Proposed Contract No. CW133988 with Health Services for Children with Special Needs, Inc.

MURIELBOWSERMAYOR
June23,2026
HonorablePhilMendelsonChairmanCounciloftheDistrictofColumbia
JohnA.WilsonBuilding1350PennsylvaniaAvenue,NW,Suite504Washington,DC 20004
Dear ChairmanMendelson:
Pursuanttosection451oftheDistrictofColumbiaHome RuleAct(D.C.OfficialCode§ 1-204.51)andsection202oftheProcurementPracticesReformActof2010(D.C.OfficialCode§2-352.02),enclosedforconsiderationandapprovalbytheCounciloftheDistrictofColumbiaisproposedContractNo.CW133988withHealthServicesforChildrenwithSpecialNeeds,Inc.(HSCSN),inthenot-to-exceedamountof$236,430,018.72.TheperiodofperformanceisfromOctober1,2026,throughSeptember30,2027.
Undertheproposedcontract,HSCSNwillprovidehealthcareservicestotheDistrict’sMedicaideligiblepopulationenrolledintheChildandAdolescentSupplementalSecurityIncomeProgram(CASSIP).TheCASSIPconsistsofMedicaid-eligiblechildrenandadolescentsreceivingSupplementalSecurityIncome(SSI)orbeneficiarieswithSSI-relateddisabilities.
My administrationisavailabletodiscussanyquestionsyoumayhaveregardingtheproposedcontract.Inordertofacilitatearesponsetoanyquestionsyoumayhave,pleasehaveyourstaffcontactMareScott, Chief OperatingOfficer,OfficeofContractingand Procurement,at(202)724-
8759.
1 look forward to the Council’sfavorableconsiderationof thiscontract.
Sincerely,
Mbriel Bpwser

GOVERNMENT OF THE DISTRICT OF COLUMBIA
Office of Contracting and Procurement

Pursuant to section 202(c) of the Procurement Practices Reform Act of 2010, as amended, D.C.
Official Code § 2-352.02(c), the following contract summary is provided:

COUNCIL CONTRACT SUMMARY
(Standard)

(A) Contract Number: CW133988

Proposed Contractor: Health Services for Children with Special Needs,
Inc. (HSCSN)

Proposed Contractor’s Principals: Donna Anthony, Interim President

Contract Amount: Not-to-exceed (NTE) $236,430,018.72

Unit and Method of Compensation: Fixed Capitated Rates

Term of Contract: October 1, 2026, through September 30, 2027

Type of Contract: Indefinite Delivery Indefinite Quantity

Source Selection Method: Competitive Sealed Proposal

(B) For a contract containing option periods, the contract amount for the base period and for
each option period. If the contract amount for one or more of the option periods differs
from the amount for the base period, provide an explanation of the reason for the
difference:

Base Period Amount: NTE $236,430,018.72

Option Period 1, Option Period 2, Option Period 3, and Option Period 4:
The capitation amount will be determined based on the annual actuarial review of the capitation
rates. Any adjustment to the capitation rates will take effect on the first day of the option period.
If a prospective adjustment to the capitation rates is required, whether there is an increase or
decrease, the District’s contracted actuary will conduct an actuarial analysis. If warranted, the
District will implement the necessary adjustment to the capitation rates.

(C) The goods or services to be provided, the methods of delivering goods or services, and any
significant program changes reflected in the proposed contract:

The contractor shall provide healthcare and pharmacy services for children and adolescents
enrolled in the Child and Adolescent Supplemental Security Income Program (CASSIP) who are
eligible under Medicaid or the Immigrant Children’s Program and who receive Supplemental
Security Income (SSI) or have SSI-related disabilities.

(D) The selection process, including the number of offerors, the evaluation criteria, and the
evaluation results, including price, technical or quality, and past performance components:

Solicitation Number Doc808208 was issued to the public on January 20, 2026, and closed on
March 4, 2026. On the closing date, the District received one proposal. The contracting officer
(CO) determined that HSCSN was responsive and their subcontracting plan complied with the
Small and Certified Business Enterprise Development and Assistance Act. HSCSN was
evaluated in accordance with the technical evaluation factors as described in the solicitation,
which are listed below.

The evaluation factors consisted of:

• Technical Approach and Methodology;
• Technical Expertise;
• Past Performance; and
• Price.

Based upon the findings of the technical evaluation panel and the CO’s independent review of
the proposals in accordance with the evaluation factors, the CO determined that the proposal
from HSCSN was the most advantageous offer to the District and that it is in the best interest of
the District that award be made to HSCSN.

(E) A description of any bid protest related to the award of the contract, including whether the
protest was resolved through litigation, withdrawal of the protest by the protestor, or
voluntary corrective action by the District. Include the identity of the protestor, the
grounds alleged in the protest, and any deficiencies identified by the District as a result of
the protest:

None

(F) A description of any other contracts the proposed contractor is currently seeking or holds
with the District:

CW97541 Child and Adolescent Supplemental Security Income Program
Department of Health Care Finance

(G) The background and qualifications of the proposed contractor, including its organization,
financial stability, personnel, and performance on past or current government or private

sector contracts with requirements similar to those of the proposed contract:

The proposed contractor has demonstrated through past performance reports that its organization
has the history, organizational and technical experience, including the key personnel, required to
successfully meet the requirements of the proposed contract. Likewise, it has been determined
that the proposed contractor maintains the financial resources, accounting and operational
controls to successfully fulfill the District’s requirement. The proposed contractor has been
determined responsible in accordance with the District’s standards of responsibility.

(H) A summary of the subcontracting plan required under section 2346 of the Small, Local,
and Disadvantaged Business Enterprise Development and Assistance Act of 2005, as
amended, D.C. Official Code § 2-218.01 et seq. (“Act”), including a certification that the
subcontracting plan meets the minimum requirements of the Act and the dollar volume of
the portion of the contract to be subcontracted, expressed both in total dollars and as a
percentage of the total contract amount:

The contractor provided a subcontracting plan with a set aside of 4.1% for a total dollar amount
of NTE $10,133,824 which aligns with the waiver granted by the Department of Small and Local
Business Development requirement.

(I) Performance standards and the expected outcome of the proposed contract:

The performance standards and expected outcome of the proposed CASSIP contract are to
ensure that all CASSIP Enrollees receive medically necessary services across physical health,
behavioral health, nursing home care, Intermediate Care Facilities for Individuals with
Intellectual Disabilities, and residential treatment settings for complex medical needs, with
consideration of how social factors influence their overall health. The contractor is expected to
comply with the District’s State Plan, including all amendments and any applicable waivers
approved by the Centers for Medicare and Medicaid Services, such as those authorized under
Sections 1115 and 1915 of the Social Security Act and Section 2703 of the Patient Protection and
Affordable Care Act. In addition, the contractor must adhere to all applicable state and federal
regulatory requirements governing Medicaid Managed Care Organizations, including the
standards set forth in 42 C.F.R. § 438 et seq.

(J) The amount and date of any expenditure of funds by the District pursuant to the contract
prior to its submission to the Council for approval:

None

(K) A certification that the proposed contract is within the appropriated budget authority for
the agency for the fiscal year and is consistent with the financial plan and budget adopted
in accordance with D.C. Official Code §§ 47-392.01 and 47-392.02:

The Office of the Chief Financial Officer has certified that funding is consistent with the
applicable financial plan and budget.

(L) A certification that the contract is legally sufficient, including whether the proposed
contractor has any pending legal claims against the District:

The contract has been reviewed by the Office of the Attorney General and found to be legally
sufficient. The contractor has no pending legal claim against the District.

(M) A certification that the Citywide Clean Hands database indicates that the proposed
contractor is current with its District taxes. If the Citywide Clean Hands Database
indicates that the proposed contractor is not current with its District taxes, either: (1) a
certification that the contractor has worked out and is current with a payment schedule
approved by the District; or (2) a certification that the contractor will be current with its
District taxes after the District recovers any outstanding debt as provided under D.C.
Official Code § 2-353.01(b):

The Citywide Clean Hands database indicates the contractor is current with its District taxes.

(N) A certification from the proposed contractor that it is current with its federal taxes, or has
worked out and is current with a payment schedule approved by the federal government:

The contractor has self-certified, via the Bidder Offeror Certification form, that it is current with
its federal taxes.

(O) A certification that the proposed contractor has been determined not to violate section 334a
of the Board of Ethics and Government Accountability Establishment and Comprehensive
Ethics Reform Amendment Act of 2011, D.C. Official Code § 1-1163.34a; and (2) A
certification from the proposed contractor that it currently is not and will not be in
violation of section 334a of the Board of Ethics and Government Accountability
Establishment and Comprehensive Ethics Reform Amendment Act of 2011, D.C. Official
Code § 1-1163.34a:

The contractor has certified, via the Bidder/Offeror Certification form, that it is (1) not in
violation of section 334a of the Board of Ethics and Government Accountability Establishment
and Comprehensive Ethics Reform Amendment Act of 2011, D.C. Official Code § 1-1163.34a;
and (2) currently is not and will not be in violation of section 334a of the Board of Ethics and
Government Accountability Establishment and Comprehensive Ethics Reform Amendment Act
of 2011, D.C. Official Code § 1-1163.34a.

(P) The status of the proposed contractor as a certified local, small, or disadvantaged business
enterprise as defined in the Small, Local, and Disadvantaged Business Enterprise
Development and Assistance Act of 2005, as amended, D.C. Official Code § 2-218.01 et seq.:

The contractor is not a certified local, small or disadvantaged business enterprise.

(Q) Other aspects of the proposed contract that the Chief Procurement Officer considers
significant:

None

(R) A statement indicating whether the proposed contractor is currently debarred from
providing services or goods to the District or federal government, the dates of the
debarment, and the reasons for debarment:

The contractor does not appear on the Office of Inspector General Exclusions Database, the
Federal Excluded Parties List or the District’s list of Debarred and Suspended Contractors.

(S) Any determination and findings issues relating to the contract’s formation, including any
determination and findings made under D.C. Official Code § 2-352.05 (privatization
contracts):

Determination and Findings for Competitive Sealed Proposals
Determination and Findings for Contractor Responsibility
Determination and Findings for Price Reasonableness

(T) Where the contract, and any amendments or modifications, if executed, will be made
available online:

http://ocp.dc.gov

(U) Where the original solicitation, and any amendments or modifications, will be made
available online:

http://ocp.dc.gov
1101 4th Street, SW
Washington, DC 20024
Date of Notice: May 18, 2026 L0016526345Notice Number:
FEIN: **-***2406
Case ID: 18967092

Government of the District of Columbia
Office of the Chief Financial Officer
Office of Tax and Revenue
HEALTH SRVCS CHLDRN WITH SPECL NDS INC
1101 VERMONT AVE NW STE 1200
WASHINGTON DC 20005-6308

Branch Chief, Collection and Enforcement Administration
Authorized By Melinda Jenkins
To validate this certificate, please visit MyTax.DC.gov. On the MyTax DC homepage, click the
“Validate a Certificate of Clean Hands” hyperlink under the Clean Hands section.
CERTIFICATE OF CLEAN HANDS
As reported in the Clean Hands system, the above referenced individual/entity has no outstanding
liability with the District of Columbia Office of Tax and Revenue or the Department of Employment
Services. As of the date above, the individual/entity has complied with DC Code § 47-2862, therefore
this Certificate of Clean Hands is issued.
TITLE 47. TAXATION, LICENSING, PERMITS, ASSESSMENTS, AND FEES
CHAPTER 28 GENERAL LICENSE
SUBCHAPTER II. CLEAN HANDS BEFORE RECEIVING A LICENSE OR PERMIT
D.C. CODE § 47-2862 (2006)
§ 47-2862 PROHIBITION AGAINST ISSUANCE OF LICENSE OR PERMIT
1101 4th Street SW, Suite W270, Washington, DC 20024/Phone: (202) 724-5045/MyTax.DC.gov

COPY
441 4th Street, NW, Suite 900 South, Washington, D.C. 20001 (202) 442-5988 FAX (202) 478-1373
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Department of Health Care Finance

Office of the Chief Financial Officer

MEMORANDUM

TO: Nancy Hapeman
Chief Procurement Officer
Office of Contracting and Procurement

THRU: Delicia Moore
Associate Chief Financial Officer
Human Support Services Cluster

FROM: Darrin Shaffer
Agency Fiscal Officer
Department of Health Care Finance

DATE: June 3, 2026

SUBJECT: Certification of Funding for Child and Adolescent Supplemental Security Income Program (CASSIP)
Contract

The Office of the Chief Financial Officer hereby certifies that the sum of $236,430,018.72 is included in the District’s Local
Budget and Financial Plan for Fiscal Year 202 7 to fund the costs associated with the Department of Health Care Finance’s
(DHCF) Child and Adolescent Supplemental Security Income Program (CASSIP) contract with Health Services for Children
with Special Needs, Inc. (HSCSN) . This certification supports the HSCSN contract during the period from October 1, 202 6
through September 30, 2027. This replaces the certification document dated 2/11/2026. This funding allocation is as follows:

Vendor: Health Services for Children with Special Needs, Inc. (HSCSN) Contract Number: CW133988

Fiscal Year 2027 Funding: 10/01/2026 – 09/30/2027

Agency DIFS
Fund
DIFS
Program
DIFS
Account Amount
HT0 1010001 700105 7141003 $70,929,005.62
HT0 4025002 700105 7141003 $165,501,013.10
FY 2027 Contract Total $236,430,018.72

Upon approval of the District’s Local Budget and Financial Plan by the Council and the Mayor and completion of the thirty-day
Congressional layover, funds will be sufficient to pay for fees and costs associated with the contract. There is no fiscal im pact
associated with the contract.

Should you have further questions, please contact me at 202-442-9079.

GOVERNMENT OF THE DISTRICT OF COLUMBIA
Office of the Attorney General

ATTORNEY GENERAL
BRIAN L. SCHWALB

Commercial Division

MEMORANDUM

TO: Tomás Talamante
Director
Office of Policy and Legislative Affairs

FROM: Robert Schildkraut
Section Chief
Government Contracts Section

DATE: June 11, 2026

SUBJECT: Approval of Contract for Healthcare and Pharmacy Services for the Child
and Adolescent Supplemental Security Income Program
Contract Number: CW133988
Contractor: Health Services for Children with Special Needs, Inc.
Proposed Estimated Base Period Amount: $236,430,018.72

This is to Certify that this Office has reviewed the above-referenced Contract and have found it to
be legally sufficient.

If you have any questions in this regard, please do not hesitate to call me at (202) 724-4018.

______________________________
Robert Schildkraut

AWARD/CONTRACT
1. Solicitation Number Page of Pages
Doc808208 1 304
2. Contract Number 3. Effective Date 4. Requisition/Purchase Request/Project No.
CW133988 See Box 20C
5. Issued By: Code 6. Administered by (If other than line 5)
Office of Contracting and Procurement
Health Services Cluster
441 4th Street, NW; Suite 330 S
Washington, DC 20001
Department of Health Care Finance
Health Care Delivery and Management Administration
441 4th Street, NW; Suite 900S
Washington, DC 20001
7. Name and Address of Contractor (No. street, city, county, state, and Zip Code)
Health Services for Children with Special Needs, Inc.
1101 Vermont Avenue, NW
Suite 1200
Washington, DC 20005
8. Delivery
FOB Origin FOB Destination
9. Discount for prompt payment:
Net 30 days
10. Submit invoices to the Address shown in Section G.2
(2 copies unless otherwise specified)
DC Vendor Portal, https://vendorportal.dc.gov
11. Ship to/Mark For Code 12. Payment will be made by Code
Department of Health Care Finance
Health Care Delivery and Management Administration
441 4th Street, NW; Suite 900S
Washington, DC 20001
Department of Health Care Finance
13. Remit Address:

14. Accounting and Appropriation Data
ENCUMBRANCE CODE:
15A. Item 15B. Supplies/Services 15C. Qty. 15D. Unit 15E. Unit Price 15F. Amount
001 Child and Adolescent Supplemental Security
Income Program (CASSIP) 1 Month $19,702,501.56 $236,430,018.72

Amount of Contract $236,430,018.72
16. Table of Contents
(X) Section Description Page (X) Section Description Page
PART I – THE SCHEDULE PART II – CONTRACT CLAUSES
X A Award/Contract 1 X I Contract Clauses 286-302
X B Contract Type, Supplies/Services and
Price/Cost 2-5 PART III – LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHMENTS
X C Specifications/Work Statement 6-226 X J Attachments 303-304
X D Packaging and Marking 227 PART IV – REPRESENTATIONS AND INSTRUCTIONS
X E Inspection and Acceptance 228-229 K Representations, Certifications and Other
Statements of Offerors X F Period of Performance and Deliverables 230-243
X G Contract Administration 244-257 L Instructions, Conditions and Notices to Offerors
X H Special Contract Requirements 258-285 M Evaluation Factors
Contracting Officer will complete Item 17 or 18 as applicable
17. CONTRACTOR’S NEGOTIATED AGREEMENT
(Contractor is required to sign this document and return (1) copy to the issuing
office.) Contractor agrees to furnish and deliver all items or perform all the services
set forth or otherwise identified above and on any continuation sheets, for the
consideration stated herein. The rights and obligations of the parties to this contract
shall be subject to and governed by the following documents: (a) this
award/contract, (b) the solicitation, if any, and (c) such provisions, representations,
certifications, and specifications, as are attached or incorporated by reference
herein. (Attachments are listed herein.)
18. AWARD
Your offer on Solicitation Number Doc808208, including the additions or
changes made by you which additions or changes are set forth in full
above, is hereby accepted as to the items listed above and on any
continuation sheets. This award consummates the contract which
consists of the following documents: (a) the Government’s solicitation
and your offer, and (b) this award/contract. No further contractual
document is necessary.
19A. Name and Title of Signer (Type or print)

20A. Name of Contracting Officer
Tracy Williams
19B. Name of Contractor

(Signature of person authorized to sign)
19C. Date Signed 20B. District of Columbia

(Signature of Contracting Officer)
20C. Date Signed

Government of the District of Columbia Office of Contracting & Procurement

DC OCP 201 (7-99)

Donna Anthony Interim President & CEO
5/26/26
CW133988 Child and Adolescent Supplemental Security Income Program

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SECTION B: CONTRACT TYPE, SUPPLIES OR SERVICES AND
PRICE/COST

B.1 The Government of the District of Columbia (the “District”), Office of Contracting and
Procurement (OCP), on behalf of the Department of Health Care Finance (DHCF) is seeking a
Managed Care Organization (MCO) (the Contractor), to provide healthcare and pharmacy
services for its Child and Adolescent Supplemental Security Income Program (CASSIP). The
CASSIP consists of Medicaid or Immigrant Children’s Program (ICP) eligible children and
adolescents receiving Supplemental Security-Income (SSI) or who have SSI-related disabilities.

B.2 The District contemplates the award of an Indefinite Delivery Indefinite Quantity (IDIQ)
Contract with a Fixed Price component in accordance with Title 27 of the District of Columbia
Municipal Regulations (DCMR) Chapter 24.

B.2.1 INDEFINITE DELIVERY- INDEFINITE QUANTITY (IDIQ) CONTRACT

This is an IDIQ contract with payments based on fixed capitated rates for the services
specified, and effective for the period stated.

B.2.1.1 Delivery or performance shall be made only as authorized by orders issued in accordance
with the Ordering Clause, G.10. The Contractor shall furnish to the District, when and if
ordered, the services specified in the Schedule up to and including the maximum quantity of
7,500 Enrollees per month. The District will order at least the minimum quantity of 500
Enrollees per month (CLIN 001) for Base Year One.

B.2.1.2 Enrollment estimates are not guaranteed. DHCF has included enrollment estimates for each
rate cohort in Section B.4 to allow the Contractor to develop pricing for the Base Years and
Option Periods utilizing the fixed capitated rates.

B.2.1.3 Capitation payments will be made by the District and retained by the Contractor for eligible
Enrollees as referenced in Section B.3. The Contractor will be paid the negotiated monthly
Capitation Rate for each eligible member enrolled in their health plan. Capitation payments
may only be made by the DHCF and retained by the Contractor for Medicaid-eligible
enrollees.

B.2.2 COST /RATE-ADJUSTMENT (Fixed Price Component – Capitated Rates)

B.2.2.1 Effective with the base period and the subsequent option periods of the Contract the District
intends to reimburse the CASSIP rates via a Shared Risk model for the applicable rate cells.
This is a process that estimates health care expenses based on the disease conditions
attributed to the CASSIP populations. The capitation rates are distributed following the
applicable rate cells for each individual enrolled with the Contractor and re-evaluated
annually.

B.2.2.2 If the District, according to the Changes Clause of the Standard Contract Provisions, adds,
deletes or changes any services to be covered by the Contractor in the base or option periods
under CASSIP, the District will review the effect of the change and may equitably adjust the
capitation rates following completion of an actuarial review and approval by DHCF.
CW133988 Child and Adolescent Supplemental Security Income Program

3

B.2.2.3 In the event a capitation rate change occurs, an adjustment shall be effective as of the first
day of the option period to which the adjusted capitation rate applies. In the event a
prospective capitation rate adjustment is required; an actuarial analysis will be completed by
the District’s contracted Actuary. If required, the District will make the necessary
adjustment to the capitation rates. The Contractor may request a review from the District of
the capitation rates if the Contractor believes the program change is not equitable. The
District will not unreasonably withhold such a review. Any dispute regarding adjustment
shall be subject to the Disputes Provision of the Standard Contract Clauses.

B.2.2.4 No later than 12 months after the date of Contract Award and during any subsequent option
periods, the actuarial review of the capitation rates may result in an adjustment, either an
increase or decrease, to the capitation rates. Any adjustment to the actuarially sound
capitation rates will be subject to the actuarial soundness requirements as defined in 42
C.F.R § 438.4, § 438.5, and § 438.7.

B.2.2.5 If the actuarial review determines that there should be no adjustment to the capitation rates,
the capitation rates will remain at the same rate for any renewal period of the contract.

B.2.2.6 If the District has not completed the actuarial review for the adjusted capitation rates by the
first day of the affected option period, the Contractor shall continue to perform under the
contract at the actuarially sound rates in effect for the preceding contract period and the
District will reimburse the Contractor the difference between the rates in effect for the
preceding Contract period. All actuarial reviews and analyses shall be concluded by no later
than the end of the third month of the option period.

B.3 PRICE SCHEDULE – IDIQ

The Contractor shall propose capitation rates based on the lower bound rates from an actuarially
sound range as outlined in Attachment J.18 (Capitation Rate Report for CASSIP) prepared on
November 7, 2025, and in accordance with 42 C.F.R. § 438.4 and 42 C.F.R. § 438.6. The
Contractor shall not submit proposed rates that are below the lower bound capitation rates stated
in the RFP. The Contractor shall analyze its own projected medical expense, administrative
expense, and any other premium needs for comparison to the lower bound rates. Enrollee
estimates are not guaranteed due to the uncertainty surrounding the number of eligible
beneficiaries. The District has included enrollment estimates for each rate cohort in Section B.3
to allow Offerors to develop pricing for the base year utilizing the fixed capitated rates in
Attachment J.18. This is not intended to be a requirements contract. This is an IDIQ contract
pursuant to the minimum and maximum requirements in Section B.2.1.

CW133988 Child and Adolescent Supplemental Security Income Program

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B.3.1 BASE YEAR
October 1, 2026, through September 30, 2027

Contract
Line-
Item No.
(CLIN)

Rate Cohort
Estimated
Total Monthly
Enrollees per
Rate
Cohort
Actuarially
Sound Rates
Total Estimated
Monthly Price
per Rate Cohort
001: Managed Care Organization to provide healthcare and pharmacy services for its Child
and Adolescent Supplemental Security Income Program (CASSIP).
001A Under 1 Year of Age 11 $12,478.41 $136,223
001B Children 1 Year of Age
through 4 Years of Age 414 $6,175.69 $2,557,765
001C Children 5 Years of Age
through 12 Years of Age 1,782 $3,452.44 $6,151,679
001D Males 13 Years of Age
through 18 Years of Age 1,045 $3,131.17 $3,273,116
001E Females 13 Years of Age
through 18 Years of Age 514 $3,549.99 $1,822,920
001F Males 19 Years of Age
through 25 Years of Age 652 $2,162.40 $1,409,164
001G Females 19 Years of Age
through 25 Years of Age 498 $2,834.45 $1,412,266
001H CFSA/DYRS – All Ages 678 $3,994.95 $2,708,246
001I Under 1 Year of Age
(Non CASSIP/Well) 44 $3,648.36 $161,136
001J
Children 1 Year of Age
through 5 Years of Age
(Non CASSIP/Well)
92 $749.38 $69,130
Estimated Monthly Total $19,702,501.56
Estimated Grand Total for Base Year (B.3.1) $236,430,018.72

B.4 NONPROFIT FAIR COMPENSATION ACT OF 2020, D.C. Code § 2-222.01 et seq.

B.4.1. Nonprofit organizations, as defined in the Act, shall include in their rates the indirect costs
incurred in provision of goods or performance of services under this contract pursuant to the
nonprofit organization's unexpired Negotiated Indirect Cost Rate Agreement (NICRA). If a
nonprofit organization does not have an unexpired NICRA, the nonprofit organization may elect
to instead include in its rates its indirect costs:
(1) As calculated using a de minimis rate of 10% of all direct costs under this contract;
(2) By negotiating a new percentage indirect cost rate with the awarding agency;
CW133988 Child and Adolescent Supplemental Security Income Program

5
(3) As calculated with the same percentage indirect cost rate as the nonprofit organization
negotiated with any District agency within the past 2 years; however, a nonprofit
organization may request to renegotiate indirect costs rates in accordance with B.4.2; or
(4) As calculated with a percentage rate and base amount, determined by a certified public
accountant, as defined in the Act, using the nonprofit organization's audited financial
statements from the immediately preceding fiscal year, pursuant to the OMB Uniform
Guidance, and certified in writing by the certified public accountant.
B.4.2. If this contract is funded by a federal agency, indirect costs shall be consistent with the
requirements for pass-through entities in 2 C.F.R. § 200.331, or any successor regulations.
B.4.3. The Contractor shall pay its subcontractors which are nonprofit organizations the same indirect
cost rates as the nonprofit organization subcontractors would have received as a prime
contractor.

CW133988 Child and Adolescent Supplemental Security Income Program

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SECTION C: SPECIFICATIONS/WORK STATEMENT

C.1 BACKGROUND

C.1.1 DHCF is the single state agency with the responsibility for implementation and
administration of the District of Columbia’s Medicaid (Title XIX of the Act) and the CHIP -
Title XXI of the Act.

C.1.2 The District has created a unique managed care program for children and adolescents with
Special Health Care Needs, the District CASSIP. CASSIP Enrollees receive comprehensive
coverage of health care services through a structured care management program for physical
health, behavioral health, nursing home care, ICF/IID and residential treatment services.
Enrollment into CASSIP is voluntary.

C.1.3 The maximum target population under the Contract is 7,500 Enrollees. DHCF may, at its
discretion and following federal law, add additional cohorts to CASSIP.

C.1.4 Children with Special Health Care Needs differ from adults with similar diagnoses in a
variety of ways that impact how they are dealt with in a managed care environment.1 First,
children have different needs at different developmental stages, and those developmental
stages may be affected by their illness, condition, or disability. As a result, these children
often see an array of both pediatric and adult healthcare providers and require intensive Care
Coordination and Case Management. Second, in children, many of the disabling conditions
are very rare, making it more difficult and expensive to “manage” their care and its
concomitant costs. Third, children’s health and development are directly related to their
family’s health and socioeconomic status.

C.1.5 Due to the specific and oftentimes complicated disorders and diagnoses of CASSIP
Enrollees, it is essential that each Enrollee and his/her family receive intensive Care
Management and referrals to community-based organizations throughout their childhood
and adolescence, including during transition from pediatric to adult health care. All high-
quality aspects of care management shall be Family-Centered Care, outcomes-focused and
data-driven. Communication with and education of the family shall be frequent and
communication among each Enrollee’s team of Providers shall be routine and thorough.

C.2 DEFINITIONS

These terms, when used in this RFP, have the following meanings:

C.2.1 Abandoned - A child who is found and whose parent, guardian, or custodian is known or
unknown and has abandoned the child, in that he or she has made no reasonable effort to
maintain a parental or custodial relationship with the child for at least four weeks and
understands what it means to abandon a child.

C.2.2 Abuse - Abuse means provider practices that are inconsistent with sound fiscal, business, or
medical practices, and result in an unnecessary cost to the Medicaid program, or in
reimbursement for services that are not Medically Necessary or that fail to meet

1 Kastner TA, et al. Managed Care and Children with Special Health Care Needs. Pediatrics.2004; 114: 1693-1698.
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professionally recognized standards for health care. It also includes beneficiary practices
that result in unnecessary costs to the Medicaid program.

C.2.3 Access - As it pertains to external quality review, means the timely use of services to
achieve optimal outcomes, as evidenced by managed care plans successfully demonstrating
and reporting on outcome information for the availability and timeliness elements defined
under § 438.68 (Network adequacy standards) and § 438.206 (Availability of services).

C.2.4 Actuary - An individual who meets the qualification standards established by the American
Academy of Actuaries for an actuary and follows the practice standards established by the
Actuarial Standards Board. In this part, Actuary refers to an individual who is acting on
behalf of the District when used about the development and certification of capitation rates.

C.2.5 Actuarially Sound Capitation Rates - Rates that have been developed following generally
accepted actuarial principles and practices that are projected to provide for all reasonable,
appropriate and attainable costs that are required under the terms of the contract and for the
operation of the MCO for the period and the population covered under the terms of the
contract; and have been certified as meeting the requirements of regulation by actuaries who
meet the qualification standards established by the American Academy of Actuaries and
follow the practice standards established by the Actuarial Standards Board.

C.2.6 Acuity - The measurement of the intensity of care management that is assigned to a CASSIP
Enrollee to estimate member to care manager staffing levels, minimum frequency of
assessment & care planning, and the scope of care management service based on an
Enrollee’s needs. Acuity is based on Assessment, is subject to change, and is defined as
below:

C.2.6.1 Level 1 Acuity (Low) - A CASSIP Enrollee who is determined, by an assessment, to
utilize few medical or behavioral health services, has an established PCP relationship, is
in a stable family environment whose family is generally successful in obtaining
services, has access to an appropriate level of services, no hospitalization related to the
primary condition required, and has a basic knowledge of his/her condition and how to
access care.

C.2.6.2 Level 2 Acuity (Intermediate) - A CASSIP Enrollee who is determined, by an
assessment, to have a chronic medical condition and while medically stable, may require
visits to multiple specialists and or linkage to community and social resources. He/she
may be a moderate-low risk for victimization, has an established or is establishing a PCP
relationship, is generally compliant but requires additional intervention, motivation,
and/or education. The member requires assistance with transportation and may be
vulnerable to ER visits due to gaps in services or outstanding health care needs. The
patient and/or caregiver has a general knowledge of the member’s condition and needs
education reinforcement regarding routine health care needs and access to services.

C.2.6.3 Level Three Acuity (High) - A member with acute or complex needs, co-morbidity, and
recent ER/Inpatient utilization. This member is medically fragile and requires multiple
visits to specialists. He/she may be a danger to self or others and may have a high
potential for volatile situations. Member may have had multiple providers or no provider
intervention and/or non-compliant with his/her Care Coordination Plan or has a complex
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treatment in progress. Family dynamics may be complex and/or crisis-oriented. The
caregiver may be unable to support the member. The member may have complex
transportation needs with significant barriers to care and/or significant compliance
problems. The member may have been hospitalized one or more times for his/her
condition in the past 12 months and have had one or more ER visits for his/her condition
or complication in the past six months. The member and his/her caregiver may have little
knowledge about his/her condition with education barriers present. The member and/or
caregiver needs education regarding access to services.

C.2.7 American Academy of Pediatrics (AAP) - The American Academy of Pediatrics (AAP) is
a professional organization of pediatricians dedicated to the optimal health, safety, and well-
being of infants, children, adolescents, and young adults, providing advocacy, education,
policy guidance, research, and resources for its members and the public.

C.2.8 Adolescent - A person who has undergone puberty but has not reached maturity, usually,
between the ages of 11-21 years.

C.2.9 Adjudicated Claim - A claim that has been processed for payment or denial.

C.2.10 Adjustments to Smooth Data - Adjustments made by cost-neutral, across rate cohort
categories, to compensate for distortions in costs, utilization, or the number of eligible
individuals. Adjustments to Smooth Data will not have any applicability to the price
evaluation described in Section M.

C.2.11 Administrative Cost - All operating costs of the Contractor, including Care Coordination,
but excluding medical costs.

C.2.12 Adults with Special Health Care Needs - An adult aged 21 and older: 1) who has a
chronic, physical, developmental, or behavioral condition in accordance 42 C.F.R. §
438.208; 2) who receives SSI, or 3) whose disabilities meets the SSI definition. This
definition includes, but is not limited to, individuals who self-identify as having a disability
and/or Enrollees identified by DHCF.

C.2.13 Advance Directive - As defined in 42 C.F.R. § 489.100, a written instruction, such as a
living will or durable power of attorney for health care, recognized under District of
Columbia law (whether statutory or as recognized by the courts of the District), relating to
the provision of health care when the individual is incapacitated.

C.2.14 Adverse Benefit Determination - In the case of a Contractor or any of its Providers,
Adverse Benefit Determination means any of the following per 42 C.F.R. § 438.400:

C.2.14.1 The denial or limited authorization of a requested service, including determinations
based on the type or level of service, requirement for medical necessity, appropriateness,
setting, or effectiveness of a covered benefit;
C.2.14.2 The reduction, suspension, or termination of a previously authorized service;
C.2.14.3 The denial, in whole or in part, of payment for a service;
C.2.14.4 The failure to provide services promptly as defined by the District; or
C.2.14.5 The failure of the Contractor to act within the timeframes for the resolution and
notification of Grievances and Appeals; and
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C.2.14.6 The denial of an enrollee's request to dispute a financial liability, including cost-sharing,
copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.

C.2.15 Adverse Event – Under DC Law 16-263, an adverse event is defined as an event,
occurrence, or situation involving the medical care of a patient by a health care provider that
results in death or an unanticipated injury to the patient. D.C. Law 16-263.

C.2.16 Affiliate - Any individual, corporation, partnership, joint venture, trust, unincorporated
organization or association, or other similar organization, controlling, controlled by or under
common control with the Contractor or its parent(s), whether such common control is direct
or indirect. Without limitation, all officers, or persons, holding five percent (5%) or more of
the outstanding ownership interests of the Contractor or its parent(s), Directors or
subsidiaries of the Contractor or parent(s) shall be presumed to be affiliates for purposes of
the Contract.

C.2.17 Alternative Services - During the term of the Contract, the Contractor may Cover services
or settings that are in place of services or settings covered under the Medicaid State plan
provide that are in addition to those covered under the Medicaid State Plan as alternative
treatment services and programs for enrolled members under 42 C.F.R. § 438.6(e).

C.2.17.1 The cost of alternative services will not be included in capitated rate calculations. The
District will only factor State Plan services into the rates plus any adjustments for
managed care efficiency. The Contractor shall perform a cost-benefit analysis for any
new services it proposes to provide, as directed by the District, including how the
proposed service would be cost-effective compared to the State Plan services. The
Contractor shall implement cost-effective services and programs only after approval by
the District.

C.2.18 Ambulatory Care Sensitive Conditions - Medical conditions for which timely and
effective ambulatory care may reduce or prevent the need for the hospital admission.

C.2.19 Applied Behavior Analysis (ABA) - Principles and techniques used in the assessment,
treatment, and prevention of challenging behaviors and the promotion of new desired
behaviors as delivered by a Board-Certified Behavior Analyst (BCBA), Other Licensed
Provider (OLP), or a Registered Behavior Technician (RBT) under the appropriate
supervision.

C.2.20 Appeal – Under 42 C.F.R. § 438.400, a review by an MCO of an Adverse Benefit
Determination.

C.2.21 Assertive Community Treatment (ACT) - An intensive, integrated, rehabilitative, crisis,
treatment, and community -based service provided by an interdisciplinary team to
individuals 18 and over with serious and persistent mental illness with dedicated staff time
and specific staff- to-consumer ratios, as defined in 22 DCMR § 3426.1.

C.2.22 Attachment Point - Insurance claim amount above which the extra coverage, bought in
addition to the primary coverage, comes into effect.

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C.2.23 Average Commercial Rate - The average rate paid for services by the highest claiming
third-party payers for specific services as measured by claims volume.

C.2.24 Behavioral Health Services - The umbrella term for the evaluation and/or treatment of
mental health conditions (including psychiatric illnesses and emotional disorders) and
substance use disorders (involving addictive and chemical dependency disorders). The term
also refers to preventing and treating co-occurring mental health conditions and substance
use disorders (SUDs).

C.2.25 Beneficiary - An individual who is eligible for medical assistance under a State plan or
waiver under title XIX of the Social Security Act.

C.2.26 Bonus - A payment the Contractor makes to a physician or physician group beyond any
salary, fee-for-service payments, capitation, or returned withholding amount.

C.2.27 Business Associate Agreement (BAA) - is a contract between a Health Insurance
Portability and Accountability Act (HIPAA) covered entity and a business or individual that
performs certain functions or activities on behalf of, or provides a service to, the covered
entity when the function, activity, or service involves the creation, receipt, maintenance, or
transmission of Protected Health Information (PHI) by the business or individual.

C.2.28 Business Day - Any day other than a Saturday, Sunday, or holiday recognized by the federal
government or the District.

C.2.29 Capitation Payment - A payment the District makes periodically to a Contractor on behalf
of each beneficiary enrolled under a contract and based on the Actuarially Sound Capitation
Rate for the provision of services under the State Plan. The District makes the payment
regardless of whether the Enrollee receives services during the period covered by the
payment.

C.2.30 Care Coordination - Services and activities that ensure all Medicaid Enrollees gain access
to necessary medical, social, and other health-related services (including education related
health services) as described in section C.5.146.

C.2.31 Care Plan - Refers to a multidisciplinary plan of care required for each CASSIP Enrollee,
irrespective of Line of Business (LOB). It includes specific services to be delivered, the
frequency of services, expected duration, community resources, Contractor interventions, all
funding options, treatment goals, and assessment of the Enrollee’s environment. The Care
Plan is updated according to acuity, and as described in section C.5.160. Care Plans are
developed in collaboration with the Enrollee and/or Guardian/personal representative,
attending physician, other specialists, and/or other District Agencies.

C.2.32 Care Management - Refers to the deliberate, planned, and consistent set of activities
intended to improve Enrollee care and reduce the need for unnecessarily accessed medical
services by enhancing coordination of care (clinical and administrative), eliminating
duplication, and helping Enrollees and their caregivers more effectively manage health
conditions. The goals of Care Management are to improve quality, have dedicated
supportive services, and control costs for Enrollees with complex conditions.

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C.2.33 CASSIP Eligibility - The determination of whether an individual qualifies for voluntary
CASSIP enrollment. This determination is made by the DHCF. A CASSIP Eligible Enrollee
is a child or adolescent who is:

C.2.33.1 In the Base Year of the Contract, under age twenty-one ; and

C.2.33.2 Has one or more physical, mental, or developmental conditions that:
C.2.33.2.1 Either does or can be expected to result in the use of health services of a type or amount
beyond that required by children, adolescents generally; and
C.2.33.2.2 Requires a special need for increased Care Coordination and Case Management to a
degree that is not customarily provided in the District’s Fee for Service Program;
C.2.33.2.3 Falls into one of the following categories at the time of enrollment:
C.2.33.2.3.1 Is receiving SSI benefits; or
C.2.33.2.3.2 Has an SSI-Related Diagnoses (as this term is defined in Section C.2.256) as determined
by DHCF or its designee; or
C.2.33.2.3.3 Is under the custody of the Department of Youth Rehabilitation Services (DYRS) ; or
C.2.33.2.3.4 Is under the custody of the Child and Family Services Agency (CFSA) .

C.2.33.3 The District reserves the right to determine additional populations during the duration of
the awarded Contract.

C.2.34 Case Management Services - Case Management services are comprehensive services
furnished to assist Enrollees that are eligible under the State Plan with access to needed
medical, social, educational and other services through the following processes in
accordance with 42 C.F.R. § 440.169(d):

C.2.34.1 An assessment of an eligible individual;
C.2.34.2 A Comprehensive assessment and periodic reassessment of the Enrollee to determine the
need for any medical, educational, social or other services;
C.2.34.3 Development (and periodic revision) of a specific care plan based on information
collected through the assessments; and
C.2.34.4 Referral to services including the coordination of such services; and
C.2.34.5 Monitoring and follow-up activities to determine whether - (i) services are being
furnished by the individual’s care plan; (ii) services in the care plan are adequate; (iii)
there are changes in the needs or status of the eligible individual.

C.2.35 Cell and Gene Therapies - Treatments that can treat rare and severe diseases by altering a
patient's cells or DNA. These therapies can correct the underlying cause of a disease, treat
symptoms, and stop the disease from progressing.

C.2.36 Certified Nurse Midwife - A registered professional nurse with advanced training in
midwifery, who is licensed under the District of Columbia Health Occupations Regulatory
Act acting within the scope of practice and complies with the requirements following 42
C.F.R. § 440.165.

C.2.37 Certificate of Need (CON) - A document obtained from the D.C. State Health Planning and
Development Agency (SHPDA) authorizing an entity to establish a new institutional health
care service or to obligate a capital expenditure or take certain other actions as specified in
DC Official Code 44-401 et. seq. of the Health Services Planning Program Re-establishment
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Act of 1996, as amended, and the CON regulations (Title 22B, DC Municipal Regulations,
sec.4000, et. seq.). A CON is issued by SHPDA and must be renewed by application to
SHPDA.

C.2.38 Child and Adolescent Supplemental Security Income Program (CASSIP) - The
Medicaid managed care program specifically designed to provide comprehensive primary,
specialty, in-patient, behavioral health, and long-term care to SSI or SSI-eligible children
and adolescents.

