970 of Title 1 DCMR and 42 C.F.R. § 431.200, an applicant, beneficiary, or community spouse may request a fair hearing to address the following matters:

(a) The amount of the Community Spouse Allowance; or

(b) The amount of income determined available to the community spouse.

9801.13 At the first annual renewal following the initial eligibility determination, the District shall verify that an institutionalized spouse has made available any amount of income under a Community Spouse Allowance to the community spouse.

SOURCE: Final Rulemaking published at 63 DCR 1605 (February 12, 2016).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9801

9802 RESOURCE TEST

9802.1 In order to be eligible for LTCSS, an applicant or beneficiary shall not have gross countable resources that exceed four thousand dollars ($4,000).

9802.2 Individuals identified at Subsection 9800.2(a) shall be exempt from the resource test in Subsection 9802.1.

9802.3 If an applicant or beneficiary has a community spouse, gross countable resources shall be determined after spousal impoverishment protections for resources have been applied.

9802.4 If an applicant or beneficiary’s gross countable resources exceed four thousand dollars ($4,000), the applicant or beneficiary may reallocate excess resources to excludable resource types without affecting eligibility for LTCSS.

9802.5 Gross countable resources shall exclude the following resource types:

(a) The personal home of the applicant or beneficiary, if one (1) of the following conditions is met:

(1) The home equity interest does not exceed the maximum home equity limit set annually by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) and available at: HYPERLINK "http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Spousal-Impoverishment-Page.html" http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Spousal-Impoverishment-Page.html (last visited October 14, 2015);

(2) The community spouse of the applicant or beneficiary resides in the home; or

(3) A child of the applicant or beneficiary who is under age twenty-one (21) or has a disability resides in the home;

(b) Accounts receivable;

(c) Burial funds that are in a separate, designated account;

(d) Promissory notes, if the notes are not related to transfers of resources within the past sixty (60) months;

(e) Earned income tax credits;

(f) Energy assistance payments;

(g) Proceeds from a home sale, if the applicant or beneficiary purchases or intends to purchase a new home within the next twelve (12) months;

(h) Household and personal goods;

(i) Inaccessible resources, which the applicant or beneficiary can neither use for ongoing support nor sell;

(j) Indian lands;

(k) Jointly owned resources, if the owner is legally unable to liquidate the resources;

(l) Land contracts;

(m) Life insurance funded funerals;

(n) Resources used to secure a loan for business purposes;

(o) Resources not fit to sell or not capable of being sold;

(p) Property pending sale;

(q) U.S. Department of Housing and Urban Development (HUD) reimbursements;

(r) One (1) vehicle per household (if there are multiple vehicles in the household, the vehicle with the highest value shall be excluded);

(s) Higher education savings plans;

(t) U.S. savings bonds, if penalties apply to early withdrawals or liquidations and they have not been renewed or reinvested during any immediately preceding period of Medicaid eligibility;

(u) Individual Retirement Accounts;

(v) Keogh accounts;

(w) Other retirement accounts including, but not limited to, 401(k), 403(b), and 457 accounts; and

(x) Funds or deposits with a Continuing Care Retirement Community (CCRC), unless all of the following conditions are met:

(1) The funds can be used to pay for care under the terms of the contract should other resources of the individual be insufficient;

(2) The entrance fee, or remaining portion, is refundable when the individual dies or leaves the community; and

(3) The fee confers no ownership interest in the community.

9802.6 The Department shall apply methods used by the Social Security Administration (SSA), detailed at: HYPERLINK "https://secure.ssa.gov/apps10/poms.nsf/lnx/0501130700" https://secure.ssa.gov/apps10/poms.nsf/lnx/0501130700 (last visited October 14, 2015), for counting resources in which countable and excluded resource types are comingled.

9802.7 The Department shall determine the total gross countable resources available to an institutionalized spouse and community spouse at the:

(a) Time of the initial eligibility determination; or

(b) Request of either spouse during the institutionalized spouse’s first period of institutionalization lasting thirty (30) or more consecutive days.

9802.8 Any countable resources held by the institutionalized spouse, the community spouse, or both spouses shall be considered available to the institutionalized spouse at the time of the initial eligibility determination, unless:

(a) The institutionalized spouse has assigned to the District any rights to support from the community spouse;

(b) The institutionalized spouse lacks the ability to execute an assignment due to physical or mental impairment, but the District has the right to bring a support proceeding against the community spouse without such assignment; or

(c) The District determines that the denial of eligibility would work an undue hardship.