C.2.39 Child and Family Services Agency (CFSA) - The District’s child welfare agency that
coordinates public and private partnerships to protect children against abuse and preserves
families in the District through foster care, adoption, and child welfare services. Formally
known as the LaShawn Receivership.

C.2.40 Children with Special Health Care Needs - A child under 21 who has a chronic, physical,
developmental, or behavioral condition and requires health and related services of a type or
amount beyond that which is required by children generally, including a child who receives
SSI, a child whose disabilities meets the SSI definition, a child in foster care and a child
with developmental delays or disabilities who needs special education and related services
under the Individuals with Disabilities Education Act.

C.2.41 Children’s Health Insurance Program (CHIP) - A health care benefit program
established by Title XXI of the Act and administered by the CMS, which makes funds
available to states that have in place federally approved programs providing health insurance
coverage to uninsured children, up to age 19 who do not meet the eligibility criteria for the
Medicaid program.

C.2.42 Choice Counseling - The provision of information and services designed to assist D.C.
Medicaid beneficiaries in making enrollment decisions; it includes answering questions and
identifying factors to consider when choosing between the voluntary managed care plan
organization, Fee-For-service (FFS), and primary care Providers. Choice Counseling does
not include making recommendations for or against enrollment into a specific MCO as
defined in 42 C.F.R. § 438.2.

C.2.43 Claim – Under 42 C.F.R. § 447.45, a bill for services, a line item of service, or all services
for one beneficiary within a bill.

C.2.44 Clean Claim – Under 42 C.F.R. § 447.45, a clean claim can be processed without obtaining
additional information from the Provider of the service or a third party. It includes a claim
with errors originating in the District’s claims system. It does not include a claim from a
Provider who is under investigation for fraud or abuse, or a claim under review for medical
necessity.

C.2.45 Committed - A child or adolescent who has been adjudicated or convicted in a criminal
prosecution, and is placed by the Court in the legal custody or under the guardianship of an
Agency of the District.

C.2.46 Community-Based Intervention (CBI) Services - Time-limited, intensive mental health
services delivered to children and youth ages six through 20 and intended to prevent the
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utilization of an out-of-home therapeutic resource or detention of the consumer, as defined
in 22 DCMR § 3422. CBI is primarily focused on the development of consumer skills to
promote behavior change in the child or youth’s natural environment and empower the child
or youth to cope with his or her emotional disturbance.

C.2.47 Community Support Services - Rehabilitation and environmental support considered
essential to assist a consumer in achieving rehabilitation and recovery goals. Community
support services focus on building and maintaining a therapeutic relationship with the
consumer, as defined in 22 DCMR § 3418. Community support is a core service.

C.2.48 Competent Professional Interpreter - An individual who is proficient in both English and
another language who has had orientation or training in the ethics of interpreting, the ability
to interpret accurately and impartially, and can interpret for medical encounters using
medical terminology in English and his/her other language.

C.2.49 Concurrent Review - A review to determine extending a previously approved, ongoing
course of treatment or number of treatments. Concurrent reviews are typically associated
with inpatient care, residential Behavioral Health care, intensive outpatient Behavioral
Health care, and ongoing ambulatory care.

C.2.50 Customer Satisfaction Surveys - Valid and reliable surveys that measure Enrollees’
satisfaction and experiences with Medicaid services and with specific aspects of those
services, to identify problems and opportunities for improvement.

C.2.51 Continuous Quality Improvement (CQI) - Methods to identify opportunities for ongoing
improvement of organizational performance, causes of poor performance, designing, testing,
and re-testing interventions, and implementing demonstrably successful interventions
system-wide.

C.2.52 Contract - The written agreement between the District and the Contractor, and comprises
the contract, any addenda, appendices, attachments, or amendments thereto.

C.2.53 Contractor - A MCO participating in the District’s CASSIP Program which includes any of
the MCO’s employees, Providers, agents, or contractors for the provision of comprehensive
health care services to Enrollees on a prepaid, capitated basis for a specified benefits
package to specified Enrollees.

C.2.54 Coordination of Benefits - The activities involved in determining Medicaid benefits when a
Medicaid Enrollee has coverage through an individual, entity, insurance, or program that is
liable to pay for health care services.

C.2.55 Copayment - A payment made by an Enrollee (especially for health services) in addition to
that made by a health plan.

C.2.56 Core Services Agency - Provider that contracts with the Department of Behavioral Health
to provide Mental Health Rehabilitation Services (MHRS) and/or specialty services such as
CBI and ACT.

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C.2.57 Counseling Services - Individual, group, or family face-to-face counseling (including
community-based) or psychotherapy services for symptom and behavior management,
development, restoration or enhancement of adaptive behaviors and skills, and enhancement
or maintenance of daily living skills.

C.2.58 Covered Entity - A covered entity is a healthcare provider, health plan or healthcare
clearinghouses that transmits electronic health care information, including payments,
insurance eligibility checks, claim status updates, and treatment authorizations.

C.2.59 Covered Services - The items and services, including transportation, care coordination, and
case management services described herein that, taken together, constitute the services that
the Contractor must provide to Enrollees under District and federal law. The term also
encompasses any additional items and services described by DHCF and/or Contractor as
being available to Enrollees.

C.2.60 Credentialing - The process of formal recognition and attestation of a Provider’s current
professional competence and performance through an evaluation of a Provider’s
qualifications and adherence to the applicable professional standard for direct patient care or
peer review. Credentialing verifies, among other things, a Provider’s license, experience,
certification(s), education, training, malpractice and adverse clinical occurrences, clinical
judgment, technical capabilities, and character by investigation and observation.

C.2.61 Credible Allegation of Fraud - A credible allegation of fraud may be an allegation, which
has been verified by the State, from any source, including but not limited to the following:
Fraud hotline complaints; Claims data mining; Patterns identified through provider audits,
civil false claims cases, and law enforcement investigations. Allegations are considered
credible when they have indicia of reliability and the State Medicaid agency has reviewed
all allegations, facts, and evidence carefully and acts judiciously on a case-by-case basis.

C.2.62 Crisis Plan - A plan developed by the Enrollee (if appropriate), the Enrollee’s family (when
relevant), and the Enrollee’s medical or Behavioral Health Provider(s) to guide the
immediate and ongoing management of medical or mental health and substance abuse crises
for which the Enrollee is at risk. In addition to conditions for Emergency Medical
Conditions, the Crisis Plan must cover mental health conditions which severely compromise
an individual’s ability to maintain his or her customary level of functioning, or which place
the individual at risk for harming self or others.

C.2.63 Crisis Services - Crisis Services respond to an individual with a new or established
behavioral health condition that is escalating in severity and risk. Crisis services can be to
avoid hospitalization or a first step in an admission or commitment process. Crisis services
include:

C.2.63.1 Comprehensive Psychiatric Emergency Program;
C.2.63.2 Psychiatric Crisis Stabilization Program;
C.2.63.3 Adult Mobile Crisis and Outreach Program;
C.2.63.4 Youth Mobile Crisis Intervention Program.

C.2.64 Cultural Competency - Skills, behaviors, and attitudes integrated into policies, procedures,
and practices to allow the Contractor to respond sensitively and respectfully to people of
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various cultures, primary spoken languages, races, ethnic backgrounds and religions, and
sexual orientations, and to communicate with them accurately and effectively to identify and
diagnose, treat and manage physical and behavioral health conditions through appropriate
plans for treatment and self-care.

C.2.65 Culturally Appropriate - The provision of care in a manner that is consistent with Cultural
Competence.

C.2.66 D.C. Health Care Alliance (Alliance) - A public program designed to provide medical
assistance to needy District residents who are not eligible for federally financed Medicaid
benefits. The Alliance provides comprehensive coverage of health care services for eligible
residents of the District.

C.2.67 Deliverables - Documents, records, analyses, and reports that shall be furnished to DHCF or
another District of Columbia agency (or an agent thereof) for review or approval on either a
one time or ongoing basis.

C.2.68 De minimis - Not significant, as determined by objective evidence evaluated by
professionals with the appropriate training, education, and skills to render judgment.

C.2.69 Denial of Services - An adverse decision in response to an Enrollee’s or Provider’s request
for the initiation, continuation, or modification of treatment. A denial may be either wholly
or partially adverse to the Provider or Enrollee. The failure to decide on a request for
treatment within the timeframes governed by the Agreement constitutes a denial of services.
A denial includes complete or partial disapproval of treatment requests, a decision to
authorize coverage for treatment that is different from the requested treatment, or a decision
to alter the requested amount, duration, or scope of treatment. A denial also constitutes an
approval that is conditioned upon acceptance of services in an alternative or different
amount, duration, scope, or setting from that requested by the Provider or Enrollee.
Approval of a requested service that includes a requirement for a concurrent review by the
Contractor during the authorized period does not constitute a denial. All denials are
considered Adverse Benefit Determinations for purposes of Grievances and Appeals.

C.2.70 Denied Claim - An adjudicated claim that either does not result in a payment obligation to a
Provider or which results in payment in an amount that is different from or less than the
amount sought by a Provider.

C.2.71 Department of Health Care Finance (DHCF) – is the agency responsible for the oversight
of the Contractor’s performance.

C.2.72 Department of Behavioral Health (DBH) - The State Behavioral Health Authority in the
District of Columbia tasked by statute, D.C. Official Code § 7-1141.06, with the
responsibility of regulating publicly funded Behavioral Health Services and supports for
District residents.

C.2.73 Department of Youth Rehabilitation Services (DYRS) - The Agency within the District
of Columbia Government responsible for the supervision, custody, and care of young people
charged with a delinquent act in the District in one of the following circumstances: Detained
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in a DYRS facility while awaiting adjudication or committed to DYRS by a DC Family
Court judge following adjudication.

C.2.74 Department of Health (DC Health) - The Agency within the District of Columbia
Government responsible for health risks educating the public on the: prevention and control
of diseases, injuries, and exposure to environmental hazards in the District of Columbia and
identified health risks that require a public response in D.C.

C.2.75 Department on Disability Services (DDS) - The Agency within the District of Columbia
Government responsible for overseeing and coordinating services for residents with
disabilities through a network of private and non-profit providers. DDS is composed of two
Administrations: Developmental Disabilities Administration (DDA) and Rehabilitation
Services Administration (RSA).

C.2.76 Developmental Delay - When a child does not reach their developmental milestones at the
expected times. It is an ongoing major or minor delay in the process of development. This
includes intellectual disability, hearing impairments (including deafness), speech or
language impairments, visual impairments (including blindness), serious emotional
disturbance, orthopedic impairments, autism, traumatic brain injury, other health
impairments, or specific learning disabilities.

C.2.77 Diagnostic Services - Any medical procedures or supplies recommended by a physician or
other licensed practitioner of the healing arts, within the scope of practice under District
law, to enable the physician or practitioner to identify the existence, nature, or extent of
illness, injury, or other health deviation in a beneficiary.

C.2.78 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) - The
2013 update to the Diagnostic and Statistical Manual of Mental Disorders (DSM) which is
the taxonomic and diagnostic tool published by the American Psychiatric Association
(APA).

C.2.79 Disease Management and Disease Management Programs - Multidisciplinary,
continuum-based approach to health care delivery that proactively identifies populations
with, or at risk for, established medical conditions. Disease management supports the
practitioner-patient relationship and plan of care and emphasizes prevention of
complications using cost-effective, evidence-based practice guidelines and patient
empowerment strategies such as self-management. The organization’s disease-specific or
condition-specific package of ongoing services and assistance includes education and
interventions.

C.2.80 Disenrollment - The process of changing enrollment from one Contractor to another,
changing enrollment from one Contractor to the DC Medicaid Fee for Service Program, or
termination from the DC Medicaid Program.

C.2.81 District - Refers to the Government of the District of Columbia.

C.2.82 District Holidays – Legal Public Holidays observed by the District of Columbia as listed by
the Department of Human Resources, https://dchr.dc.gov/page/holiday-schedules#gsc.tab=0,
including New Year’s Day, Inauguration Day, Dr. Martin Luther King, Jr’s Birthday,
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Washington’s Birthday, DC Emancipation Day, Memorial Day, Juneteenth National
Independence Day, Independence Day, Labor Day, Indigenous Peoples’ Day, Veterans day,
Thanksgiving Day, and Christmas Day.

C.2.83 District of Columbia Healthy Families Program (DCHFP) - A program that provides
health insurance to DC residents who meet certain income and U.S. citizenship criteria or
eligible immigration status to qualify for DC Medicaid.

C.2.84 District of Columbia State Plan for Medical Assistance (State Plan) - The State Plan is a
comprehensive written statement by the DHCF describing the nature and scope of its
Medicaid program and giving assurance that it will be administered in conformity with the
specific requirements of Title XIX regulations, and other applicable official issuances of the
U.S. Department of Health and Human Services. The State Plan contains all information
necessary for CMS to determine whether the State is approved for Federal Financial
Participation (FFP).

C.2.85 Dual Eligible - An individual who is enrolled in both Medicare and the DC Medicaid
Program.

C.2.86 Durable Medical Equipment (DME) - Medical equipment that can withstand repeated use,
is primarily and customarily used to serve a purpose consistent with the amelioration of
physical, mental, or developmental conditions that affect healthy development and
functioning, is generally not useful in the absence of a physical, mental, or developmental
health condition, and is appropriate for use in a home or community setting.

C.2.87 Early Intervention (EI) - Services that are provided through Part C of the Individuals with
Disabilities Education Act (20 U.S.C. § 1431 et seq.), as amended, and in accordance with
34 CFR § 303.13 , which are designed to meet the developmental needs of each child and
the needs of the family related to enhancing the child's development; and are provided to
children from birth to age three who have (i) a 25% developmental delay in one or more
areas of development, (ii) atypical development, or (iii) a diagnosed physical or mental
condition that has a high probability of resulting in a developmental delay.

C.2.88 Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Benefit -
The health benefit for individuals under age 21, combined with informational, scheduling
and transportation services required under federal law. The EPSDT benefit is defined in
1905(r) of the Act. The EPSDT benefit encompasses regularly scheduled assessments
beginning at birth and continuing through age 20 interperiodic (as needed) assessments
when a physical, developmental, or mental condition is suspected, comprehensive vision
care (including regularly scheduled and as-needed eye exams and eyeglasses), hearing care
(including regularly scheduled and as-needed exams and hearing aids and batteries), dental
care needed to treat emergencies, restore the teeth and maintain dental health and the items
and services outlined in Section 1905(a) of the Act that is needed to ameliorate or correct
any physical or mental condition identified through a periodic or inter-periodic assessment,
whether or not included in the District’s State Medicaid Plan.

C.2.89 Economic Security Administration (ESA) - District agency responsible for eligibility
determination for benefits under the Temporary Cash Assistance for Needy Families
(TANF), Medical Assistance, Supplemental Nutrition Assistance Program (SNAP)
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(formerly Food Stamps), Child Care Subsidy, Burial Assistance, Interim Disability
Assistance, Parent and Adolescent Support Services (PASS) and Refugee Cash Assistance
programs.

C.2.90 Eligibility Period - A period during which an Enrollee is eligible to receive CASSIP
benefits through enrollment in CASSIP. An eligibility period is indicated by the eligibility
start and end date, as determined by DHCF.

C.2.91 Emergency Medical Condition - A medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in the following as defined in 42 C.F.R. §
438.114; placing the health of the individual (or, for a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy; serious impairment to bodily functions;
serious dysfunction of any bodily organ or part.

C.2.92 Emergency Medical Transportation - Transportation services for an Emergency Medical
Condition.

C.2.93 Emergency Room (ER) Care - Treatment for an Emergency Medical Condition in a
hospital room or area staffed and equipped to provide emergency care services.

C.2.94 Emergency Service - Covered inpatient and outpatient services that are as follows as
defined in 42 C.F.R. § 438.114; furnished by a Provider that is qualified to furnish these
services under this Title; and needed to evaluate or Stabilize an Emergency Medical
Condition.

C.2.95 Encounter - An in-person or face-to face visit or service exchanged between a health care
or health- care-related service Provider and an Enrollee. An Encounter may also refer to a
report of a health care service provided to an Enrollee, created, and submitted to DHCF
following a specified manner and format.

C.2.96 Encounter Data (Enrollee) - The information relating to the receipt of any item(s) or
service(s) by an Enrollee under a contract between the District and the Contractor that is
subject to the requirements in 42 C.F.R. §§ 438.242 and 438.818.

C.2.97 Enrollee - An individual who is currently enrolled in CASSIP. Enrollee also refers to the
parent, legal guardian, or personal representative of the Enrollee in cases where the Enrollee
is a minor or incapacitated as determined by a court.

C.2.98 Enrollment - The process by which an eligible Enrollee’s entitlement to receive services
from a Contractor is initiated.

C.2.99 Enrollment Activities - Activities such as distributing, collecting, and processing
enrollment materials and taking enrollments by phone, in person, or through electronic
methods of communication as defined in 42 C.F.R. § 438.810.

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C.2.100 Evidence of Coverage - A DHCF-approved certificate, agreement, contract, or notification
issued to an Enrollee that sets forth the responsibilities of the Enrollee and services available
to the Enrollee.

C.2.101 Excluded Services - Health care services that are not covered by a health plan or the
Contractor.

C.2.102 Experimental Treatment - Diagnostic or treatment services that, following relevant
evidence, are not considered to fall within the range of professionally accepted clinical
practice for illness, disability, or condition that is the focus of a coverage determination.

C.2.103 External Quality Review (EQR) - The analysis and evaluation by an EQRO, of aggregated
information on quality, timeliness, and access to the health care services that an MCO entity
(described in 42 C.F.R. §438.310(c)), or their contractors furnish to Medicaid beneficiaries
as described in 42 C.F.R. §438.320.

C.2.104 External Quality Review Organization (EQRO) - An organization that meets the
competence and independence requirements outlined in 42 C.F.R. § 438.354, and performs
the external quality review, other EQR-related activities as outlined in 42 C.F.R. § 438.358,
or both.

C.2.105 Fair Hearing - An administrative process run by the District that gives applicants and
Enrollees the opportunity to contest Adverse Benefit Determinations regarding eligibility
and benefits as required under 42 C.F.R. § 431(E).

C.2.106 Family - The parents, foster parents, legal guardians, or relatives who serve as an Enrollee’s
primary caregiver.

C.2.107 Family-Centered Care - Best practice principles for the provision of medical, therapeutic,
and mental health care for children with Special Health Care or developmental needs.
Family-Centered Care establishes parents as the central beneficiaries of a team of
professionals that plan and implement services needed to address a child’s needs; build upon
the strengths of the family; recognize and address the impact of a child with Special Health
Care Needs on caregivers, siblings, and other family members; and arrange for services to
be provided in the home or other natural settings whenever possible.

C.2.108 Family Planning Services and Supplies - Any medically approved diagnostic procedure,
treatment, counseling, drug, supply, or device which is prescribed or furnished by a Provider
to individuals of childbearing age to enable such individuals to freely determine the number
and spacing of their children.

C.2.109 Federal Poverty Level (FPL) - The set minimum amount of gross income that a family
needs for food, clothing, transportation, shelter, and other necessities. In the United States,
this level is determined by the Department of Health and Human Services. FPL varies
according to family size.

C.2.110 Federally Qualified Health Center (FQHC) - Federally designated and financially
supported community-based primary health clinics that provide services to medically
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underserved areas. FQHCs are Medicaid Providers as defined by Section 1905(l)(A) that
receive funding under a Public Health Service (PHS) Act 330 grant.

C.2.111 Fee-for-Service (FFS) - Payment to Providers on a per-service basis for health care services
provided to Medicaid beneficiaries not enrolled in a Medicaid Managed Care Program.

C.2.112 Fiscal Agent - Any corporation or other legal entity that has contracted with the DHCF to
receive, process, and adjudicate claims under the Medicaid program.

C.2.113 Formulary - Under 42 U.S.C. § 1396r-8(d), the list of prescription drugs covered by the
Contractor without the need for an exception by DHCF.

C.2.114 Fraud - As defined in 42 C.F.R. § 455.2, an intentional deception or misrepresentation
made by a person with the knowledge that the deception could result in some unauthorized
benefit to himself or some other person. It includes any act that constitutes fraud under
applicable federal, or District law.

C.2.115 Full-time Employee - For a calendar month, an employee is employed on average at least
30 hours per week, or 130 hours per month.

C.2.116 Grievance - An oral or written expression of dissatisfaction about any matter other than an
Adverse Benefit Determination. Grievances may include but are not limited to, the quality of
care or services provided and aspects of interpersonal relationships, such as rudeness of a
Provider or employee or failure to respect the Enrollee’s right, regardless of whether
remedial action is requested. Grievance includes an Enrollee’s right to dispute an extension
of time proposed by the MCO to make an authorization decision.

C.2.117 Grievance and Appeal System - Under 42 C.F.R. § 438.400, the processes the MCO
implements to handle Appeals of an Adverse Benefit Determination and Grievances, as well
as the processes to collect and track information about them.

C.2.118 Guardian - A person with legal responsibility for providing the care and management of an
incapable person, either due to age (below the legal age of consent) or due to a physical,
mental, or emotional impairment, of administering his or her affairs.

C.2.119 Habilitation Services and Devices - Health care services and devices that help an
individual acquire, keep, learn, or improve skills and functioning for communication and
daily living.

C.2.120 Health Care Professional - A physician or any of the following: a podiatrist, optometrist,
chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist,
therapist assistant, speech-language pathologist, audiologist, registered or practical nurse
(including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist,
and Certified Nurse Midwife), license certified social worker, registered respiratory
therapist, certified respiratory therapy therapist, and any other professional licensed or
certified by the D.C. Health Occupations Regulatory Act, D.C. Code § 3– 1201.01 et seq.
and regulations promulgated thereunder.

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C.2.121 Health Education - Consciously constructed opportunities for learning, involving some
form of communication designed to improve health literacy, including improving knowledge
and developing life skills, which are conducive to individual and community health. Health
education is not limited to the dissemination of health-related information, but also fostering
the motivation, skills, and confidence (self-efficacy) necessary to take action to improve
health, as well as the communication of information concerning the underlying social,
economic, and environmental conditions impacting on health, as well as individual risk
factors and risk behaviors and use of the health care system.

C.2.122 HealthCheck Provider - Health care Providers identified as routinely furnishing
Health/EPSDT Check screening services.

C.2.123 HealthCheck -See “EPSDT”. The well-child screen/visit required under EPSDT is
commonly referred to as a Health Check visit.

C.2.124 HealthCheck Provider Training Module - A web-based EPSDT Provider training
developed by Georgetown University’s National Center for Education in Maternal and Child
Health in collaboration with DHCF and the Medicaid Managed Care Contractors. The
HealthCheck Provider Training Module is based on the Bright Futures guidelines and
materials and has been tailored to the needs of the DC Provider community. The
HealthCheck Provider Training Module satisfies the EPSDT and IDEA Provider training
requirements of HealthCheck Providers described throughout Section C.5.50. Successful
completion of the HealthCheck Provider Training Module shall provide HealthCheck
Provider Providers a maximum of five hours in category, one credit towards the AMA
Physician’s Recognition Award, paid for by the Contractors. The HealthCheck Provider
Training Module is managed and maintained by Georgetown University.

C.2.125 Health Home (HH) - A service delivery model that focuses on providing individualized,
person-centered recovery-oriented case management and care coordination consistent with
standards under Section 2703 of the Patient Protection and Affordable Care Act and District
Standards.

C.2.126 Health Home Provider - A Provider that meets the standards developed by DHCF to fulfill
the federal requirements for DHCF’s health home programs.

C.2.127 Health Home Services - Addresses the full spectrum of individuals’ health needs (i.e.,
primary care, Behavioral Health, specialty services, long-term care services, and supports).
There are seven types of core HH services which includes the following:

C.2.127.1 Comprehensive Case Management
C.2.127.2 Care Coordination
C.2.127.3 Health Promotion
C.2.127.4 Comprehensive Transitional Care
C.2.127.5 Individual and Family Support Services
C.2.127.6 Referral to Community
C.2.127.7 Social Support Services

C.2.128 Health Insurance - A contract that requires a health plan to pay some or all of an
individual’s health care costs.
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C.2.129 Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Federal
legislation establishing health insurance portability and coverage protections for qualified
individuals and authorizes the promulgation of federal regulations related to health
information privacy, health information security, information simplification, and the transfer
of electronic health information among health care payers, plans, Providers and certain third
parties. HIPAA also refers to the federal regulations promulgated in at 45 C.F.R. § 160-164.

C.2.130 Health Maintenance Organization (HMO) - A District of Columbia licensed risk bearing
entity which combines health care delivery and financing, and which furnishes and arranges
for Covered Services to an Enrollee for a fixed, prepaid fee.

C.2.131 Health Promotion - The process of enabling people to increase control over, and to
improve, their health. It moves beyond a focus on individual behavior towards a wide range
of social and environmental interventions.

C.2.132 HEDIS® (Healthcare Effectiveness Data and Information Set) - A set of performance
measures developed by the National Committee for Quality Assurance (NCQA) to measure
the quality of health care furnished by health plans. Please see https://www.ncqa.org/hedis/.

C.2.133 High-Risk Newborn - Any Newborn who, based on objective evidence, including the
professional opinion of treating clinicians and experts, is presumed to have experienced a
complicated prenatal course of development and is either experiencing or is considered at
risk for elevated morbidity or mortality during infancy and early childhood (up to age three).
Conditions considered to create “high risk” status per se are severe prematurity (gestational
age before 32 weeks at the time of birth), congenital abnormalities, genetic syndromes,
malignancies, acute and chronic infections, prolonged Neonatal Intensive Care Unit (NICU)
stay and departure from health norms at the time of birth regardless of etiology.

C.2.134 Home Health Care - Health care services that can be provided in the home for an illness or
injury.

C.2.135 Home-Visiting Outreach - Home visit to newborns by a RN licensed by the District Health
Occupations Regulatory Act and its implementing regulations. At the time of the home visit,
the nurse shall review home records, educate parents and caregivers about the importance of
immunizations, assist with scheduling provider appointments, and follow up to determine
whether the provider appointment was attended.

C.2.136 Hospice - Services to provide comfort and support for persons in the last stages of a
terminal illness and their families.

C.2.137 Hospitalization - Admission to a hospital for treatment.

C.2.138 Hospital Outpatient Care - Care in a hospital that usually does not require an overnight
stay.

C.2.139 Immigrant Child - As defined in 29 DCMR § 7399, any child who is ineligible for
Medicaid by the child's immigration status.

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C.2.140 Immigrant Children’s Program (ICP) - Under 29 DCMR § 57A00, a health coverage
program that is offered to children under age 21, who are not eligible for Medicaid due to
citizenship or immigration status who meet the income guidelines as determined by the
Economic Security Administration (ESA). The beneficiaries enrolled in the ICP are only
eligible for medical services when enrolled in a MCO.

C.2.141 Incentive Arrangement - A compensation arrangement that is intended to improve
Contractor performance by rewarding or penalizing performance.

C.2.142 Independent Contractor - Any person or organization that the Contractor has contracted
with or delegated some of its functions, services or its responsibilities for providing medical
or allied care, goods or services; or its claiming or claims preparation or processing
functions or responsibilities, including but not limited to Providers.

C.2.143 Indian, or referred to as Indigenous Person or Native American - An individual, defined
at title 25 of U.S.C. § 1603, 1603(28). 1679(a) or who has been determined eligible, as an
Indian, under 42 C.F.R. §136.12 of Title V of the Indian Health Care Improvement Act, to
receive health care services from Indian health care Providers (IHS, an Indian Tribe, Tribal
Organization, or Urban Indian Organization–I/T/U) or through referral under Contract
Health Services.

C.2.144 Indian Health Services or referred to as Indigenous Health Services - A health care
program, including a Contracted Health Service, operated by the IHS or by an Indian Tribe,
Tribal Organization, or Urban Indian Organization (otherwise known as an I/T/U) as those
terms are defined in § 4 of the Indian Health Care Improvement Act (25 U.S.C. §1603).

C.2.145 Individual and Family Support - Services that support the individual and their support
team (including family and authorized representatives) in meeting their range of
psychosocial needs and accessing resources, such as medical transportation and other
available benefits.

C.2.146 Individuals with Disabilities Education Act (IDEA) - Federal law governing the rights of
infants and toddlers to receive Early Intervention (EI) and the educational rights of school
age children and youth with education-related disabilities.

C.2.147 Individualized Education Program (IEP) - A legally binding document for each child
with a disability that describes the educational program that has been designed to meet that
child's unique needs following the IDEA that is developed, reviewed, and revised in a
meeting per 34 C.F.R. § 300.320 through 300.324.

C.2.148 Individualized Family Service Plan (IFSP) - A legally binding document that guides the
EI process for children with disabilities and their families following the IDEA.

C.2.149 In Loco Parentis - Of, relating to, or acting as a temporary guardian or caretaker of a child,
taking on all or some of the responsibilities of a parent.

C.2.150 Inpatient Mental Health Service - Residence and treatment provided in a psychiatric
hospital or unit licensed or operated by the District of Columbia.

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C.2.151 Intellectual Disabilities (ID) - Replaces the term “mental retardation.” On October 5, 2010,
signed into law as “Rosa’s Law.” Individuals with intellectual disabilities have substantive
developmental limitations in the areas of intellectual (cognitive) functioning, self-care skills,
verbal and non-verbal language, functional academics, social skills, capacity for independent
living, and health/safety awareness.

C.2.152 Intensive Day Treatment - Facility-based, structured, intensive mental health, and
coordinated acute treatment program which serves as an alternative to acute inpatient
treatment or as a step-down service from inpatient care. Its duration is time limited.
Intensive Day Treatment is provided in an ambulatory setting.

C.2.153 Intensive Outpatient Program Services (IOP) - A structured, intensive, mental health
outpatient treatment program that serves as a step up from outpatient services or a stepdown
service from inpatient hospital care, intensive day services, or partial Hospitalization.
Services are rendered by an interdisciplinary team to provide stabilization of psychiatric
impairments to patients that typically cannot be stabilized with outpatient therapy.

C.2.154 Interactive Voice Response System (IVR) - The information system maintained by the
District of Columbia Economic Security Administration allows Providers to verify the
eligibility status of Medicaid, Alliance, CASSIP, and ICP beneficiaries. IVR instructions can
be found in Attachment J.20.

C.2.155 Intermediate Care Facility for Individuals with Intellectual Disability (ICF/IID) -
Under 42 CFR § 435.1010, an institution that meets federal Conditions of Participation
(CoP) and has as its primary purpose the provision of health or rehabilitation services to
individuals with an intellectual disability or related conditions receiving care and services
under the Medicaid program. The ICF/ID CoP recognizes the developmental, social, and
behavioral needs of individuals with intellectual disability who live in residential settings by
requiring that each individual both require and receive active treatment for the ICF/IID care
to be eligible for Medicaid funding. Services include a protected residential setting, ongoing
evaluation, diagnosis, treatment, planning, 24 hour supervision, coordination, and
integration of health or rehabilitative services to help each function at his/her greatest
ability.

C.2.156 Interpreter - An individual proficient in both English and another language, who, has had
orientation or training in the ethics of interpreting, interprets accurately and impartially, and
can interpret for medical Encounters using medical terminology in English and his/her other
non-English language.

C.2.157 Involuntary Disenrollment - The termination of an Enrollee’s participation in CASSIP
and the Contractor under conditions permitted in Section C.5.36.

C.2.158 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) -
National organization that sets accreditation standards for hospitals and other health care
organizations and conducts periodic reviews to determine conformance with standards.

C.2.159 Katie Beckett (See also Tax Equity and Fiscal Responsibility Act (TEFRA), C.2.265) -
Category of Medicaid eligibility authorized under § 1902(e) of the Social Security Act for
certain children aged 0-18 years old who have long-term disabilities or complex medical
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needs. It allows children to be served at home by the family with additional supports, instead
of in an institution. Under TEFRA/Katie Beckett, only the child’s income and resources are
considered for Medicaid eligibility (not those of the parents). Children enrolled in D.C.
Medicaid in the TEFRA eligibility pathway receive the same covered services as all children
enrolled in D.C. Medicaid.

C.2.160 Limited or No English Proficiency Individual - An individual whose primary language is
a language other than English, and as a result, does not speak, read, write, or understand the
English language at a level that permits effective interaction with Contractor or its Provider
network.

C.2.161 Long-Term Services and Supports (LTSS) - Services and supports provided to
beneficiaries of all ages who have functional limitations and/or chronic illnesses that have
the primary purpose of supporting the ability of the beneficiary to live or work in the setting
of their choice, which may include the individual's home, a worksite, a provider-owned or
controlled residential setting, a nursing facility, or other institutional settings.

C.2.162 Low Birth Weight - A Newborn weighing under 2,500 grams or 5 lbs. 8 oz.

C.2.163 Managed Care Eligible - District residents who have been determined eligible for
Medicaid in an eligibility category that requires them to participate in the DCHFP Medicaid
Managed Care Program by enrolling in an MCO. This also refers to individuals who are
eligible for voluntary CASSIP enrollment.

C.2.164 Managed Care Enrollment File - A monthly report submitted by the District to the
Contractor identifying eligible beneficiaries enrolled with the Contractor.

C.2.165 Managed Care Organization (MCO)/ Managed Care Plan (MCP) - An entity that has,
or is seeking to qualify for, a comprehensive risk or shared risk contract that is:

C.2.165.1 A Federally qualified HMO that maintains written policies and procedures that meet the
advance directive requirements of 42 C.F.R. Part 489, Subpart I; or

C.2.165.2 Any public or private entity that:
C.2.165.2.1 Makes the services it provides to Enrollees as accessible in terms of timeliness, amount,
duration, and scope as those services are to other Medicaid beneficiaries in the District;
C.2.165.2.2 Meets the solvency standards defined in 42 C.F.R. § 438.116; and
C.2.165.2.3 Complies with the requirements of the D.C. HMO Act, D.C. Code § 31-3401 et seq.

C.2.166 Management Information System (MIS) - Computerized or other systems for collection,
analysis, and reporting of information needed to support management activities.

C.2.167 Manager - Contractor’s staff member who has decision-making authority, and is
accountable, for the performance of a major function or department.

C.2.168 Marketing - Any communication between a representative of CASSIP and a CASSIP
Eligible Enrollee, identified by DHCF, who is not enrolled in CASSIP that can reasonably
be interpreted as intended to influence the recipient to enroll in CASSIP. Marketing does not
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include communication to a Medicaid beneficiary from the issuer of a qualified health plan,
as defined in 45 C.F.R. §155.20, about the qualified health plan.

C.2.169 Marketing Activities - Activities conducted by the Contractor that involve Marketing or
during which Marketing may occur.

C.2.170 Marketing Materials - Materials produced in any medium, by or on behalf of a Contractor,
that a reasonable person would interpret as intended to market to potential Enrollees.

C.2.171 Material Adjustment - Material adjustment means an adjustment that, using reasonable
actuarial judgment, has a significant impact on the development of the capitation payment
such that its omission or misstatement could impact a determination whether the
development of the capitation rate is consistent with generally accepted actuarial principles
and practices.

C.2.172 Material Change - Include any change of the size or composition of services, coverage,
procedures, Provider network, or any change that could be expected to affect Enrollees’
access to care.

C.2.173 Medicaid - A program established by Title XIX of the Act that provides payment of medical
expenses for eligible persons who meet income and/or other criteria.

C.2.174 Medicaid Managed Care Program (MMCP) - A program for the provision and
management of specified Medicaid services through contracted MCO. MMCP was
established under the Medicaid Managed Care Amendment Act of 1992, effective March 17,
1992 (D.C. Law 9 247, D.C. Code § 1-307.02) as amended.

C.2.175 Medicaid Management Information System (MMIS) - A federally required mechanized
claims processing and information retrieval system. The objectives of the system and its
enhancements include the Title XIX program control and administrative costs; service to
beneficiaries, Providers, and inquiries; operations of claims control and computer
capabilities; and management reporting for planning and control.

C.2.176 Medicaid-Reimbursable Emergency Medical Services - Services that meet the definition
of 42 C.F.R. § 440.225 that are rendered after the sudden onset of an Emergency Medical
Condition.

C.2.177 Medical Loss Ratio - The allowed medical expenses for the Covered Services provided to
Enrollees under the Contract divided by the number of net capitation payments or revenues
recorded by the Contractor.

C.2.178 Medical Record - Documents, whether created or stored in paper or electronic form, which
correspond to and contain information about the medical health care, or allied care, goods,
or services furnished in any place of service. The records may be on paper or electronic.
Medical records must be dated, signed, or otherwise attested to (as appropriate to the media)
and be legible.

C.2.179 Medically Necessary - Services for individuals that promote normal growth and
development and prevent, diagnose, detect, treat, ameliorate the effects or a physical,
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mental, behavioral, genetic, or congenital condition, injury, or disability and following
generally accepted standards of medical practice, including clinically appropriate, in terms
of type, frequency, extent, site, and duration and considered effective for the Enrollee’s
illness, injury, disease, or physical or mental health condition.

C.2.180 Member Month - A period consisting of a single Enrollee who is enrolled in CASSIP for
one month.

C.2.181 Mental Health and Substance Use Disorder Services (SUDS) - Treatment for mental
disorders, emotional disorders, chemical dependency, addiction, persistent unwanted use of
substances, and co-occurring disorders. .

C.2.182 Mileage and Travel Time Standards - A source of treatment within five miles of an
Enrollee’s residence or no more than 30 minutes Travel Time by public transportation,
unless specified in the Contract.

C.2.183 Monthly Capitation Payment - A fixed payment made by the District monthly to a
contractor for each Rate Cohort under the Contract for the provision of medical services
under CASSIP. DHCF makes the fixed payment regardless of whether an Enrollee receives
services during the month covered by the capitation payment. The Monthly Capitation
Payment only applies to the individual currently enrolled in CASSIP, not the parent, legal
guardian, or personal representative.

C.2.184 Multi-Systemic Therapy - An intensive model of treatment based on empirical data and
evidence-based interventions that target specific behaviors with individualized behavioral
interventions, as defined in 22 DCMR § 3422.

C.2.185 National Committee on Quality Assurance (NCQA) - An independent 501(c) nonprofit
organization in the United States that works to improve health care quality through the
administration of evidence-based standards, measures, programs, and accreditation.

C.2.186 Net Worth - The residual interest in the assets of an entity that remains after deducting its
liabilities.

C.2.187 Network - All contracted or employed Providers in the health plan that are providing
Covered Services to Enrollees.

C.2.188 Network Provider (Participating Provider) - Any Provider, group of Providers, or entity
that has a Provider Network Provider Agreement with the Contractor, or a subcontractor,
and receives Medicaid funding directly or indirectly to order, refer, or render Covered
Services as a result of the District’s contract with the CASSIP Contractor. A Network
Provider is not a subcontractor by the Provider Network Provider Agreement.

C.2.189 Never Events - Reportable errors in medical care that are of concern to both the public and
health care professionals and Providers, clearly identifiable and measurable (and thus
feasible to include in a reporting system), and of a nature such that the risk of occurrence is
significantly influenced by the policies and procedures of the Contractor and the DHCF.

C.2.190 Newborn - A live child born to an Enrollee during eligibility under the CASSIP.
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C.2.191 Non-CASSIP Enrollee (Formerly attributed as Well-Child) - Newborn(s) born to
CASSIP enrolled women who are not diagnosed with any special health care need(s). Non-
CASSIP enrollment may last up to the age of six but the Non-CASSIP Enrollee shall be
disenrolled the same month the CASSIP enrolled mother is no longer enrolled due to
disenrollment, aging-out, or other eligibility changes.

C.2.192 Non-Participating Provider - A Provider that is not a member of the Contractor’s Provider
network.

C.2.193 Notice of Adverse Benefit Determination - Under 42 C.F.R. § 438.400 et seq. and 29
DCMR § 9508, a Notice of Adverse Benefit Determination is a written notice of a decision
by a Contractor to:

C.2.193.1 Authorize, deny, terminate, suspend, reduce or delay requested services for a specific
Enrollee;
C.2.193.2 Approve or deny a Grievance; or
C.2.193.3 Approve or deny an Appeal; and
C.2.193.4 The Date of the Notice of Adverse Benefit Determination shall be the date that the
Notice of Adverse Benefit Determination is mailed, as evidenced by the postmark on the
envelope.

C.2.194 Nursing Facility - A facility that is licensed as a nursing home under the requirements
outlined in the “Health Care and Community Residence License Act of 1983, effective
February 24, 1984 (D.C. Law 5-48; D.C. Official Code § 44-501 et seq.) and meets the
federal conditions of participation for nursing facilities in the Medicaid program as outlined
in 42 C.F.R. Part 483.

C.2.195 Ombudsman – An entity that engages in an impartial and independent investigation of
individual Grievances, advocates on behalf of consumers, and issues recommendations. This
function may be operated by an organization independent of the Contractor or by a
designated and appropriately delineated and empowered unit in a government agency.

C.2.196 Out-of-Network Provider - An individual or entity that does not have a written Provider
Agreement with a Contractor and, therefore, is not identified as a member of the
Contractor’s network.

C.2.197 Outpatient - A patient of an organized medical facility or distinct part of that facility who
is expected by the facility to receive and who receives professional services for less than a
24 hour period regardless of the hour of admission, whether or not a bed is used, or whether
or not the patient remains in the facility past midnight.

C.2.198 Outreach - Activities performed by the Contractor, or its designee, to contact its Enrollees
and their families, and to communicate information, monitor the effectiveness of care,
encourage the use of Medicaid resources and treatment compliance, and provide education.

C.2.199 Overpayment - Any payment made to a Network Provider by a Contractor to which the
Network Provider is not entitled under Title XIX of the Act, or any payment to a Contractor
by DHCF to which the Contractor is not entitled to under Title XIX of the Act.
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C.2.200 Patient Protection and Affordable Care Act (PPACA) - A federal statute addressing
several aspects of health care reform including health insurance coverage, health insurance
exchanges, insurance subsidies for individuals and families, payment for these new
proposals, Medicare and Medicaid reform, the individual mandate, employer mandate, and
bans illegal immigrant participation from subsidy programs.

C.2.201 Partial Hospitalization Program (PHP) - A facility–based, structured, intensive, and
coordinated psychiatric treatment program that serves as a step up from outpatient services
or as a step-down service for inpatient care, rendered by an interdisciplinary team to provide
stabilization of psychiatric impairments.

C.2.202 Persons with Related Conditions - Under 42 C.F.R. § 435.1010, individuals who have a
severe, chronic disability that meets all the following conditions:

C.2.202.1 Is attributable to cerebral palsy, epilepsy, or any other condition other than mental
illness, found to be closely related to intellectual disability because this condition results
in impairment of general intellectual functioning or adaptive behavior similar to that of
intellectual disability and requires treatment or services similar to those required for
these persons;

C.2.202.2 It is manifested before the person reaches the age of 22;

C.2.202.3 It is likely to continue indefinitely;

C.2.202.4 It results in substantial functional limitations in three or more of the following areas of
major life activities:

C.2.202.4.1 Self-care;
C.2.202.4.2 Understanding and use of language;
C.2.202.4.3 Learning;
C.2.202.4.4 Mobility;
C.2.202.4.5 Self-direction; and
C.2.202.4.6 Capacity for independent living.

C.2.203 Peer - Individuals with lived experience of the healthcare system, including but not limited
to mental health or substance use disorder treatment, as defined in 22A DCMR 7399.

C.2.204 Personal Care Aide (PCA) – An individual who provides services through a Provider
agency to assist the patient in activities of daily living (i.e., bathing, dressing, toileting,
ambulation, or eating)

C.2.205 Physician Incentive Plan – Under 42 C.F.R. § 422.208, any compensation arrangement to
pay a physician or physician group that may directly or indirectly have the effect of reducing
or limiting the services provided to any plan Enrollee.

C.2.206 Physician Services - Health care services a licensed medical physician (M.D. – Medical
Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

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C.2.207 Potential Criminal Event – Potential Criminal Event is defined as the following: any
instance of care ordered by or provided by someone impersonating a physician, nurse,
pharmacist, or other licensed healthcare providers; abduction of a patient/resident of any
age; sexual abuse/assault on a patient or staff member within or on the grounds of a
healthcare setting; or Death or serious injury of a patient or a staff member resulting from a
physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting.

C.2.208 Post Stabilization Services - Covered Services, related to an Emergency Medical Condition
that is provided after an Enrollee is Stabilized to maintain the Stabilized condition, or, under
the circumstances described in 42 C.F.R. § 438.114 to improve or resolve the Enrollee's
condition.

C.2.209 Potential Enrollee - A Medicaid beneficiary who is subject to mandatory enrollment or
may voluntarily elect to enroll in a given MCO, Prepaid Inpatient Health Plan (PIHP),
Prepaid Ambulatory Health Plan (PAHP), Primary Care Case Manager (PCCM) or PCCM
entity, but is not yet an enrollee of a specific MCO, PIHP, PAHP, PCCM, or PCCM entity.
Potential Enrollee can also refer to a D.C. Medicaid beneficiary who is CASSIP Eligible and
may elect to voluntarily enroll in CASSIP with the Contractor.

C.2.210 Potential Payments - The maximum payments possible to physicians or physician groups,
including payments for services they furnish directly, and additional payments based on use
and costs of referral services, such as withholds, bonuses, capitation, or any other
compensation to the physician or physician group. Bonuses and other compensation that are
not based on the use of referrals, such as quality of care furnished, patient satisfaction, or
committee participation, are not considered payments in the determination of Substantial
Financial risk.

C.2.211 Premature Birth - A birth less than 37 weeks of gestation.

C.2.212 Premium - A premium is a sum of money paid regularly to a health plan for health care
coverage.

C.2.213 Prescription Drug Coverage - Health insurance or plan that helps pay for prescription
drugs and medications.

C.2.214 Prescription Drugs - A pharmaceutical drug that legally requires a medical prescription to
be dispensed.

C.2.215 Preventive Services - Services recommended by a physician or other licensed practitioner
of the healing arts acting within the scope of authorized practice under District law to
prevent disease, disability, and other health conditions or their progression; prolong life;
and promote physical and behavioral health.

C.2.216 Primary Care - Medical and health care items and services that are lawful under District
law and that are of the type customarily furnished by or through a licensed medical
professional considered to be a member of a primary care specialty, such as a general family
practice, family medicine, internal medicine, obstetrics and gynecology, and pediatrics.

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C.2.217 Primary Care Physician (PCP) - A board-certified or board-eligible physician who has a
contract with a Managed Care Plan to furnish primary care and case management services to
Contractors. A physician with a specialty in general practice, pediatrics,
obstetrics/gynecology, internal medicine, family medicine, or any other specialty the
Contractor designates in accordance with Section C.5.101 may serve as a PCP. A clinic
may also serve as a PCP.

C.2.218 Primary Dental Provider (PDP) - A dental professional who provides comprehensive oral
health care by treating dental concerns and diseases and promotes prevention and oral health
literacy.

C.2.219 Primary Source Verification - Credentialing procedures for the review and verification of
original documents submitted for credentialing, including confirmation of references,
appointments, and licensure from licensing authorities.

C.2.220 Prior Authorization or Preauthorization (Authorization) - The process used to determine
whether to approve a treatment request involving services covered under the Contract. (See
also “Service Authorization”)

C.2.221 Protected Health Information (PHI) is identifiable health information that is created,
collected, maintained, or transmitted by or to a covered entity, whose access and use is
regulated by HIPAA.

C.2.222 Provider - Under 42 C.F.R. § 400.203, any individual or entity that is engaged in the
delivery of health care services or ordering or referring for those services, and is legally
authorized to do so by the State in which it delivers the services.

C.2.223 Provider Agreement - Any DHCF-approved written subcontract, between the Contractor
and a Provider to provide medical or professional services to Enrollees to fulfill the
requirements of the Contract. Provider Agreements shall incorporate all subcontracting
requirements contained in the Contract.

C.2.224 Psychiatric Residential Treatment Facility (PRTF) - Under 42 C.F.R. §483.352, a
facility, other than a hospital, that provides inpatient psychiatric services to individuals
under age 21.

C.2.225 Qualified Family Planning Provider (QFPP) - Any public or not-for-profit health care
Provider that complies with Title X guidelines and standards and receives Title X funding.

C.2.226 Rate Cell - Capitation rates are usually separately developed and paid in individual
capitation rate cells based on characteristics that cause costs to differ materially. Examples
of these characteristics include age, gender, qualifying event (for example, maternity
delivery), geographic region, Medicaid eligibility group, eligibility for Medicare benefits,
diagnosis, or risk adjustment factors, and MCO differences.

C.2.227 Readily Accessible - Readily accessible means electronic information and services which
comply with modern accessibility standards such as Section 508 guidelines, Section 504 of
the Rehabilitation Act, and W3C's Web Content Accessibility Guidelines (WCAG) 2.0 AA
and successor versions.
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C.2.228 Referral Services - Any specialty, inpatient, outpatient, or laboratory services that a
physician or physician group orders, arranges, or recommends, but does not furnish directly.

C.2.229 Rehabilitation Services and Devices - Health care services that help a person keep, get
back, or improve skills and functioning for daily living that has been lost or impaired
because a person was sick, hurt, or disabled.

C.2.230 Rejected Claim - A claim that has erroneously been assigned a unique identifier and is
removed from the claims processing system before adjudication.

C.2.231 Remittance Advice - A written explanation accompanying payment to a Provider indicating
how the payment is to be applied.

C.2.232 Residential Treatment Facility - 24-hour treatment facility primarily for children with
significant behavioral problems who need long-term treatment.

C.2.233 Respite Services - Pre-scheduled services intended to relieve the beneficiary’s primary
caregiver to provide a range of activities associated with the PCA’s role in accordance with
29 DCMR §4232.2.

C.2.234 Retrospective Review - Determination of the appropriateness or necessity of services after
they have been delivered, generally through the review of the medical or treatment record.

C.2.235 Reversal Void - An MCO transmitted nullification of a previously submitted encounter with
no intent to correct or resubmit the encounter. A Reversal Void must be electronically
submitted to the District at the time of the next scheduled submission day following the
recouped payment.

C.2.236 Risk - The potential for financial loss, which is assumed by an MCO, that arises when the
cost of providing care, goods, or services threatens to exceed the capitation or other payment
made by DHCF to the MCO under the terms of the Contract.

C.2.237 Risk Assessment - An assessment process based on comprehensive relevant and reliable
evidence, including medical records, patient interviews in appropriate settings, consultation
with treating health professionals, and other means for assessing health care risk, to
determine whether an Enrollee needs a particular set of treatments and interventions related
to the risk assessment.

C.2.238 Risk-Based Capital (RBC) - A method of measuring the minimum amount of capital
appropriate for a reporting entity (MCOs and CASSIP) to support its overall business
operations in consideration of its size and risk profile.

C.2.239 Risk Contract - A contract under which the Contractor assumes the risk for the cost of the
services covered under the Contract and incurs financial loss if the cost of furnishing the
services exceeds the payments under the contract.

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C.2.240 Risk Corridor - A risk-sharing mechanism in which the District and the Contractor may
share in profits and losses under the contract outside of a predetermined threshold amount,
under 42 C.F.R § 438.6.

C.2.241 Risk Pool - A specific fund whose proceeds shall be shared among Contractors and/or
Providers using a defined formula based on certain indicators such as enrollment, utilization,
outcomes, and/or financial experience during the year.

C.2.242 Risk Threshold - The maximum risk, if the risk is based on referral services, to which a
Physician Incentive Plan without being at Substantial Financial Risk. This is set at a 25%
risk.

C.2.243 Salazar Consent Decree - Since 1993, a Settlement Agreement - In October 2025, a
Settlement Agreement was filed in Salazar v. District of Columbia. Pending final approval
by the Court, the Settlement Agreement will vacate the consent decree that has governed
how the District provides "EPSDT" services under the Social Security Act from a ruling in
Salazar, et al. v. DC, et al., (Civil Action No. 93-452). See Attachment J.36 for MCO
responsibilities under the Consent Decree. Settlement Agreement. See Attachments J.19 and
J.22 for historical information on Salazar v. District of Columbia.

C.2.244 School-Based Health Center - A health care site located on school building premises that
provide, at a minimum, on-site, age-appropriate primary and preventive health services with
parental consent, to children in need of primary health care.

C.2.245 Screening Services - The use of standardized tests given under medical direction in the
mass examination of a designated population to detect the existence of one or more
particular diseases or health deviations or to identify for more definitive studies individuals
suspected of having certain diseases.

C.2.246 Service Authorization (Authorization) - A determination made by the Contractor to
approve a Provider’s or an Enrollee’s request for treatment involving one or more covered
items or services under the Contract. (See also “Prior Authorization”)

C.2.247 Service Authorization Request - A request by a Provider or Enrollee for treatment
involving one or more Covered items and Services under the Contract.

C.2.248 Severe Mental Illness (SMI) - Diagnosable mental, behavioral, or emotional disorder
(including those of biological etiology) which substantially impairs the mental health of the
person or is of sufficient duration to meet diagnostic criteria specified within the DSM-V or
International Statistical Classification of Diseases and Related Health Problems, 10th
Revision (ICD-10-CM) equivalent (and subsequent revisions) except for DSM-V “V” codes,
substance use disorders, intellectual disabilities, and other developmental disorders, or
seizure disorders, unless those exceptions co-occur with another diagnosable mental illness.

C.2.249 Shall - Indicates a mandatory requirement or a condition to be met.

C.2.250 Single Case Agreement - A contractual agreement between the Contractor and a Provider
to provide a specific and time-limited health service to an Enrollee. The Provider is usually
not a participant in the D.C. Medicaid provider network.
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C.2.251 Skilled Nursing Care - Services from licensed nurses provided in a home or a nursing
home. Skilled care services are from technicians and therapists in a home or a nursing home.

C.2.252 Social Security Act (the Act) - An Act to provide for the general welfare by establishing a
system of Federal old-age benefits, and by enabling the several States to make more
adequate provisions for aged persons, blind persons, dependent and crippled children,
maternal and child welfare, public health, and the administration of their unemployment
compensation laws; to establish a Social Security Board; to raise revenue; and for other
purposes.

C.2.253 Specialist - A physician specialist focuses on a specific area of medicine or a group of
patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A
non-physician specialist is a provider who has more training in a specific area of health care.

C.2.254 Stabilize - Under 42 C.F.R. §489.24, to provide such medical treatment of the condition
necessary to ensure, within reasonable medical probability, that no material deterioration of
the condition is likely to result from or occur during the transfer of the individual from a
facility or that, concerning an “Emergency Medical Condition” as defined in this section
under paragraph of that definition, the woman has delivered the child and the placenta.

C.2.255 Start Date - The first date which Enrollees are eligible for Covered Services under the
Contract, and on which the Contractor is operationally responsible and financially liable for
providing Medically Necessary Services to Enrollees.

C.2.256 Sub-capitation - A method of compensating a Provider in the Contractor’s network on a per
member/per month basis for some or all the services the Provider provides. This method
may pass on a portion of the risk to Providers.

C.2.257 Subcontract - Any written agreement between the Contractor and another party that
requires the other party to provide services or items that the Contractor is obligated to
furnish under the Contract. Subcontracts shall incorporate the requirements found in
Sections H.9 and I.7.

C.2.258 Subcontractor - An individual or entity that has a contract with the Contractor that relates
directly or indirectly to the performance of the Contractor’s obligations under its contract
with the District. A network provider is not a subcontractor by the network provider
agreement with the Contractor.

C.2.259 Substance Use Disorder Services (SUDS) - Management and care of a patient suffering
from alcohol or drug abuse, a condition which is identified as having been caused by that
abuse, or both, to reduce or eliminate the adverse effects upon the patient.

C.2.260 Substantial Financial Risk - Risk for referral services that exceeds the 25% risk threshold.

C.2.261 Sui Juris - Having full legal rights or capacity as in the case of emancipated minors.

C.2.262 Supplemental Security Income (SSI) - A cash welfare assistance program authorized
under Title XVI of the Act for individuals who meet conditions of eligibility related to age,
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disability, financial need, and other matters. SSI beneficiaries are automatically entitled to
Medicaid without a separate application under the D.C. Medicaid program.

C.2.263 Supplemental Security Insurance -Related - A Medicaid eligibility category consisting of
individuals who would qualify for SSI, but for the failure to meet one or more SSI eligibility
criteria, as determined by DHCF or its designee.

C.2.264 Temporary Assistance for Needy Families (TANF) - The cash welfare assistance program
under Title IV-A of the Social Security Act provides cash assistance to families with
children who meet its eligibility requirements

C.2.265 Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) - (See Katie Beckett,
C.2.159). Category of Medicaid eligibility authorized under 1902(e) of the Social Security
Act for certain children aged 0-18 years old who have long-term disabilities or complex
medical needs that would qualify for institutionalized care. Children eligible through the
Katie Beckett waiver are eligible for the same Medicaid benefits as other children on
Medicaid. Parental income, resources, and assets are not considered for eligibility
determination. Children enrolled in D.C. Medicaid in the TEFRA eligibility pathway receive
the same covered services as all children enrolled in D.C. Medicaid.

C.2.266 Telemedicine - A service delivery model that delivers healthcare services through a two-
way, real-time interactive video audio communication for evaluation, diagnosis,
consultation, or treatment.

C.2.267 Termination - Discontinuation of the Contract for any reason before the expiration date, as
described in Attachment J.1, the Government of the District of Columbia Standard Contract
Provisions for Use with the Supplies and Services Contracts (July 2010).

C.2.268 Third-Party Liability (TPL) - An insurance issuer, health plan, or other legally liable third-
parties who is responsible for payment for some or all the cost of covered items and services
under the Contract. The term third-party liability encompasses all forms of insurance
(health, life, disability, auto, accidental death, and dismemberment), employer sponsored
health benefit plans, workers’ compensation, tortfeasors, and estates. TPL recovery
procedures are governed by 42 C.F.R. Part 433, Subpart D, and described in Section
C.5.210.

C.2.269 Timely - A Grievance or Appeal that is filed by or on behalf of an Enrollee following
applicable time frames as defined in Section C.5.196.

C.2.270 Timely Interpreter Services – Oral interpretation services that meet the following
standards:

C.2.270.1 For Emergency Services or Urgent Care Services, Contractor shall ensure that all
Providers furnish or arrange for the furnishing of free oral interpreter services on a 24
hour, seven day a week basis immediately after a request for such services is made by or
on behalf of an Enrollee with limited English proficiency; or a determination by the
treating Provider that the Enrollee requires such services.

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C.2.270.2 For Non-Emergency Services, Contractor shall furnish, or arrange for the furnishing of
free oral interpreter services to any Enrollee with limited English proficiency:

C.2.270.2.1 At the time a scheduled appointment begins; or
C.2.270.2.2 Within one hour of the time an unscheduled appointment is requested by or on behalf of
the Enrollee with limited English proficiency.

C.2.271 Total Contract Value – The monetary worth of the goods and services provided including
any modifications and changes.

C.2.272 Transitional Enrollment Period – The first 60 days in which an Enrollee is newly enrolled
in the Contractor’s plan.

C.2.273 Transportation Services (Non-Emergency) – The mode of transportation that is
appropriate to an Enrollee’s medical needs. Acceptable forms of transportation include, but
are not limited to bus, subway, or taxi vouchers, wheelchair vans, and ambulances.

C.2.274 Travel Time – The time required in transit to travel to a source of treatment from the
Enrollee’s residence. Travel Time does not include the time that is spent waiting for the
arrival of regularly scheduled public vehicles (i.e., bus or metro) but does include waiting
times for specially arranged modes of transportation, including wheelchair vans,
ambulances, and taxis.

C.2.275 Technical Assistance (TA) - Programs, activities, services, and resources provided by
Managed Care Plans, DHCF or designated vendors to provide specialized support to
providers to enhance capacity, improve performance, and/or address specific needs. TA may
involve but not limited to transfer of knowledge, skills, or resources.

C.2.276 Triple Aim - A framework developed by the Institute for Healthcare Improvement for
optimizing health system performance by focusing on the health of populations, the
experience of care for individuals within populations, and the per capita cost of health care.

C.2.277 Urgent Medical Care - The diagnosis and treatment of a medical condition, including
mental health and/or substance use disorder which is severe and/or painful enough to cause a
prudent layperson possessing an average knowledge of medicine to believe that the
condition requires medical evaluation or treatment within 24 hours to prevent serious
deterioration of the individual’s condition or health. The Contractors shall provide Urgent
Medical Care within 24 hours of an Enrollee’s request.

C.2.278 Urgent Medical Condition - A condition, including a mental health and substance use
disorder, which is severe and/or painful enough to cause a prudent layperson possessing an
average knowledge of medicine to believe that the condition requires medical evaluation or
treatment within 24 hours to prevent serious deterioration of the individual’s condition or
health.

C.2.279 Utilization Management (UM)- An objective and systematic process for planning,
organizing, directing, and coordinating health care resources to provide Medically
Necessary, timely, and quality health care services in the most cost-effective manner.

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C.2.280 Utilization Review Criteria - Detailed standards, guidelines, decision algorithms, models,
or informational tools that describe the clinical factors to be considered relevant to making
determinations of medical necessity including, but not limited to, level of care, place of
service, the scope of service, and duration of service.

C.2.281 Value-Based Purchasing (VBP) - Linking provider payments to improved performance by
health care providers. This form of payment holds health care providers accountable for both
the cost and quality of care they provide. It attempts to reduce inappropriate care and to
identify and reward the best-performing providers.

C.2.282 Verification of Birth (VOB) - Form A form, provided by DHCF and completed by the
Contractor, that confirms a newborn’s birth.

C.2.283 Vital Documents - Following D.C. Code § 2-1931 et seq., notices, Grievance/Appeal forms,
enrollment, and outreach materials that inform individuals about their rights and eligibility
requirements for benefits and participation under the District’s services, programs, and
activities.

C.2.284 Void - MCO transmitted nullification of a previously submitted Encounter with the intent to
correct and resubmit the Encounter electronically.

C.2.285 Waiver - A process by which the District may obtain approval from CMS for an exception
to a federal Medicaid requirement(s).

C.2.286 Waste - Overutilization of services or other practices that, directly or indirectly, result in
unnecessary costs to the healthcare system,

C.2.287 Withhold Arrangement - Any payment mechanism under which a portion of a capitation
rate is withheld from a Contractor and a portion of or all the withheld amount will be paid to
the Contractor for meeting targets specified in a Contract. The targets for a Withhold
Arrangement are distinct from general operational requirements under the Contract.
Arrangements that withhold a portion of a capitation rate for noncompliance with general
operational requirements are a penalty and not a Withhold Arrangement.

C.2.288 Women’s Health - The branch of medicine that focuses on the treatment and diagnosis of
diseases and conditions that affect a woman's physical and emotional well-being.

C.2.289 ACRONYMS:

C.2.289.1 ACA - Affordable Care Act
C.2.289.2 APP – American Academy of Pediatrics
C.2.289.3 ADT - Admission, Discharge, and Transfer
C.2.289.4 CA - Contract Administrator
C.2.289.5 CAHPS® - Consumer Assessment of Health Plans Studies
C.2.289.6 CASSIP - Child and Adolescent Supplemental Security Income Program
C.2.289.7 CBI - Community-Based Intervention
C.2.289.8 CEO - Chief Executive Officer
C.2.289.9 CFO - Chief Financial Officer
C.2.289.10 C.F.R. - Code of Federal Regulations
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C.2.289.11 CFSA - Child and Family Services Agency
C.2.289.12 CHIP - Children’s Health Insurance Program
C.2.289.13 CIO - Chief Information Officer
C.2.289.14 CLIA - Clinical Laboratory Improvement Amendment
C.2.289.15 CMO - Chief Medical Officer
C.2.289.16 CMS - Centers for Medicare and Medicaid Services
C.2.289.17 CO - Contracting Officer
C.2.289.18 COO - Chief Operating Officer
C.2.289.19 CQI - Continuous Quality Improvement
C.2.289.20 CQO - Chief Quality Officer
C.2.289.21 DBH - District Department of Behavioral Health
C.2.289.22 DC - District of Columbia
C.2.289.23 DCHFP - District of Columbia Healthy Families Program
C.2.289.24 DCMR - District of Columbia Municipal Regulations
C.2.289.25 DCPS - District of Columbia Public Schools
C.2.289.26 DHCF - District Department of Health Care Finance
C.2.289.27 DHS - District of Columbia Department of Human Services
C.2.289.28 DISB - District Department of Insurance Securities and Banking
C.2.289.29 DME - Durable Medical Equipment
C.2.289.30 DRG - Diagnostic Related Group
C.2.289.31 DSLBD - District Department of Small Local Business Development
C.2.289.32 DSM - Diagnostic and Statistical Manual of Mental Disorders
C.2.289.33 DSM-V - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
C.2.289.34 DUR - Drug Utilization Review
C.2.289.35 DYRS - District Department of Youth Rehabilitative Services
C.2.289.36 ECHO - Experience of Care and Health Outcomes
C.2.289.37 EI - Early Intervention
C.2.289.38 EPSDT - Early and Periodic Screening, Diagnosis, and Treatment
C.2.289.39 EQR - External Quality Review
C.2.289.40 EQRO - External Quality Review Organization
C.2.289.41 ER - Emergency Room
C.2.289.42 ESA - Economic Security Administration
C.2.289.43 FFS - Fee-for-Service
C.2.289.44 FFP - Federal Financial Participation
C.2.289.45 FPL - Federal Poverty Level
C.2.289.46 FQHC - Federally Qualified Health Center
C.2.289.47 GAO - United States Government Accountability Office
C.2.289.48 GME - Graduate Medical Education
C.2.289.49 HAHSTA - HIV/AIDS, Hepatitis, STD and TB Administration
C.2.289.50 HCAC - Health Care Acquired Condition
C.2.289.51 HEDIS® - Healthcare Effectiveness Data and Information Set
C.2.289.52 HHA - Health Home Agencies
C.2.289.53 HHS - Health and Human Services
C.2.289.54 HIPAA - Health Insurance Portability and Accountability Act
C.2.289.55 HIV/AIDS - Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome
C.2.289.56 HMO - Health Maintenance Organization
C.2.289.57 ICFs/IID - Intermediate Care Facilities for Individuals with Intellectual Disabilities
C.2.289.58 ICP - Immigrant Children’s Program
C.2.289.59 IDEA - Individuals with Disabilities Education Act
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C.2.289.60 IDIQ - Indefinite Delivery Indefinite Quantity
C.2.289.61 IEP - Individualized Education Plan
C.2.289.62 IFSP - Individualized Family Services Plan
C.2.289.63 IMD - Institution of Mental Diseases
C.2.289.64 I/T/U - Indian Health, Tribal and Urban Indian Health
C.2.289.65 IVR - Interactive Voice Response System
C.2.289.66 JCAHO - Joint Commission on Accreditation of Healthcare Organizations
C.2.289.67 LANE - Low Acuity Non-Emergent ED Visit
C.2.289.68 LOB - Line of Business
C.2.289.69 LTSS - Long-term Services and Supports
C.2.289.70 MCAC - Medical Care Advisory Committee
C.2.289.71 MCO - Managed Care Organization
C.2.289.72 MD - Medical Doctor
C.2.289.73 MFCU - District of Columbia’s Medicaid Fraud Control Unit
C.2.289.74 MLR - Medical Loss Ratio
C.2.289.75 MMCP - Medicaid Managed Care Program
C.2.289.76 NAIC - National Association of Insurance Commissioners
C.2.289.77 NCQA - National Committee for Quality Assurance
C.2.289.78 NQTL - Non-quantitative Treatment Limit
C.2.289.79 NPI - National Provider Identifier
C.2.289.80 OB/GYN - Obstetrics/ Gynecology
C.2.289.81 OIG - Office of Inspector General (Federal)
C.2.289.82 OSSE - District Office of the State Superintendent of Education
C.2.289.83 PBM - Pharmacy Benefits Manager
C.2.289.84 PCA - Personal Care Aide
C.2.289.85 PCP - Primary Care Physician
C.2.289.86 PDP - Primary Dental Provider
C.2.289.87 PHI - Protected Health Information
C.2.289.88 PIP - Physician Incentive Plan or Performance Improvement Plan
C.2.289.89 PPACA - Patient Protection and Affordable Care Act (PPACA)
C.2.289.90 PPRTF - Patient Psychiatric Residential Treatment Facility
C.2.289.91 PRTF - Psychiatric Residential Treatment Facility
C.2.289.92 QAPI - Quality Assessment and Performance Improvement
C.2.289.93 RBC - Risk-Based Capital
C.2.289.94 RFP - Request for Proposal
C.2.289.95 RN - Registered Nurse
C.2.289.96 SDOH - Social Determinants of Health
C.2.289.97 SSI - Supplemental Security Income
C.2.289.98 SSA - Social Security Administration
C.2.289.99 SUDS - Substance Use Disorder Services
C.2.289.100 TEFRA - Tax Equity and Fiscal Responsibility Act of 1982
C.2.289.101 TPL - Third Party Liability
C.2.289.102 TTY/TDD - Teletypewriter /Telecommunications Device for the Deaf
C.2.289.103 UM - Utilization Management
C.2.289.104 VBP - Value Based Purchasing
C.2.289.105 VFC - Vaccines for Children

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C.2.290 Inpatient specialty facilities – are medical and behavioral health institutions with inpatient
capabilities for facility specialty types under 42 CFR 422.116(b)(2) which includes:

(i) Acute Inpatient Hospitals.
(ii) Cardiac Surgery Program.
(iii) Cardiac Catheterization Services.
(iv) Critical Care Services—Intensive Care Units (ICU).
(v) Surgical Services (Outpatient or ASC).
(vi) Skilled Nursing Facilities.
(vii) Diagnostic Radiology.
(viii) Mammography.
(ix) Physical Therapy.
(x) Occupational Therapy.
(xi) Speech Therapy.
(xii) Inpatient Psychiatric Facility Services.
(xiii) Outpatient Infusion/Chemotherapy.
(xiv) Outpatient behavioral health, which can include marriage and family therapists (as
defined in section 1861(lll) of the Act), mental health counselors (as defined in
section1861(lll) of the act), opioid treatment programs (as defined in section 1861(jjj)
of the act),community mental health centers (as defined in section 1861(ff)(3)(b) of the
act), or those of the following who regularly furnish or will regularly furnish
behavioral health counseling or therapy services including psychotherapy or
prescription of medication for substance use disorders; physician assistants, nurse
practitioners and clinical nurse specialists (as defined in section 1861(aa)(5) of the
Act); addiction medicine physicians; or outpatient mental health and substance use.
CW133988 Child and Adolescent Supplemental Security Income Program

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C.3 APPLICABLE DOCUMENTS

The following documents are applicable to this procurement and are hereby incorporated by this
reference:

Item
No.
Document
Type Title Date
1 Federal Law
Title XIX of the Social Security Act, the Medicaid Statute
https://www.govinfo.gov/content/pkg/USCODE-2010-
title42/html/USCODE-2010-title42-chap7-subchapXIX.htm
Most
Recent
2 Federal Law
Disclosure of Ownership and Related Information under
Section 1124 of the Act (42 U.S.C. 1320a-3)
https://www.govinfo.gov/content/pkg/USCODE-2023-
title42/pdf/USCODE-2023-title42-chap7-subchapXI-partA-
sec1320a-3.pdf
Most
Recent
3 Federal Law
Exclusion of Certain Individuals and Entities from
Participation in Medicare and State Health Care Programs
under Section 1128 of the Act (42 U.S.C. § 1320a-7)
https://www.ssa.gov/OP_Home/ssact/title11/1128.htm
Most
Recent
4 Federal Law
Civil Monetary Penalties under Section 1128A of the Act
(42 U.S.C. § 1320a-7a)
https://www.govinfo.gov/content/pkg/USCODE-2010-
title42/pdf/USCODE-2010-title42-chap7-subchapXI-partA-
sec1320a-7a.pdf
Most
Recent
5 Federal Law
Criminal Penalties for Acts Involving Federal Health Care
Programs under Section 1128B of the Act (42 U.S.C. §
1320a-7b)
https://www.govinfo.gov/app/details/USCODE-2023-
title42/USCODE-2023-title42-chap7-subchapXI-partA-
sec1320a-7b
Most
Recent
6 Federal Law
Standards for Information Transactions and Data Elements
under Section 1173 of the Act (42 U.S.C. § 1320d-2)
https://www.ssa.gov/OP_Home/ssact/title11/1173.htm
Most
Recent
7 State Contract
The District of Columbia State Plan for Medical Assistance
under Section 1902 of the Act (42 U.S.C. § 1396a)
https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publicatio
n/attachments/Amount%2C%20Duration%20and%20Scope
%20of%20Services%20Attachment%203.1F_0.pdf

Most
Recent
8 Federal Law
Examination and Treatment for Emergency Medical
Conditions and Women in Labor under Section 1867 of the
Act (42 U.S.C. 1395dd)
https://www.ssa.gov/OP_Home/ssact/title18/1867.htm
https://code.dccouncil.gov/us/dc/council/code/sections/1-
307.02
Most
Recent
CW133988 Child and Adolescent Supplemental Security Income Program

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Item
No.
Document
Type Title Date
9 Federal Law
Definitions under Section 1905 of the Act (42 U.S.C. §
1396d)
https://www.govinfo.gov/content/pkg/USCODE-2011-
title42/html/USCODE-2011-title42-chap7-subchapXIX-
sec1396d.htm
Most
Recent
10 Federal Law
Payment for Covered Outpatient Drugs under Section 1927
of the Act (42 U.S.C. § 1396r-8)
https://www.govinfo.gov/app/details/USCODE-2023-
title42/USCODE-2023-title42-chap7-subchapXIX-
sec1396r-8
Most
Recent
11 Federal Law
Terms and provisions of the waiver of federal law granted to
the District by the Secretary of Health and Human Services
under Section 1915(b) of the Act (42 U.S.C. § 1396n(b))
https://www.ssa.gov/OP_Home/ssact/title19/1915.htm
Most
Recent
12 Federal Law
Section 504 of the Rehabilitation Act (29 U.S.C. § 794)
https://www.govinfo.gov/app/details/USCODE-2023-
title29/USCODE-2023-title29-chap16-subchapV-
sec794/summary
Most
Recent
13 Federal Law
Americans with Disabilities Act (ADA) (42 U.S.C. § 12101
et seq.)
https://www.ada.gov/law-and-regs/ada/
Most
Recent
14 Federal Law
Confidentiality of Alcohol and Drug Abuse Patient Records
under 42 C.F.R. Part 2
https://www.ecfr.gov/current/title-42/chapter-I/subchapter-
A/part-2
Most
Recent
15 Federal Law
State Organization and General Administration under 42
C.F.R. Part 431
https://www.ecfr.gov/current/title-42/chapter-
IV/subchapter-C/part-431
Most
Recent
16 Federal Law
Federal Financial Participation under 42 C.F.R. Part 434
Subpart F and Implementing Federal Regulations under 42
C.F.R. § 434 et seq
https://www.ecfr.gov/current/title-42/chapter-
IV/subchapter-C/part-434/subpart-F
Most
Recent
17 Federal Law
Managed Care under 42 C.F.R. Part 438
https://www.ecfr.gov/current/title-42/chapter-
IV/subchapter-C/part-438
Most
Recent
18 Federal Law
Services: General Provisions under 42 C.F.R. Part 440 and
Services: Requirements and Limits Applicable to Specific
Services under 42 C.F.R. Part 441
https://www.ecfr.gov/current/title-42/chapter-
IV/subchapter-C/part-441
Most
Recent
19 Federal Law Payment for Services under 42 C.F.R. Part 447 Most
Recent
CW133988 Child and Adolescent Supplemental Security Income Program

43
Item
No.
Document
Type Title Date
https://www.ecfr.gov/current/title-42/chapter-
IV/subchapter-C/part-447
20 Federal Law
Provider Agreements and Supplier Approval under 42
C.F.R. Part 489
https://www.ecfr.gov/current/title-42/chapter-
IV/subchapter-G/part-489
Most
Recent
21 Federal Law
Program Integrity: Medicaid under 42 C.F.R. Part 455
https://www.ecfr.gov/current/title-42/chapter-
IV/subchapter-C/part-455?toc=1
Most
Recent
22 Federal Law
Section 2703 of the Patient Protection and Affordable Care
Act
https://www.dhcs.ca.gov/provgovpart/Documents/HealthHo
mes/ACA_Section_2703.pdf
Most
Recent
23 Federal Law
Uniform Administrative Requirements for Awards and
Subawards to Institutions of Higher Education, Hospitals,
Other Nonprofit Organizations and Commercial
Organizations 45 C.F.R. Part 74, including Appendix A –
Contract Provisions
https://www.govinfo.gov/app/details/CFR-2024-title45-
vol1/CFR-2024-title45-vol1-part74
Most
Recent
24 Federal Law
Substance Use Disorder Prevention that Promotes Opioid
Recovery and Treatment for Patients and Communities
(SUPPORT) Act
https://www.congress.gov/bill/115th-congress/house-bill/6
Most
Recent
25 Federal Law
Mental Health Parity and Addiction Equity Act of 2008; 29
U.S. C. § 1185a
https://www.govinfo.gov/app/details/USCODE-2023-
title29/USCODE-2023-title29-chap18-subchapI-subtitleB-
part7-subpartB-sec1185a
Most
Recent
26 Federal Law
District of Columbia Medical Assistance Program under
D.C. Code § 1-307.02
https://code.dccouncil.gov/us/dc/council/code/sections/1-
307.02
Most
Recent
27 District
Regulation
Conditions of participation applicable to Providers of
managed care services under District of Columbia
Municipal Regulation, Title 29, Chapters 53, 54, and 55
https://www.dcregs.dc.gov/Common/DCMR/RuleList.aspx?
ChapterNum=29-53
https://www.dcregs.dc.gov/Common/DCMR/RuleList.aspx?
ChapterNum=29-54
https://www.dcregs.dc.gov/Common/DCMR/RuleList.aspx?
ChapterNum=29-55
Most
Recent
28 Federal Law
Prompt Payment Act under D.C. Code § 31-3132
https://code.dccouncil.gov/us/dc/council/code/sections/31-
3132
Most
Recent
CW133988 Child and Adolescent Supplemental Security Income Program

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Item
No.
Document
Type Title Date
29 Federal Law Insurance and Securities, D.C. Code § Title 31
https://code.dccouncil.gov/us/dc/council/code/titles/31
Most
Recent
30 Federal Law
Health Maintenance Organizations, D.C. Code § 31-34 et
seq.
https://code.dccouncil.gov/us/dc/council/code/titles/31/chapt
ers/34
Most
Recent
31 Federal Law
Regulations to Prevent Spread of Communicable Disease
under D.C. Code §§ 7-131 and 7-132 and Title 22 of the
D.C. Code of Municipal Regulations
https://code.dccouncil.gov/us/dc/council/code/sections/7-
131
Most
Recent
32 Federal Law
Childhood Lead Poisoning Screening and Reporting
Legislative Review Emergency Act of 2002, D.C. Code § 7-
871.03
https://code.dccouncil.gov/us/dc/council/code/sections/7-
871.03
Most
Recent
33 Federal Law
Law on Examinations, D.C. Code § 31-1400 et seq.
https://code.dccouncil.gov/us/dc/council/code/titles/31/chapt
ers/14
Most
Recent
34 Federal Law
Newborns and Mothers’ Health Protection Act of 1996,
Section 2704 of the Public Health Service Act, USC 300gg-
4 and 29 USC 1185a, 63 Fed Reg 57545
https://www.govinfo.gov/content/pkg/CRPT-
104srpt326/html/CRPT-104srpt326.htm
Most
Recent
35 District
Regulation
22 DCMR § 33 (published at 48 D.C. Reg. 9140)
https://www.dcregs.dc.gov/Common/DCMR/RuleList.aspx?
ChapterNum=22-B33
Most
Recent
36 Federal Law
District of Columbia Mental Health Information Act, D.C.
Code §§ 7-1201.01 – 7- 1208.07
https://code.dccouncil.gov/us/dc/council/code/titles/7/chapte
rs/12
Most
Recent
37 Federal Law
District of Columbia Health Occupations Regulatory Act,
D.C. Code § 3-1200 et seq.
https://code.dccouncil.gov/us/dc/council/code/sections/3-
1201.02
Most
Recent
38 Federal Law
District of Columbia Language Access Act of 2004, D.C.
Code § 2-1931 et seq.
https://code.dccouncil.gov/us/dc/council/code/titles/2/chapte
rs/19/subchapters/II
Most
Recent
39 Federal Law
Drug Abuse, Alcohol Abuse, and Mental Illness Insurance
Coverage, D.C. Code § 31-31 et seq.
https://code.dccouncil.gov/us/dc/council/code/titles/31/chap
ters/31
Most
Recent
CW133988 Child and Adolescent Supplemental Security Income Program

45
Item
No.
Document
Type Title Date
40 Federal Law
D.C. Behavioral Health Parity Act of 2018; D.C. Code § 22-
242
https://code.dccouncil.gov/us/dc/council/laws/22-242
Most
Recent
41 Federal
Guidance
Guidance to Financial Assistance Beneficiaries Regarding
Title VI Prohibition against National Origin Discrimination
Affecting Limited English Proficient Persons published by
the Office for Civil Rights, United States Department of
Health and Human Services, available at:
https://www.hhs.gov/civil-rights/for-individuals/special-
topics/limited-english-proficiency/index.html
Most
Recent
42 Federal Law
Assisted Suicide Funding Restriction Act of 1997
https://uscode.house.gov/view.xhtml?path=/prelim@title42/
chapter138&edition=prelim
Most
Recent
43 Federal Law
Medicare Advantage Program Provisions under 42 C.F.R.
Part 422
https://www.ecfr.gov/current/title-42/chapter-
IV/subchapter-B/part-422
Most
Recent
44 Federal Law
Fiscal Year 2025 Budget Support Appropriations Act for
the District of Columbia, available at
https://code.dccouncil.gov/us/dc/council/acts/25-506
Most
Recent
45 Federal Law
Balanced Budget Act of 1997, P.L. 105-33
https://www.govinfo.gov/app/details/PLAW-
105publ33/summary
Most
Recent
46 Federal Law
Court orders pertaining to Salazar et al v.
The District of Columbia
https://media.cadc.uscourts.gov/opinions/docs/2018/07/16-
7065.pdf
Most
Recent

C.4 SCOPE

C.4.1 DHCF is seeking a Contractor to provide healthcare and pharmacy services to its Medicaid
and ICP eligible population enrolled in the District’s CASSIP.

C.4.2 The Contractor must comply with the State Plan including amendments, any Waivers, as
applicable, and approved by Centers for Medicare and Medicaid Services (CMS), including
sections 1115 and 1915 of the Act or under Section 2703 of the Protection and Affordable
Care Act (PPACA). The Contractor must:

C.4.2.1 Follow state and federal regulatory standards applicable to Medicaid MCOs, including,
but not limited to, 42 C.F.R. § 438 et seq;
C.4.2.2 Under C.F.R. 42 § 438.207, §438.68 and §438.206(c), have the capacity to serve the
expected enrollment as defined in Section B.3, and comply with the District’s standards
for timely access to care, as described in Section C.5.119;
C.4.2.3 Have the capacity to offer an appropriate range of preventive, primary care, specialty
services, and Long-Term Services and Supports (LTSS) that is adequate for the
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46
anticipated number of Enrollees for the District to the eligible CASSIP populations; and
C.4.2.4 Have a well-defined organizational structure with clearly assigned and documented
responsibilities for managing the CASSIP contract. At a minimum, the Contractor must:

C.4.2.4.1 Have a comprehensive design for the delivery of services to CASSIP Enrollees;
C.4.2.4.2 Submit complete, timely, and accurate Encounter Data from all participating Network
Providers and Out-of-Network Providers;
C.4.2.4.3 Submit complete data regarding Enrollee utilization of prescription drugs and services;
C.4.2.4.4 Comply with all Health Maintenance Organization (HMO) and District insurance
requirements, incorporated herein by reference;
C.4.2.4.5 Satisfy the specifications and criteria outlined in sections C and H, including the ability
to comply with all requirements related to External Quality Review (EQR);
C.4.2.4.6 Have a well-defined, organized, and clear care management and care coordination
program that is innovative and reliant on evidence-based standards of care for children
and adolescents with Special Health Care Needs.