9802.9 The Department shall determine the spousal share of resources allocated to each spouse either:

(a) At the time of the initial eligibility determination; or

(b) At the request of either spouse during the institutionalized spouse’s first period of institutionalization lasting thirty (30) or more consecutive days.

9802.10 A community spouse shall be entitled to retain a Community Spouse Resource Allowance equal to the spousal share, unless the spousal share is less than the minimum amount or greater than the maximum amount established annually by CMS and available at: HYPERLINK "http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Spousal-Impoverishment-Page.html" http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Spousal-Impoverishment-Page.html (last visited October 14, 2015).

9802.11 If the spousal share is less than the minimum amount, the institutionalized spouse may transfer excess countable resources to the community spouse to raise the Community Spouse Resource Allowance to the minimum amount.

9802.12 If the spousal share is greater than the maximum amount, the community spouse may only retain the maximum amount.

9802.13 Where an institutionalized spouse is allowed to transfer excess countable resources following the initial eligibility determination to a community spouse, the institutionalized spouse shall reallocate excess countable resources before the first annual renewal.

9802.14 In accordance with Section 2970 of Title 1 DCMR and 42 C.F.R. § 431.200, an applicant, beneficiary, or community spouse may request a fair hearing to address the following matters:

(a) The spousal share of resources;

(b) The amount of the Community Spouse Resource Allowance; or

(c) The amount of resources attributed to each spouse.

9802.15 At the first annual renewal following the initial eligibility determination, the District shall verify that a beneficiary has transferred excess countable resources to the community spouse.

SOURCE: Final Rulemaking published at 63 DCR 1605 (February 12, 2016).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9802

9803 IMPROPER RESOURCE TRANSFERS AND PENALTY PERIOD

9803.1 At the time of the initial eligibility determination, the Department shall conduct a review to determine whether the applicant, the applicant’s spouse, or an individual with legal authority to act in place of or on behalf of the applicant or the applicant's spouse has improperly transferred resources for less than fair market value within sixty (60) months prior to the date of an application for LTCSS.

9803.2 The Department shall impose a penalty period if the applicant, the applicant’s spouse, or an individual with legal authority to act in place of or on behalf of the applicant or the applicant’s spouse has transferred resources for less than fair market value within sixty (60) months prior to the date of an application for LTCSS.

9803.3 The penalty period shall be the length of time during which an individual is ineligible for Medicaid coverage of LTCSS due to improper resource transfers made within sixty (60) months prior to the date of an application for LTCSS.

9803.4 The length of the penalty period shall be based on the following formula:

Total Uncompensated Value of All Transferred Resources ÷ Average Monthly Cost of a Private Nursing Facility Patient in the Community = Number of Months of Penalty Period.

9803.5 The Department shall determine the total uncompensated value of all transferred resources by subtracting the amount received by the individual for the improperly transferred resources from the fair market value of those resources.

9803.6 The Department shall determine the average monthly cost of a private nursing facility patient in the community on an annual basis, using a single standard figure for all LTCSS applicants.

9803.7 Where a partial month period exists at the end of the penalty period, the applicant is only eligible for LTCSS for the portion of the month after the penalty period ends.

9803.8 The Department may waive the penalty period if it could create an undue hardship. Undue hardship may exist:

(a) For applicants in an institutional setting, if the individual has been threatened with eviction from a long-term care facility or medical institution and has exhausted all legal methods to prevent the eviction; or

(b) For applicants eligible for Home and Community-Based Services (HCBS) Waiver, if the individual's service provider has threatened to terminate services; and

(1) The individual to whom the resource was transferred is no longer in possession of the transferred resource and has no other resources of comparable value with which to pay the cost of care; and

(2) There is no family member or other individual or organization able and willing to provide care to the individual; or

(c) For all LTCSS applicants, if the applicant would be deprived of medical care that would endanger his or her life or health; or food, clothing, shelter, or other necessities of life; or

(d) For all LTCSS applicants, if any other undue hardship or good cause exemption exists, as may be defined by the Secretary for the U.S. Department of Health and Human Services or the Secretary for the U.S. Department of Agriculture.