C.4.3 The Contractor is responsible for diverse CASSIP Enrollees that receive Medically
Necessary services for physical health, behavioral health, nursing home care, Intermediate
Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), and residential
treatment services for complex medical needs with a consideration of how social factors
impact their overall health. CASSIP Enrollees include those at high risk or increased risk for
health care disparities.

C.4.4 The Contractor plays a vital role in achieving better health outcomes, fostering health care
innovation, and delivering high-quality, cost-effective care for its CASSIP enrollees. The
Contractor is responsible for strengthening the managed care delivery system for CASSIP
Enrollees.

C.4.5 The Contractor must adhere to the goals and objectives of DHCF to promote healthy
outcomes for children and adolescents with Special Health Care Needs. The Contractor
must:

C.4.5.1 Transform CASSIP into an organized, accountable, and person-centered system that best
supports the District’s Medicaid beneficiaries in managing and improving their health
care needs;
C.4.5.2 Align the structure, operations, and performance of managed care with the diverse range
of preventive, acute, and chronic health diseases, and conditions of CASSIP Enrollees;
C.4.5.3 Ensure that all Enrollees receive timely, appropriate, and coordinated care following
professionally accepted standards of care, within a health care system responsive to the
full spectrum of preventive, acute, chronic, and developmental health care needs;
C.4.5.4 Ensure that the diverse array of health care provided to each CASSIP Enrollee is
carefully planned, provided, and managed in an integrated, coordinated, and supportive
approach;
C.4.5.5 Improve and strengthen the performance of the District’s Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) Services Benefit to ensure that all CASSIP
Enrollees can benefit from the earliest possible health care interventions necessary to
correct or ameliorate identified physical or Behavioral Health conditions before they
affect healthy development;
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C.4.5.6 Ensure compliance with the Salazar Consent Decree Settlement Agreement
requirements as described in Attachment J.36 and Section C.5.48;

C.4.5.7 Improve and strengthen coordination of CASSIP with other educational, health,
community organizations, and social service systems serving Enrollees such as the
Individuals with Disabilities Education Act (IDEA), programs serving Enrollees with
certain chronic conditions such as HIV/AIDS, family planning services and supplies,
services for Behavioral Health and programs that manage communicable and infectious
diseases such as tuberculosis;

C.4.5.8 Encourage the establishment of culturally competent & sensitive, and linguistically
appropriate information and support activities for Enrollees representative of their native
language to promote Enrollee-involvement in their health care;

C.4.5.9 Assure a process of Continuous Quality Improvement (CQI) through the establishment
and use of benchmarks that link improvements in the delivery of health care to
improvements in the health status of CASSIP Enrollees;

C.4.5.10 Reward Provider performance through innovative compensation approaches such as
Value-Based Purchasing (VBP) and other Alternative Payment Models (APMs), which
align to specific financial incentives with measurable improvements in health outcomes,
care quality, patient satisfaction, and cost-efficiency;

C.4.5.11 Ensure that Enrollees, healthcare Providers, community organizations, policymakers,
and other stakeholders obtain timely, complete, and transparent information about
program performance;

C.4.5.12 Support the continued development and routine use and exchange of health information
technology, including an accurate, complete, and timely electronic data reporting system
for internal and external management and evaluation; and

C.4.5.13 Promote a strong partnership between the Enrollee, Contractor, DHCF, and community
stakeholders by actively engaging CASSIP Enrollees and their families as primary
decision-makers.

C.5 REQUIREMENTS

C.5.1 Covered Populations

The Contactor shall provide CASSIP services to eligible children and adolescents who
are receiving Social Security Income from the Social Security Administration (SSA),
and/or have been determined to have an SSI-like disability as determined by the DHCF
or its designee. The Contractor shall provide CASSIP services to eligible children and
adolescents 0 through age 20 and up to an Enrollee’s 26th birthday if the beneficiary is
enrolled before their 21st birthday.

C.5.1.1 The Contractor shall ensure enrollment into CASSIP is voluntary.

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C.5.1.2 The Contactor shall provide CASSIP services to eligible children and adolescents who
have one or more physical, behavioral, or developmental conditions that:

C.5.1.2.1 Either does or can be expected to, result in the use of health services of a type or amount
that may be beyond that required by children and adolescents generally;
C.5.1.2.2 Requires a special need for increase Care Coordination and Case Management that is not
customarily available in D.C.’s Non-Waiver, Medicaid Fee for Service Program; and
C.5.1.2.3 Falls into one of the following categories at the time of enrollment:

C.5.1.2.3.1 Is receiving SSI benefits due to a disability;
C.5.1.2.3.2 Has an SSI-Related Diagnosis (as this term is defined in Section C.2.263);
C.5.1.2.3.3 Is under the custody of the DYRS; or
C.5.1.2.3.4 Is under the custody of the CFSA.

C.5.2 Authority to Operate

C.5.2.1 The Contractor shall maintain a Certificate of Authority to operate a HMO in the District
from the District Department of Insurance Securities and Banking (DISB) and shall
remain in compliance with all DISB requirements concerning equity, capitalization,
reserves, and insurance coverage throughout the term of the contract.

C.5.2.2 The Contractor shall notify the District within one business day of the Contractor’s
notification of any actions or investigations by DISB regarding the Contractor’s
compliance with DISB laws, regulations, or policies, including any actions to revoke or
limit the Contractor’s license or authority to operate.

C.5.3 Ineligible Organizations

Under the Act, 42 U.S.C. § 1396a, the District, will exclude any specified individual or
entity from participation in the program under the State Plan for the period specified by the
Secretary of the US Department of Health and Human Services (“Secretary”). When
required by the Secretary to do so according to the Act, 42 U.S.C. § 1320a–7, the District
will terminate the participation of any individual or entity in such program if (subject to such
exceptions as are permitted concerning exclusion under Sections 1128(c)(B) and
1128(d)(B)) participation of such individual or entity is terminated under title XVIII or any
other State Plan under this title,) and provide that no payment may be made under the plan
for any item or service furnished by such individual or entity during such period.

C.5.4 Accuracy of Information Submitted

Under 42 C.F.R. § 438.604 and § 438.606, the Contractor’s Chief Executive Officer (CEO),
Chief Financial Officer (CFO), and Chief Medical Officer (CMO) shall attest, in writing, to
the best of their knowledge, to the truthfulness, accuracy, and completeness of all submitted
data, submitted with all related data and deliverables following DHCF specifications. The
certified data shall include, but are not limited to, all documents specified by the District,
Encounter Data as described in section C.5.223, Provider Agreements as described in
section C.5.124, Medical Loss Ratio (MLR) calculations, other data regarding Claims the
Contractor has paid, and other information contained in contracts, proposals, and the
Contractor’s bid/response to this RFP.
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C.5.5 Organizational Structure

C.5.5.1 The Contractor shall establish a strategic staffing plan to include standards for
implementing an effective system of health care delivery to CASSIP Enrollees. The
staffing plan shall be presented to the District for review and approval during the
Readiness Assessment, as described in Section H.12. The Contractor shall notify the
District of any changes to the staffing plan within 30 days of the decision and shall
submit an alternative plan if the change results in a decrease in personnel.

C.5.5.2 The Contractor shall identify and maintain key personnel to carry out essential
functions as defined below:

C.5.5.2.1 All key personnel must be full-time employees, work and have office space located in
the Contractor’s office, in the District, with primary responsibility for the requirements
included under the Contract. Key personnel that have approved DHCF alternative work
arrangements, such as telework, must be available for in-person meetings with DHCF,
upon request. Key personnel must work at minimum four days a week in the
Contractor’s office located in the District, with one telework day.
C.5.5.2.2 The Contractor shall not reassign these key personnel or appoint replacements, without
written permission from the District. Key personnel positions that remain vacant for 60
days or more are subject to the provisions found in section H.13.
C.5.5.2.3 Before the removal of any key personnel, the Contractor shall notify the CA and
Contracting Officer (CO) within two business days of the decision and shall submit
justification (including proposed substitutions) in sufficient detail to permit evaluation of
the impact on the delivery of Covered Services.

C.5.5.3 The Contractor shall be responsible for the following key personnel, including but not
limited to:

C.5.5.3.1 CEO with authority over the Contractor’s District operations;
C.5.5.3.2 Chief Operating Officer (COO) assigned to the day-to-day management of all operations
and ensures that performance measures from the District and CMS requirements are met.
The COO may also serve as the primary liaison with the District for all operational
issues;
C.5.5.3.3 CFO to oversee all budgeting and accounting requirements and systems;
C.5.5.3.4 Management Information System Manager responsible for the Contractor’s Management
Information System and overseeing all efforts related to the Medicaid Management
Information System (MMIS);
C.5.5.3.5 CMO who must possess a current unrestricted licensed and be board-certified to practice
medicine in the District. The CMO must have a minimum of three years of training in a
medical specialty and five years of experience providing clinical services to children and
adolescent populations. The CMO must provide timely medical advice and consultation
as needed. The CMO must be board certified in his/her specialty and actively involved in
all major, clinical, utilization, and quality management decisions of the Contractor and
shall have experience and/or knowledge of the health needs of diverse, low-income
populations. The CMO shall be responsible for the following:

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C.5.5.3.5.1 Developing, implementing, and interpreting medical policies and procedures. These
duties may include, but not limited to service authorizations, claims review, discharge
planning, credentialing, referral management, culturally competent care, and medical
review of Grievances and Appeals;
C.5.5.3.5.2 Identifying and implementing evidence-based practice guidelines throughout the
Contractor’s Provider network;
C.5.5.3.5.3 Overseeing the quality of clinical care for network and non-Network Providers;
C.5.5.3.5.4 Engaging the Contractor’s Provider network in CQI through the diffusion of practice
standards and through an internal quality assurance program that measures the Network
Provider’s performance against standards of high quality, especially the performance
standards embodied in the HEDIS® program;
C.5.5.3.5.5 Overseeing, reviewing, and resolving disputes related to the quality of care;
C.5.5.3.5.6 Assuring a high-performing Utilization Management (UM) system that adheres to the
Covered Services and other benefits specified in section C.5.48 and the requirements of
section C.5.142 that utilizes evidence-based standards in making coverage
determinations in individual patient cases;
C.5.5.3.5.7 Ensuring that all aspects of Enrollee health care are coordinated and managed through
appropriate staff oversight;
C.5.5.3.5.8 Assisting with recruitment and oversight of an adequate, high-quality Provider network;
and;
C.5.5.3.5.9 Ensuring Culturally Competent care and access for individuals who are limited English
Proficient and/or require accommodations.

C.5.5.3.6 Chief Psychiatric Medical Officer, who shall be a physician currently licensed to
practice psychiatry (children and adults) in the District, board-certified or board eligible
in Psychiatry and whose responsibilities parallel those of the CMO to patients diagnosed
with mental illness, a substance use disorder, or co-occurring disorders;

C.5.5.3.7 Chief Quality Officer (CQO), who shall engage and lead the Contractor, the Contractor’s
Provider network, as well as delegated Providers in CQI activities as defined in sections
C.5.270 and C.5.271. The CQO shall be responsible for the following:

C.5.5.3.7.1 Accountable for the administrative success of the Quality Assessment and Performance
Improvement (QAPI) program and CQI plan.
C.5.5.3.7.2 Development, implementation, and evaluation of the QAPI program and the CQI plan.
Coordinate the Contractor’s QAPI program and CQI plan with the activities of the
District’s External Quality Review Organization (EQRO) and any performance
measurement and quality improvement activities or initiatives mandated by the District.
C.5.5.3.7.3 Collaborate with the CMO on health care performance measurement and quality
improvement activities.
C.5.5.3.7.4 Provide oversight of the quality of clinical care provided by network, non-network,
subcontracted and delegated Providers for services rendered to Enrollees.

C.5.5.3.8 A Chief Information Officer (CIO) to oversee Contractor operations and performance
relevant to the collection and provision of information & data, along with ensuring
Contractor’s compliance with District health information exchange requirements.

C.5.5.3.9 Care Management Manager is responsible for designing, administering, and evaluating a
unique program of Care Management for children, adolescents and adults with Special
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Health Care Needs who is licensed to practice in the District of Columbia. This Manager
shall oversee the provision of a range of targeted, clinical services and benefits as
described in Section C.5.150.

C.5.5.3.10 Enrollee Services Manager with responsibility for overseeing an Enrollee services
program that operates 24 hours per day, seven days per week, that is capable of
providing information, answering questions, assisting Enrollees with locating services
and providing referrals to community-based organizations, in addition to resolving
Enrollee Grievances, assisting Enrollees to file and pursue Appeals involving the denial,
termination or reduction of benefits and services and serving as the primary point of
contact for the DHCF Ombudsman.

C.5.5.3.11 Provider Relations Manager who administers a Provider services program that furnishes
Network Provider support and as applicable, non-Network Provider support; serves as an
entry point for both network and non-Network Providers that have disputes with the
Contractor and participates in the dispute resolution process.

C.5.5.3.12 EPSDT Manager who oversees EPSDT services for Enrollees under age 21, including
the Salazar Consent Decree requirements, and services provided to children under the
IDEA. Manages all EPSDT/court-related reports; coordinates with the DHCF Division
of Children’s Health Services; serves on the EPSDT Working Group and other child-
related initiatives.

C.5.5.3.13 Chief Compliance Officer who is responsible for establishing and overseeing a
Compliance program to ensure that the Contractor complies with all Federal and District
laws and regulations, has effective internal controls, and an effective risk management
program. The Chief Compliance Officer, if qualified, may also serve as the Program
Integrity Director.

C.5.5.3.14 Program Integrity Director who is responsible for developing an effective program to
reduce and remediate Provider and beneficiary fraud, waste, and abuse. The Program
Integrity Director shall serve as a liaison to the DHCF Division of Program Integrity.

C.5.5.3.15 Pharmacy Manager responsible for overseeing the pharmacy program that is currently a
licensed pharmacist in the District of Columbia that shall oversee pharmacy utilization,
manage Enrollee education, and serve as a liaison with DHCF on pharmacy issues;

C.5.5.3.16 Marketing Manager responsible for overseeing all marketing, branding, and awareness
activities, including activities related to growth and retention of enrollment;

C.5.5.3.17 Utilization Manager with the responsibility for designing, administering, and evaluating
a program of Utilization Management, who is licensed to practice their profession in the
District of Columbia. This Director shall oversee UM (Authorization, Notice of Action,
and Appeals) of the provision of services and benefits from multiple Network Providers.
This includes overseeing all efforts related to the identification, delivery, installation,
operation, and regular maintenance of DME and assistive technologies in collaboration
with a biomedical engineer;

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C.5.5.3.18 DDS Manager responsible for coordinating services with the Department on Disability
Services (DDS), including providing assistance in Care Coordination for eligible
Enrollees and serving as a contact liaison with DDS;

C.5.5.3.19 SSI Benefits Manager or employee responsible for coordinating benefits under SSI/SSI-
related eligibility categories and is responsible for overseeing specific requirements for
Medicaid, SSI, and SSI-related eligibility and benefits for CASSIP Enrollees This
individual shall establish and demonstrate collaborative relationships with SSA, ESA,
and any DHCF designee;

C.5.5.3.20 DME Manager responsible for overseeing all efforts related to the timely identification,
delivery, installation, operation, and regular maintenance of DME and assistive
technologies;

C.5.5.3.21 Privacy and/or Security Officer who is responsible for developing, maintaining,
implementing, overseeing the compliance of and enforcing compliance with the BAA,
HIPAA and other applicable federal and state privacy laws within the Contractor’s
business. The Privacy and/or Security Officer shall have an understanding of electronic
PHI (e-PHI) and the technologies used to protect it and have a solid understanding of
HIPAA requirements under 45 C.F.R. Parts 160, 162, and 164, to include the Breach
Notification Rule.

C.5.5.3.22 Outreach Manager responsible for overseeing all outreach activities, including health
education targeting CASSIP enrolled populations; and

C.5.5.3.23 The Contractor shall designate one of the above employees, except for the CEO, to serve
as the Liaison to DHCF on day-to-day operational issues, who will serve as the District
Liaison. The District Liaison shall be designated in writing and shall be authorized to
represent the Contractor regarding inquiries, shall be available during normal business
hours, and shall hold decision-making authority concerning urgent situations that may
arise. The District Liaison shall be available for follow-up inquiries initiated by DHCF.

C.5.6 Business Place and Hours of Operation

C.5.6.1 The Contractor shall maintain a place of business located in the District of Columbia, which
shall operate, at a minimum, from Monday through Friday, 8:00 a.m. to 5:30 p.m. The
Contractor shall obtain approval from DHCF regarding any changes to the place of business
and hours of operation, at least 90 days before the proposed change.

C.5.6.2 All personnel must report in person to the Contractor’s place of business located in the
District of Columbia as described in C.5.6, no less than four days per each work week,
excluding holidays.

C.5.7 Advisory Committees

C.5.7.1 The Contractor shall ensure that key personnel designated by the Contractor or required by
DHCF, attend and participate in each Medical Care Advisory Committee (MCAC) meeting
convened by the District. The purpose of the MCAC is to advise the DHCF leadership on
health and medical care services that may be covered by Medicaid. MCAC is comprised of
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beneficiaries, health care Providers, District agencies, and community stakeholders related
to the delivery of health care services.

C.5.7.2 The Contractor shall develop and implement an Enrollee Advisory Committee and a
Provider Advisory Committee.

C.5.7.2.1 Each Committee shall meet quarterly to advise the Contractor on health and medical care
services.
C.5.7.2.2 The Committees shall be comprised of Enrollees, parents/caregivers of Enrollees,
pediatric physical and behavioral health care Providers, District agencies, and youth-
centered community stakeholders related to the delivery of health care and/or
educational services.

C.5.7.3 The Contractor shall submit the following information to the CA within three Business Days
of Any Advisory Committee Meeting:

C.5.7.3.1 Scheduled Date, Time, Length of Meeting;
C.5.7.3.2 Location of Scheduled Meeting;
C.5.7.3.3 A List of Invitees; and
C.5.7.3.4 The Meeting’s Proposed Agenda

C.5.7.4 The Contractor shall generate and maintain Minutes or another Official Record of the
Committee Meetings, issues raised, and any recommendations made by Committee
members to resolve identified issues and/or strengthen the Contractor’s operations. These
records shall be completed within three Business Days of each meeting and shall be made
available to DHCF and its agents or representatives upon request.

C.5.7.5 The Contractor shall designate representatives to participate in the District’s HIE Policy
Board, and each subcommittee as defined by DHCF. Contractor participation shall include:

C.5.7.5.1 A designated representative to attend attendance scheduled HIE Policy Board Meetings,
C.5.7.5.2 Designate at least one representative to serve on each of the HIE Policy Board
Subcommittees, and
C.5.7.5.3 Contractor participation in subcommittee activities shall include active engagement in
policy considerations, technical guidance, and governance discussions relevant to health
information exchange activities and interoperability goals.

C.5.8 Language Access and Cultural Competence

C.5.8.1 Cultural Competence & Sensitivity

C.5.8.1.1 The Contractor shall respond with sensitivity to the needs and preferences of culturally
and linguistically diverse Enrollees. To ensure that all Enrollees are treated in a
culturally and linguistically appropriate manner, the Contractor shall develop, maintain,
and ensure compliance with policies and procedures that:

C.5.8.1.1.1 Recognize Enrollees’ beliefs;
C.5.8.1.1.2 Address cultural and linguistic differences in a competent manner; and
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C.5.8.1.1.3 Ensure interpersonal interactions, by staff and the provider network, that respect and
honor diversity of enrollees.

C.5.8.2 The Contractor shall ensure that its policies and procedures incorporate any laws,
regulations, and guidance about Cultural Competence and language access issued by the
Government of the District and the U.S. Department of Health and Human Services. These
requirements include but are not limited to:

C.5.8.2.1 Title VI of the Civil Rights Act of 1964 and the implementing regulations;
C.5.8.2.2 D.C. Language Access Act of 2004 (Attachment J.23) and the implementing regulations;
and
C.5.8.2.3 Section 1557 of the PPACA.

C.5.8.3 The Contractor shall distribute its policies and procedures on Cultural Competence to its
subcontractors and Network Providers and ensure compliance by all with the policies and
procedures.

C.5.8.4 The Contractor shall conduct Cultural Competency training annually for all staff, Network
Providers, and subcontractors. Such training shall address at a minimum:

C.5.8.4.1 Enhanced awareness of Cultural Competency imperatives and issues related to
improving access and quality of care for Enrollees;
C.5.8.4.2 Health Equity, Health Equity Disparities, and Bias (Implicit and Explicit);
C.5.8.4.3 The Contractor’s policies and procedures on Cultural Competence;
C.5.8.4.4 Requirements of Title VI of the Civil Rights Act of 1964 and the implementing
regulations;
C.5.8.4.5 Requirements of the D.C. Language Access Act of 2004 and the implementing
regulations; and
C.5.8.4.6 The Contractor’s policies and procedures on language access, including how staff can
access language assistive services on behalf of Enrollees with limited English
proficiency.

C.5.8.5 Cultural Competency training shall provide a forum for staff and providers to reflect on their
own cultures and values and how they relate to the delivery of services to those with
differing beliefs and practices.

C.5.8.6 Written Materials and Translation Services

C.5.8.6.1 Under the D.C. Language Access Act of 2004, the Contractor shall print and provide
written materials and Vital Documents, including applications, notices, forms,
agreements, and outreach materials that the Contractor publishes or distributes to inform
beneficiaries about their rights or eligibility requirements for benefits, services, or
participation in the District’s programs, in prevalent non-English languages designated
by the DHCF.

C.5.8.6.2 The Contractor shall make written materials for potential Enrollees and Enrollees
available through auxiliary aids and services in an appropriate manner that takes into
consideration the special needs of Enrollees or potential Enrollees with disabilities or
limited English proficiency, in accordance with 42 C.F.R. § 438.10(d).
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C.5.8.6.3 The Contractor shall comply with any applicable guidance issued by the District Office
of Human Rights, the District agency responsible for enforcing the Language Access Act
of 2004.

C.5.8.6.4 When printing and distributing written materials, the Contractor shall comply with the
Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition
Against National Origin Discrimination Affecting Limited English Proficient Persons
published by the U.S. Department of Health and Human Services, Office for Civil
Rights (see Attachment J.35).

C.5.8.6.5 The Contractor shall ensure that Vital Documents and written materials provided to
Enrollees are culturally appropriate.

C.5.8.6.6 The Contractor shall ensure that Vital Documents and written materials provided to
Enrollees meet alternative format standards necessary to conform with § 504 of the
Rehabilitation Act of 1973 and the ADA.

C.5.8.6.7 Vital Documents and written materials distributed to Enrollees shall be developed in
accessible formats for persons with visual impairments and are available in printed
format with no less than twelve point font size.

C.5.8.6.8 The Contractor shall inform all Enrollees that all Vital Documents and written material
are available to Enrollees in alternative formats and languages and that auxiliary aids and
services are available upon request at no cost Enrollees shall be informed on how to
access those formats in accordance with 42 C.F.R. 438.10.

C.5.8.6.9 Written materials that are critical to obtaining services for Enrollees and Potential
Enrollees shall include taglines in the prevalent non-English language in the District, as
directed by the DHCF. The taglines should include the availability of written translations
or oral interpretation, how to request auxiliary aids and services, and explains the
availability of the toll-free and Teletypewriter /Telecommunications Device for the Deaf
(TTY/TDD) telephone number of the Contractor’s Enrollee Services telephone number
in accordance with 42 C.F.R. 438.10(d). Taglines for written materials critical to
obtaining services must be printed in a conspicuously visible font-size approved by the
DHCF.

C.5.8.6.10 The Contractor shall send written materials, including notices that inform Enrollees
about their rights or eligibility requirements for benefits, services, or participation in
District programs, in the Enrollee’s preferred language no more than 48 hours after an
Enrollee initiates contact with the Contractor using the language access taglines
approved by the DHCF.

C.5.8.6.11 The Contractor shall provide an attestation/certification to the DHCF, based on the best
information, knowledge, and belief that the translated document is accurate.

C.5.9 Oral Interpretation Services

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C.5.9.1 The Contractor shall provide oral interpretation and use of auxiliary aids such as Sorenson
VRS or a similar service, TTY/TDD and American Sign Language (ASL) services free of
charge to each Enrollee. The Contractor shall contract with a language access line (or a
comparable service) or through on-site interpretation services, regardless of language
spoken. The oral interpretation services shall be provided by using a professional and
certified interpreter. In accordance with 42 C.F.R. 438.10(d).

C.5.9.2 The Contractor shall inform Enrollees that oral interpretation services are available for any
language, free of charge, and the process for accessing the services.

C.5.9.3 If an Enrollee elects to use a family member or friend or refuses the Contractor’s oral
interpretation services, the Contractor shall obtain written consent from the Enrollee that
waives the Enrollee’s right to oral interpretation services. Family members or friends chosen
by Enrollees for oral interpretation services must be at least 21 years of age.

C.5.9.4 The Contractor shall provide a Cultural Competence and Language Access quarterly report
in a format determined by the DHCF, detailing the usage of language assistive services
and/or devices.

C.5.10 Marketing, Outreach, Health Education and Health Promotion

C.5.10.1 The Contractor’s marketing, outreach, health education, and health promotion activities shall
conform to all applicable rules, policies, and other regulations set forth by the District and
federal requirements in accordance with 42 C.F.R. § 438.10 and 42 C.F.R. § 438.104. All
information shall be true and fair and maintain the integrity of CASSIP. Communication
practices that deceive or mislead the public or disparage a competing Contractor are strictly
prohibited.

C.5.10.2 The Contractor shall ensure all marketing, outreach, health education, and health promotion
materials are available in alternative formats including in printed formats with no less than
12-point font size that are accessible and appropriate for individuals who have disabilities
(i.e. those with visual or hearing impairments) to conform with § 504 of the Rehabilitative
Act of 1973 and the ADA.

C.5.10.3 The Contractor shall obtain approval from DHCF before the production and distribution of
any marketing, outreach, health education, and health promotion materials.

C.5.10.4 The Contractor shall specify in writing to DHCF, the methods it shall use to ensure all
materials are accurate and does not mislead, confuse, or defraud Potential Enrollees,
Enrollees, or the District.

C.5.10.5 The Contractor shall resubmit all previously approved outreach, health promotion and health
education materials to the DHCF annually for review and DHCF approval.

C.5.10.6 Under 42 C.F.R. § 438.104(b)(ii), the Contractor shall distribute marketing materials to the
entire service area of the District. The Contractor shall not distribute materials in
neighboring jurisdictions.

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C.5.10.7 The Contractor shall comply with the information requirements of 42 C.F.R. § 438.10 and
have a mechanism to assist Enrollees and potential Enrollees to understand the CASSIP,
including the requirements and benefits of the Contractor. The Contractor shall ensure that
information is accurate and provided both orally and in writing.

C.5.10.8 Materials shall not contain assertions or statements (whether written or oral) that the
beneficiary must enroll with the Contractor to obtain benefits or to not lose benefits.

C.5.10.9 All written brochures and materials provided to the beneficiaries and Enrollees shall be
written at the fifth (5th) grade reading level, as determined by the Flesch-Kincaid readability
tool.

C.5.10.10 The Contractor shall make auxiliary aids and services available upon request in an
appropriate manner that takes into consideration the special needs of Enrollees or potential
Enrollees with disabilities or limited English proficiency.

C.5.11 Marketing Plan

C.5.11.1 The Contractor shall develop and implement a Marketing Plan that shall detail all marketing
activities and materials. The Marketing Plan must be submitted and presented to the DHCF
for review and approval at a minimum of 45 business days before October 1, annually.

C.5.11.2 Any changes to the Marketing Plan must be submitted to DHCF for review and approval, at
a minimum of 60 business days before the intended implementation of the change.

C.5.12 Marketing, Outreach, Health Education and Health Promotion Materials

C.5.12.1 The Contractor’s marketing, outreach, health education, and health promotion activities shall
conform to all applicable rules, policies, and other regulations set forth by the District and
federal requirements following 42 C.F.R. § 438.10 and 42 C.F.R. § 438.104. All information
shall be true and fair and maintain the integrity of CASSIP. Communication practices that
deceive or mislead the public or disparage a competing Contractor are strictly prohibited.

C.5.12.2 The Contractor shall ensure all marketing, outreach, health education, and health promotion
materials are available in alternative formats including in printed formats with no less than
12-point font size that are accessible and appropriate for individuals who have disabilities
(i.e. those with visual or hearing impairments) to conform with § 504 of the Rehabilitative
Act of 1973 and the ADA.

C.5.12.3 The Contractor shall obtain approval from DHCF before the production and distribution of
any marketing, outreach, health education, and health promotion materials.

C.5.12.4 The Contractor shall specify in writing to DHCF, the methods it shall use to ensure all
materials are accurate and does not mislead, confuse, or defraud Potential Enrollees,
Enrollees, or the District. Statements that will be considered inaccurate, false, or misleading
include, but are not limited to, any assertion or statement (whether written or oral) that the
entity is endorsed by CMS, the Federal or District government, or similar entity.

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C.5.12.5 The Contractor shall re-submit all previously approved outreach, health promotion, and
health education materials to the DHCF annually for review and the DHCF approval.

C.5.12.6 Under 42 C.F.R. § 438.104(b)(ii), the Contractor shall distribute marketing materials to the
entire service area of the District. The Contractor shall not distribute materials in
neighboring jurisdictions.

C.5.12.7 The Contractor shall comply with the information requirements of 42 C.F.R. § 438.10 and
have a mechanism to assist Enrollees and potential Enrollees to understand the CASSIP,
including the requirements and benefits of the Contractor. The Contractor shall ensure that
information is accurate and provided both orally and in writing.

C.5.12.8 Materials shall not contain assertions or statements (whether written or oral) that a D.C.
Medicaid Enrollee must enroll with the Contractor to obtain Medicaid benefits or to not lose
Medicaid benefits.

C.5.12.9 All written brochures and materials provided to Potential Enrollees and Enrollees shall be
written at the fifth (5th) grade reading level, as determined by the Flesch-Kincaid readability
tool.

C.5.12.10 The Contractor shall make auxiliary aids and services available upon request in an
appropriate manner that takes into consideration the special needs of CASSIP Enrollees or
Potential Enrollees.

C.5.13 Marketing, Outreach, Health Education and Health Promotion Materials Review

C.5.13.1 The Contractor shall submit all marketing, outreach, health education and health promotion,
and other similar materials to the DHCF for review and decision, no later than 30 business
days before distribution or dissemination. All written marketing materials must be
developed to assist Potential and current Enrollees in making an informed choice, and shall
be clear, concise, accurate and written in a culturally competent manner that the target
population can easily understand. These materials include but are not limited to items in 42
C.F.R. § 438.10.

C.5.13.2 The Contractor shall submit a monthly report of all marketing, outreach, health education,
and health promotion activities in a format as required by the DHCF.

C.5.13.3 The Contractor shall refer to the DHCF Marketing and Outreach Manual and Style Guide
for an outline of requirements and procedures in Marketing and Outreach.
C.5.14 Permissible Marketing, Outreach, Health Education and Health Promotion Activities

C.5.14.1 The Contractor is permitted to distribute DHCF approved marketing, outreach, health
education, and health promotion materials to the public through technology and other
marketing platforms that describe but are not limited to the scope of covered services, value
add benefits, enrollee services, and other information to assist the Potential Enrollee and
Enrollee in making an informed choice.

C.5.14.2 The Contractor shall require through written Provider agreements that its Network Providers
comply with the Contract in performing any marketing activities on the Contractor’s behalf.
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All such information shall include a statement that Enrollees can choose to enroll with any
District Contractor.

C.5.14.2.1 The following Outreach activities are permissible:

C.5.14.2.1.1 Health promotion and health education activities that benefit the entire community or a
subset thereof;
C.5.14.2.1.2 Health education events and programs for Enrollees to promote improved health
outcomes;
C.5.14.2.1.3 Use of DHCF approved social media platforms to promote the events and activities of
the Contractor. The Contractor is responsible for monitoring all public comments for
appropriateness and sensitivity of information and/or language;
C.5.14.2.1.4 Telephone calls, mailings, and home visits to introduce new Enrollees to the Contractor
and the CASSIP Enrollee population during the initial 90 day period of enrollment;
C.5.14.2.1.5 Assisting current Enrollees with completing Medicaid renewal forms, as applicable, and
within 60 days of loss of Medicaid eligibility, assist former Enrollees to restore
Medicaid eligibility; and
C.5.14.2.1.6 Assisting current Enrollees with completing SSI renewal or recertification forms.

C.5.14.2.2 The following health promotion and health education activities are permissible:

C.5.14.2.2.1 Written materials and information about targeted health-related programs offered by or
available through the Contractor;
C.5.14.2.2.2 Promotional gift incentives may be awarded only to Enrollees for the completion of one
or more preventive health service(s).

C.5.14.2.2.2.1 All incentives, including gift cards must be of a nominal value not to exceed the
maximum award of $75 per eligible Enrollee within a calendar year, unless the
DHCF issues a written waiver.
C.5.14.2.2.2.2 The Contractor may not use gift cards that can be converted to cash or used to
purchase alcohol or tobacco products;

C.5.14.2.2.3 Telephone calls, mailings, and home visits are permissible only to individuals who have
been identified by DHCF as CASSIP Eligible, for the sole purpose of educating those
individuals about services offered by or available through Contractor; and
C.5.14.2.2.4 The Contractor shall submit a quarterly incentive report in a format designated by
DHCF.

C.5.15 Prohibited Marketing, Outreach, Health Education and Health Promotion Activities

C.5.15.1 The Contractor and its Network Providers are prohibited from engaging in the following
marketing, outreach, health education and health promotion activities:

C.5.15.1.1 The use of written or oral information, which is false or misleading in any material
respect, including but not limited to the Provider’s network, availability of services,
qualifications of Network Providers, hours, and location of network services;
C.5.15.1.2 Marketing activities that occur within a Provider’s office or network hospital;
C.5.15.1.3 Offering gifts of more than De minimis value, cash, promotions and/or other items,
which are perceived or designed to induce enrollment;
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C.5.15.1.4 Compensation arrangements with marketing, health education and health promotion
personnel that utilize any type of payment structure in which compensation is tied to the
number (or classes) of beneficiaries who enroll in the health plan; and
C.5.15.1.5 Direct marketing outside of the Prospect List as provided by DHCF, use of health
education and health promotion activities as direct marketing to Potential Enrollees,
either by mail, door-to-door, or telephone.

C.5.15.2 If a Potential Enrollee initiates contact with the Contractor, the Contractor shall adhere
to the following guidelines:

C.5.15.2.1 Refrain from making any comparisons with other Contractors;
C.5.15.2.2 Providing factual information about how to enroll in the CASSIP program, and refer
questions related to eligibility, enrollment and disenrollment to the CA or DHCF
Designee; and

C.5.15.2.3 Influence enrollment in conjunction with the sale or offer of any private insurance.

C.5.16 Value-Added Benefits

C.5.16.1 The Contractor may offer value-added benefits in addition to Covered Services as
defined in C.5.48 Value-added benefits are voluntarily delivered at the Contractor’s
discretion. These benefits are distinct from covered Medicaid services, do not rely on
Medicaid funding, and are not included in capitation rate development. These benefits
seek to improve quality of care, health outcomes, reduce costs by reducing the need for
more expensive care, and promote total health wellness by addressing social factors.

C.5.16.2 The Contractor shall submit all proposed value-added benefits for review and approval
prior to implementation in a format as determined by DHCF.

C.5.16.3 If the Contractor operates a community facility (e.g., Wellness Center), at a minimum
the community facility shall:

C.5.16.3.1 provide face-to-face case management
C.5.16.3.2 provide health education, outreach and other activities
C.5.16.3.3 address social determinants of health (SDOH) and
C.5.16.3.4 provide face-to-face support to homeless Enrollees.

C.5.16.4 The Contractor shall ensure that all services provided directly to enrollees meet the
clinical documentation standards of the Medicaid Program, when appropriate, regardless
of whether the direct service is reimbursed within the capitation rate framework.

C.5.17 Website

C.5.17.1 The Contractor shall maintain a website to facilitate, disseminate, and provide access of
information electronically to Enrollees, Potential Enrollees and Network Providers. All
materials posted on the Contractor’s website must meet the general requirements within
section C.5.17. The Contractor’s website shall, at a minimum provide or contain the
following:

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C.5.17.1.1 Contact information, hours of operation and Covered Services;
C.5.17.1.2 A link to the DHCF website;
C.5.17.1.3 Any material that includes a web address for the Contractor’s website must link directly
to the Contractor’s homepage;
C.5.17.1.4 Web-based technology and information standards for people with disabilities, as
specified in § 508 of the Rehabilitation Act; and
C.5.17.1.5 Compliance with the Language Access and Cultural Competence requirements in C.5.8.

C.5.17.2 Electronic Enrollee Information

C.5.17.2.1 If the Contractor chooses to provide required information to Enrollees in an electronic
format as described in 42 C.F.R. § 438.10(c) all of the following shall be met:
C.5.17.2.1.1 The format is readily accessible;
C.5.17.2.1.2 The information is placed in a location on the Contractor’s website that is prominent and
readily accessible;
C.5.17.2.1.3 The information is provided in an electronic form which can be electronically retained
and printed;
C.5.17.2.1.4 The information is consistent with the content and language requirements of 42 C.F.R.
438.10; and
C.5.17.2.1.5 The Enrollee is informed that the information is available in paper form without charge
and is provided within five business days of request.

C.5.18 Sponsorships

C.5.18.1 The Contractor shall submit all requests for sponsorships to DHCF for approval, at a
minimum of 30 business days prior to the event or activity to be sponsored.

C.5.18.2 The Contractor shall submit any collateral information about the sponsored event and
sponsorship level along with its request.

C.5.18.3 All sponsorship requests must be submitted in a format as determined by the DHCF.

C.5.18.4 The Contractor shall notify DHCF if the Contractor’s affiliated Foundation or Corporate
entity funds a sponsorship.

C.5.18.5 The Contractor is limited to sponsorships located within the District.

C.5.19 Enrollment, Education and Outreach

C.5.19.1 The Contractor shall provide enrollment, outreach, education, and Covered Services to
CASSIP eligible enrollees as defined in C.2.33.

C.5.19.2 The DHCF may, at its discretion and in accordance with District and federal law during
any period, add eligible Medicaid population groups to the scope of coverage under this
Contract.

C.5.20 Misclassification of an Enrollee

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C.5.20.1 The Contractor shall notify DHCF within two business days of when the Contractor
becomes aware that an Enrollee’s eligibility has been misclassified. The eligibility status
shall be reviewed by DHCF and ESA. DHCF will notify the Contractor of the outcome
and any enrollment changes, as applicable.

C.5.20.2 The Contractor shall notify DHCF promptly when the Contractor becomes aware of
changes in an Enrollee's circumstances that may affect the Enrollee's eligibility including
all of the following:

C.5.20.2.1 Changes in the Enrollee's residence;
C.5.20.2.2 The death of an Enrollee;
C.5.20.2.3 Change in SSI eligibility;
C.5.20.2.4 Change in income; and/or
C.5.20.2.5 Change in family composition.

C.5.21 Enrollment and Education Activities

C.5.21.1 The Contractor shall have in place procedures and materials that assist new CASSIP
Enrollees in selecting a PCP; inform them of Covered Services, benefits, and
procedures; and inform Enrollees of their rights with the Contractor and in Medicaid.
The Contractor shall incorporate into its educational materials a full explanation of
Grievances and Appeals, as well as information regarding how Enrollees can exercise
both Grievance and Appeals rights. All written materials shall conform to the
requirements of section C.5.8.6 and be submitted to DHCF for review and decision prior
to distribution.

C.5.21.2 The Contractor shall coordinate its educational activities with those of DHCF to ensure
consistency of information regarding Enrollee rights and the CASSIP.

C.5.21.3 The Contractor shall comply with the information requirements of 42 C.F.R. § 438.10
and have a mechanism to assist Enrollees and potential Enrollees to understand CASSIP,
including the requirements and benefits of the Contractor. The Contractor shall ensure
that information provided to Enrollees is accurate and available both orally and in
writing.

C.5.22 Non-Discrimination and Acceptance of All Enrollees

C.5.22.1 The Contractor shall not discriminate against individuals eligible to enroll on the basis of
health status or need for health care services in accordance with 42.C.F.R. § 438.3(d).

C.5.22.2 The Contractor shall not discriminate against individuals eligible to enroll on the basis of
race; color; national origin; disability; or sex which includes sex characteristics,
including intersex traits; pregnancy or related conditions; sexual orientation; gender
identity; and sex stereotypes; and will not use any policy or practice that has the effect of
discriminating on the basis of race; color; national origin; disability; or sex which
includes discrimination on the basis of sex characteristics, including intersex traits;
pregnancy or related conditions; sexual orientation; gender identity; and sex stereotypes
in accordance with 42.C.F.R. § 438.3(d).

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C.5.22.3 The Contractor shall accept all Enrollees who select or are assigned to the Contractor by
the District, without regard to physical or mental condition, health status, need for health
services, marital status, age, sex, sexual orientation, national origin, race, color, religion
or political beliefs and shall not use any policy or practice that has the effect of such
discrimination in accordance with 42 C.F.R. § 438.3(d).

C.5.23 Enrollment Package

C.5.23.1 The Contractor shall send each of their new Enrollees an enrollment package by mail
within 10 business days from the date the District or its agent notifies the Contractor of
enrollment.

C.5.23.2 The enrollment package shall include:

C.5.23.2.1 The name, address, and telephone number of the assigned or voluntarily selected PCP
and PDP of each Enrollee;
C.5.23.2.2 An Enrollee Handbook;
C.5.23.2.3 Notification that the Provider Directory is available via the Contractor’s website, mobile
accessible (if applicable), or in paper format by request;
C.5.23.2.4 An Enrollment Card; and
C.5.23.2.5 Other materials as directed by DHCF.

C.5.23.3 For any Enrollee that DHCF directs Contractor to enroll retroactively, Contractor shall
notify and send the enrollment package within 24 hours, or the next business day.

C.5.24 After-Hours Care and Urgent Care

C.5.24.1 The Contractor shall establish and maintain a toll-free number during normal business
hours to furnish prompt assistance to CASSIP Enrollees. The Contractor shall operate or
contract with a Nurse Advice Line service 24 hours-per-day, seven days per-week,
including holidays and weekends, with a toll-free telephone number that is staffed at all
times by a qualified clinical staff person. The Contractor may also participate in regional
or District-wide efforts to provide Nurse Advice Line services that would meet the
requirements of this section.

C.5.24.2 The Contractor shall provide timely access to services, taking into account the need to
reduce inappropriate emergency department use and the need for urgent care.

C.5.24.3 The Contractor shall ensure the availability of Covered Services 24/7 when Medically
Necessary.

C.5.25 Enrollee Handbook and Enrollee Notices

C.5.25.1 The DHCF will distribute to the Contractor a standard Enrollee Handbook Template that
the Contractor shall utilize to develop the CASSIP Enrollee handbook. The Contractor
shall not modify the Enrollee Handbook without DHCF’s written permission. The
Enrollee Handbook shall not contain information for programs or services not included
in the Contract, unless specifically noted otherwise (i.e. value-added benefits) or upon
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prior approval from DHCF.

C.5.25.2 The Enrollee Handbook shall be written and distributed to Enrollees in accordance with
section C.5.25.

C.5.25.3 The Enrollee Handbook shall be specific to the CASSIP. Additionally, the Enrollee
Handbook shall not contain information for programs or services not included in the
Contract, unless specifically noted otherwise (i.e. value-added benefits) or upon prior
approval from DHCF.

C.5.25.4 The Enrollee Handbook shall be updated any time the Contractor makes a Material
Change. The Contractor shall send the most current version of the Enrollee Handbook to
all Enrollees at the time of initial enrollment and at least bi-annually if the Contractor
has made District-approved changes to the Handbook. DHCF reserves the right to
determine - when each Contractor shall revise and redistribute the Enrollee Handbook.
DHCF must be notified of any changes at least 30 days before the intended effective date
of the change.

C.5.25.5 The DHCF will distribute to the Contractor standard templates for Enrollee notifications
that the Contractor shall utilize.

C.5.25.6 The Contractor shall provide information to Enrollees within five business days of an
Enrollee’s request. All such information shall be prepared in advance, require DHCF’s
prior approval, and comply with the requirements found in section C.5.25.

C.5.25.7 Under 42 C.F.R. § 438.100(a), the Contractor shall have written policies regarding
general Enrollee rights discussed below as well as specific Enrollee rights regarding Fair
Hearings (section C.5.200), selection of a PCP (section C.5.26), and obtaining family
planning services (section C.5.109.2). Additionally, the Contractor shall comply with
any applicable Federal and District laws that pertain to Enrollee rights and ensure that its
employees and contracted providers observe and protect all Enrollee rights.

C.5.25.8 Under 42 C.F.R. § 438.100(b), the Contractor shall guarantee each Enrollee the
following rights:

C.5.25.8.1 To receive information following 42 C.F.R. § 438.10;
C.5.25.8.2 To be treated with respect and with due consideration for dignity, privacy and cultural
preferences;
C.5.25.8.3 To receive information on available treatment options and alternatives, presented in a
manner appropriate to the Enrollee’s condition(s) and ability to understand;
C.5.25.8.4 To participate in decisions regarding his or her health care, including the right to refuse
treatment;
C.5.25.8.5 To be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience, or retaliation, as specified in other Federal regulations on the
use of restraints and seclusion;
C.5.25.8.6 Under 45 C.F.R. Parts 160 and 164, to request and receive a copy of his/her medical
records, and request that they be amended or corrected, as specified in 45 C.F.R. §§
164.524 and 164.526; and
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C.5.25.8.7 To be furnished health care services following 42 C.F.R. § 438.206 through § 438.210.

C.5.25.9 In the case of a counseling or referral service that the Contractor does not cover because
of moral or religious objections, the Contractor shall inform Enrollees within 30 days:

C.5.25.9.1 That the service is not covered by the Contractor;
C.5.25.9.2 How they can obtain information from the District about how to access those services;
and
C.5.25.9.3 When it adopts a policy to discontinue coverage of a counseling or referral service based
on moral or religious objections at least 30 day prior to the effective date of the policy
for any particular service in accordance with 42 C.F.R. 438.102(b)(i)(B) and 42 C.F.R.
438.10(g).

C.5.25.10 The Contractor shall distribute the Enrollee Handbook to Enrollees (except when
included in the enrollment package, which the Contractor shall mail to Enrollees) by:

C.5.25.10.1 Mailing a printed copy to the Enrollee’s mailing address;
C.5.25.10.2 Emailing the Enrollee an electronic copy after obtaining the Enrollee's agreement to
receive the information by email; and
C.5.25.10.3 Posting the information on its website and advising the Enrollee in paper or electronic
form that the information is available on the Internet and include the applicable Internet
address:

C.5.25.10.3.1 Enrollees with disabilities who cannot access this information online are auxiliary aids
and services upon request; or
C.5.25.10.3.2 Provide the information by any other method that can reasonably be expected to result in
the Enrollee receiving that information.

C.5.25.11 Under 42 C.F.R. § 438.100(c), the Contractor shall ensure each of its Enrollees is free to
exercise his or her rights, and that exercise of those rights does not adversely affect the
manner in which the Contractor or its Providers treats the Enrollee.

C.5.25.12 Under 42 C.F.R. § 438.100(d), the Contractor shall comply with any other applicable
Federal and State laws (including: Title VI of the Civil Rights Act of 1964, as
implemented by regulations at 45 C.F.R. part 80; the Age Discrimination Act of 1975, as
implemented by regulations at 45 C.F.R. part 91; the Rehabilitation Act of 1973; Title
IX of the Education Amendments of 1972 (regarding education programs and activities);
Titles II and III of the ADA; and section 1557 of the PPACA.

C.5.26 Selection of Primary Care Provider and Primary Dental Provider

C.5.26.1 The Contractor shall allow each Enrollee freedom of choice in selecting a PCP and PDP
and the ability to change Providers as requested following 42 C.F.R. § 438.3(l). These
materials shall be provided per section C.5.25.

C.5.26.2 The Contractor shall allow each CASSIP Enrollee, who shall have been automatically
assigned a PCP and PDP at the time of enrollment, the opportunity to change his or her
primary Providers. The Contractor shall notify Enrollees of procedures for changing
Providers. Providers should be limited to health professionals with the training and
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experience to appropriately treat and manage the condition of children and adolescents
with special health care needs. These materials shall be provided per section C.5.25.

C.5.26.3 The Contractor shall permit female Enrollees to designate as their PCP a participating
physician or advanced practice RN who specializes in obstetrics and gynecology, so long
as the specialist is willing to perform all responsibilities of a PCP.

C.5.26.4 The Contractor shall permit an Enrollee with a chronic, disabling or life-threatening
condition the opportunity to choose an appropriate participating specialist as his or her
PCP, so long as the specialist is willing to perform all responsibilities of a PCP.

C.5.26.5 If the Enrollee desires, the Contractor shall allow him or her to remain with his or her
existing PCP/PDP if the Provider is a member of the Contractor’s primary care network.

C.5.26.6 The Contractor shall ensure that all new Enrollees select or are assigned to a PCP/PDP
within 10 days of enrollment. The Contractor shall ensure all Enrollees receive
information about how and where they can receive care during the time period between
enrollment and PCP/PDP selection/assignment.

C.5.26.7 If an Enrollee does not choose a PCP or PDP, the Contractor shall:

C.5.26.7.1 Assign Enrollees to a Provider in the Network who has previously provided services to
the Enrollee, if the information is available, if the Provider has the capacity to accept the
Enrollee and if the PCP/PDP is geographically accessible as these terms are defined in
section C.5.94;
C.5.26.7.2 In the absence of previous service by a PCP or PDP within the Network, designate a
Provider who is geographically accessible to the Enrollee;
C.5.26.7.3 Assign all CASSIP Enrollees within a single family to the same PCP and PDP; and
C.5.26.7.4 Ensure notification of assignments shall be postmarked within 10 days of assignment.

C.5.26.8 The Contractor shall notify DHCF within two business days upon awareness or receipt
of termination notice from provider of any termination of a contract with a Network
Provider.

C.5.26.9 Under 42 C.F.R. § 438.10(f), the Contractor shall send written notice of termination of a
Network Provider to each Enrollee who received his or her primary care or was seen on
a regular basis by the terminated Provider, within 15 days after the Contractor’s receipt
or issuance of the termination notice. The Contractor shall notify DHCF of a Provider
termination prior to sending notification to each Enrollee and shall comply with the
requirements of section C.5.132 with respect to this notification.

C.5.26.10 The Contractor shall report the number of requests to change PCPs and PDPs the reasons
for such requests to DHCF on a quarterly basis in a manner determined by DHCF.

C.5.26.11 The Contractor shall allow any Native American/Indigenous Person and any Native
American/Indigenous Person who is enrolled in a non-Native American Managed Care
Entity and eligible to receive services from a participating I/T/U Provider, to elect that
I/T/U as his or her primary care Provider, if that I/T/U participates in the network as a
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primary care Provider and has capacity to provide the services.

C.5.27 Enrollment Process

C.5.27.1 The Contractor shall comply with § 1902 of the Social Security Act, 42 U.S.C. §1396a,
42 C.F.R. § 435, 438, 441, any additional applicable federal regulations, policies, and
other CMS and DHCF guidance related to enrollment and disenrollment in performing
enrollment and disenrollment activities. This includes the requirements that Contractor
engage in respect for all persons, accept all Enrollees in the order in which they apply
following 42 C.F.R. § 438.6(d), and any additional Enrollee rights set forth in section
C.5.25.8.

C.5.27.2 Enrollment into CASSIP is completely voluntary. Individuals eligible for enrollment in
CASSIP will be identified by DHCF. By the 5th of each month, DHCF will send a
CASSIP eligibility file to Contractor.

C.5.27.3 The Contractor shall send the identified CASSIP-Eligible Enrollees a DHCF approved
letter to inform them of their opportunity to choose between enrolling in CASSIP or
remaining in the FFS Medicaid. Eligible individuals have 10 Business Days to respond
from the date of the postmark of the letter.

C.5.27.4 The Contractor shall submit a report of those individuals that have elected to enroll in
CASSIP, to DHCF, via DHCF’s secure e-mail server by the 15th of the following
month. (See attachment J.25 “CASSIP New Member Enrollment Report/CASSIP New
Enrollee Log”).

C.5.27.5 DHCF shall enroll the individual in CASSIP based on the eligibility status. Individuals
shall be enrolled effective the first (1st) day of the following month. DHCF shall return
the CASSIP New Member Enrollment report back to the Contractor with a disposition of
each individual. Contractor shall update their Membership Database and notify their
vendors, including their PBM.

C.5.27.6 CASSIP-Eligible individuals who do not select the option to enroll in CASSIP will
remain in FFS Medicaid. The Contractor shall document each time an eligible individual
or parent/caregiver has been offered enrollment in CASSIP. The Contractor may offer
enrollment to each eligible individual on a quarterly basis, unless the individual has
requested not to be further contacted. The Contractor shall keep a record of those
individuals who have requested to no longer be contacted regarding CASSIP enrollment
and shall furnish a copy of those records to DHCF upon request.

C.5.27.7 The Contractor shall maintain the capacity to receive the enrollment data from DHCF as
described in section C.5.225.

C.5.27.8 The Contractor shall submit to DHCF, within 30 days following the Date of Award, a
written notice that Contractor has the technical capacity to electronically approve all
enrollment information from the District including an explanation of procedures used to
substantiate the enrollment process.

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C.5.27.9 In addition, the Contractor shall submit to DHCF, a notice of any change(s) to the
technical capacity to electronically approve all enrollment information from the District.

C.5.27.10 Under 42 C.F.R. § 438.10(c), the Contractor shall have in place a mechanism to help
Enrollees understand the requirements and benefits of CASSIP.

C.5.28 Newborn Enrollment

C.5.28.1 Within 10 business days of delivery of all newborns born to CASSIP Enrollees, the
Contractor shall submit to DHCF the VOB form. DHCF will subsequently upload the
VOB form into the District of Columbia Access System.

C.5.28.2 The Newborn shall remain enrolled with the birth mother’s MCO from the time of birth
and shall remain an Enrollee of the MCO Contractor until a separate Medicaid number is
assigned and a parent, subsequent to the assignment of a number, makes a decision to
enroll the Newborn in a different MCO as the eligibility warrants. The Contractor shall
explain to the parent that the Newborn must remain enrolled in the Contractor’s plan
until the date on which a parent is notified of the Newborn’s DC-issued Medicaid ID
number.

C.5.28.3 The parent or guardian of the Newborn may choose to disenroll the newborn and to
transition the newborn to FFS Medicaid or an MCO, as the eligibility warrants. If the
newborn remains in CASSIP, the Contractor shall distribute an enrollment package
specifically designed for newborns.

C.5.28.4 If the Newborn is Abandoned, the Newborn shall remain in CASSIP as long as the birth
mother remains a CASSIP Enrollee. The Contractor shall immediately notify DHCF if a
Newborn is abandoned. The Contractor shall ensure that the Newborn has a Medicaid
number before a transfer from CASSIP. If the Newborn is placed under custody of
CSFA, the Newborn shall remain in CASSIP if requested by CFSA as long as the birth
mother remains a CASSIP Enrollee. The Contractor shall ensure the Newborn has a DC
Medicaid number before the transfer of the Newborn.

C.5.28.5 The Contractor shall ensure that prior to disenrollment from CASSIP, the mother has
designated a PCP for the Newborn, the PCP is available, and the PCP has registered the
Newborn as a patient and scheduled the first appointment. If there is no selection by the
mother within 10 business days of birth, the Contractor shall auto-assign a PCP.

C.5.28.6 The Contractor shall submit the following Quarterly reports in accordance with Section
C.5.28:

C.5.28.6.1 Disenrollment Report regarding the Number of Enrollees; and
C.5.28.6.2 Pregnancy, Prenatal Care & Deliveries Quarterly Report.

C.5.28.7 Contractor shall submit to DHCF by the 5th of each month, a Reconciliation of
Newborns report, which consists of all newborns born to CASSIP Enrollees for that
month. DHCF shall ensure that a capitated payment is applied. (See Attachment J.26
‘Reconciliation of Newborn Monthly Report’).

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C.5.29 Non-CASSIP Eligible Newborns and Enrollees

C.5.29.1 If the newborn is a CASSIP Eligible Enrollee, the parent or guardian may choose to
enroll the newborn in CASSIP or transition the newborn to FFS. If the newborn remains
in CASSIP, Contractor shall distribute an enrollment package specifically designed for
newborns.

C.5.29.2 Non-CASSIP Newborns shall have the right to remain enrolled with Contractor from the
time of birth and may remain an Enrollee of Contractor up to the age of six, unless the
mother ages out of CASSIP or is otherwise disenrolled before that child reaches their 6th
birthday. The mother can also choose to enroll her Non-CASSIP Eligible newborn into a
different Contractor or MCO. Contractor shall provide information to the CASSIP
Enrollee on how to contact the District’s Enrollment Broker for enrollment into another
Contractor or MCO, as applicable.

C.5.29.3 Non-CASSIP Newborns and Non-CASSIP Enrollees shall receive Medicaid Covered
Benefits, and the Benefits offered by the Contractor, excluding Respite Care services.

C.5.29.4 A comprehensive assessment and Care Plan shall be developed at least annually for
Non-CASSIP Eligible Enrollees with ongoing monitoring as often as their needs
indicates. The ongoing monitoring of Non-CASSIP Eligible Enrollees shall be
documented in the Care Plan.

C.5.29.5 Each newborn shall be assigned to Acuity Level One for care coordination.

C.5.29.6 A care manager shall be assigned to each newborn, regardless of CASSIP or Non-
CASSIP Enrollment.

C.5.29.7 Each newborn shall receive care coordination for all health services, including EPSDT
and specialty care.

C.5.29.8 If the medical status of the Non-CASSIP Enrollee changes to a category of complex
medical needs or disability, the Contractor shall assist the parent with applying for SSI
benefits, with parental consent. Likewise, the Contractor shall assist the parent with
notifying ESA of the Non-CASSIP Enrollee’s medical condition(s) to determine any DC
Medicaid eligibility changes. Once SSI benefits have been established or the Non-
CASSIP Enrollee has been deemed disabled by the SSA or ESA, the Enrollee shall be
transitioned to the Contractor’s CASSIP LOB with the consent of the parent(s).

C.5.29.9 If a Non-CASSIP newborn is born a Premature Birth or Low Birth Weight for
gestational age and meet SSA’s criteria for presumptive SSI benefits, the Newborn shall
be transitioned to CASSIP LOB, with the consent of the parent(s). The Contractor shall
assist the parents in applying for SSI benefits. (See attachment J.27 for SSA’s
Presumptive Premature Newborn Eligibility Criteria).

C.5.29.10 Non-CASSIP Enrollees transitioned to the CASSIP LOB shall receive all required
services, covered benefits and CASSIP benefits in accordance with section C.5.48 of this
Contract.

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C.5.30 Home Visiting Outreach for Newborns Born to CASSIP Enrollees

C.5.30.1 The Contractor shall assure that all newborns born to CASSIP Enrollees receive a home
visit from a RN licensed in accordance with the D.C. Health Occupations Regulatory
Act and its implementing regulations, within 48 hours of discharge or per the
discharging physician orders from the birthing hospital or birthing center.

C.5.30.2 The Contractor shall have home visiting guidelines in accordance with applicable
standards of practice.

C.5.30.3 During the home visit, the RN shall:

C.5.30.3.1 Use a patient assessment guide during the home visit for both the newborn and the
Parent(s) which, at a minimum, shall address an assessment of the home environment;
C.5.30.3.2 Assess and facilitate parent-child attachment, including newborn attachment if
necessary;
C.5.30.3.3 Assess the diagnostic and treatment needs of the CASSIP Enrollee as well as the
newborn, including assessment of need for postpartum care types and follow-up care
related to a physical condition or a behavioral health need;
C.5.30.3.4 Arrange and coordinate all follow-up care and transportation for both the newborn and
the parent(s) (including protocols for parents who are under age 21 and/or who need
postpartum care);
C.5.30.3.5 Ascertaining family resource needs, supports, and potential linkages, as well as family
and parent risk factors;
C.5.30.3.6 Arrange and coordinate follow-up health care for both the Newborn and the mother;
C.5.30.3.7 Provide care Coordination related to EI through Office of the State Superintendent of
Education (OSSE), Women, Infants and Children (WIC) through DC Health, and family
support services through the Department of Human Services (DHS), and other services
as applicable; and
C.5.30.3.8 Provide ongoing follow-up for the newborn in accordance with section C.5.30 including
consulting with the assigned Care Manager for the Newborn if the Newborn remains
enrolled with the Contractor. This shall include but not be limited to additional home
visiting to the Newborn and care giver(s), PCP and Specialist care coordination, and
providing additional community resources to address identified social factors.

C.5.31 Disenrollment

Under 42 C.F.R. § 438.56(a), the provisions of this section apply to all managed care
arrangements, whether enrollment is mandatory or voluntary.

C.5.32 Disenrollment Procedures

C.5.32.1 Under 42 C.F.R. § 438.56(d), the Contractor shall accept an oral or written request for
disenrollment from the Enrollee, or his or her representative, and transmit this
information to DHCF.

C.5.32.2 If a disenrollment determination is not made by DHCF within the timeframes specified
in 42 C.F.R. § 438.56(e), the disenrollment is considered approved.

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C.5.33 Disenrollment from DC Medicaid

C.5.33.1 The Contractor shall not request Disenrollment from the DC Medicaid program because
of an adverse change in the Enrollee’s health status, or because of the Enrollee’s
utilization of medical services, diminished mental capacity, or uncooperative or
disruptive behavior resulting from his or her special needs (except when his or her
continued enrollment seriously impairs the Contractor’s ability to furnish services to the
Enrollee or other Enrollees).

C.5.33.2 The Contractor shall not initiate MCO disenrollment and shall refer all requests for
disenrollment to DHCF.

C.5.33.3 The Contractor shall only request MCO disenrollment in accordance with Sections
C.5.31 through C.5.37.

C.5.33.4 Under 42 C.F.R. § 438.56(d), the Contractor shall accept an oral or written request for
disenrollment from an Enrollee.

C.5.33.5 The Contractor shall have policies and procedures approved by DHCF for termination of
the Enrollee/Provider relationship within 30 days from date of Contract Award. All such
terminations are subject to the Grievance and Appeals process.

C.5.33.6 Any unresolved Grievance shall be completed in time to permit disenrollment (if
approved) to be effective following the timeframe specified in 42 C.F.R. § 438.56(e).

C.5.34 Disenrollment Requested by the Enrollee

C.5.34.1 Under 42 C.F.R. § 438.56(c)(d), an Enrollee may request disenrollment from the
Contractor for cause at any time. For purposes of this provision, “cause” shall include:

C.5.34.1.1 An Enrollee moves out of the Contractor’s service area;
C.5.34.1.2 Contractor does not, because of moral or religious objections, cover the service(s) that
Enrollee seeks;
C.5.34.1.3 Enrollee requires related services to be performed at the same time and not all of the
related services are available within Contractor’s Network and the Enrollee’s PCP or
another Provider determines that to receive the services separately would subject the
Enrollee to unnecessary risk;
C.5.34.1.4 An Enrollee believes that Contractor has discriminated against him/her based upon the
Enrollee’s race, gender, ethnicity, national origin, religion, disability, pregnancy, age,
genetic information, marital status, sexual orientation, gender identification, personal
appearance, familial responsibilities, political affiliation, and/or source of income or
place of residence; or
C.5.34.1.5 Other reasons, including but not limited to, poor quality of care, lack of access to
Covered Services, or lack of access to Providers experienced in dealing with Enrollees’
with special health care needs.

C.5.34.2 For enrollees that use MLTSS, the enrollee would have to change their residential,
institutional, or employment supports provider based on that provider's change in status
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from an in-network to an out-of-network provider with the MCO, PIHP, or PAHP and,
as a result, would experience a disruption in their residence or employment.

C.5.34.3 If Contractor’s provider agreement with an Enrollee’s PCP is terminated and that
Enrollee is unable to select a new PCP, the Enrollee may elect to disenroll from the
Contractor because of, but not limited to:

C.5.34.3.1 Available PCPs no longer accept new patients;
C.5.34.3.2 Enrollee’s desire to access a location comparable to terminated PCP; or
C.5.34.3.3 Disruption in continuity of care.

C.5.34.4 The Contractor shall notify DHCF electronically, including secure email, all requests
for disenrollment via the Disenrollment Log, by the 10th day of each month. If the
request is approved by DHCF, the disenrollment will be effective the first (1st) day of
the following month. (See attachment J.30, CASSIP Disenrollment Log)

C.5.35 Disenrollment Without Cause Initiated by an Enrollee

C.5.35.1 A CASSIP Enrollee may request disenrollment from Contractor without cause at any
time.

C.5.35.2 Contractor shall notify DHCF of an Enrollee’s disenrollment request in accordance with
section C.5.31 through C.5.38.3.

C.5.36 Involuntary Disenrollment

C.5.36.1 If the Enrollee is no longer eligible for CASSIP or D.C. Medicaid, disenrollment shall be
effective no later than the first (1st) day of the first (1st) month following the loss of
eligibility. If disenrollment occurs due to the loss of SSI eligibility, Contractor shall
work closely with the Enrollee to determine why SSI eligibility was terminated and how
to reapply for the benefit.

C.5.36.2 If Contractor is unable to locate the Enrollee and/or the Enrollee has not utilized
covered benefits for a period of at least six months, the Contractor shall submit a
disenrollment request to DHCF, in accordance with section C.5.31 through C.5.37. The
Contractor shall inform the Enrollee, Parent and/or Guardian in writing of this action,
prior to submitting the disenrollment request to DHCF.

C.5.36.3 If the Enrollee refuses Care Management services, the Contractor shall submit a
disenrollment request to DHCF in accordance with section C.5.31 through C.5.37. The
Contractor shall inform the Enrollee, Parent and/or Guardian in writing of this action,
prior to submitting the disenrollment request to DHCF.

C.5.37 Disenrollment Requests Initiated by Contractor for Reasons for Fraud

C.5.37.1 Contractor shall immediately initiate special disenrollment requests to DHCF based on
suspicions of fraud being committed by the Enrollee within three business days of the
date the Contractor documents the suspicion.

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C.5.37.2 The Enrollee shall be given an opportunity to appeal the ruling to the Office of
Administrative Hearings.

C.5.37.3 Where the disenrollment involves an allegation of fraudulent and deceptive use of
Contractor services, a final decision will be transmitted by the District to the Enrollee.

C.5.37.4 Involuntary disenrollment under this section shall be effective not later than the 1st day
of the following month following the approval of the involuntary disenrollment by the
District.

C.5.37.5 DHCF reserves the right to require additional information from Contractor to assess the
appropriateness of the disenrollment request.

C.5.38 Enrollment and Disenrollment Reporting Requirements

C.5.38.1 The Contractor shall submit to DHCF within 30 Business Days after the Date of Award,
for DHCF review and approval and prior to distribution, a copy of enrollment policies,
procedures, and related materials. In addition, Contractor shall submit to DHCF, prior to
implementation and distribution, a notice of any change(s) to such enrollment policies
and procedures.

C.5.38.2 The Contractor shall submit a Quarterly Disenrollment Report in accordance with the
requirements set forth in Section C.5.38.

C.5.38.3 The Contractor shall submit the Enrollment Request Report weekly.

C.5.38.3.1 If the report is submitted by the 15th of the month the enrollment will become effective
the following month.

C.5.38.3.2 If the report is submitted after the 15th of the month the enrollment will become effective
the month after the following month.

C.5.38.4 The Contractor shall submit the Disenrollment Request Report to DHCF by the 10th of
each month.

C.5.39 Transition of Care Due to Disenrollment

C.5.39.1 The Contractor shall comply with all District laws and DHCF’s policies and procedures,
including DHCF’s Transition of Care Policy if:

C.5.39.1.1 The Contractor’s Contract with the District ends or is otherwise terminate;
C.5.39.1.2 An Enrollee is no longer eligible for DC Medicaid; or
C.5.39.1.3 An Enrollee is transitioned from or to DC Medicaid FFS.

C.5.39.2 The Contractor remains responsible for Enrollees’ Covered Services, including but not
limited to Care Coordination services defined in Section C.2.28, until the date of each
Enrollee’s transfer.

C.5.40 Enrollee Services
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C.5.40.1 The Contractor shall maintain an Enrollee Services Department that is adequately staffed
with qualified individuals (as outlined in Section C.5.41), which includes enrollee
service representatives that are able to assist the caller or route the call to staff and/or
services capable to meet the language needs, as identified in Section 1557 of the
PPACA.

C.5.40.2 The enrollee service representatives shall assist Enrollees, Enrollees’ families, or
caregivers (consistent with laws on confidentiality and privacy) in obtaining information
and Covered Services under CASSIP.

C.5.40.3 The Contractor shall have a protocol for furnishing Enrollee information accurately and
completely to Enrollees, per Section C.5.25, in a timely manner, including but not
limited to Enrollees with limited literacy skills, require alternative formats, and/or
English is not their first language or preference.

C.5.40.4 The Contractor shall verify the following information obtained from the District during
its first interaction with the Enrollee:

C.5.40.4.1 Primary language spoken by each Enrollee and the parent, Guardian, or caretaker (if
Enrollee is a minor) of each Enrollee;
C.5.40.4.2 Whether that Enrollee would prefer written materials be sent in Enrollee’s primary
language; and
C.5.40.4.3 The racial and ethnic group of each Enrollee by following any applicable Federal
standards for race and ethnicity data collection.

C.5.41 Staffing Requirements

C.5.41.1 To be considered adequately staffed, a Contractor’s Enrollee Services Department must
be of sufficient size to ensure that:

C.5.41.1.1 Enrollees’ calls are answered in accordance with the requirements throughout Section
C.5.43;
C.5.41.1.2 Enrollees’ requests for information are answered within one business day;
C.5.41.1.3 Enrollees’ requests for assistance are responded to within one business day; and
C.5.41.1.4 The requirements set forth in Sections C.5.40 and C.5.43 are met.

C.5.41.2 To be considered qualified individuals, those individuals staffing Contractor’s Enrollee
Services Department shall be familiar with the requirements set forth in the Contract and
shall be capable of providing services and assistance (or arranging for the provision of
services and assistance) in accordance with Section C.5.44.

C.5.42 New Enrollee Orientation

C.5.42.1 The Contractor shall offer new Enrollee orientation sessions for new CASSIP Enrollees
face to face or virtually. These sessions shall be conducted in accordance with Section
C.5.42, shall be for Enrollees and families of Enrollees only, and shall occur within 60
days of new Enrollee enrollment.

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C.5.42.2 Orientation sessions shall be conducted in either a group setting or in individual
meetings and shall, at a minimum, cover the following topics:

C.5.42.2.1 Explanation of all Covered Services and how to access such services, and specifically:

C.5.42.2.1.1 CASSIP Covered Services;
C.5.42.2.1.2 EPSDT services;
C.5.42.2.1.3 Primary and preventive health care services, including dental services;
C.5.42.2.1.4 Specialty care services;
C.5.42.2.1.5 Appropriate use of and access to Emergency Services;
C.5.42.2.1.6 LTSS as applicable;
C.5.42.2.1.7 Available community resources applicable to CASSIP Enrollees, and how to request a
referral for community-based services;
C.5.42.2.1.8 Availability and scheduling of language access and transportation services;
C.5.42.2.1.9 Promotion of Family-Centered Care and family involvement in care and Care
Coordination Planning;
C.5.42.2.1.10 Procedures for accessing care including services for mental health and substance use
disorder received outside of the Contractor’s network;
C.5.42.2.1.11 The types of assistance that can be provided by the DC Health Care Ombudsman and
how to contact the Ombudsman’s Office;
C.5.42.2.1.12 Enrollee rights in CASSIP and with the Office of Administrative Hearings;
C.5.42.2.1.13 Enrollee’s responsibility for reporting any third-party payment source to the Contractor;
C.5.42.2.1.14 The roles of and how to select, PCPs;
C.5.42.2.1.15 Explanation of rights and services available under the IDEA;
C.5.42.2.1.16 Use of the toll-free Enrollee Services telephone line;
C.5.42.2.1.17 The process for filing Grievances and Appeals; and
C.5.42.2.1.18 The availability of reasonable accommodations.

C.5.43 Enrollee Services Telephone Line

C.5.43.1 The Contractor shall operate a live-access, toll-free Enrollee Services telephone line
during hours of operation as defined in C.5.115.1 and provide a Quarterly report in a
format as determined by DHCF, identifying the number of received calls.

C.5.43.2 The Contractor shall maintain an Enrollee Services telephone line that includes, at a
minimum:

C.5.43.2.1 Procedures effective in promptly identifying special language needs and routing them to
staff and/or services capable of meeting those needs;
C.5.43.2.2 Sorenson Video Relay or comparable services for people who are Deaf or Hard of
Hearing;
C.5.43.2.3 A system that allows non-English speaking callers to talk to a bilingual staff person or an
interpreter accessed through a language line or an equivalent service, who can translate
to an English-speaking staff person. The Contractor shall report to DHCF upon request
the number of calls to the language line (or equivalent service);
C.5.43.2.4 Have and implement procedures for answering calls in an average of 20 seconds; and
C.5.43.2.5 A process to connect the caller to the appropriate individual immediately. If an
appropriate individual is unavailable, he/she must return the call no later than the next
business day.
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C.5.43.3 The Contractor shall monitor its Enrollee Services telephone line to measure
performance in areas such as, but not limited to, total call volume, average call length,
average hold time in queue, abandonment rate, and average response time to live
interaction.

C.5.44 Enrollee Assistance

C.5.44.1 The Contractor shall coordinate any educational and outreach activities performed by
Enrollee Services, with DHCF, to ensure consistency of information regarding Enrollee
rights and procedures for use of Covered Services.

C.5.44.2 The Contractor shall ensure that Enrollee Services staff is also available to assist
Enrollees in person, telephone, or virtually, when needed during hours of operation as
defined in C.5.115.1.

C.5.44.3 Enrollee Services staff shall:

C.5.44.3.1 Provide information related to Covered Services, accessing care, and CASSIP
enrollment status;
C.5.44.3.2 Provide information on how to access services for behavioral health;
C.5.44.3.3 Provide information on how to access services for intellectual or developmental
disabilities;
C.5.44.3.4 Assist any Enrollee to file a Grievance or Appeal if the Enrollee Services staff is unable
to resolve the issue at the time request;
C.5.44.3.5 Schedule appointments, arrange transportation, and language access accommodations for
medical appointments. if requested and if necessary;
C.5.44.3.6 The Contractor shall not restrict Enrollees’ access to this service and may not establish
requirements that such requests be made more than five days in advance for non-
EPSDT appointments and two days for well-child visits and other Medically Necessary
Services;
C.5.44.3.7 Assist Enrollees in selecting a PCP or PDP, or locating another Network Provider;
C.5.44.3.8 Provide information on contacting the Ombudsman for assistance with filing a
Grievance or Appeal; and
C.5.44.3.9 Schedule services and arrange transportation and language access accommodations
necessary for pre-approved Out-of-Network Providers.

C.5.44.4 The Contractor shall ensure that its Enrollee Services staff has access to current
information about all Providers in the network, including behavioral health Providers,
and all Providers in the DBH Behavioral Health Provider Network. This information
shall include but is not limited to the following information about each Provider:

C.5.44.4.1 Specialty;
C.5.44.4.2 Board certification status;
C.5.44.4.3 Geographic location, including address and telephone number;
C.5.44.4.4 Office hours;
C.5.44.4.5 Open or closed panels;
C.5.44.4.6 Accessibility; and
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C.5.44.4.7 Cultural and linguistic capabilities.

C.5.45 Enrollee Notification

Under 42 C.F.R. § 438.10 (g) the Contractor shall give each Enrollee written notice of any
change (that DHCF defines as a material change) at least 30 days before the intended
effective date of the change.

C.5.46 Continuity of Care

C.5.46.1 If a Provider furnishing care to Enrollees terminates their provider agreement with the
Contractor, the Contractor shall immediately notify the DHCF in writing and take the
following steps to maintain Enrollees’ Continuity of Care:

C.5.46.1.1 Provide all Enrollees written notice from both the Contractor and the Provider within
fifteen days after the Contractor’s receipt or issuance of the termination notice, or thirty
days prior to the date of termination of the Provider agreement, whichever is earlier.
The Contractor shall ensure that Enrollee’s designated Care Managers are also notified
and instructed to provide any needed assistance to the Enrollee.

C.5.46.1.2 The notice shall provide Enrollees with information regarding the assistance available
through the Contractor in securing a new Provider, and where and how to obtain
assistance. The notice shall contain:

C.5.46.1.2.1 The name and contact information of the Enrollee’s Care Manager;
C.5.46.1.2.2 An announcement that the Provider will no longer be a Network Provider;
C.5.46.1.2.3 The date of the Provider’s contract termination;
C.5.46.1.2.4 Arrangements for transferring Enrollees’ Protected Health Information and medical
records; and
C.5.46.1.2.5 Future contact information for the Provider.

C.5.46.2 The Contractor shall submit a weekly report to DHCF to ensure continuity of care for
Enrollees when securing enrollment with a new Provider.

C.5.46.3 In accordance with section C.5.34, if an Enrollee is unwilling or unable to select a new
PCP/PDP following Contractor’s termination of a Provider Agreement with a Provider,
for any reason, the Enrollee may disenroll from that Contractor.

C.5.46.4 The Contractor shall report to DHCF within five business days of any requests for
disenrollment due to termination of a Network Provider or an Enrollee’s inability or
unwillingness to select a new PCP/PDP following a Provider’s termination.

C.5.46.5 In the event that a CASSIP Enrollee is unable to secure a new Network Provider within
three business days, the Contractor shall arrange for Covered Services from an Out-of-
Network Provider at a level of service comparable to that received from a Network
Provider until the Contractor is able to arrange for such service from a Network
Provider.

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C.5.46.5.1 The Contractor shall pay for such services at a rate negotiated by the Contractor and the
non-Network Provider.

C.5.47 Provider-Enrollee Communications

C.5.47.1 Under 42 C.F.R. § 438.102(a), the Contractor shall not prohibit or otherwise restrict a
health care professional acting within the lawful scope of practice, from advising or
advocating on behalf of an Enrollee who is his or her patient, regarding the following:

C.5.47.1.1 The Enrollee’s health status, medical care, or treatment options, including any
alternative treatment that may be self-administered or administered by a parent or
caregiver;
C.5.47.1.2 Any information the Enrollee needs in order to decide among all relevant treatment
options;
C.5.47.1.3 The risks, benefits, and consequences of treatment or non-treatment according to
medical advice; and
C.5.47.1.4 The Enrollee’s right to participate in decisions regarding his or her health care, including
the right to refuse treatment, and to express preferences about future treatment decisions.

C.5.47.2 Subject to the information requirements of 42 C.F.R. § 438.102(b) regarding services
that the Contractor would otherwise be required to provide, reimburse for, or provide
coverage of a counseling or referral service, the Contractor is not required to do so if the
Contractor objects to the service on moral or religious grounds in accordance with 42
C.F.R. § 438.102(a).

C.5.47.3 In accordance with 42 C.F.R. § 438.102(b), if the Contractor elects not to provide,
reimburse for, or provide coverage for services under Section C.5.48 the Contractor shall
furnish information about the non-Covered Services as follows:

C.5.47.3.1 To the District, with its application for a Medicaid contract and whenever the Contractor
elects not to provide, reimburse for, or provide coverage for services under section
C.5.48 during the term of its contract;
C.5.47.3.2 To Potential Enrollees, before and during enrollment; and
C.5.47.3.3 To Enrollees, within thirty days of adopting the policy with respect to any particular
service.

C.5.47.4 The Contractor shall furnish the information at least forty-five days before the effective
date of the policy to DHCF.

C.5.47.5 Under 42 C.F.R. § 438.102(c), for each service excluded by the Contractor on moral or
religious grounds, DHCF shall provide information on how and where to obtain the
service, as specified in 42 C.F.R. §§ 438.10(g)(ii)(A) and (B).

C.5.47.6 The Contractor shall inform Enrollees (including the parent/Guardian of children and
adolescent Enrollees, if legally permissible) for whom residential treatment is being
considered of their options for residential or inpatient placement. The information shall
include alternatives to residential or inpatient treatment and the benefits, risks, and
limitations of each so the Enrollees can provide their informed consent.

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C.5.47.7 If the Contractor violates the prohibition of 42 C.F.R. § 438.102 paragraph (a), the
Contractor is subject to intermediate sanctions imposed by the DHCF in accordance with
42 C.F.R. § 438.702.

C.5.48 Covered Services and Other Benefits

C.5.48.1 For CASSIP Enrollees, the Contractor is required to cover and pay for Diagnostic,
Screening, and Preventive clinical services that are assigned a grade of A or B (strongly
recommended or recommended, respectively) by the United States Preventive Services
Task Force;

C.5.48.1.1 Approved vaccines recommended by the Advisory Committee on Immunization
Practices;
C.5.48.1.2 Preventive care and screening of infants, children and adults recommended by the Health
Resources and Services Administration’s Bright Futures program; and additional
preventive services for women recommended by the Institute of Medicine.
C.5.48.1.3 Preventive services shall be recommended by a physician or other licensed practitioner
of the healing arts acting within the authorized scope of practice under the Health
Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C.
Official Code § 3-1201.01 et seq.), or comparable law in the state where the Provider is
licensed.

C.5.48.2 The Contractor shall furnish all, but not limited to the services listed in the Medicaid
Enrollee Covered Services Table (Table A below) to the extent the services meet the
District’s medical necessity requirements as defined in Section C.5.242.

C.5.49 Amount, Duration and Scope of Services

C.5.49.1 The Contractor shall furnish services in an amount, duration and scope that is no less
than the amount, duration and scope for the same services furnished to beneficiaries
through an FFS arrangement, following 42 C.F.R. § 438.210(a) and as a requirement of
the State Plan.

C.5.49.2 Under 42 C.F.R. § 438.210(a)(i), a service described in Section C.5.49 must be sufficient
in amount, duration, or scope to reasonably achieve the purpose for which the service is
furnished.

C.5.49.3 Under 42 C.F.R. § 438.210(a)(ii), the Contractor shall not arbitrarily deny or reduce the
amount, duration, or scope of a required Medicaid service solely because of an
Enrollee’s diagnosis, type of illness, or condition of the Enrollee.

C.5.49.4 The Contractor shall not limit the amount, duration, or scope of a service identified in
Section C.5.49, except as expressly permitted in these sections or as permitted, in
writing, by DHCF.

C.5.49.5 The Contractor shall place appropriate limits on services for the purpose of utilization
control, provided that the furnished services can reasonably achieve their purpose as
required in 42 C.F.R. § 438.210 (a)(i). Services supporting Enrollees with ongoing or
chronic conditions or who require LTSS, are authorized in a manner that reflects the
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Enrollee's ongoing need for such services and supports. Family planning services shall
be provided in a manner that protects and enables the Enrollee's freedom to choose the
method of family planning without coercion or mental pressure to be used consistent
with 42 C.F.R. § 441.20.

C.5.49.6 The Contractor shall not apply any amount, duration, or scope limitation to a diagnostic
or treatment service for a CASSIP Enrollee through age 20, the need for which is
disclosed by an EPSDT screening service.