9803.9 Transfers of resources under the following circumstances shall not be subject to the penalty period described in Subsection 9803.3:

(a) The resource that was transferred was the applicant’s personal home, and title to the home was transferred to:

(1) The spouse of the applicant;

(2) A child of the applicant who:

(i) Was under the age of twenty-one (21);

(ii) Was blind or permanently and totally disabled; or

(iii) Had been residing in the home for at least two (2) years immediately before the date the applicant became institutionalized and who provided care to the applicant which permitted the applicant to reside at home, rather than in an institution; or

(3) A sibling of the applicant who had an equity interest in the home and who had been residing in the home for at least one (1) year immediately before the date the applicant became institutionalized.

(b) Any type of resource that was transferred:

(1) To the applicant’s spouse or to another for the sole benefit of the spouse;

(2) From the applicant’s spouse to another for the sole benefit of the spouse;

(3) To the applicant’s child who is blind or permanently and totally disabled, or to a trust established for the sole benefit of such child; or

(4) To a trust established for the sole benefit of an individual under the age of sixty-five (65) who is disabled as defined by SSI.

(c) Any type of resource that was transferred, and for which a satisfactory showing is made to the District that:

(1) The applicant intended to dispose of the resources at fair market value;

(2) The resources were transferred exclusively for a purpose other than to qualify for medical assistance; or

(3) All resources transferred for less than fair market value have been returned to the applicant, or the fair market equivalent has been returned.

9803.10 Establishment of the following types of trusts s shall not be subject to the penalty period described in Subsection 9803.3:

(a) A “special needs” trust containing the resources of an individual under the age of sixty-five (65) with a disability, which may also contain the resources of other individuals and which meets the following conditions:

(1) The trust is established for the sole benefit of the individual by a parent, grandparent, legal guardian, or court; and

(2) The trust contains a provision stating that, upon the death of the individual, the District receives all amounts remaining in the trust, up to the total amount of medical assistance paid on behalf of the individual.

(b) A “pooled” trust containing the resources of an individual with a disability which meets the following conditions:

(1) The trust is established for the sole benefit of the individual by a parent, grandparent, legal guardian, or court;

(2) The trust is established and managed by a non-profit association;

(3) A separate account is maintained for each beneficiary, but funds are pooled for investment and management purposes; and

(4) The trust contains a provision stating that, to the extent that any amounts remaining in the individual’s account upon his or her death are not retained by the trust, the trust pays to the District the amount remaining in the account up to the total amount of medical assistance paid on behalf of the individual.

9803.11 The purchase of an annuity shall not be subject to the penalty period described in Subsection 9803.3 under the following conditions:

(a) Annuities purchased on or after February 8, 2006 name the District as the primary remainder beneficiary, or secondary remainder beneficiary after a community spouse or minor child or child with a disability, for an amount equal to the total amount of medical assistance paid on the behalf of the applicant; and

(b) Annuities purchased on or after February 8, 2006, are irrevocable, non-assignable, actuarially sound, and provide for payments in equal amounts during the annuity term, with no deferral or balloon payments; or meet the requirements pertaining to retirement plans in 42 U.S.C. § 1396p(c)(1)(G)(i).

9803.12 For annuities purchased prior to February 8, 2006, actions taken by the individual that change the course of payments to be made by the annuity or treatment of the income or principal of the annuity subject the annuity to the requirements for those purchased on or after February 8, 2006.

9803.13 Routine changes and automatic events that do not require action by the individual do not subject an annuity purchased prior to February 8, 2006, to the requirements for those purchased on or after February 8, 2006.

9803.14 The purchase of a life estate interest in another individual’s home shall not be subject to the penalty period described in Subsection 9803.3 when the purchaser lives in the home for at least one (1) year after the date of purchase.

9803.15 The full purchase price of the life estate interest shall be deemed a transfer of resources for less than fair market value if the purchaser has not lived in the home for at least one (1) year.

9803.16 Notwithstanding the length of time the purchaser lives in the home, if the purchase amount of the life estate interest is greater than the computed value of the interest, the difference is considered a transfer of resources for less than fair market value.

9803.17 The purchase of a promissory note or loan shall not be subject to the penalty period described in Subsection 9803.3 under the following conditions:

(a) The repayment terms are actuarially sound;

(b) Payments are made in equal amounts with no balloon payments; and

(c) The note, loan or mortgage prohibits cancellation of the debt upon the death of the lender.