C.5.49.7 The Contractor shall provide all Medicaid Covered Services defined in the State Plan,
which includes, but is not limited to services listed in Table A below:

Table A: Medicaid Covered Services
Service Benefit Limit
Emergency Services
As described in section 1932(b)(B) of the Act, 42.
C.F.R. § 438.114 (a) , including (on a twenty-four hour-per day, seven
day-per-week basis) triage to determine the existence of an Emergency
Medical Condition, regardless of whether the triage is furnished on an
inpatient or outpatient basis and regardless of whether the Provider
furnishing triage and/or stabilization services is a member of
Contractor’s network.
Post-Stabilization
Services
As described in 42 C.F.R. §§ 422.113(c)(i) and 438.114(e) et seq.,
Contractor is required to cover post-stabilization services whether in or
outside the network when pre-approved or if not pre-approved, when
provided to maintain the Enrollees Stabilized condition within 1 hour of
a request for pre-approval of services, or if Contractor does not or cannot
timely respond to request for pre-approval.
Physicians’ Services As described in 42 C.F.R.§440.50(a)
Laboratory and X-ray
Services As described in 42 C.F.R.§440.30
Inpatient Hospital
Services As described in 42 C.F.R.§ 440.10
Outpatient hospital
services other than
services in an
institution for mental
diseases.
As described in 42 C.F.R.§ 440.20(a)
Adult wellness
services
When furnished in accordance with the scheduling and content
recommendations of the United States Preventive Services Task Force,
available at: http://www.ahrq.gov/clinic/pocketgd/gcps1.htm
Women’s Wellness
Services
Consisting of an annual routine pelvic exam that includes screening and
immunization for the Human Papilloma Virus (HPV) in accordance with
recommendations of the Advisory Committee on Immunization
Practices, as well as screening, and clinical preventive medicine for
sexually transmitted diseases.
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Table A: Medicaid Covered Services
Service Benefit Limit
Screenings
Covered screening services include breast cancer, osteoporosis, prostate
cancer, diabetes, obesity, high blood pressure and depression, and other
screenings consistent with the US Preventive Services Task Force A and
B Recommendations.
https://www.uspreventiveservicestaskforce.org/Page/
Name/uspstf-a-and-b-recommendations/
Tobacco cessation
counseling No limits for tobacco cessation counseling.
Immunizations As recommended by the Advisory Committee on Immunization
Practices
Federally Qualified
Health Center
(FQHC) services
As defined in § 1905(l) of the Act, 42 U.S.C. § 1396d(l), and any other
ambulatory services offered by a FQHC which are otherwise included in
the state medical assistance plan for the District, as described in §
1905(a)(C) of the Act, 42 U.S.C. § 1396d(a)(C).
Early Periodic
Screening Diagnosis
and Treatment
(EPSDT)
Covered for Medicaid eligible Children under age 21 as described in
section C.5.48.
Mental Health and
Inpatient Substance
Use Disorder
Treatment
Covered as described in section C.5.55.
Dental Services Covered as described in section C.5.68.
Substance Use
Disorder screening
and behavioral
counseling
Covered as described in section C.5.55.
Prescription drugs As described in 42 C.F.R. § 440.120 except as described in section
C.5.72 through C.5.76.
Family planning
services and supplies
Covered for individuals of child-bearing age as described in §
1905(a)(C) of the Act, 42 U.S.C. § 1396d(a)(C).
Pregnancy-related
services As described in 42 C.F.R. §§ 440.210(a) and 440.210(a).
Nurse Midwife
services As described in 42 C.F.R. § 440.165.
Nurse practitioner
services
As described in 42 C.F.R. § 440.166 when furnished by pediatric nurse
practitioners and family nurse practitioners.
Routine screening for
sexually transmitted
diseases
Covered for individuals of child-bearing age as described in §
1905(a)(C) of the Act, 42 U.S.C. § 1396d(a)(C).
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Table A: Medicaid Covered Services
Service Benefit Limit
HIV/AIDS screening,
testing, and
counseling
No limit for screening, testing and counseling services.
Podiatrist services When furnished by licensed podiatrists within the scope of practice
under District of Columbia law.
Physical therapy
services As described in 42 C.F.R. § 440.110(a).
Occupational therapy
services As described in 42 C.F.R. § 440.110(b).
Hearing services Including diagnosis and treatment of conditions related to hearing,
hearing aids and hearing aid.
Speech therapy As described in 42 C.F.R. § 440.110(c)
DME As described in 42 C.F.R. § 440.70(b)
Diet and behavioral
counseling As Medically Necessary
Prosthetic devices As described in 42 C.F.R. § 440.120(c), which either are listed in
DHCF’s Procedures, Codes and Price List or are Medically Necessary.
Eyeglasses
As described in 42 C.F.R. § 440.120(d), limited to one complete pair in
a twenty-four month period except when an Enrollee has lost his or her
eyeglasses or when the Enrollee’s prescription has changed more than
one-half (0.5) diopter.
Tuberculosis-related
services
As described in § 1902(z) of the Act, 42 U.S.C. § 1396a(z) for Enrollees
determined to be infected with tuberculosis and whose condition is
identified either by a member of Contractor’s Provider network, or any
other health care Provider examining the Enrollee. Such services consist
of prescription drugs, physician services and hospital outpatient services,
laboratory and x ray services necessary to confirm the existence of
infection, clinic services and FQHC services, case management services,
and services (other than room and board) designed by the treating health
professional or entity to encourage completion of treatment regimens by
outpatients, including services to observe directly the intake of
prescribed drugs.
Home health services As described in 42 C.F.R. § 440.70.
Private duty nursing
services As described in 42 C.F.R. § 440.80.
Personal Care
Services As described in 42 C.F.R. § 440.167.
Nursing facility
services As described in section C.2.189.
Hospice care As described in § 1905(o) of the Act, 42 U.S.C. § 1396d(o).
Non-Emergency
Transportation
services
As described in 42 C.F.R. § 440.170(a) for NEMT and DDS Services as
described in Section C.5.63.
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Table A: Medicaid Covered Services
Service Benefit Limit
Gender Reassignment
Surgery/Services As described in the DHCF Gender Reassignment Surgery Policy.

C.5.50 General Rules of Coverage for CASSIP Enrollees

C.5.50.1 This section identifies classes of Covered Services that Contractor is required to both
cover and furnish to CASSIP Enrollees under age twenty-six (26) and up to the month of
a CASSIP-Eligible Enrollee’s 26th birthday. This section sets forth all classes of Covered
Services and incorporates by reference the service definitions that are set forth in the
federal regulations and in this Contract.

C.5.50.2 Practice guidelines (as required in Section C.5.87) applied to Enrollees under age
twenty-one must conform to the classes of Covered Services set forth in this section and
must adhere to the standard of medical necessity applicable to Enrollees under age
twenty-one and set forth in Section C.5.142.

C.5.50.3 The Contractor shall furnish the EPSDT benefit described in 42 USC 1905(a)(B) and
1905(r), 42 C.F.R. § 440.40(b) and Subpart B of 42 C.F.R. Part 441, unless otherwise
excluded in section C.5.82. EPSDT services include:

C.5.50.3.1 Periodic and inter-periodic EPSDT screening services whenever an Enrollee is under 21,
or the Enrollee’s parent or caretaker relative on his or her behalf, requests the services,
unless the Contractor verifies and documents that the most recent age-appropriate
screening services due under the periodicity schedule specified have already been
provided to the Enrollee.

C.5.50.3.2 Periodic and inter-periodic assessments of infant, child, and adolescent health and
development, shall be furnished:

C.5.50.3.2.1 At intervals specified under the District of Columbia HealthCheck Periodicity Schedule
(Attachment J.28) and upon request by DHCF, at times other than regularly scheduled
intervals; and
C.5.50.3.2.2 Within 60 days of enrollment with the Contractor, unless the Contractor is able to
secure written documentation from the child’s medical record that the child is up-to-date
in accordance with the periodicity schedule and that no separate request for an
assessment has been received.

C.5.50.4 The Contractor shall ensure that Network Providers serving children furnish periodic and
inter-periodic assessments that shall consist of:

C.5.50.4.1 A comprehensive health and developmental history (including an assessment of
physical, oral health and mental health development); an unclothed comprehensive
health exam; immunizations in accordance with recommendations of the AAP
(Attachments J.28, J.29, and J.30); laboratory tests including assessment of blood lead
levels in accordance with C.5.233 and health education including anticipatory guidance.

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C.5.50.5 Vision screening services in accordance with the District of Columbia Health Check
periodicity schedule (Attachment J.28) and at such other intervals as may be needed to
identify the existence of a suspected illness or condition, including the diagnosis and
treatment for vision-related defects or conditions, including eyeglasses and corrective
lenses.

C.5.50.6 Hearing screening services in accordance with the District of Columbia Health Check
Periodicity Schedule (Attachment J.28) and at such other intervals as may be needed to
identify the existence of a suspected illness or condition, including diagnosis and
treatment of defects in hearing, including hearing aids.

C.5.50.7 Dental screening services in accordance with the District of Columbia Dental Periodicity
Schedule (Attachment J.29) and at such other intervals as may be needed to identify the
existence of a suspected illness or condition, including relief of pain and infection,
restoration of teeth and maintenance of dental health. Contractor shall reimburse for up
to four applications of fluoride varnish per year, furnished either by a dentist or, for
Enrollees under the age of three years, by a PCP who has completed the fluoride varnish
training approved by DHCF through the Health Check Training and Resource Center.

C.5.50.8 Mental health and substance use disorder screenings as required by the District’s
Periodicity Schedule. The PCP shall use a validated, brief behavioral health screener.

C.5.50.9 Enrollees who screen positive for a referral to behavioral health services shall receive
timely access to an appointment for further assessment and treatment by a behavioral
health Provider.

C.5.50.10 The Contractor shall furnish any diagnostic or treatment service specified in § 1905(a) of
the Act, 42 U.S.C. § 1396d(a) to correct or ameliorate defects and physical and mental
illnesses and conditions discovered by the screening services, regardless of whether the
service is listed in Section C.5.48.

C.5.50.11 The Contractor shall furnish any service described in section C.5.48 and included in an
Enrollee’s IDEA Individualized Family Service Plan (IFSP) plan unless Contractor
demonstrates to DHCF prior to the denial of the service that the service is not Medically
Necessary, as described in Section C..5.142; or the service is excluded under Section
C.5.82 or subject to the exclusion for certain health-related IDEA services described in
Section C.5.52.

C.5.50.12 Following an Enrollee’s transfer to CFSA and transition to FFS, the Contractor shall
remain responsible for covered EPSDT services described in this section. If CFSA’s
initial assessment of the Enrollee demonstrates that Enrollee did not receive services that
should have been provided while enrolled in the Contractor’s plan, Contractor shall
furnish such services.

C.5.50.13 The Contractor shall ensure that all applicable Network Providers are enrolled in the
Vaccines for Children (VFC) Program for the provision of immunizations to Enrollees 0
– 18 (under 19) years of age. The Contractor shall not reimburse Network Providers for
vaccines provided through the VFC Program unless the Contractor can demonstrate
through written documentation to DHCF that the vaccine was unavailable through the
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VFC Program. Contractor remains responsible for reimbursement of administrative fees
associated with vaccines.

C.5.50.14 The Contractor shall furnish Medically Necessary Case Management services as defined
in 42 C.F.R. §440.169.

C.5.50.15 The Contractor shall furnish skilled nursing facility services for Enrollees under age 21
as described in 42 C.F.R. § 440.155.

C.5.50.16 The Contractor shall ensure that Enrollees are scheduled to be seen by an outpatient
provider within the first seven days of discharge to the community from a psychiatric
inpatient facility admission or Psychiatric Residential Treatment Facility (PRTF). The
Contractor shall ensure that within those seven days the provider must assess the
Enrollee, provide prescriptions, if needed, and make arrangements for pick up or
delivery of the medication, if assistance is needed. The Contractor shall ensure that a
subsequent appointment occurs within the first thirty days of discharge from any acute
care admission.

C.5.50.17 All CASSIP Enrollees, under the age of 18, admitted to an acute care facility for
behavioral health purposes must be screened for eligibility to receive CBI and Intensive
Care Coordination. Referrals should occur within 48 hours of admission by contacting
the DBH Child/Youth Division. CBI is an intensive in-home service, and the Contractor
is responsible for care management for Enrollees receiving the service.

C.5.51 Screening Tool Requirements

C.5.51.1 The Contractor shall select screening tools for identification of Behavioral Health
(mental health and substance use disorder) needs in primary care settings and submit the
tool(s)s for DHCF review and approval prior to Contractor implementing or utilizing the
screening tools.

C.5.51.2 DHCF shall, at its discretion, select a tool or tools for implementation by all PCPs or
Providers in Contractor’s network.

C.5.52 Individuals with Disabilities Education Act (IDEA) Covered Services

C.5.52.1 This section sets forth expectations regarding coverage rules for CASSIP Enrollees in
any educational or education related setting.

C.5.52.2 The Contractor shall cover all Medically Necessary Services, as defined in sections
C.5.48 and C.5.142 for CASSIP Enrollees under age four , regardless of whether the
service in question is also identified as a “Related Service” under a child’s education
related IFSP.

C.5.52.3 The Contractor shall cover all transportation to and from covered Medically Necessary
Services listed on an Enrollee’s IFSP, as defined in this Sections C.5.48 and C.5.142 for
CASSIP Enrollees, regardless of whether the medical or health care service in question
is also identified as a “Related Service” under an Enrollee’s IFSP unless such
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transportation services are otherwise provided by District of Columbia Public Schools
(DCPS), OSSE or the LEA.

C.5.52.4 The Contractor shall identify all Enrollees who also receive EI or medical services under
the IDEA and shall report to DHCF all coverage denials or exclusions involving such
children within three days of denial or exclusion or in compliance with any
Memorandum of Agreement (MOA) between DHCF, DCPS and OSSE, as applicable.

C.5.52.5 The Contractor shall have policies and procedures, including an electronic tracking tool,
in a format as determined by DHCF, that monitors compliance with IDEA.

C.5.52.6 The Contractor shall ensure staff attends IFSP planning meetings, with consent of the
parent/caregiver. The Contractor shall, on a quarterly basis, provide to DHCF, a
summary of the information contained in the tracking tool with a summary of the
number of staff and Enrollees attending IFSP meetings, along with the number and
percentage of meetings that staff and Enrollees did not attend due to circumstances such
as late notice to the MCO or the Enrollee fails to attend the meeting.

C.5.52.7 The Contractor shall ensure that appropriate staff attend DHCF, OSSE, and DCPS
training sessions to inform them about the requirements, services, and procedures of
IDEA and shall communicate this information to its PCP, pediatric Provider Network,
and Contractor staff through written and/or other appropriate effective means.

C.5.52.8 The Contractor shall ensure that its designated contact person for DCPS, OSSE Strong
Start/EI Program, and District Head Start programs regularly attends any working
group(s) sponsored by the District regarding the coordination and communication of
physical, and behavioral health services of Enrollees served by DCPS, Head Start, and
OSSE Strong Start/EI Program.

C.5.52.9 The Contractor’s Network shall include providers qualified to perform evaluations for
IDEA eligibility and provide health related IDEA services for children under the age of
four , and older, unless and until those services are provided by DCPS or DC Medicaid.

C.5.52.10 The Contractor shall be responsible for the Care Coordination of all health-related
services rendered to Enrollees, even when the provider of services is DCPS or another
LEA.

C.5.52.11 The Contractor shall submit an EI quarterly report, which includes the date that EI
referral is received, the date of evaluation, the date that the IFSP is signed, the percent of
developmental delay, the services that the enrollee receives, Contractor’s attendance in
the IFP Meeting, Type of Contractor participation, and reason(s) for not attending, if
applicable.

C.5.53 Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Coverage Rules

C.5.53.1 The Contractor shall ensure that determinations of medical necessity in the case of
Enrollees under age twenty-one are made in accordance with the medical necessity
standards applicable to EPSDT services under section C.5.142.

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C.5.53.2 The Contractor shall not be responsible for coverage or payment of screening,
diagnostic, and treatment services when such services are furnished to an Enrollee in a
school setting by a school program. Contractor shall be responsible for those items and
services that are not provided in a school setting in accordance with C.5.53.

C.5.53.3 The Contractor shall inform families and caregivers about EPSDT in accordance with
Sections C.5.19 and C.5.40. The Contractor shall provide scheduling and transportation
services necessary to ensure timely receipt of assessments and timely initiation of
treatment under 42 C.F.R. § 441.56, et seq. Transportation services consist of:

C.5.53.3.1 Health care related Non-emergency medical transportation services required by children
who also are participating in educational programs, unless transportation is furnished
directly by the school system; and
C.5.53.3.2 Health care related Non-emergency medical related transportation services for Enrollees
under age twenty-one in foster care or out-of-home placements.

C.5.53.4 Service Alignment with Medicaid Fee-for- Service

C.5.53.4.1 The Contractor shall align with DHCF criteria and processes for clinical and pharmacy-
based services, programs and initiatives when and as directed by DHCF.
C.5.53.4.2 The Contractor shall align its criteria and processes and comply with such requirements
no later than thirty days after written notification is sent to the Contractor from DHCF,
unless otherwise noted.
C.5.53.4.3 Any systems or policy and process changes required to implement new alignment
requirements shall be made at no cost to the District.

C.5.54 EPSDT Outreach Activities

C.5.54.1 The Contractor shall be responsible for outreach activities and for informing Enrollees
who are under the age of twenty-one , or their parent or caretaker relative, of the
availability of EPSDT services, including services that are due and overdue.

C.5.54.1.1 In addition to targeted EPSDT outreach to specific Enrollees, the Contractor shall
provide Enrollee education and outreach in the community settings and shall, by
September 1 of each year, submit to DHCF an outreach plan.

C.5.54.1.1.1 The outreach plan shall be divided by month, that includes, but is not limited to, a
schedule of planned outreach initiatives in school-based settings, the local community,
and the contractor's facilities.

C.5.54.1.1.1.1 The outreach plan will be reviewed by DHCF for implementation in the following
fiscal year.

C.5.54.2 The Contractor shall have the ability to conduct EPSDT outreach in formats appropriate
to Enrollees who are blind, Deaf, Hard of Hearing, illiterate/have difficulty reading or
have limited English proficiency (LEP). Outreach attempts identified above shall advise
Enrollees how to request and/or access such assistance and information.

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C.5.4.2.1 The Contractor shall collaborate with agencies that have established procedures for
working with special populations to develop effective EPSDT outreach and materials.

C.5.54.3 The Contractor shall have policies and procedures, including an electronic tracking tool,
to monitor children’s compliance with EPSDT, including EPSDT periodicity schedule,
and shall conduct outreach activities to assist Enrollees under age 21 to make and keep
EPSDT appointments.

C.5.54.3.1 The outreach activities shall include every reasonable effort, including a telephone call
or mailed reminder prior to the due date of each EPSDT screening service.

C.5.54.3.1.1 In the case of a first missed appointment, the Contractor shall contact the Enrollee by
telephone or mailed reminder.

C.5.54.3.1.1.1 If Contractor is unable to get a response from enrollee, parent(s) and/or caregiver(s)
within 14 days, a home visit shall be conducted to urge the parent(s) and/or caregiver(s)
to bring the child for his or her EPSDT appointment.

C.5.54.3.2 When appropriate, such contacts shall be directed to sui juris teenagers.

C.5.54.4 The Contractor shall offer scheduling and transportation assistance, such as paying for
Enrollees’ transportation costs, prior to the due date of each Enrollee’s periodic
examination and shall provide this assistance when requested and necessary.

C.5.55 Behavioral Health & Other Coverage

C.5.55.1 The Contractor shall provide Behavioral Health Services, as applicable to the
Contractor’s scope of coverage, as defined in the State Plan and all applicable DCMR
and waivers, which includes, but is not limited to services listed in Table B below.

C.5.55.2 The Contractor shall ensure access to Behavioral Health Services in accordance with the
Mental Health Parity and Addiction Equity Act of 2008, which generally requires that
health insurance plans treat mental health and substance use disorder benefits on equal
footing as medical and surgical benefits.

C.5.55.3 Within 45 days of contract award, the Contractor shall submit standardized tools,
including those required by DC Regulation, to determine length of stay, admission
criteria, and authorization, for approval by DHCF, specifically related to BH.

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C.5.55.4 Table B: Medicaid Behavioral Health Services
Service Contractor’s Coverage Requirements
C.5.55.4.1
C.5.55.4.1.1
C.5.55.4.1.2
C.5.55.4.1.3
C.5.55.4.1.4
C.5.55.4.1.5
C.5.55.4.1.6
C.5.55.4.1.7
C.5.55.4.1.8
C.5.55.4.1.9
C.5.55.4.1.10
C.5.55.4.1.11
C.5.55.4.1.12
Services Regulated by DBH or
DHCF under the 1115 Behavioral
Health Demonstration Waiver:
CBI
Multi-Systemic Therapy (MST)
ACT
Transitional Assertive Community
Treatment (TACT)
Community Support
Recovery Support Services
Adolescent Community
Reinforcement Approach (ACRA)
Vocational Supported
Employment Clubhouse Services
Trauma Recovery Empowerment
Model
(TREM)
Trauma Systems Therapy (TST)
Functional Family Therapy (FFT)
Other Services Provided by DBH
Care coordination
Case Management
Transportation
C.5.55.4.2
C.5.55.4.2.1
C.5.55.4.2.2
C.5.55.4.2.3
C.5.55.4.2.4
C.5.55.4.2.5
Physician and mid-level visits
including:
Diagnostic and Assessment
Services
Individual counseling
Group counseling
Family counseling FQHC services
Medication/Somatic Treatment
Services furnished by the Contractor’s
network of Behavioral Health Providers.
C.5.55.4.3 Crisis Services Mobile crisis/Emergency Services, excluding
beneficiaries actively receiving services from
the Child and Adolescent Mobile Psychiatric
Service (ChAMPS) Care Coordination, Case
Management, Transportation (when
applicable) for CASSIP Enrollees who are
enrolled in a DBH certified entity.
C.5.55.4.4 Inpatient Hospitalization and
Emergency Department Services
Inpatient hospitalization and emergency
department services.
C.5.55.4.5 Case Management Services At minimum:
Case Management services, as described in
42 C.F.R. § 440.169
C.5.55.4.6 Inpatient psychiatric Facility
services
Inpatient psychiatric facility services for
individuals under age 21 as described in 42
C.F.R. § 440.160.
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C.5.55.4 Table B: Medicaid Behavioral Health Services
Service Contractor’s Coverage Requirements
C.5.55.4.7 Pregnancy related services Pregnancy-related services described in 42
C.F.R. §§ 440.210(a)(2), and (3), including
treatment for any mental condition that could
complicate the pregnancy.
C.5.55.4.8 Patient Psychiatric Residential
Treatment Facility (PPRTF)
PPRTF Services for Enrollees less than age
21 years.
C.5.55.4.9 Access to Behavioral Health
Services
Education regarding how to access behavioral
health services provided by the Contractor as
well as Medicaid-covered Services outside
the scope of this contract.
C.5.55.4.10 Pediatric Behavioral Health
Services
All medically necessary behavioral health
services for children that are included in an
IEP or IFSP during holidays, school
vacations, or sick days from school. All
medically necessary behavioral health
services that are included in an IFSP
C.5.55.4.11 Inpatient detoxification Covers inpatient detoxification.
C.5.55.4.12 Outpatient Substance Use
Disorder Services (SUDS)
Clinic and OLP services. Contractor is
responsible for referrals to DBH-certified
Providers for Youth Outpatient Rehabilitation
Services (ASURS).
C.5.55.4.13 Behavioral Health Service to
Students in School Settings
Services are covered if the following is met:
(1) The Provider has a Sliding Fee Schedule
for billing for children and youth without an
IEP; (2) The Provider is credentialed as a
Network Provider by the Contractor; (3) The
Provider has an office in the school and
provides services in that office; and (4) The
Provider bills the MCO for the services using
the codes provided by DHCF.
C.5.55.4.14 Institution for Mental Disease
(IMD)
The Contractor shall provide inpatient
treatment for Enrollees aged 21-64 years of
age in an IMD, as defined in 42 C.F.R. §
435.1010, so long as the facility is a hospital
providing psychiatric or substance use
disorder inpatient care or a sub-acute facility
providing psychiatric or substance use
disorder crisis residential services, and length
of stay in the IMD is for a short term stay of
no more than 15 days per month.

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C.5.55.5 The Contractor shall, in accordance with DHCF directives:

C.5.55.5.1 Disseminate and train PCPs in the use of DHCF tool(s) for the screening and early
intervention of behavioral health services for CASSIP Enrollees;
C.5.55.5.2 Ensure that PCPs administer behavioral health screening tools as a routine part of every
Enrollee’s preventive health examination or well child visit; and
C.5.55.5.3 Communicate routinely with PCPs for the ongoing coordination of behavioral health
treatment needs and with providers that are in or outside of the Contract’s Network
serving their Enrollees, in accordance with the Enrollee’s consent to share information
about such treatment if necessary.

C.5.56 Services to Enrollees in IDD Waiver

C.5.56.1 The Contractor shall ensure that Enrollees that are also enrolled in DHCF’s IDD Waiver
have their medical services coordinated in collaboration with the designated DDS
representative.

C.5.56.2 Contractor shall work with any DDS Case Manager or other Representative to include
DDS services in the Enrollee’s Care Plan. The Contractor shall be responsible for non-
emergency medical transportation (NEMT) for DDS activities.

C.5.57 Long Term Care and Psychiatric Residential Treatment Facility Services

C.5.57.1 The Contractor shall provide Long Term Care and Long-Term Care-like services for
Enrollees in home and community-based services and admitted to or residing in Skilled
Nursing Facilities, Rehabilitation Hospitals, ICF/IIDs, and PRTF.

C.5.57.1.1 LTSS provided by the Contractor in a community-based setting that is authorized
through a section 1915(c) waiver, a section 1915(i) SPA, or a section 1915(k) SPA, shall
be provided in a setting which complies with the 42 C.F.R. § 441.301(c) requirements
for home and community-based settings.

C.5.57.2 The Contractor shall pay for medical care provided to Enrollees at these facilities,
whether such care is provided by the facility or through Contractor’s Network via
telemedicine.

C.5.57.3 For Enrollees in a Long-Term Care facility or PRTF, Contractor shall conduct monthly
teleconferences and quarterly face to face visits at the facility. Quarterly face to face
visits may occur via virtual platforms with prior approval from DHCF. Based on the
findings from these visits, the Contractor shall determine whether more visits are
warranted.

C.5.57.4 Additional calls and visits are required when there are Adverse Findings and/or concerns
with care and service delivery provided to the Enrollee. The Enrollee and/or caregiver
shall participate in discussions and meetings, as appropriate. Documentation is required
to justify non-participation by the Enrollee and/or their caregiver.

C.5.57.5 If the Contractor makes an Adverse Finding upon its visit, the Contractor shall notify
DHCF within twenty-four hours and follow-up with a written report within two
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Business Days. The Adverse Finding report shall include a detailed description of the
basis of its finding, Contractor’s action plan, copy of the Enrollee’s most recent Care
Coordination Plan, a copy of the discharge plan, and a copy of the transition plan.

C.5.57.6 Under 42 C.F.R. 438.210 (a)(ii)(D), the Contractor shall provide opportunity for an
Enrollee receiving long-term services and supports to have access to the benefits of
community living, to achieve person-centered goals, and live and work in the setting of
their choice.

C.5.57.7 Under § 42 C.F.R. 441.301(c) and , the Contractor shall ensure that there is a person-
centered Care Plan, developed by individuals trained in person centered care planning,
the duration of the LTC or PRTF length of stay.

C.5.57.8 Under 42 C.F.R. § 441.301(c), the Contractor shall review and revise the Care Plan upon
reassessment of functional need and in accordance with the Enrollee’s Acuity, as
described in section C.2.7 and when the Enrollee's circumstances or needs change
significantly, or at the request of the Enrollee during the length of stay.

C.5.57.9 The Contractor shall ensure that Enrollees are scheduled for an outpatient provider
within the first seven days of discharge to the community from a psychiatric inpatient
facility admission or PRTF. Within those seven days the provider must assess the
Enrollee, provide prescriptions, if needed, and make arrangements for pick up or
delivery of the medication, if assistance is needed. The Contractor is responsible for the
care coordination for a subsequent appointment which must occur within the first thirty
days of discharge from an acute care admission.

C.5.57.10 The Contractor shall submit a Monthly report on behavioral health including behavioral
health related inpatient hospitalization and emergency department visits, denials for
inpatient behavioral health hospitalization, seven and thirty day follow up after
hospitalization, readmissions within thirty days after hospitalizations, court-ordered
behavioral health evaluations and PRTF placements.

C.5.57.11 The Contractor shall provide Institutional and Long-Term Care Reports comprised of the
Monthly and Annual Report on Enrollee Admissions to PRTFs, Nursing Facilities,
Skilled Nursing Facilities, and ICF/IIDs by age and gender for:

C.5.57.11.1 Number of Enrollees by name of facility;
C.5.57.11.2 Number of admissions to long term care facilities (PRTFs, Nursing Facilities, Skilled
Nursing Facilities, and ICF/IIDs) located in the District of Columbia, as well as other
jurisdictions, city and state;
C.5.57.11.3 Name of each Enrollee;
C.5.57.11.4 Name of the PRTF;
C.5.57.11.5 Length of stay;
C.5.57.11.6 Name of the District agency responsible for the placement;
C.5.57.11.7 Number of out-of-state admissions, by state of placement; and
C.5.57.11.8 Number of Enrollees by length of stay.

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C.5.57.12 The Contractor shall submit a Monthly Report on Enrollees receiving alternative care
under cost-effective services, including but not limited to:

C.5.57.12.1 Name;
C.5.57.12.2 Medicaid ID;
C.5.57.12.3 Facility/provider;
C.5.57.12.4 State Plan service treatment need;
C.5.57.12.5 Date of admission/service;
C.5.57.12.6 Total days of service to date;
C.5.57.12.7 Discharge or care termination potential;
C.5.57.12.8 Target discharge or care termination date;
C.5.57.12.9 Discharge or care termination disposition; and
C.5.57.12.10 Date(s) of weekly telephonic or electronic clinical review.

C.5.58 Respite Care Coverage

C.5.58.1 The Contractor shall ensure Respite Services are provided to Enrollees under the age of
twenty-one who are enrolled in the CASSIP line of business in accordance with 29
DCMR § 4232.

C.5.58.2 Respite Services are excluded for CASSIP Enrollees who are enrolled in the Non-
CASSIP line of business, enrollees over the age of twenty-one, and Enrollees enrolled in
the District’s IDD/DD Waiver.

C.5.58.3 Respite Services shall not be available for Enrollees residing in a nursing facility or
ICF/IID.

C.5.58.4 Respite Services shall be provided in the following locations:

C.5.58.4.1 Eligible Enrollee’s home or place of residence including a relative’s home or place of
residence;
C.5.58.4.2 Licensed foster care placement;
C.5.58.4.3 Licensed assisted living facility contracted as a residential center for Enrollees under age
21;

C.5.58.4.4 Licensed residential facility or group home that meets all requirements consistent with
the District Agency that governs that facility and DC Health, if applicable (i.e., DBH,
DDS, etc.); and
C.5.58.4.5 Hotels, shelters, churches, and alternative facilities located in the District when client is
displaced due to public health emergency.

C.5.58.5 Respite Services shall not include services that require skills of a licensed professional
nor services usually performed by a chore worker that would include cleaning of areas
not occupied by the Enrollee, laundry or shopping for items that does not belong or for
the Enrollee.

C.5.58.6 The Contractor shall develop policies and procedures that include, but not limited to:

C.5.58.6.1 Timeframes for requesting and approving Respite Services;
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C.5.58.6.2 Notification process for approval, denial, and alternative available dates;
C.5.58.6.3 Requirements for a written emergency notification plan; and
C.5.58.6.4 Other applicable requirements in accordance with 29 DCMR §§ 4231 and 4232.

C.5.58.7 The Contractor shall include the delivery of all Respite Services in the enrollees Care
Plan.

C.5.59 Respite Provider Service Agreements

C.5.59.1 The Contractor shall develop a network of Respite Service providers with the capacity to
deliver Respite Services in accordance with 29 DCMR § 4231.1 through § 4231.4, 29
DCMR § 1930.7 for DDS Providers and in-facility non-skilled staff appropriate to
provide Respite Services.

C.5.59.2 The Contractor shall ensure the Respite Services Provider Network contains an
adequate number of providers, a variety of resources, and contingency plans for
unexpected peak respite demands.

C.5.59.3 The Contractor shall ensure that a Respite Provider Service Agreement is executed with
each network provider prior to the delivery of respite services.

C.5.59.4 The Contractor shall not establish or maintain Respite Services agreements with
providers that have been debarred or suspended from participating in Federal or District
procurements or those providers that have been terminated from the District’s Medicaid
program.

C.5.59.5 The Contractor shall ensure that copies of the executed agreement and other relevant
documents are maintained in the Contractor’s provider files.

C.5.59.6 The Contractor shall ensure all Respite Service providers complete trainings as required
in accordance with 29 DCMR§§ 4231.3 and 4231.4 and/or DDS in-home supports
training.

C.5.60 Contractor and Respite Provider Requirements

C.5.60.1 Reimbursement for Respite Services

C.5.60.1.1 In accordance with 29 DCMR §§ 4213.3 and 4213.4, reimbursement for Respite
Services shall be limited to a maximum number of four hundred and eighty (480) hours
per year per eligible Enrollee.

C.5.60.1.2 The Contractor shall not carry over unused Respite Services hours to the next respite
period or otherwise transfer respite hours from one CASSIP Enrollee to another.

C.5.60.1.3 The Contractor shall not reimburse for services provided by the Enrollee’s parent,
caregiver, or other legally or non-legally responsible relative or court-appointed
guardian.

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C.5.60.1.4 Medicaid reimbursable Respite Services shall not be billed in combination with or at the
same time as PCA services or billed as an in-lieu of service in accordance with C.5.90.

C.5.60.1.5 The Contractor shall only reimburse for non-skilled Respite Services provided in a home
or in a facility. The Contractor shall not reimburse for any non-respite services.

C.5.60.1.6 Respite Services shall not be used to supplement or supplant payment for an Enrollee for
the following:

C.5.60.1.6.1 Summer Camp(s);
C.5.60.1.6.2 Day Camp(s);
C.5.60.1.6.3 Recreational activities;
C.5.60.1.6.4 Membership fees or dues of any kind; and
C.5.60.1.6.5 Any activity that is offered that is not described in Section C.5.58

C.5.60.1.6.6 Respite Services shall not supplement or supplant:

C.5.60.1.6.6.1 Daycare while an Enrollee’s parent or guardian is at work or school; and
C.5.60.1.6.6.2 Personal Care Hours available under the State Plan Amendment.

C.5.60.1.6.7 A unit of Medicaid reimbursable service for respite care shall be one hour spent
performing allowable tasks, following Title 29 DCMR, Chapter 42.

C.5.61 RESERVED

C.5.62 Respite Services Reporting Requirements

C.5.62.1 The Contractor is responsible for submitting a Respite Care Utilization report quarterly
in a manner defined or approved by DHCF.

C.5.62.2 The Contractor is responsible for submitting an annual Respite Care Utilization report in
a manner defined or approved by DHCF.

C.5.63 Transportation Services

C.5.63.1 The Contractor shall be responsible for the provision of the following transportation
services to Enrollees:

C.5.63.1.1 Non-Emergency Transportation services described in 42 C.F.R. § 440.170(a).
Transportation includes expenses for transportation and other related travel expenses
determined to be necessary by DHCF to secure medical examinations and treatment for
an Enrollee;

C.5.63.1.2 EPSDT transportation services described in 42 C.F.R. § 441.56;

C.5.63.1.3 Health care related transportation services required by Enrollees who also are
participating in educational programs, unless transportation is furnished directly by the
public-school, charter or local LEA system;

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C.5.63.1.4 Health care related transportation services for Enrollees under age twenty-one in foster
care or out-of-home placements;

C.5.63.1.5 Round trip transportation from the Enrollee’s home to an Enrollee Advisory Committee
meeting;

C.5.63.1.6 Any transportation associated with Medically Necessary services identified in the
Enrollee’s IFSP but excluding transportation to/from school for the sole purpose of
accessing school-based services; and

C.5.63.1.7 All transportation associated with a DDS service that is outlined in the Enrollee’s Care
Plan.

C.5.63.1.8 The Contractor shall not reimburse for Emergency Medical Transportation services
provided to a CASSIP Enrollee. Emergency Medical Transportation entities providing
Medicaid reimbursable services must submit claims directly to DHCF for
reimbursement.

C.5.64 Informing, Scheduling, and Transportation Services

The Contractor shall provide scheduling and transportation services necessary to ensuring
the timely receipt of assessments and the timely initiation of treatment under 42 C.F.R. §
441.56, et seq.

C.5.65 Transportation Personnel

C.5.65.1 The Contractor shall develop and implement a policy and procedure that describes the
process and methodologies that will be used to monitor and ensure all drivers that
transport CASSIP Enrollees are vetted with a valid driver’s license the other
requirements outlined throughout Sections C.5.65 and C.5.66.

C.5.65.2 The Contractor shall submit its policies and procedures to DHCF within thirty days of
Contract Award and upon DHCF request.

C.5.65.3 The Contractor shall undergo monthly oversight activities with their Transportation
subcontractor(s) to ensure compliance with the Contractor’s policies and procedures.

C.5.65.4 The Contractor shall ensure that any individual who is found to pose a safety risk is
prohibited from transporting CASSIP Enrollees, in accordance with Contractor’s
policies and procedures.

C.5.65.5 The Contractor shall ensure their Transportation subcontractor(s) conduct initial drug
testing of all transportation personnel within thirty days of hire and regular
unannounced drug testing of all transportation personnel according to their policies and
procedures. The Contractor shall not permit individuals who test positive for substance
abuse to transport Enrollees.

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C.5.65.6 The Contractor shall maintain personnel records with the results of criminal background
checks, alcohol, and drug test results for individuals who provide transportation to
Enrollees, in accordance.

C.5.66 Vehicle Requirements

The Contractor shall ensure that all vehicles to be used in the delivery of transportation
services shall comply with ADA regulations applicable to the services provided, District
Department of Motor Vehicles (DMV) licensing and inspection requirements, District safety
standards D.C. Official Code Title 50 Registration of Motorized Vehicles, and the
requirements described in the TPSA.

C.5.67 Driver and Attendant Requirements for the Contractor & Transportation Providers

C.5.67.1 The Contractor shall ensure that its policies and procedures minimally include that no
transportation personnel:

C.5.67.1.1 Have prior convictions for substance abuse or a sexual crime or crime of violence within
the last 15 years. Any person that has been convicted of a felony during the last ten
years may drive or aid passengers only after satisfactory review and approval by the
Contractor and the District;
C.5.67.1.2 May not have any felony convictions during the Contract period; and
C.5.67.1.3 Fluent in the English language.

C.5.68 Dental Services

C.5.68.1 The Contractor may subcontract with a delegated dental benefit entity and shall adhere
to all provisions and requirements for delegated entities in accordance with Section
H.11.2.3.

C.5.68.2 The delegated dental benefit entity need not be located in the District but shall be
available and present at any meeting upon DHCF’s request.

C.5.68.3 The Contractor shall ensure that dental services are provided to all CASSIP Enrollees as
defined in the State Plan and shall include but is not limited to services and requirements
listed below:

C.5.68.3.1 Medicaid beneficiaries under the age of twenty-one shall be eligible to receive
orthodontic services subject to the requirements set forth in C.5.68.3.3.

C.5.68.3.2 Before delivering an orthodontic service to a Medicaid beneficiary under the age of
twenty-one, each provider shall obtain prior authorization from the Contractor. To be
eligible for orthodontia services, the enrollee’s dental or orthodontia provider shall
demonstrate that the enrollee meets at least one of the following criteria:

C.5.68.3.2.1 Has an adjusted score greater than or equal to fifteen on the Handicapping Labio-
Lingual Deviation (HLD) Index;

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C.5.68.3.2.2 Exhibits one or more of the following Automatic Qualifying Condition(s) that cause
dysfunction due to a handicapping Malocclusion and is supported by evidence in the
Enrollee’s treatment records:

C.5.68.3.2.2.1 Cleft palate deformity;
C.5.68.3.2.2.2 Cranio-facial anomaly;
C.5.68.3.2.2.3 Deep impinging overbite causing the destruction of soft tissues of the palate and
tissue laceration and/or clinical attachment loss are present;
C.5.68.3.2.2.4 Crossbite of individual anterior teeth causing clinical attachment loss and recession of
the gingival margin are present;
C.5.68.3.2.2.5 Severe traumatic deviation;
C.5.68.3.2.2.6 Overjet greater than nine millimeters (9 mm.) or mandibular protrusion greater than
three and half millimeters (3.5 mm.);
C.5.68.3.2.2.7 Has otherwise established a medical need for orthodontic treatment by demonstrating
two or more – conditions below and justified the need in an accompanying narrative
prepared by the recommending dentist, orthodontist, primary care physician, speech
pathologist, or behavioral health provider:

C.5.68.3.2.2.7.1 A speech pathology that has proven non-responsive to medical treatment without
orthodontic treatment, which has been diagnosed by a licensed speech therapist;
C.5.68.3.2.2.7.2 Dysfunctional masticatory capacity as a result of the existing relationship between
the maxillary and mandibular arches;
C.5.68.3.2.2.7.3 Significant facial asymmetry;
C.5.68.3.2.2.7.4 Severe maxillary, mandibular, or bi-maxillary protrusion or other physical
deviation; or
C.5.68.3.2.2.7.5 Other conditions that affect the medical, social, or emotional function of the patient
as demonstrated by objective evidence provided by the patient’s primary care
physician or behavioral health provider.

C.5.68.3.2.3 The Contractor shall reimburse for up to four applications of fluoride varnish per year,
furnished either by a dentist or, for enrollees under the age of three years, by a primary
care provider (PCP) who has completed the fluoride varnish training approved by the
DHCF.