SOURCE: Final Rulemaking published at 63 DCR 1605 (February 12, 2016).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9803

9804 POST-ELIGIBILITY TREATMENT OF INCOME

9804.1 The Department shall determine how much monthly income a beneficiary must contribute toward the cost of LTCSS after an initial eligibility determination.

9804.2 The Department shall project the beneficiary’s gross countable monthly income for a six (6) month prospective period to determine a beneficiary’s contribution to the cost of care.

9804.3 Gross countable monthly income shall be calculated as follows:

(a) Income received on a yearly basis or less often than monthly shall be converted to a monthly amount or prorated;

(b) If the amount or frequency of regularly received income is known, the Department shall average the income over the period between payments; or

(c) If neither the amount nor the frequency of income is predictable, the Department shall not average the income but count income only for the month in which it is received.

9804.4 The Department shall subtract the following types of deductions from the beneficiary’s gross countable monthly income:

A Personal Needs Allowance, the amount of which shall be annually posted by DHCF on its website at HYPERLINK "https://dhcf.dc.gov/page/general-information-0"https://dhcf.dc.gov/page/general-information-0, and shall be equal to:

One hundred and three dollars and twenty cents ($103.20) starting on January 1, 2024, and adjusted annually thereafter by the federal cost-of-living adjustment (COLA) for that year published by the Social Security Administration, for any beneficiary:

In a nursing facility;

(B) Who receives waiver-funded residential support through the District Department on Disability Services (DDS) and receives Social Security benefits;

(C) In an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) who receives supplemental security income (SSI); and

(D) In an ICF/IID who receives Social Security Disability Income (SSDI);

Two hundred and six dollars and forty cents ($206.40) starting on January 1, 2024, and adjusted annually thereafter by the federal COLA for that year published by the Social Security Administration, for a couple if each individual spouse is institutionalized in a nursing facility; or

One hundred and thirty-four dollars and sixteen cents ($134.16), and adjusted annually thereafter by the federal COLA for that year published by the Social Security Administration, for any beneficiary who is:

(A) Enrolled in the Home and Community Based Waiver for Persons who are Elderly and Individuals with Physical Disabilities (EPD) and receives Optional State Supplemental Payments (OSSP); or

(B) In a community residence facility or assisted living residence and receives SSI;

(b) A Community Maintenance Needs Allowance, for a beneficiary enrolled in an HCBS Waiver program only, equal to the Special Income Standard (SIS);

(c) A Community Spouse Allowance, for a beneficiary who has a community spouse only;

(d) A Dependent Family Allowance, equal to the annual MNIL, for a beneficiary who has:

(1) Minor or dependent children, including disabled adult children of the beneficiary or community spouse, who reside in the personal home with the community spouse;

(2) Dependent parents of the beneficiary or community spouse who reside in the personal home with the community spouse; or

(3) Dependent siblings of the beneficiary or community spouse who reside in the personal home with the community spouse;

(e) Incurred Medical Expenses, if the expenses are not subject to payment by a third party, including incurred medical expenses used to meet a spend down obligation;

(f) Incurred remedial expenses, if the expenses are not subject to payment by a third party, including incurred remedial expenses used to meet a spend down obligation;

(g) A Home Maintenance Deduction equal to the MNIL for a beneficiary residing in an institutional facility. A home maintenance deduction may be deducted only:

(1) For up to six (6) months;

(2) When a community spouse does not reside in the home; and

(3) If a physician certifies that the beneficiary is likely to return to the home within six (6) months; and

(h) The full amount of SSI or State Supplementary Payment Benefits for a beneficiary who resides in a long term care facility.

9804.5 The amount of the beneficiary’s gross countable income that remains after allowable deductions and spousal impoverishment protections for income and resources (if applicable) have been applied is the amount of the beneficiary’s contribution to the cost of care.

9804.6 The Department shall reduce its payment for LTCSS by the amount of the beneficiary’s contribution to the cost of care.

9804.7 The Department shall reconcile the beneficiary’s projected income with the beneficiary’s actual income at the end of every six (6) month period in which a beneficiary receives Medicaid coverage of LTCSS, or whenever any significant change in the beneficiary’s income or circumstances occurs.