C.5.68.3.3 Dental Services as described in 42 C.F.R. § 440.100, including dentures as described in
42 C.F.R.§ 440.120(b);

C.5.68.3.4 Crowns

C.5.68.3.4.1 General dental examinations consisting of preventive services, which include routine
maintenance cleaning with oral hygiene instruction limited to once every six months;
C.5.68.3.4.2 Surgical services and extractions;
C.5.68.3.4.3 Emergency care;
C.5.68.3.4.4 Fillings;
C.5.68.3.4.5 Reline or rebase of a removable denture is limited to two in five years unless there is a
prior authorization;
C.5.68.3.4.6 Complete radiographic survey, full series of X-rays or panoramic X-ray of the mouth is
limited to once every three years. Additional complete radiographic survey, full series
of X-rays or panoramic X-ray of the mouth requires prior authorization;
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C.5.68.3.4.7 Full mouth debridement;
C.5.68.3.4.8 Oral Prophylaxis limited to once every six months;
C.5.68.3.4.9 Bitewing series;
C.5.68.3.4.10 Palliative treatment;
C.5.68.3.4.11 Sealant application;
C.5.68.3.4.12 Removable partial and full dentures;
C.5.68.3.4.13 Root canal treatment;
C.5.68.3.4.14 Periodontal scaling and root planning, if:

C.5.68.3.4.14.1 Evidence of bone loss must be present on the current full mouth x-ray series or
bitewing x-rays to support the diagnosis of periodontitis;
C.5.68.3.4.14.2 There must be current periodontal charting with six point measurements and
mobility noted, including the presence of pathology and periodontal prognosis;
C.5.68.3. 4.14.3 The pocket depths are greater than four millimeters; and
C.5.68.3.4.14.4 Classification of the Periodontology case type is in accordance with documentation
established by the American Academy of Periodontology.

C.5.68.3.5 Removal of impacted teeth

C.5.68.3.5.1 Initial placement or replacement of a removable prosthesis (any dental device or
appliance replacing one or more missing teeth, including associated structures, if
required, that is designed to be removed and reinserted), one per arch every five years
per beneficiary, unless the prosthesis:

C.5.68.3.5.1.1 Was misplaced, stolen or damaged due to circumstances beyond the beneficiary’s
control; and
C.5.68.3.5.1.2 Cannot be modified or altered to meet the beneficiary’s dental needs.

C.5.68.3.5.2 A removable partial prosthesis is covered if:

C.5.68.3.5.2.1 The crown to root ratio is better than 1:1;
C.5.68.3.5.2.2 The surrounding abutment teeth and the remaining teeth do not have extensive tooth
decay; and
C.5.68.3.5.2.3 The abutment teeth do not have large restorations or stainless-steel crowns.

C.5.68.3.5.3 Dental implants shall require Prior authorization and must be approved before the
initiation of treatment; and

C.5.68.3.5.4 Any dental service provided to a Medicaid beneficiary that requires inpatient
hospitalization or general anesthesia shall be prior authorized.

C.5.69 Excluded Dental Services from Medicaid Coverage

C.5.69.1 Local anesthetic that is used in conjunction with a surgical procedure and billed as a
separate procedure;
C.5.69.2 Hygiene aids, including toothbrushes;
C.5.69.3 Medication dispensed by a dentist that a beneficiary is able to obtain from a pharmacy;
C.5.69.4 Acid etch for a restoration that is billed as a separate procedure;

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C.5.69.5 Prosthesis cleaning;
C.5.69.6 Removable unilateral partial denture that is a one-piece cast metal including clasps and
teeth;
C.5.69.7 Replacement of a denture when reline or rebase would correct the problem;
C.5.69.8 Duplicative x-rays;
C.5.69.9 Space maintainers;
C.5.69.10 Fixed prosthodontics (bridge), unless it is cost effective for a beneficiary who cannot use
a removable prosthesis and prior authorization is required;
C.5.69.11 Gold restoration, inlay or onlay, including cast nonprecious and semiprecious metals;
C.5.69.12 Dental services for cosmetic or aesthetic purposes; and
C.5.69.13 Dental implants replacing wisdom teeth.

C.5.70 Dental Providers

The Contractor shall maintain a sufficient Network of dental Providers, including pediatric
dentists, endodontists, orthodontists, and oral surgeons, to meet the needs of CASSIP
Eligible Enrollees, including specialists who are licensed to perform dental work in an
operating suite. In accordance with C.5.93 and C.5.94, the Provider Network shall have at
least one full time dentist for every 750 child and adolescent (up to age 20) Enrollees.
Contractor shall ensure that a primary dentist is selected or assigned to every Enrollee.

C.5.71 Dental Reporting Requirements

C.5.71.1 The Contractor shall provide the following reports in a format determined by DHCF,
detailing the Contractor’s dental provider network, the enrollee’s utilization of dental
services, and the enrollee’s requests for dental services that require prior authorization:

C.5.71.1.1 Dental Provider Biannual Report
C.5.71.1.2 Dental Utilization by Specific Current Dental Terminology (CDT) Code Annual Report
C.5.71.1.3 Dental Prior Authorization Report

C.5.72 Covered Pharmacy Services

C.5.72.1 The Contractor shall provide coverage of covered outpatient drugs as defined in § 1927
(k) of the Act.

C.5.72.2 The Contractor shall employ a D.C. licensed pharmacist responsible for overseeing the
pharmacy program, including but not limited to: managing Enrollee access to and
utilization of pharmaceuticals, overseeing Enrollee education on the use of medication
(including over-the-counter medications and contraindications), and acting as a liaison
with DHCF on pharmacy issues.

C.5.72.3 The Contractor shall comply with all provisions of 1902(a)(85) and Section 1004 of the
Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for
Patients and Communities Act (SUPPORT Act) 1004 of the Substance Use-Disorder
Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities
Act (SUPPORT Act). The Contractor shall have the following in place:

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C.5.72.3.1 Prospective system safety edits on opioid prescriptions to address days’ supply, early
refills, duplicate fills and quantity limitations for clinical appropriateness;

C.5.72.3.2 Prospective system safety edits on maximum daily morphine milligram equivalents
(MME) on opioids prescriptions to limit the daily morphine milligram equivalent (as
recommended by clinical guidelines);

C.5.72.3.3 Retrospective review process on opioid prescriptions exceeding these above limitations
on an ongoing basis; and

C.5.72.3.4 Prospective and retrospective review process on concurrent utilization of opioids and
benzodiazepines as well as opioids and antipsychotics on an ongoing periodic basis.

C.5.72.4 The Contractor shall have programs to monitor and manage antipsychotic medications
use in children and young adults. Antipsychotic agents shall be reviewed for
appropriateness for all Enrollees including foster children based on approved indications
and clinical guidelines to be reported annually in the CMS DUR Annual Report.

C.5.72.5 The Contractor shall have an established process to identify potential fraud or abuse of
controlled substances by enrolled individuals, health care providers and pharmacies.

C.5.73 Medicaid Formulary

C.5.73.1 The Contractor shall use its own Formulary, but if the Formulary does not include a
covered outpatient drug that is otherwise covered by the State Plan pursuant to §1927 of
the Act, the Contractor must ensure access to the non-formulary covered outpatient drug
with the prior authorization consistent with applicable law.

C.5.73.2 The Contractor shall maintain its own Formulary of covered outpatient drugs and
selected over the counter (OTC) items. Covered outpatient drugs newly approved or
authorized by the Food and Drug Administration (FDA) shall be available to the
Contractor’s Enrollees. Contractor’s Formulary shall be submitted to DHCF upon
Contract Award for review and approval and quarterly, thereafter. The Contractor must
ensure access to the nonformulary covered outpatient drugs with prior authorization
consistent with applicable law.

C.5.73.3 The Contractor shall provide information in electronic or paper format about which
generic and name brand drugs are covered and what tier each drug is on. A formulary
list shall be made available on the Contractor’s website in a machine-readable file and
format following 42 C.F.R. § 438.10 (h)(i).

C.5.73.4 The Contractor shall make all reasonable efforts to ensure that Enrollees affected by a
formulary change do not experience delays or disruptions in obtaining Medically
Necessary medications as a result of the formulary change.

C.5.74 Dual Eligibles

For Dual Eligibles, the Contractor shall be responsible for all medications exempted from
payment by the Medicare Prescription Drug Benefit in accordance with § 1927(d) and
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1935(d) of the Social Security Act and the DC State Plan Amendment Supplement 1 to
Attachment 3.1 ( J.30).

C.5.75 Other Covered Medications

C.5.75.1 The Contractor shall be responsible for covering:

C.5.75.1.1 Select agents when used for weight gain (megesterol);
C.5.75.1.2 Select prescription vitamins and mineral products limited to single agent Vitamin B1,
Vitamin B6, Vitamin B12, Vitamin D and folic acid products; and
C.5.75.1.3 Select over-the-counter medications (single ingredient analgesics and antacids) or the
service is one that is described in Section C.5.72 for which the Contractor has received
prior approval in writing from the DHCF to exclude from the formulary.

C.5.76 HIV Pharmacy Carve Out for Medicaid Enrollees

Enrollees with an HIV/AIDS positive health status shall receive HIV/AIDS-related
medications from any of the pharmacies enrolled in the Contractor’s Pharmacy Provider
Network. The pharmacy provider will submit claims for these HIV/AIDS-related
medications on behalf of HIV/AIDS positive Enrollees to the Medicaid FFS program PBM
for payment.

C.5.77 Drug Utilization and Data Reporting

C.5.77.1 The Contractor shall operate a drug utilization program that complies with the
requirements of § 1927(g) of the Act.

C.5.77.2 The Contractor shall conduct drug utilization review (DUR) activities, as these activities
promote the delivery of quality care in a cost effective and responsible manner and
assure that prescriptions are appropriate and Medically Necessary; and are not likely to
result in adverse medical events.

C.5.77.3 The Contractor shall provide a description of its DUR activities, including the prior
authorization process in a format determined by DHCF, on a quarterly basis, consistent
with the minimum requirements set forth at § 1927(d) of the Act.

C.5.77.4 The Contractor shall participate in quarterly meetings with the DHCF DUR Board and
coordinate targeted interventions and educational outreach for both providers and
Enrollees when appropriate.

C.5.77.5 The Contractor shall report drug utilization data to DHCF in accordance with § 1927(b)
of the Act. The report shall be submitted within forty-five days after the end of each
quarterly rebate period, to be determined by DHCF. The utilization information must
include, at a minimum, information on the total number of units of each dosage form and
strength and package size by National Drug Code (NDC) of each covered outpatient
drug dispensed or covered by the Contractor.

C.5.77.6 The Contractor shall complete and submit to DHCF all requested data on the MCO DUR
Annual Report at least forty-five days prior to the due date.
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C.5.78 Prior Authorization

C.5.78.1 The Contractor shall establish and submit to DHCF, its prior authorization process for
covered outpatient drugs in accordance with § 1927(d) of the Act within ninety days of
the Contractor’s Start Date.

C.5.78.2 Prior Authorization requests shall be acknowledged within twenty hours of receipt. All
decisions and notification of that decision shall be determined within seventy-two hours
of PA request.

C.5.78.3 A 72 hour supply of a covered outpatient drug shall be dispensed in an emergency
situation. The Contractor may extend the 72 hour time period by up to fourteen days if
the Enrollee requests an extension, or if the Contractor justifies to DHCF a need for
additional information and how the extension is in the Enrollee’s interest.

C.5.78.4 For all covered outpatient drug authorization decisions, the Contractor must provide
notice as described in section § 1927(d)(A) of the Act.

C.5.78.5 If Contractor requires prior authorization for an outpatient prescription drug, the
Contractor shall provide a response within twenty-four hours of the request and
dispense, at least, a 72-hour supply in an emergency situation (i.e. without prior
authorization) in accordance with 42 C.F.R. §438.3(s).

C.5.78.6 The Contractor shall ensure that prior to the termination of the 72-hour (or more),
supply, the applicable Provider has been notified and an alternate regimen identified for
the Enrollee.

C.5.78.7 The Contractor may utilize a specialty pharmacy management program to provide
oversight of the quality of pharmacy utilization, monitor cost of dispensing expensive
specialty medications, and ensure optimal drug therapy management for CASSIP
Enrollees. This program would be responsible for prior authorization protocols, which
will take into account, complaints, appeals and grievances, patient education, clinical
data and guidelines for specialty drugs, and current medication usage.

C.5.79 340B Drug Utilization Data

C.5.79.1 Covered outpatient drugs dispensed to Medicaid Enrollees from covered entities
purchased at 340B prices, which are not subject to Medicaid rebates, should be excluded
from the Contractor’s reports to DHCF.

C.5.79.2 To ensure that drug manufacturers will not be billed for rebates of drugs purchased and
dispensed under the 340B Drug Pricing Program, the Contractor shall have mechanisms
in place to identify these drugs and exclude the reporting of this utilization data to DHCF
to prevent duplicate discounts on these products.

C.5.79.3 Covered outpatient drugs are not subject to the rebate requirements if such drugs are both
subject to discounts under 340B and dispensed by health maintenance organizations,
including Medicaid MCOs.
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C.5.80 Pharmacy Benefit Manager (PBM) Agreement Pricing Transparency

C.5.80.1 The Contractor shall submit their PBM contract to DHCF within 60 days prior to the
Start Date and annually thereafter. The Contractor shall submit any changes to the PBM
contract within 5 business days of a contractual change.

C.5.80.1.1 The Contractor is prohibited from allowing “spread pricing” or entering into a contract
with a PBM that allows the PBM to charge the Contractor more than what was paid to a
network pharmacy that dispenses prescription drugs to an Enrollee.

C.5.80.2 The Contractor shall submit a report in a format and frequency as determined by DHCF
of all claims level details that provides the basis for comparing the actual amount paid to
pharmacies to the amount that the PBM charged the Contractor for the transaction. This
report shall include at a minimum the following:

C.5.80.2.1 Dispensing fee, ingredient costs paid to pharmacies, and all revenue received, including
but not limited to pricing discounts paid to the PBM, rebates, inflationary payments, and
supplemental rebates;
C.5.80.2.2 All payment streams, including any financial benefits such as rebates, discounts, credits,
claw-backs, fees, grants, chargebacks, reimbursements, or other payments that the PBM
receives related to services provided for the Contractor; and
C.5.80.2.3 Administrative fees that covers the cost of providing pharmacy benefit management
services to the Contractor.

C.5.81 Denials of Prescription Drugs

C.5.81 If an Enrollee or Provider is disputing a denial of a prescription drug or pharmacy
service through a Grievance or Appeals process, the Contractor shall fill a prescription
for:

C.5.81.1.1 Seventy-two hours for prescriptions drugs that are administered or taken daily or more
than once per day; or
C.5.81.1.2 One full course for prescription drugs that are administered or taken less frequently than
once per day.

C.5.81.2 Unless Enrollee directs otherwise, Contractor shall contact the Provider who wrote the
prescription to resolve any outstanding issues with respect to the prescription while the
Grievance or Appeal is pending.

C.5.81.3 In the event the prescription Denial is overturned, the Contractor shall ensure the
Enrollee receives the full balance of the prescription.

C.5.81.4 The Contractor shall ensure that each network pharmacy complies with DHCF
instructions to post a notice of DC Medicaid beneficiary rights in the pharmacy.

C.5.81.5 The Contractor shall ensure network pharmacies distribute to Enrollees the DHCF official
beneficiary notice whenever a prescription drug is denied at the pharmacy point of sale.
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Contractor shall monitor and track distribution of the notice and submit a report in a
format and frequency as determined by DHCF.

C.5.81.5.1 The Contractor shall conduct a monthly audit of network pharmacies to assess
compliance with distribution of the DHCF official beneficiary notice, as described in
C.5.81.5 in accordance with a process defined by DHCF.

C.5.82 Excluded Medicaid Services

C.5.82.1 The following items and services are excluded from coverage. The Contractor shall
exclude a service from coverage or deny payment for a service only under the
circumstances described below:

C.5.82.1.1 The service is not included as a Covered Service in the State Plan;
C.5.82.1.2 The service is of an amount, duration, and scope in excess of a limit expressly set forth
in section C.5.49;
C.5.82.1.3 The service is not Medically Necessary as defined in section C.2.174;
C.5.82.1.4 The service is a prescription drug for which the Contractor has received prior approval in
writing from DHCF to exclude from the Contractor’s Formulary;
C.5.82.1.5 The service is an inpatient transplantation surgery; the Contractor shall cover pre- and
post-operative costs of the transplant surgery;
C.5.82.1.6 The service is cosmetic, except the following services shall not be considered cosmetic:

C.5.82.1.6.1 Surgery required correcting a condition resulting from surgery or disease;
C.5.82.1.6.2 Surgery required to correct a condition created by an accidental injury;
C.5.82.1.6.3 Surgery required to correct a congenital deformity;
C.5.82.1.6.4 Surgery required correcting a condition that impairs the normal function of a part of the
body; or
C.5.82.1.6.5 Surgery to address gender dysphoria as identified in DHCF Gender Reassignment
Surgery Policy (Attachment J.34);

C.5.82.1.7 The service is sterilization for any CASSIP Enrollee under age twenty-one ; and
C.5.82.1.8 The service is an abortion and does not meet the provisions in accordance with 42 C.F.R.
§ 457.475.

C.5.82.2 Nothing in this section shall be construed as prohibiting the expenditure by a State,
locality, entity, or private person of State, local, or private funds (other than a State’s or
locality’s contribution of Medicaid matching funds).

C.5.82.3 Nothing in this section shall be construed as restricting the ability of the Contractor from
offering abortion coverage or the ability of a state or locality to contract separately with
such a Provider for such coverage with State funds (other than a State’s or locality’s
contribution of Medicaid matching funds).

C.5.82.4 The service is described as an excluded-Contractor Covered Service, which is covered
by the State Plan, and therefore not the responsibility of the Contractor under the
Contract.

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C.5.82.5 The service is an investigational or Experimental Treatment if it is a diagnostic or
treatment service that, in accordance with relevant evidence, is not considered to fall
within the range of professionally accepted clinical practice with respect to illness,
disability, or condition that is the focus of a coverage determination.

C.5.82.6 In the case of CASSIP-Eligible Enrollees who are receiving clinical investigational
treatment conducted pursuant to a formal clinical trial, covered treatment will be
considered medically necessary if it satisfies the requirements of 42 U.S.C. §
1396d(a)(B) and 1396d(r).

C.5.82.7 In the case of an individual aged twenty-one who is pending disenrollment from
CASSIP, who are receiving investigational treatment conducted pursuant to a formal
clinical trial, covered treatments, items or services will be considered medically
necessary if they are furnished as part of a clinical investigational trial that meets
Medicare applicable standards.

C.5.82.8 The services are part of a clinical trial protocol. The Contractor shall cover all inpatient
and outpatient services furnished over the course of a clinical trial but shall not cover the
services included in the clinical trial protocol.

C.5.83 Excluded from Reimbursement

C.5.83.1 The Contractor is prohibited from paying for an item or service (other than an
emergency item or service, not including items or services furnished in an ER of a
hospital) furnished by an individual or entity to whom the District has failed to suspend
payments during any period when there is a pending investigation of a credible
allegation of fraud against the individual or entity, unless the District determines there is
good cause not to suspend such payments.

C.5.83.2 The Contractor is prohibited from paying for an item or service (other than an
emergency item or service, not including items or services furnished in an ER of a
hospital) with respect to any amount expended for which funds may not be used under
the Assisted Suicide Funding Restriction Act of 1997.

C.5.83.3 The Contractor is prohibited from paying for an item or service (other than an
emergency item or service, not including items or services furnished in an ER of a
hospital) with respect to any amount expended for roads, bridges, stadiums, or any other
item or service not covered under the State Plan.

C.5.83.4 The Contractor is prohibited from paying for an item or service (other than an
emergency item or service, not including items or services furnished in an ER of a
hospital) furnished under the plan by any individual or entity during any period when the
individual or entity is excluded from participation under title V, XVIII, or XX or under
this title pursuant to sections 1128, 1128A, 1156, or 1842(j) of the Act.

C.5.83.5 The Contractor is prohibited from paying for an item or service (other than an
emergency item or service, not including items or services furnished in an ER of a
hospital) furnished at the medical direction or on the prescription of a physician, during
the period when such physician is excluded from participation under title V, XVIII, or
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XX or under this title pursuant to sections 1128, 1128A, 1156, or 1842(j) of the Act and
when the person furnishing such item or service knew, or had reason to know, of the
exclusion (after a reasonable time period after reasonable notice has been furnished to
the person).

C.5.83.6 Cell and Gene Therapy

C.5.83.6.1 The Contractor shall reimburse for medically necessary cell and gene therapies (CGTs)
rendered to a CASSIP Enrollee, with the exception of CGTs which are experimental or
investigational, or are included in DHCF’s list of single-use curative CGT products
which will be directly reimbursed by DHCF (See Attachment J.34).

C.5.83.6.2 DHCF shall define the medication list of outpatient and inpatient single-use curative
CGT products to be excluded from reimbursement by the Contractor.

C.5.83.6.3 The Contractor shall remain financially responsible for all medical services related to the
administration and clinical management of the single-use CGTs including but not limited
to:

C.5.83.6.3.1 Pre-treatment diagnostics, genetic testing, and evaluations;
C.5.83.6.3.2 Facility costs inpatient or outpatient for therapy administration;
C.5.83.6.3.3 Physician and provider professional fees;
C.5.83.6.3.4 Observation and post-treatment monitoring;
C.5.83.6.3.5 Adverse event management and supportive care;
C.5.83.6.3.6 Behavioral health and care coordination services; and
C.5.83.6.3.7 Transportation services.

C.5.83.6.4 The Contractor shall provide timely medical services, and the reimbursement carve out
of the medication from the benefit should not delay care.

C.5.83.6.5 The Contractor shall comply with all DC FFS Medicaid and federal guidance related to
the CMS Cell and Gene Therapy Access Model including but not limited to:

C.5.83.6.5.1 Notification of member eligibility;
C.5.83.6.5.2 Data sharing and reporting on clinical outcomes and utilization; and
C.5.83.6.5.3 Coordination with the FFS Medicaid Program and designated providers to ensure timely
access to therapy.

C.5.84 Coordination with Other Medicaid Services

DHCF shall, at its sole discretion, require that the Contractor implement protocols and
procedures for coordinating managed care services with the provision of other Medicaid
services, including all Behavioral Health Services.

C.5.85 Alternative Levels of Care

C.5.85.1 During the term of the Contract, the Contractor may provide cost-effective services that
are in addition to those covered under the State Plan as alternative treatment services and
program for Enrollees under 42 C.F.R. § 438.3(e).
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C.5.85.1.1 The cost of alternative services shall not be included in capitated rate calculations.
DHCF shall only factor the State Plan services into the rates, plus any adjustments for
managed care efficiency.
C.5.85.1.2 The Contractor shall perform a cost-benefit analysis for any new services it proposes to
provide, as directed by DHCF, including how the proposed service would be cost
effective compared to State Plan services.
C.5.85.1.3 The Contractor shall implement cost-effective services and programs only after written
approval by DHCF.

C.5.85.2 The Contractor shall submit a monthly report to DHCF on Enrollees receiving
alternative care under cost-effective services in a template provided by DHCF.

C.5.86 Special Coverage Rules and Disputes

The Contractor shall notify DHCF within two business days of any questions regarding
coverage and level of care determinations, including denials of coverage. DHCF shall
respond to the Contractor within two business days.

C.5.87 Practice Guidelines

C.5.87.1 Under 42 C.F.R. § 438.236, the Contractor shall adopt and disseminate clinical practice
guidelines relevant to its Enrollees for the provision of preventive, acute and chronic
medical and Behavioral Healthcare services.

C.5.87.2 All practice guidelines shall be based on valid and reliable scientific clinical evidence or
drawn from expert and professional Provider consensus which includes the results of
peer reviewed studies.

C.5.87.3 The Contractor shall adopt practice guidelines in consultation with Network Providers
located in the District. These practice guidelines shall be reviewed, updated, and
approved periodically, as appropriate, at least every two years by the Contractor’s
Quality Improvement (QI) Committee or a designated clinical Committee.

C.5.87.4 Practice guidelines shall be disseminated to all contracted Providers, and shall be
readily available through mail, fax, e-mail, or through the Contractor’s website. Practice
guidelines shall be made available upon request to Enrollees and potential Enrollees.

C.5.87.5 The Contractor shall utilize the application of practice guidelines to assist Providers and
Enrollees to make decisions about appropriate health care UM for specific clinical
circumstances and Behavioral Health Services.

C.5.87.6 Under no circumstances shall any of the Practice Guidelines used by Contractor serve as
conclusive evidence to determine whether a service is considered Medically Necessary.

C.5.87.7 At a minimum, the Contractor shall consider utilization of the following guidelines:

C.5.87.7.1 The Centers for Disease Control and Prevention Sexually Transmitted Disease
Treatment Guidelines;
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C.5.87.7.2 The American Academy of Pediatrics Treatment of Attention- Deficit/Hyperactivity
Disorder Treatment Guidelines, Transportation for Children with Special Health Care
Needs Guidelines, and Emergency Preparedness for Children with Special Health Care
Needs Guidelines;
C.5.87.7.3 The American Academy of Pediatric Dentists Clinical Guidelines on Periodicity of
Examination, Preventive Dental Services;
C.5.87.7.4 National Institutes of Health (NIH) Guidelines for the Diagnosis and Management of
Asthma;
C.5.87.7.5 Recommendations of the American College of Obstetricians and Gynecologists (ACOG)
in the case of pregnancy-related services;
C.5.87.7.6 The American Academy of Pediatrics for pediatric services;
C.5.87.7.7 The American Psychiatric Association and American Psychological Association;
C.5.87.7.8 The Society for Adolescent Medicine;
C.5.87.7.9 The Advisory Committee on Immunization Practices; and
C.5.87.7.10 Guidelines that consider the needs of CASSIP Enrollees.

C.5.87.8 The Contractor shall establish or adopt care management protocols and clinical and
administrative guidelines for purposes of promoting improvements in the quality of care
management and the appropriate use of resources for Contractor’s Care Management
staff.

C.5.87.9 Care Management guidelines shall be updated as necessary, reviewed and approved by
the Contractor at least annually and shall be disseminated to all Care Management staff,
and shall be readily available through electronic means or otherwise. Within forty-five
days of Contract Award, Contractor shall submit a copy of its Care Management
Practice Guidelines for DHCF review and approval.

C.5.88 Coverage of In-Patient Services at the Time of Enrollment

The Contractor shall not be responsible for the payment of claims for Covered Services
provided during a hospital stay if the date of admission precedes the date of Enrollee’s
enrollment with Contractor.

C.5.89 Coverage of In-Patient Services at the Time of Disenrollment

The Contractor shall be responsible for the payment of claims for Covered Services during
an entire inpatient or hospital stay when an Enrollee’s discharge is subsequent to the
Enrollee’s disenrollment from Contractor.

C.5.90 In Lieu of Services

C.5.90.1 The Contractor may cover, for Enrollees, services or settings that are in lieu of services
or settings covered under the State Plan as follows per 42 C.F.R. § 438.3(e):

C.5.90.1.1 DHCF determines that the alternative service or setting is a medically appropriate and
cost-effective substitute for the Covered Service or setting under the State plan;
C.5.90.1.2 The Enrollee is not required by the Contractor to use the alternative service or setting;

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C.5.90.1.3 The approved in lieu of services are authorized and identified in this Contract, and will
be offered to Enrollees at the option of the Contractor; and
C.5.90.1.4 The utilization and actual cost of in lieu of services are taken into account in developing
the component of the capitation rates that represents the covered State plan services,
unless a state or regulation explicitly requires otherwise.

C.5.91 Mental Health Parity

C.5.91.1 The Contractor shall cover, in addition to Covered Services under the State Plan, any
services necessary for compliance with the requirements for parity in mental health and
substance use disorder benefits in 42 C.F.R. part 438, subpart K, and this Contract
identifies the types and amount, duration and scope of services consistent with the
analysis of parity compliance conducted by either the District or the Contractor.

C.5.91.2 The Contractor shall not include an aggregate lifetime or annual dollar limit on any
medical/surgical benefits or include an aggregate lifetime or annual dollar limit that
applies to less than one-third of all medical/surgical benefits provided to Enrollees
through a contract with the District, it may not impose an aggregate lifetime or annual
dollar limit, respectively, on mental health or Substance Use Disorder Services.

C.5.91.3 The Contractor shall not apply any financial requirement or treatment limitation to
mental health or SUDS. in any classification that is more restrictive than the
predominant financial requirement or treatment limitation of that type applied to
substantially all medical/surgical services in the same classification furnished to
Enrollees (whether the services are furnished by the same Contractor).

C.5.91.4 Except for services defined as Rehabilitation Behavioral Health Services, as described in
section C.5.55 Table B, the Contractor shall provide mental health and Substance Use
Disorder Services in every classification in which medical/surgical services are
provided.

C.5.91.5 The Contractor shall not impose non-quantitative treatment limits (NQTLs) for mental
health or SUDS in any classification whereas, under the policies and procedures of the
Contractor as written and in operation, any processes, strategies, evidentiary standards,
or other factors used in applying the NQTL to mental health or SUDS in the
classification are comparable to, and are applied no more stringently than, the processes,
strategies, evidentiary standards, or other factors used in applying the limitation for
medical/surgical services in the classification.

C.5.91.6 The Contactor shall report to DHCF upon request the necessary documentation required
in accordance with 42 C.F.R. part 438, subpart K regarding parity in mental health and
SUDS.

C.5.91.7 The Contractor shall not impose Prior Authorization requirements for mental health or
SUDS that are greater or more restrictive than the Prior Authorization requirements for
comparable medical/ surgical services following 42 C.F.R. § 438.910(d).

C.5.92 Telemedicine

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The Contractor shall cover and reimburse healthcare services delivered through
Telemedicine, per Title 29 DCMR § 910.

C.5.93 Provider Network and Access Requirements

C.5.93.1 The Contractor shall develop and maintain a Provider Network which is sufficient to
provide timely access to the full range of Covered Services to Enrollees including
physical, behavioral, and other specialty services and all other services required under
this Contract.

C.5.93.2 The Contractor shall ensure Covered Services are reasonably accessible to Enrollees in
terms of location and hours of operation. The Contractor shall have available
nonemergent after-hours physician or primary care services within its network when
Medically Necessary. There shall be sufficient personnel for the provision of Covered
Services, including emergency medical care on a 24-hour-a-day, seven-days-a-week
basis.

C.5.93.3 The Contractor’s Provider Network shall be comprised of appropriately credentialed,
licensed, or otherwise qualified Providers to meet the requirements of this Contract and
as determined and designated by DHCF. The Contractor shall execute written
agreements with all Providers that include, at a minimum, all applicable provisions
required by this Contract.

C.5.93.4 The Contractor’s failure to comply with the Provider Network and Access requirements
in this section will result in DHCF requiring the Contractor to develop and implement a
corrective action plan (CAP) to remedy the failure. In addition, DHCF may impose
sanctions on the Contractor in response to Provider network and access violations. The
sanctions may include those outlined in Section G.6.7 and permitted under District or
Federal law.

C.5.93.5 The Contractor shall comply with federal standards governing the adequacy of capacity
and services found at 42 C.F.R. §§ 438.206-438.210. The Contractor shall have the
capacity to serve Enrollees in accordance with the standards of access to care set forth in
section C.5.93.

C.5.93.6 The Contractor shall have the capacity to successfully perform the required services set
forth in this solicitation or awarded contract and have a sustainable Provider Network
that can furnish the effective care, in the appropriate setting, and in a timely fashion, to
Enrollees.

C.5.93.7 The Contractor shall submit Encounter Data, claims data, and other data documenting
service utilization in an electronic format (as specified by DHCF) to DHCF, regardless
of how the information is obtained from the Contractor’s Providers.

C.5.93.8 The Contractor shall offer an appropriate range and geographic distribution of
preventive, primary care, specialty care, and LTSS, including Behavioral Health
Services that is adequate for the anticipated number of Enrollees as defined in section
B.3.2.

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C.5.93.9 The Contractor shall maintain and monitor a network of appropriate Providers that is
sufficient to provide adequate access to all services covered under the contract for all
CASSIP Enrollees, including those with limited English proficiency, co-occurring
disorders, or comorbidity.

C.5.93.10 The Contractor’s network of Providers must be sufficient in number, mix and geographic
distribution in accordance with C.5.93 to meet the needs of the anticipated enrollment.
Contractor’s network of physicians, hospitals, pharmacies, and specialized treatment
programs for persons with chronic physical and behavioral health disorders and
conditions must be sufficient, as documented by data on network composition,
Encounter Data, and other data documenting service utilization as DHCF may require,
meeting the needs of Enrollees.

C.5.93.11 DHCF shall evaluate prior to the contract start date and throughout the term of the
contract, the sufficiency of Contractor’s network based upon whether Contractor is in
compliance with the Network Adequacy standards as specified in DHCF’s Quality
Strategy found here: https://dhcf.dc.gov/managed-care-quality-strategy and requirements
of this Contract.

C.5.93.12 The Contractor shall arrange and administer Covered Services in accordance with
section C.5.48 to all CASSIP Enrollees through its network. Where Contractor’s
network is not able to adequately furnish Covered Services, the Contractor shall arrange
for Covered Services to be provided on an out-of-network basis in accordance with
section C.5.93.

C.5.93.13 In accordance with 42 C.F.R. § 438.210, the Contractor shall provide medical care that is
accessible to Enrollees in an amount, duration and scope that is no less than the amount,
duration and scope for the same services provided to beneficiaries under FFS Medicaid.

C.5.93.14 In establishing a network, the Contractor shall include all classes of Providers necessary
to furnish Covered Services, including but not limited to all acute care hospitals in the
District as required in Section C.5.106, physicians (specialists and primary care), nurse
midwives, nurse practitioners, pediatric nurse practitioners, federally qualified health
centers, medical specialists, dentists, mental health and substance use disorder Providers,
allied health professionals, ancillary Providers, DME Providers, home health Providers,
and transportation Providers, as described in C.5.63.

C.5.93.15 The Contractor’s network shall include an adequate number of pediatric Providers with
the training, experience, and skills necessary to furnish quality care to CASSIP Enrollees
in accordance with C.5.93 and to do so in a manner that is accessible and Culturally
Competent.

C.5.93.16 All Providers must be appropriately licensed or registered in accordance with the District
of Columbia Health Occupation Regulatory Act (D.C. Code § 3-1200 et seq.) and any
regulations thereunder or, if located in a jurisdiction outside of the District, in
accordance with the health occupations regulatory requirements in the jurisdiction in
which the Provider practices. The Contractor must demonstrate that its Network
Providers are credentialed as required by 42 C.F.R. § 438.214.

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C.5.93.17 The Contractor shall ensure all Network Providers shall comply with the District of
Columbia Mental Health Information Act D.C. Code §§ 7-1201.01 – 7-1208.07, for the
purposes of sharing mental health information among providers and third-party payers
and for CQI activities.

C.5.93.18 Under 42 C.F.R. § 438.602(b), the Contractor shall ensure each of its Network Providers
are screened and enrolled as a Medicaid Provider by DHCF. This provision does not
require the Network Provider to render services to FFS beneficiaries.

C.5.93.19 The Contractor shall execute Network Provider agreements pending the outcome of
DHCF’s process to screen and enroll as a Medicaid Provider by DHCF. This process
may take up to 120 days. The Contractor shall terminate a Network Provider
immediately upon notification from DHCF that the Network Provider cannot be enrolled
or upon the expiration of one 120-day DHCF process period without enrollment of the
Provider. The Contractor shall then notify affected Enrollees about the Network
Provider’s termination.

C.5.93.20 The Contractor’s Providers shall be eligible (i.e., not excluded, suspended or debarred)
to participate in any District and Federal health care benefit program. Individuals or
organizations suspended, excluded or debarred from participation in a Federal, state, or
District health care benefit program shall not provide services under the Contract.

C.5.93.21 The Contractor shall, at the time it enters into this Contract, on a quarterly basis, and
upon DHCF’s request throughout the term of the Contract, provide written
documentation (consistent with the requirements in 42 C.F.R. § 438.207 and C.5.93) that
it has sufficient capacity to handle the maximum number of Enrollees specified under
section B.2.1.1 in accordance with DHCF’s standards for access to care, and Federal
standards at 42 C.F.R. § 438.68 and § 438.206(c).

C.5.93.22 In the event that there is a Material Change in the Contractor’s operations or a change in
the health status of its Enrolled population that would affect the adequacy of capacity
and services, including changes in the Contractor benefits, geographic service areas,
Provider Network, payments, or enrollment of a new population, the Contractor must
report the Material Change in writing to DHCF immediately and include a CAP. The
Contractor shall submit new documentation regarding its Network adequacy to DHCF
within thirty days.

C.5.93.23 The Contractor shall have in place written guidelines and procedures to ensure Enrollees
are provided Covered Services without regard to race, color, gender, creed, religion, age,
national origin, ancestry, marital status, sexual orientation, political affiliation, personal
appearance, or physical or mental disability. In addition, the Contractor shall require
that all of its Network Providers are in compliance with the requirements of the ADA, 42
U.S.C. §§ 12101 et seq., § 504 of the Rehabilitation Act of 1974, 29 U.S.C. § 794 and
other requirements set forth in section H.6.

C.5.93.24 Access and cultural considerations. Each MCP shall participate in the State's efforts to
promote the delivery of services in a culturally competent manner to all enrollees,
including those with limited English proficiency and diverse cultural and ethnic
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backgrounds, disabilities, and regardless of sex which includes sex characteristics,
including intersex traits; pregnancy or related conditions; sexual orientation; gender
identity and sex stereotypes.

C.5.93.25 The Contractor shall, on a quarterly basis, analyze the composition of its network and,
based upon the health status and needs of its Enrollees, identify any gaps or areas
requiring expansion, including the provision of primary care, specialty care, dental,
Behavioral Health Services and LTSS, including but not limited to services on weekends
and evenings. This information shall be provided to DHCF upon request.

C.5.93.26 The Contractor shall establish mechanisms to ensure that Network Providers comply
with the timely access requirements and monitor them regularly to determine compliance
and take corrective action if a Network Provider fails to comply.

C.5.93.27 The Contractor shall at least annually conduct access and availability audits to validate
Provider Network access of individual Providers within the Contractor’s Provider
Network. The Contractor may coordinate with other MCOs to conduct these audits to
avoid duplicate contacts to Providers. Reviews shall include the use of “secret shopper”
calls and activities.

C.5.93.28 The Contractor shall provide DHCF with results of all access and availability audits
upon request. The Contractor shall take corrective action to remediate instances of
identified non-compliance with access and availability or other Contract standards and
report all non-compliance to DHCF within thirty Days of the audit. Should DHCF
identify and notify the Contractor of non-compliance with this Contract’s access and
availability standards, the Contractor shall provide to DHCF a CAP within fifteen Days
of receipt of such notice.

C.5.93.29 The Contractor shall have written policies and procedures that comply with the
requirements of 42 C.F.R. § 438.214 and C.5.122 regarding the selection, retention, and
exclusion of Providers and meet, at a minimum, the requirements related to
credentialing. The Contractor shall submit such written policies and procedures
annually to DHCF, if amended.

C.5.93.30 The Contractor shall collaborate with the District's Designated HIE to offer education
and Technical Assistance (TA) to its provider network on effective utilization of the DC
HIE. These efforts should prioritize high-impact settings, including, but not limited to,
emergency departments, skilled nursing facilities, behavioral health providers, and
FQHCs. The Contractor shall track provider participation in such education and report
outcomes annually as defined by DHCF.

C.5.94 Network Composition, Network Adequacy Requirements

C.5.94.1 The Contractor shall ensure that its Provider Network is sufficient in number, geographic
distribution, and type of Providers to ensure that all Covered Services, including an
appropriate range of pediatric preventive, primary care, and specialty services, are
accessible to meet the needs of the anticipated number of Enrollees within 90 days of the
Start Date.

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C.5.94.2 The Contractor shall meet relevant District network adequacy standards, following 42
C.F.R. § 438.68, in all geographic areas in which the Contractor operates, as well as,
adhere to the time and distance standards developed by the District for the following
Provider types:

C.5.94.2.1 Adult PCPs, as applicable;
C.5.94.2.2 Pediatric PCPs;
C.5.94.2.3 Obstetrics/ Gynecology (OB/GYN) Providers;
C.5.94.2.4 Adult Behavioral Health (mental and substance use disorder) providers, as applicable;
C.5.94.2.5 Pediatric Behavioral Health (mental and substance use disorder) providers;
C.5.94.2.6 Adult Specialist Providers, as applicable;
C.5.94.2.7 Pediatric Specialist Providers;
C.5.94.2.8 Hospitals and LTSS Providers;
C.5.94.2.9 Pharmacies;
C.5.94.2.10 Adult Dental Providers;
C.5.94.2.11 Pediatric Dental Providers; and
C.5.94.2.12 Any additional Provider types when it promotes the objectives of the Medicaid program
as determined by CMS and adopted by DHCF.

C.5.94.3 The Contractor is not required to contract with more providers than necessary to meet
the needs of its Enrollees or use different reimbursement amounts for different
specialties or for different practitioners in the same specialty.

C.5.94.4 The Contractor shall establish measures that are designed to maintain quality of services
and control costs that are consistent with its responsibilities to Enrollees per 42 C.F.R. §
438.12(b).

C.5.94.5 Providers that have not been enrolled or reenrolled with DHCF shall be excluded in the
Contractor’s network adequacy assessment or accessibility requirements.

C.5.95 Primary Care

For all Enrollees, the Contractor shall have at least two age-appropriate PCPs who are both
geographically available and contractually required to meet Mileage and Travel Time
Standards and other requirements of this Contract. The Contractor shall monitor and manage
its PCP network composition for Enrollees 21 and under based on access to pediatricians
and other PCPs recognized as having primary care expertise to treat children.

C.5.96 Obstetric-Gynecological Care

C.5.96.1 The Contractor shall develop and maintain a Provider network that ensures that female
Enrollees have access to care from Obstetric-Gynecological Providers in accordance
with the Mileage and Travel Time Standards.