9804.8 The reconciliation may include a period of up to six (6) months prior to the month in which the reconciliation is done.

9804.9 The Department may redetermine the beneficiary’s contribution to the cost of care:

After the reconciliation process;

At annual renewals; and

When a beneficiary reports a significant change of income or other circumstances.

9804.10 Any redetermination of or adjustment to the beneficiary’s contribution to the cost of care resulting from the reconciliation shall not be applied until timely and adequate notice of the redetermination or adjustment is provided to the beneficiary.

9804.11 The Department shall adjust the beneficiary’s contribution to the cost of care prospectively when the income actually received by the beneficiary during the six (6) month reconciliation period differs from the beneficiary’s projected income for that period.

9804.12 If the income actually received by the beneficiary during the six (6) month period exceeds the beneficiary’s projected income for that period, an adjustment shall be added to the beneficiary’s contribution to the cost of care in a future month or months to reflect the amount that should have been contributed during the six (6) month period.

9804.13 If an income change or change in circumstances renders a beneficiary ineligible for Medicaid coverage of LTCSS, a prospective adjustment cannot be added to the former beneficiary’s contribution to the cost of care. Under these circumstances, the Department may seek to recover the full amount of the adjustment by requesting voluntary repayment from the former beneficiary.

9804.14 The Department may pursue recovery by appropriate action, pursuant to District law, against the income or resources of the former beneficiary if the Department is unable to recover the full amount of the adjustment through voluntary repayment from the former beneficiary.

9804.15 If the income actually received by the beneficiary during the six (6) month period is less than the beneficiary’s projected income for that period, the beneficiary’s contribution to the cost of care shall be reduced in a future month or months to reflect the amount that should not have been contributed during the six (6) month period.

SOURCE: Final Rulemaking published at 63 DCR 1605 (February 12, 2016); as amended by Final Rulemaking published at 69 DCR 012069 (October 7, 2022); as amended by Final Rulemaking published at 72 DCR 010230 (September 19, 2025).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9804

9899 DEFINITIONS

For the purposes of this chapter, the following terms shall have the meanings ascribed:

Community Maintenance Needs Allowance (CMNA): A standard income amount that an HCBS Waiver participant living at home may retain to afford the costs associated with living in the community, such as expenses related to mortgage, rent, food, utilities, taxes, and home repairs.

Community Spouse: A spouse of an institutionalized individual who is not institutionalized or enrolled in a Waiver program.

Community Spouse Allowance (CSA): The amount of the institutionalized spouse’s income that can be maintained by or transferred to the community spouse. The CSA is the amount needed to maintain or raise the community spouse’s income to the Minimum Monthly Maintenance Needs Allowance (MMMNA).

Community Spouse Resource Allowance (CSRA): An allowance of resources that can be maintained by or transferred to the community spouse without incurring penalties.

Cost of Care: The amount of money charged by a long term care facility or HCBS Waiver service provider for LTCSS.

Dependent: A dependent family member may include a parent, minor child, dependent child, or dependent sibling, including half and step siblings, of either member of a couple who resides with the community spouse and who may be claimed as a dependent by either member of the couple for tax purposes pursuant to 26 U.S.C. § 152.

Dependent Family Allowance: An allowance of income for each dependent family member residing with the community spouse.

Exceptional Circumstances: Circumstances that threaten the community spouse’s ability to remain in the community due to severe financial duress.

Excess Shelter Allowance: An allowance of the community spouse’s income for shelter including rent or mortgage payment, taxes, utilities, and insurance.

Fair Market Value: In accordance with 26 C.F.R. § 20.2031-1(b), the fair market value is the price at which the property would change hands between a willing buyer and a willing seller, neither being under any compulsion to buy or to sell and both having reasonable knowledge of relevant facts.

Federal Benefit Rate: The share of the Supplemental Security Income (SSI) grant paid by the federal government, which does not include any applicable State supplement.

Gross Countable Income: Includes an individual’s total gross earned and unearned income, excluding income from non-countable sources.

Gross Countable Resources: Includes all resources available to the individual, excluding exempt categories of resources.

Home and Community-Based Services Waiver (HCBS Waiver) Programs: HCBS Waiver programs, the Home and Community-Based Services Waiver for Persons who are Elderly and Individuals with Physical Disabilities (EPD), and the Home and Community-Based Services Waiver for Persons with Intellectual and/or Developmental Disabilities (IDD), that provide home and community-based services that assist Medicaid-eligible individuals to live in the community and avoid institutionalization.

Home Maintenance Deduction: A standard income amount that an individual residing in an institutional setting may retain to pay for the maintenance of the home.

Incurred Medical Expenses: Medically necessary medical expenses incurred by an individual, family member, or financially responsible relative that are not subject to payment by a third party.

Institutional Level of Care: The level of care furnished to individuals residing in a nursing facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID).

Institutionalized Individual: An individual receiving an institutional level of care in an institutional setting (i.e., nursing facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)). An individual in an acute care facility is considered institutionalized if the individual receives, or is likely to receive, an institutional level of care for more than thirty (30) days.

Institutionalized Spouse: An individual who is residing in an institutional setting and who is married to a person who is not in a medical institution or nursing facility.

Land Contract: A contract between a seller and buyer of real property in which the seller provides financing to the buyer to purchase the property for an agreed-upon purchase price and the buyer repays the loan in installments.

Long term care services and supports (LTCSS): Health-related care and services, above the level of room and board, that are needed regularly due to a mental or physical condition, provided in a nursing facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or in a home or community setting through a Home and Community-Based Services Waiver (HCBS Waiver) program.

Maximum Home Equity Limit: The amount established annually by CMS which limits the home equity interest an individual may have in his or her personal home, and still be eligible for LTCSS.

Medically Needy Income Level (MNIL): Fifty percent (50%) of the Federal Poverty Level (FPL) for a household of two (2) or larger; the MNIL for a household of one is ninety-five percent (95%) of that for a household of two.

Minimum Monthly Maintenance Needs Allowance (MMMNA): The minimum amount of monthly income that the community spouse is entitled to possess. This may consist solely of the community spouse’s income or the sum total of the community spouse’s income plus the Community Spouse Allowance.

Personal Home: An individual’s primary residence.

Personal Needs Allowance (PNA): A standard income amount that an individual residing in an institution or receiving residential supports through the Department on Disability Services (DDS) may retain to pay for personal needs not provided by the institution.

Pooled Trust: A trust which contains the resources of an individual with a disability, is established for the sole benefit of the individual by a parent, grandparent, legal guardian, or court, and meets the requirements of 42 U.S.C. § 1396p(6)(4)(C).

Remedial Care Expenses: Shall have the same meaning as set forth under Chapter 95 of Title 29 DCMR.

Sibling: One (1) of two (2) or more children related by blood or adoption through a common legal parent or through the marriage of the children’s legal or biological parents.

Special Income Standard (SIS): Three hundred percent (300%) of the SSI federal benefit rate (FBR) defined by the Social Security Administration (SSA).

Special Needs Trust: A trust which contains the resources of an individual under the age of sixty-five (65) with a disability, is established for the sole benefit of the individual by a parent, grandparent, legal guardian, or court, and meets the requirements of 42 U.S.C § 1396p(d)(4)(a).

Spend Down: Spend down is the process by which an individual may use medical expenses to reduce countable income to the Medicaid income limit to meet financial eligibility requirements for Medicaid coverage.

Spousal Impoverishment Protections: Allowances and deductions to a couple’s income and resources, defined in Section 1924 of the Social Security Act, that are designed to protect the income and resources of the community spouse. Spousal impoverishment protections apply to HCBS Waiver individuals and institutionalized individuals who were institutionalized in a long-term care facility on or after October 1, 1989.

Spousal Share: Half (1/2) of the total countable resources available to either the institutionalized or community spouse.

Spouse: A person married under District law, including members of common-law and same-sex couples whose marriages or civil unions are recognized under the Religious Freedom and Civil Marriage Equality Act of 2009 (D.C. Official Code § 46-401). The term does not include registered domestic partners.

State Supplementary Payment: Payments made to individuals residing in a Certified Residential Facility (CRF) or Adult Living Facility (ALF).

SOURCE: Final Rulemaking published at 63 DCR 1605 (February 12, 2016); as amended by Final Rulemaking published at 69 DCR 012069 (October 7, 2022).

District of Columbia Municipal Regulations

Public Welfare 29 DCMR § 9899