C.5.96.2 The Contractor shall demonstrate that its Provider Network includes family planning
providers to deliver timely access to Covered Services by enrollees seeking the
respective services.

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C.5.96.3 The Contractor shall ensure that Network Providers provide physical access, reasonable
accommodations, and accessible equipment for all CASSIP Enrollees, no matter their
physical or behavioral health needs.

C.5.97 Behavioral Health and Hospital Care

The Contractor shall ensure that the Travel Time to general, acute care hospitals, or
behavioral health providers providing inpatient mental health and substance use disorder
treatment shall not exceed thirty minutes Travel Time by public transportation.

C.5.98 Pharmacies

C.5.98.1 The Contractor shall ensure that at least two pharmacies are located within two miles of
each Enrollee’s residence. The Contractor’s pharmacy network must include at least one
24 hour seven day a week pharmacy and at least one pharmacy that provides home
delivery service within four hours.

C.5.98.2 The Contractor shall include at least one mail-order service.

C.5.99 Laboratory Providers

C.5.99.1 The Contractor shall demonstrate that it has Laboratory Providers in accordance with
Mileage and Travel Time Standards. Providers must have either a Clinical Laboratory
Improvement Amendment (CLIA) certificate of registration or a CLIA certificate of
waiver.

C.5.99.2 The Contractor shall ensure that the Travel Time to nursing facilities and assisted living
facilities shall not exceed sixty (60) minutes Travel Time by public transportation.

C.5.100 Geographic Access Reporting Requirements

C.5.100.1 The Contractor shall submit evidence of compliance with the requirements of Mileage
and Travel Time Standards at least 30 days prior to the Start Date of the Contract,
quarterly, and as requested by DHCF.

C.5.100.2 The Contractor shall submit a Geographic Access analysis in a format specified by
DHCF using GeoAccess or a comparable software program. The Contractor shall
clearly indicate the percentage of Enrollees who do not have Provider access, as defined
by the Mileage and Travel Time standards.

C.5.100.3 The Contractor shall use the most recent eligibility files provided by DHCF. The
Contractor shall use the most recent Enrollee data to geocode each Enrollee by street
address. All Network Provider street addresses should be exactly geocoded. The
Contractor shall only include in its Geographic Access data reports those Providers that
operate a Full-Time Provider Location. For purposes of this requirement, a Full-Time
Provider Location is defined as a location operating for 20 or more hours each week in
an office location.

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C.5.100.4 The Contractor shall prepare separate Geographical Access reports addressing each
Provider type included in the Mileage and Travel Time Standards. The Contractor shall
prepare separate Geographical Access reports for PCPs, showing Providers with open
panels only and showing all open and closed panels. A closed panel is any Provider that
the Contractor recognizes as no longer accepting new beneficiaries. An open panel is
any Provider that the Contractor does not recognize as closed. The Contractor shall
review and update the PCP panel status of its network at least quarterly.

C.5.100.5 In addition to the Geographic Access data reports, the Contractor shall report to DHCF
on a quarterly basis, the Contractor’s plans or corrective action to enhance access for
Enrollees who have less than 98% of Provider access, as defined by the Mileage and
Travel Time Standards. If enhanced access is not possible, (i.e., no Providers are
available to contract with the Contractor or available Providers only practice part-time)
the Contractor shall describe the limitations to enhancing access in its report.

C.5.100.6 For purposes of Section C.5.100, the Contractor’s delivery network shall be sufficient if
the Contractor is in compliance with the geographic, Mileage and Travel Time
Standards, Appointment Time Standards, and other standards established in Sections
C.5.94, C.5.115 and C.5.116 in documenting the adequacy of its network.

C.5.100.7 Under 42 C.F.R. § 438.68, the Contractor shall demonstrate its ability to meet DHCF’s
network adequacy standards which includes:

C.5.100.7.1 The anticipated CASSIP enrollment;
C.5.100.7.2 The expected utilization of services, considering Enrollee characteristics and the health
care needs of specific Medicaid populations covered by this Contract;
C.5.100.7.3 The number and types of Providers (in terms of training, experience, capacity, and
specialization) required to furnish contracted Covered Services;
C.5.100.7.4 The number of Network Providers not accepting new patients;
C.5.100.7.5 The geographic location of Providers and Enrollees, distance, Travel Time, normal
means of transportation, including public transportation, used by Enrollees and whether
Provider locations are accessible to Enrollees with disabilities; and
C.5.100.7.6 The routine appointment waiting times (i.e., time routinely spent waiting to see the
Provider once the Enrollee has arrived) at Network Providers and the time it takes for an
Enrollee to schedule an initial and follow-up appointment.

C.5.100.8 The ability of Network Providers to communicate with Enrollees who have limited
English proficiency in their preferred language.

C.5.100.9 The ability of Network Providers to ensure physical access, reasonable accommodations,
culturally competent communications, and accessible equipment for Medicaid Enrollees
with special health care needs.

C.5.100.10 The availability of triage lines or screening systems, as well as the use of Telemedicine
following Title 29 DCMR § 910, e-visits, and/or other evolving and innovative
technological solutions.

C.5.100.11 At a minimum, the Contractor must have at least one full-time equivalent PCP,
regardless of specialty type, for every 500 Enrollees, and there must be one full-time
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equivalent PCP with pediatric training and/or experience for every 500 children and
adolescents through the age of 20 within the Mileage and Time Travel Standards.
Qualifying PCP provider types is defined on C.5.101.

C.5.100.11.1 At a minimum, the Contractor must have at least one full-time equivalent PDP for every
750 children and adolescent who serves the pediatric population through the age of 20
within the Mileage and Time Travel Standards.

C.5.100.12 The Contractor shall report to DHCF quarterly, all PCPs, including groups, health
centers, and individual physician practices and sites, which are not accepting new
patients and have been granted the ability to do so by the Contractor. The Contractor
shall not allow any individual PCP to have a panel that includes more than five hundred
Enrollees at any point in time, unless the Contractor requests and receives prior written
approval from DHCF to temporarily waive the five Enrollee restriction. Such approval
shall be granted at the sole discretion of DHCF.

C.5.100.13 The Contractor shall use the minimum requirements established in this Contract to
determine network adequacy.

C.5.100.14 Whenever the Contractor has an insufficient number or type of Network Providers to
provide a covered service, the Contractor shall develop and implement a CAP to address
network adequacy and ensure that the Enrollees obtain the covered service at no cost; as
if the covered service was obtained from the Contractor’s network.

C.5.100.15 The Contractor shall provide an access plan to DHCF quarterly and upon request. The
access plan must be consistent with the GeoAccess or comparable software reporting
requirements and maps, as required in Section C.5.100, and describe or contain at least
the following:

C.5.100.15.1 A list of the names and specialties of the Contractor’s participating Providers;
C.5.100.15.2 The Contractor’s procedures for making referrals within and outside of its network;
C.5.100.15.3 The Contractor’s process for monitoring and ensuring on an ongoing basis, the
sufficiency of the Contractor’s network to meet the special health care needs of CASSIP
Enrollees;
C.5.100.15.4 The Contractor’s methods for assessing the health care needs of Enrollees; and
C.5.100.15.5 The Contractor shall recruit licensed, Board-certified, or Board-eligible Providers
needed to provide comprehensive, accessible, and Culturally Competent care on an
ongoing basis.

C.5.100.16 The Contractor shall demonstrate that there are sufficient I/T/UI Health Providers in the
network to ensure timely access to services available under the Contract for Enrollees
who are eligible to receive services from such Providers.

C.5.101 Primary Care Providers

A PCP may be any of the following: family practice physician, general practice
physician, internal medicine physician, OB/GYN, pediatric physician (when appropriate
to the Enrollee), osteopath, clinic or FQHC, nurse practitioner, or a subspecialty
physician, when appropriate in light of an Enrollee’s Special Health Care Needs.
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C.5.102 Clinics as Providers

C.5.102.1 Enrollees may designate a clinic as a PCP. Clinics must comply with the capacity
standards defined in Section C.5.115. In addition, each Full-time Equivalent PCP in the
clinic may have no more than a total patient load of 2,000 Enrollees, which includes
individuals enrolled in CASSIP. The Appointment Standards in Section C.5.116 shall
apply to clinics.

C.5.102.2 The Contractor shall ensure that PCPs have adequate capacity as this term is defined by
the standard of care, prevailing industry norms and community standards, including any
CMS or DHCF guidance on this issue.

C.5.102.2.1 In evaluating the capacity of PCPs, the Contractor shall take into consideration both a
PCP’s existing Contractor Enrollee load, overall Enrollee load, Medicaid patient load, as
well as its total patient load and shall assess the overall patient load against community
standards for any specialty involved.

C.5.102.2.2 The Contractor shall consider whether the Provider is compliant with the Appointment
Time Standards set forth in Section C.5.116.

C.5.102.2.3 In no event shall the Contractor assign additional Enrollees to a single PCP if the
Contractor believes that the PCP has reached his/her capacity to provide high quality
services to Enrollees.

C.5.102.2.4 The Contractor shall provide evidence of adequate capacity to DHCF, upon request.

C.5.102.3 The Contractor shall submit a monthly report to DHCF on the number of participating
PCPs accepting new patients (i.e., PCPs with fully open panels), Providers known to
have closed panels, and specialists authorized to serve as PCPs, including identifying
whether or not they are open or closed to new patients.

C.5.103 Specialty Care Providers

C.5.103.1 The Contractor shall have a network that includes sufficient numbers and classes of
specialty Providers to furnish covered specialty services to meet the appointment access
and availability. The Contractor’s network shall include medical sub-specialists and
specialists serving children and adolescents through age twenty (20), and sub-specialists
within the defined Mileage and Travel Time standards.

C.5.103.2 The Contractor’s network shall, at a minimum, include:

C.5.103.2.1 Dermatologists;
C.5.103.2.2 Orthopedic surgeons;
C.5.103.2.3 Neurologists;
C.5.103.2.4 Neurosurgeons;
C.5.103.2.5 Neonatologists;
C.5.103.2.6 Perinatologists;
C.5.103.2.7 Oncologists/Hematologists;
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C.5.103.2.8 Allergists and Immunologists;
C.5.103.2.9 Cardiologists;
C.5.103.2.10 Endocrinologists;
C.5.103.2.11 Gastroenterologists (Pediatric and Adult);
C.5.103.2.12 Geneticists;
C.5.103.2.13 Nephrologists;
C.5.103.2.14 Obstetricians/Gynecologists;
C.5.103.2.15 Ophthalmologists;
C.5.103.2.16 Otolaryngologists;
C.5.103.2.17 Podiatrists;
C.5.103.2.18 Pulmonary Specialists;
C.5.103.2.19 Psychiatrists;
C.5.103.2.20 Rheumatologist;
C.5.103.2.21 Surgeons;
C.5.103.2.22 Urologists;
C.5.103.2.23 Inpatient specialty facilities; and
C.5.103.2.24 Rehabilitation Providers.

C.5.103.3 In the event the Contractor’s network is insufficient to furnish a specialty service, the
Contractor shall pay for the cost of out of network services, including transportation, for
as long as the Contractor is unable to provide the services through a Network Provider.

C.5.104 Specialist as a Primary Care Provider

C.5.104.1 The Contractor shall offer each CASSIP Enrollee the option of choosing as his/her PCP,
a specialist participating in the Contractor’s network who has the experience and
expertise in the treatment of the Enrollee’s Special Health Care Need and is willing and
has the capacity (as defined by Section C.5.115) to accept the Enrollee.

C.5.104.2 The Contractor shall determine the need for a specialist to function as an Enrollee’s PCP.
The determination shall be made on a case-by-case basis and in consultation with the
Enrollee and the Enrollee’s current PCP.

C.5.104.2.1 If the Enrollee disagrees with the Contractor’s determination, the Contractor shall inform
the Enrollee of his or her right to file a Grievance with Contractor and/or to utilize the
Fair Hearing process described in Section C.5.201.

C.5.105 Dental Providers

C.5.105.1 The Contractor shall maintain a sufficient network of Dental Providers, including
General Dentists, Endodontists, Pediatric Dentists, dentists serving children and
adolescents through age 20, Orthodontists, and Oral Surgeons, to meet the needs of
Enrollees within the defined Mileage and Travel Time standards.

C.5.105.2 The Contractor shall submit a monthly report on the number and distribution of
participating Dental Providers categorized as Dentists, Pediatric Dentists, Endodontists,
Orthodontists, or Oral Surgeons and identify whether the Dental Providers have fully
open patient panels and identify those known to the Contractor to be closed to accepting
new patients.
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C.5.105.3 The Contractor shall ensure there is at least one PDP that has a fully open patient panel
for every 750 Enrollees.

C.5.105.4 The Contractor shall reimburse providers no less than 100% of the District's FFS rates
for dental services provided to CASSIP enrollees.

C.5.106 Hospitals

C.5.106.1 At a minimum, the Contractor shall have and maintain hospital agreements with all
current and future District acute care hospitals and hospital related provider groups
which currently include:

C.5.106.1.1 Howard University Hospital;
C.5.106.1.2 Medstar Washington Hospital Center;
C.5.106.1.3 Medstar Georgetown Hospital;
C.5.106.1.4 Children’s National Hospital;
C.5.106.1.5 Cedar Hill Hospital;
C.5.106.1.6 Sibley Hospital;
C.5.106.1.7 George Washington Hospital: and
C.5.106.1.8 Hospital for Sick Children Pediatric Center.

C.5.106.2 The Contractor shall demonstrate that all hospitals are accredited by The Joint
Commission and verifies to the District that the hospital has met all state licensing and
certification requirements. Moreover, the Contractor must comply with the requirements
of § 1867 of the Act, 42 U.S.C. § 1395dd.

C.5.106.3 The Contractor shall include Sheppard Pratt Health System, which provides services for
mental health, substance use disorder, special education, developmental disability, and
social services, or a hospital providing comparable services approved by DHCF, in its
network.

C.5.106.4 In addition to the requirements above, the Contractor shall include at least two hospitals
that deliver pediatric care in its network.

C.5.106.5 For Enrollees who receive Emergency Services at an out-of-network hospital, the
Contractor shall pay the out-of-network hospital the District’s FFS rates. If the
Contractor has a contract with the out-of-network hospital, the Contractor shall pay the
out-of-network hospital those contracted rates.

C.5.107 Behavioral Health Providers

C.5.107.1 The Contractor shall have a sufficient number of appropriately skilled Providers to
provide Covered Mental Health Services to Enrollees within the defined Mileage and
Travel Time standards. Contractor’s mental health services network shall include a
sufficient number of the following to meet the needs of the Contractor’s enrolled
beneficiaries:

C.5.107.1.1 Psychiatrists, both adult and pediatric;
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C.5.107.1.2 Specialists in developmental delays and disorders;
C.5.107.1.3 Behavioral Health medicine;
C.5.107.1.4 Psychologists, both adult and pediatric;
C.5.107.1.5 Independently Licensed Social Workers, including those specializing in treatment of
mental health and substance abuse;
C.5.107.1.6 Inpatient psychiatric units for adults and pediatric Enrollees;
C.5.107.1.7 Residential treatment facilities within 30 miles from enrollee’s residence OR 60 minutes
travel time by public transportation; and
C.5.107.1.8 Partial Hospitalization and Intensive Outpatient Programs.

C.5.107.2 The Contractor shall have the capacity necessary to effectively manage individuals
dually diagnosed with both mental health and substance abuse disorders.

C.5.107.3 The Contractor shall submit a quarterly report of a GeoAccess or comparable software
showing participating mental health Providers by zip code of office locations and shall
highlight all Providers with less than eighty percent (80%) panel availability.

C.5.107.4 Failure to maintain an adequate and sufficient network that ensures Enrollees have
access to covered Mental Health services without unreasonable delays, and as described
in section C.5.116, can result in corrective action, fines, penalties and/or sanctions
imposed by the District, including, but not limited to the amount listed in section G.6.7.

C.5.107.5 The Contractor shall ensure that services for the assessment and stabilization of
psychiatric crises, including those experienced with treating children or adolescents, are
available on a twenty-four hour bases, seven days a week, including weekends and
holidays. Phone based assessment and/or screening must be provided within fifteen
minutes of request and, when Medically Necessary, intervention or face- to-face
assessment shall be provided within ninety minutes of completion of the phone
assessment. These services shall be provided by practitioners with appropriate expertise
in mental health with on- call access to an adult or child and adolescent psychiatrist.

C.5.107.6 The Contractor shall report to DBH any changes in a DBH-certified Provider’s
credentialing information, including Contractor’s refusal to credential or re-credential a
DBH-certified Provider.

C.5.108 FQHCs Providers

C.5.108.1 The Contractor shall contract for the provision of primary care services, dental services,
preventive care services and/or specialty/referral services with FQHCs or FQHC
lookalikes. The Contractor shall ensure Enrollees currently using FQHC services are
offered the opportunity to continue receiving services from the FQHC.

C.5.108.2 The Contractor shall be aware of and consider the unique status of FQHCs when
developing Provider Networks. The Contactor shall contract with all FQHCs and FQHC
look-alikes located in the District of Columbia to provide services to CASSIP Enrollees.

C.5.108.3 If the Contractor is unable to execute a provider agreement with any of the FQHC clinics
in the District, the Contractor shall notify DHCF in writing.

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C.5.108.4 The Contractor shall reimburse FQHCs and FQHC look-alikes at the established DHCF
Prospective Payment System (PPS) rate or the APM rate, following 29 DCMR Chapter
45.

C.5.109 Women’s Health

C.5.109.1 In addition to a PCP (or, at the Enrollee’s option, in lieu of a PCP) a female Enrollee
may have a provider who specializes in Women’s Health. The Contractor shall provide
female Enrollees with direct access to a provider that specializes in Women’s Health
within the network for Covered women’s routine and preventive health care services.
This is in addition to the Enrollee’s designated source of primary care if that source is
not a provider who specializes in Women’s Health.

C.5.109.2 Under 42 C.F.R.§ 431.51, all Enrollees have the right to receive family planning services
from a provider of their choice, whether the provider is in or out of the Contractor’s
network. In addition, Enrollees do not need a referral to access family planning services.
Out-of-network family planning providers should be paid directly by the Contractor for
services provided to Enrollees and such payments should be at a rate no less than the
Medicaid fee-for-service rate or in-network rates, whichever is greater.

C.5.110 IDEA Service Providers

The Contractor’s network shall include certified EI Providers for health-related IDEA
services to children under age three . Additionally, the Contractor’s network shall
include Providers qualified to perform evaluations for IDEA eligibility and provide
health related IDEA services for children four years of age and older, unless and until
these services are provided by DCPS. Such Providers shall include those who provide
rehabilitation services for improvement, maintenance, or restoration of functioning,
including respiratory (including home-based), occupational, speech, and physical
therapies.

C.5.111 Allied Health Professionals

C.5.111.1 The Contractor’s network shall include the following classes of Allied Health
professionals:

C.5.111.1.1 Pediatric Personal Care Aides/Assistants;
C.5.111.1.2 Pediatric Home Health Providers;
C.5.111.1.3 Registered Dieticians;
C.5.111.1.4 Speech, Physical, Occupational, and Respiratory Therapists;
C.5.111.1.5 Audiologists;
C.5.111.1.6 Providers of genetic screening and counseling; and
C.5.111.1.7 Pharmacists.

C.5.112 Contractor Referrals to Out-of-Network Providers for Services

C.5.112.1 If the Contractor’s network is unable to provide Medically Necessary Services required
under the Contract, the Contractor must cover these services through an Out-of-Network
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Provider until the Contractor establishes a provider agreement with that Out-of-Network
Provider.

C.5.112.1.1 The Contractor shall coordinate with Out-of-Network Providers for authorization and
payment in these instances and ensure that cost of the services and transportation to the
Enrollee is no greater than it would be if the services were furnished within the
Contractor’s network. The accessibility standards defined in section C.5.120 are
applicable to services provided to Enrollees by Out-of-Network Providers.

C.5.112.2 The Contractor shall pay I/T/U Providers, whether participating in the provider network
or not, for covered managed care services provided to Indian Enrollees who are eligible
to receive services from the I/T/U either at a negotiated rate between the Contractor and
the I/T/U Provider, or if there is no negotiated rate, at a rate no less than the level and
amount of payment that would be made if the Provider were not an I/T/U Provider, per
42 C.F.R. 438.14 (b).

C.5.112.2.1 The Contractor shall permit an out-of-network I/T/U Providers to refer an Indian
enrollee to a network provider.

C.5.113 Capacity to Serve Enrollees with Diverse Cultures and Languages

C.5.113.1 The Contractor shall include Providers in its network that understand and are respectful
of health-related beliefs, cultural values, communication styles, attitudes,
intersectionality, and behaviors of the cultures represented in the CASSIP Enrollee
population and provide translation services to those that request instructions in their
native language, following C.5.8.6.

C.5.113.2 Per section C.5.9, the Contractor shall ensure that its non-English speaking Enrollees
have access to free interpreters, if needed, in the following situations:

C.5.113.2.1 During emergencies, twenty-four hours a day, seven days a week;
C.5.113.2.2 During appointments with their Providers and when talking to the Contractor; and
C.5.113.2.3 When technical, medical, or treatment information is to be discussed.

C.5.113.3 Enrollees, especially minor children, shall not be used as interpreters in assessments,
therapy, or other medical situations in which impartiality and confidentiality are
necessary, unless specifically requested by the Enrollee. Every attempt should be made
to help the Enrollee understand the availability of non-familial interpreters and Provider
concerns with utilizing minor children as interpreters, even at the Enrollee’s request.

C.5.113.4 A family member or friend may be used as an interpreter only if that individual can be
relied upon to provide a complete and accurate interpretation of information between
Provider and the Enrollee, provided that the Enrollee is advised that there is a free
interpreter available, and the Enrollee expresses a preference to rely on the family
member or friend. If a family member or friend is used as an interpreter, the Contractor
shall document the reason for doing so in accordance with section C.5.9. Family
members or friends that are selected for use as interpreters by the Enrollee must be at
least 21 years of age.

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C.5.113.5 The Contractor shall permit any Native American/Indigenous Person who is enrolled
with a non-Indian Health Services Provider and who is eligible to receive services from
a participating I/T/U Provider to choose to receive Covered Services from that I/T/U
Provider.

C.5.114 Provider Directory

C.5.114.1 The Contractor shall publish a Provider Directory that complies with the requirements of
section C.5.10. The Provider Directory shall be made available to Enrollees in paper
format upon request, mobile accessible (if applicable), and on the Contractor’s public
website in a machine-readable file.

C.5.114.2 The Contractor shall publish a Provider Directory that is made available in prevalent
languages and alternative formats following DC Language Access Act of 2004, upon
request.

C.5.114.3 Under 42 C.F.R. § 438.10 (h), the Provider Directory shall, at a minimum, include:

C.5.114.3.1 A list of Contractor’s current Provider Network, including PCPs, specialists, hospitals,
and other Providers described in sections C.5.93 and C.5.94;
C.5.114.3.2 Alphabetical and geographical Provider list by type of Provider (e.g. PCP, Behavioral
Health, LTSS, Hospital);
C.5.114.3.3 Whether or not the office is accessible for people with disabilities, including offices,
exam room(s) and equipment;
C.5.114.3.4 Instructions for the Enrollee to contact the Contractor’s toll-free Enrollee Services
telephone line for assistance in finding a convenient Provider;
C.5.114.3.5 Providers’ Addresses and telephone numbers;
C.5.114.3.6 The availability of evening and weekend hours for Providers;
C.5.114.3.7 Identification of Providers that are not accepting new patients, which Contractor shall
revise quarterly to ensure that the information is accurate;
C.5.114.3.8 Information regarding Board certification, hospital admitting privileges, and languages
spoken by the Provider;
C.5.114.3.9 The Network Providers’ web site URLs, as appropriate;
C.5.114.3.10 Information regarding specialty care, as appropriate;
C.5.114.3.11 The provider's cultural and linguistic capabilities, including languages (including
American Sign Language) offered by the provider or a skilled medical interpreter at the
provider's office; and
C.5.114.3.12 The availability of telehealth, telemedicine, e-visits and/or other technological access.

C.5.114.4 The Contractor shall update the paper format Provider Directory at least monthly if the
Contractor does not have a mobile-enabled, electronic directory, or quarterly, if the
Contractor has a mobile-enabled, electronic provider directory.

C.5.114.5 The Contractor shall submit a complete database of all Network PCPs, including unique
National Provider Identifiers (NPIs) to DHCF. Such PCP database shall be submitted
electronically in a format and timeframe established by DHCF.

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C.5.114.6 The Contractor shall submit a complete database of all Network Behavioral Health
Providers, including NPIs to DHCF. Such database shall be submitted electronically in a
format and timeframe established by DHCF.

C.5.114.7 The Contractor shall provide DHCF with additional updates and materials that DHCF
may request for purposes of providing information to assist Enrollees in selecting a
Contractor, or to assist DHCF in assigning an Enrollees who do not make a selection.

C.5.114.8 The Contractor’s Provider directory must include the information in C.5.114 for each of
the following provider types covered under this Contract:

C.5.114.8.1 Physicians, including specialists;
C.5.114.8.2 Hospitals;
C.5.114.8.3 Pharmacies;
C.5.114.8.4 Behavioral health providers; and
C.5.114.8.5 Long Term Support Services providers, as appropriate.

C.5.115 Access to Covered Services

C.5.115.1 Hours of Operation

C.5.115.1.1 The Contractor’s Network Providers shall offer hours of operation that are no less than
the hours of operation offered to commercial Enrollees or hours that are comparable to
Medicaid FFS, if the Provider serves only Medicaid Enrollees.

C.5.115.1.2 Routine Care shall be available from Providers during their regular and scheduled office
hours.

C.5.115.1.2.1 The Contractor shall ensure that a sufficient number of its Providers offer evening and
weekend hours of operation, in addition to scheduled daytime hours. This information
shall be included in the Enrollee Handbook and Provider Directory.

C.5.115.1.2.2 The Contractor shall provide notice to Enrollees of the hours and locations of service for
their assigned PCP.

C.5.115.1.3 PCPs may maintain more than one practice location. DHCF may require that the
Contractor delete a location from its PCP network if it, in its sole discretion, believes
that the location’s hours of operation or staffing levels are inadequate for serving as an
Enrollee’s PCP. PCPs must provide clear information to Enrollees about the hours of
operation at each location and the information regarding each location’s hours of
operation and staffing must:

C.5.115.1.3.1 Be reported to DHCF at least twice each year, in addition to anytime the hours of
operation or staffing levels change, and/or at DHCF’s request; and
C.5.115.1.3.2 Be clearly printed in the Contractor’s CASSIP Enrollee Handbook.

C.5.115.1.4 In the event that a specialist is assigned to act as a PCP, the Enrollee must be informed
of the specialist’s hours of operation.

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C.5.115.1.5 In circumstances where teaching hospitals use residents as Providers in a clinic and a
supervising physician is designated as the PCP by the Contractor; the supervising
physician must be available on-site during the hours that residents are serving Enrollees.

C.5.116 Appointment Time Standards for Services

C.5.116.1 The Contractor shall meet and require its Network Providers to meet all DHCF standards
for timely access to care and services, taking into account the urgency of the need for
services.

C.5.116.1.1 The Contractor shall make services included in the Contract available 24 hours a day,
seven days a week, when Medically Necessary.

C.5.116.1.2 The Contractor shall establish mechanisms to ensure compliance with accessibility
standards by Network Providers.

C.5.116.1.3 The Contractor shall monitor Network Providers regularly to determine compliance with
accessibility standards and take corrective action if there is a failure to comply by a
Network Provider.

C.5.116.2 The Contractor shall ensure that Enrollees with appointments who arrive by their
scheduled appointment time shall not routinely be made to wait more than forty-five
minutes from their scheduled appointment time to see a PCP. The Contractor shall
monitor Enrollee wait times to make an appointment with the Provider, as well as the
length of time the Enrollee actually spent waiting to see the Provider.

C.5.116.3 The Contractor shall have established criteria for monitoring appointment scheduling for
Routine and Urgent Care and for monitoring wait times in Provider offices. The
Contractor’s established criteria and data regarding appointment wait times and the
monitoring criteria must be submitted quarterly and upon DHCF’s request.

C.5.116.4 The Contractor shall ensure that its PCPs offer new CASSIP Enrollees, ages twenty-one
and over, as applicable, an initial appointment within forty-five days of their date of
enrollment with the PCP or within thirty days of request, whichever is sooner.

C.5.116.5 The following routine appointments shall take place within thirty days of the Enrollee’s
request:

C.5.116.5.1 Diagnosis and treatment of health conditions and problems that are not urgent;
C.5.116.5.2 Routine and well-health assessments of adults ages twenty-one and older; and
C.5.116.5.3 Non-urgent referral appointments with specialists.

C.5.116.6 The Contractor shall ensure that there is a reliable system for providing 24 hour access to
Urgent Care and Emergency Care seven days a week, including weekends and holidays.
Urgent Care may be provided directly by the PCP or directed by Contractor through
other arrangements.

C.5.116.7 The Contractor shall ensure that direct contact with a qualified clinical staff person is
available through a toll-free telephone number at all times.
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C.5.116.8 The Contractor shall ensure that services for the assessment and stabilization of
psychiatric crises, including those experienced with treating children or adolescents, are
available on a 24-hour basis, seven days a week, including weekends and holidays.

C.5.116.8.1 Phone based assessment must be provided within fifteen minutes of request and, when
Medically Necessary, intervention or face- to-face assessment shall be provided within
ninety minutes of completion of the phone assessment.

C.5.116.8.2 These services shall be provided by practitioners with appropriate expertise in mental
health with on-call access to an adult or child and adolescent psychiatrist.

C.5.116.9 The Contractor shall ensure that initial appointments for pregnant women or Enrollees
desiring family planning services are provided within ten days of the Enrollee’s request.

C.5.116.10 The Contractor’s Providers shall offer appointments for initial EPSDT screenings to new
Enrollees within 60 days of the Enrollee’s enrollment date with the Contractor or at an
earlier time if an earlier exam is needed to comply with the periodicity schedule or if the
Enrollee’s case indicates a more rapid assessment is needed or a request results from an
Emergency Medical Condition.

C.5.116.10.1 The initial screening shall be completed within three months of the Enrollee’s
enrollment date with the Contractor, unless the Contractor determines that the new
Enrollee is up to date with the EPSDT periodicity schedule.

C.5.116.10.2 To be considered timely, all EPSDT screenings, laboratory tests, and immunizations
shall take place within thirty days of their scheduled due dates for children under the
age of two and within 60 days of their due dates for children age two and older.
Periodic EPSDT screening examinations shall take place within thirty days of a request
by an Enrollee or parent/guardian.

C.5.116.11 IDEA multidisciplinary assessments for infants and toddlers at risk of disability shall be
completed within thirty days of request by an Enrollee or parent/guardian, and any
needed treatment shall begin within twenty-five (25) days upon the Contractor’s receipt
of the completed and signed IFSP assessment.

C.5.116.12 The Contractor and/or its Network Providers shall furnish evaluations and/or reports, as
required by any Court or Court Monitor within the timeframes specified by the Court or
Court Monitor.

C.5.117 Second Medical Opinions

The Contractor shall, upon Enrollee request, provide Enrollees the opportunity to have a
second opinion from a qualified Network Provider, subject to referral procedures
approved by DHCF. If an appropriately qualified Provider is not available within the
network, Contractor shall arrange for a second opinion outside the network at no charge
to the Enrollee.

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C.5.118 Choice of Health Care Professional

The Contractor shall offer each Enrollee the opportunity to choose a PCP and PDP
affiliated with the Contractor, to the extent possible and appropriate. If the Contractor
assigns Enrollees to PCPs, then the Contractor shall notify beneficiaries of the
assignment. The Contractor shall permit Enrollees to change PCPs upon the Enrollee’s
request.

C.5.119 Network Management

C.5.119.1 Standards to Ensure Access to Care

C.5.119.1.1 The Contractor shall have written protocols to ensure that Enrollees have access to
screening, diagnosis and referral, and appropriate treatment for those conditions and
Covered Services under the CASSIP. The Contractor’s protocols must include methods
for identification, outreach to and screening/assessment, of Enrollees with Special
Health Care Needs including use of a DHCF-mandated screening tool, if required at
DHCF’s sole discretion.

C.5.119.1.2 The Contractor shall establish procedures for PCPs to notify the Contractor at least thirty
days in advance of reaching maximum Enrollee capacity and the Contractor shall notify
DHCF within two Business days of the notification from the Provider.

C.5.119.1.3 The Contractor shall have in place procedures for monitoring PCPs’ compliance with the
capacity standards defined in sections C.5.93 and C.5.94.

C.5.119.1.3.1 The Contractor shall immediately notify DHCF, in writing, any time the Contractor
believes that a PCP does not have further capacity to accept Enrollees and any time that
the Contractor is unable to accept additional Enrollees because its network has reached
capacity.

C.5.119.1.3.2 The Contractor understands and agrees that upon receipt of such notification, DHCF
may suspend new enrollment into the Contractor’s Plan until additional PCP capacity
becomes available.

C.5.119.1.3.3 If DHCF determines that the Contractor has exceeded its permissible capacity for PCPs
or assigns a PCP more Enrollees than the PCP has capacity to manage DHCF may freeze
access for voluntary enrollment in the Contractor’s health plan.

C.5.119.1.4 All standards, procedures and protocols required under this provision shall be in place
within 90 days of Contract Award.

C.5.120 Written Standards for Accessibility of Care

C.5.120.1 The Contractor shall develop and maintain written standards for Enrollee accessibility of
care and services that comply with the requirements of Section C.5.119. These standards
shall be established within ninety days of Contract Award and must be communicated to
Providers and monitored by the Contractor. These standards shall include the following:

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C.5.120.1.1 Enrollee wait times for care at facilities;
C.5.120.1.2 Enrollee wait times for appointments;
C.5.120.1.3 Number and types of Providers who are not accepting new Medicaid patients;
C.5.120.1.4 Total number of Medicaid patients assigned to or being served by a Provider;
C.5.120.1.5 Total number of patients assigned to or being served by a Provider;
C.5.120.1.6 Statement that Providers’ hours of operation do not discriminate against CASSIP
Enrollees; and
C.5.120.1.7 Whether or not Provider speaks a language other than English.

C.5.121 Unique Physician Identifier

The Contractor shall require every physician providing services to Enrollees to have a
unique physician identifier, as specified in § 1173(b) of the Act.

C.5.122 Credentialing

C.5.122.1 The Contractor shall develop and maintain written policies and procedures for
credentialing and re-credentialing all Providers to ensure the Covered Services are
provided by appropriately licensed and accredited Providers. These policies and
procedures shall, at a minimum, comply with NCQA standards.

C.5.122.2 The Contractor shall follow DHCF’s uniform screening and enrollment process (also
referred to as credentialing and recredentialing) available on the DHCF Provider Portal
that addresses acute primary, behavioral, substance use disorders, and Long-Term
Support Services Providers as appropriate at:
https://www.dcpdms.com/Documents/PDMS_How_To_Enroll_User_Guide.pdf

C.5.122.3 The Contractor shall re-credential Providers at least every two years, or if the Contractor
is NCQA accredited, the Contractor shall re-credential based on NCQA requirements.

C.5.122.4 The Contractor shall ensure that Network Providers residing and providing services in
bordering states (i.e., Maryland and Virginia) meet all applicable licensure and
certification requirements within that state.

C.5.122.5 The Contractor shall have written policies and procedures for monitoring its Providers
and for sanctioning Providers who are out of compliance with the Contractor 's medical
management and quality of care standards or have been excluded, suspended or debarred
from participating in any District, state, or Federal health care benefit program, per 42
C.F.R. § 438.610.

C.5.122.6 The Contractor’s credentialing procedures shall not include selection criteria that
discriminate against Providers that specialize in complex conditions.

C.5.122.7 The Contractor shall ensure that all Providers are credentialed prior to becoming
Network Providers and that the Contractor conducts a site visit for all PCP and
Behavioral Health Providers before they provide services to Enrollees.

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C.5.122.8 The Contractor shall maintain a documented re-credentialing process which shall take
into consideration various forms of data including, but not limited to, Grievances, results
of quality reviews, UM information, and Enrollee satisfaction surveys.

C.5.122.9 The Contractor shall require that physician Providers and other licensed and certified
professional Providers, including Behavioral Health Providers, maintain current
knowledge, ability, and expertise in their practice area(s) by requiring them, at a
minimum, to obtain Continuing Medical Education (CME) credits or Continuing
Education Units (CEUs) and participate in other training opportunities, as appropriate
for Provider’s respective licensure and/or certification.

C.5.122.10 Upon written notice from DHCF, the Contractor shall not authorize any Providers
terminated or suspended from Medicare, Medicaid, or CHIP program in accordance with
42 C.F.R. 455.101. The Contractor shall deny payment to such Providers for services
provided after the Contractor notified the Provider.

C.5.122.11 The Contractor shall not contract with, or otherwise pay for any items or services
furnished, directed or prescribed by a Provider that has been excluded from participation
in federal health care programs.

C.5.122.12 The Contractor shall not establish Provider selection policies and procedures that
discriminate against particular Providers that serve high-risk populations or specialize in
conditions that require costly treatment.

C.5.122.13 The Contractor shall ensure that no credentialed Provider engages in any practice with
respect to any Enrollee that constitutes unlawful discrimination under any state or
federal law or regulation.

C.5.122.14 The Contractor shall ensure that the Provider credentialing process is completed within
one hundred eighty (180) days upon the Contractor’s receipt of all required documents.
The Contractor’s failure to credential or re-credential Providers in a timely manner may
result in corrective action, sanctions, fines and/or penalties as described in Sections
C.5.180, C.5.181 and G.6.7.

C.5.122.15 The Contractor shall maintain Provider credentialing files (or a copy thereof) in its
District office. Provider credentialing files can be maintained electronically; however,
the Contractor shall have the capability to print out a paper file upon DHCF request. The
Contractor’s Provider credentialing files shall include but not be limited to:

C.5.122.15.1 Licensure status;
C.5.122.15.2 Specialty or subspecialty;
C.5.122.15.3 Professional affiliations;
C.5.122.15.4 Hospital admitting privileges;
C.5.122.15.5 Languages spoken;
C.5.122.15.6 Education and training;
C.5.122.15.7 Board eligibility/ certification;
C.5.122.15.8 Professional credentials and/or certifications;
C.5.122.15.9 Basic demographic information;
C.5.122.15.10 Hours of operations;
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C.5.122.15.11 Office locations;
C.5.122.15.12 Languages spoken by office staff;
C.5.122.15.13 Status of panel (open, closed);
C.5.122.15.14 Satisfaction Survey responses;
C.5.122.15.15 Malpractice coverage;
C.5.122.15.16 Reported incidents;
C.5.122.15.17 Documentation that the Provider has not been suspended, excluded or debarred from
participation in any District, state, and/or Federal health care benefit programs; and
C.5.122.15.18 Documentation that Providers have completed all training modules required by
DHCF or the Contractor, including, but not limited to, EPSDT training for Health
Check Providers.

C.5.122.16 The Contractor shall report to DBH any changes in a mental health Provider’s
credentialing information, including the Contractor’s refusal to credential or re-
credential a mental health Provider.

C.5.122.17 The Contractor shall require in its Provider Agreements, that it shall furnish to DHCF or
the Secretary, information related to business transactions following 42 C.F.R. §
455.105, including:

C.5.122.17.1 The ownership of any subcontractor with whom the Provider has had business
transactions totaling more than twenty-five thousand dollars ($25,000) during the twelve
(12) month period preceding the date of DHCF’s or the Secretary’s request.
C.5.122.17.2 Any significant business transactions between the Provider and any wholly owned
supplier during the five year period preceding DHCF’s or the Secretary’s date of the
request.
C.5.122.17.3 Any significant business transactions between the Provider and any subcontractor during
the five-year period preceding the date of DHCF’s or the Secretary’s request.

C.5.122.18 The Contractor shall require in its Provider Agreements that Providers shall disclose the
information set forth in Sections C.5.122.17.1 – C.5.122.17.1.3 within thirty-five days
upon the request of DHCF or the Secretary.

C.5.122.19 The information on persons convicted of crimes identified in 42 C.F.R. § 455.106,
including:

C.5.122.19.1 The name of any person who has ownership or control interest in the Provider who has
been convicted of a criminal offense related to that person’s involvement in any program
under Medicare, Medicaid, or the Title XX services program, since the inception of
those programs; and
C.5.122.19.2 The name of any person who is an agent or managing employee of the Provider who has
been convicted of a criminal offense related to that person’s involvement in any program
under Medicare, Medicaid, or the Title XX services program, since the inception of
those programs.

C.5.122.20 The Contractor shall require in its contracts with Providers language stating that the
Contractor shall not reimburse Providers for procedures relating to the following Health
Care Acquired Conditions (HCAC), identified in the Section 2702 of the PPACA, when
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any of the following conditions are not present upon admission in any inpatient setting,
but subsequently acquired in that setting:

C.5.122.20.1 Foreign Object Retained after Surgery;
C.5.122.20.2 Air Embolism;
C.5.122.20.3 Blood Incompatibility;
C.5.122.20.4 Catheter Associated Urinary Tract Infection;
C.5.122.20.5 Pressure Ulcers (Decubitus Ulcers);
C.5.122.20.6 Vascular Catheter Associated Infection;
C.5.122.20.7 Mediastinitis after Coronary Artery Bypass Graft (CABG);
C.5.122.20.8 Hospital Acquired Injuries (fractures, dislocations, intracranial injury, crushing
injury, burn and other unspecified effects of external causes);
C.5.122.20.9 Manifestations of Poor Glycemic Control;
C.5.122.20.10 Surgical Site Infection following Certain Orthopedic Procedures;
C.5.122.20.11 Surgical Site Infection following Bariatric Surgery for Obesity; and
C.5.122.20.12 Deep Vein Thrombosis and Pulmonary Embolism following Certain Orthopedic
Procedures, except for Pediatric (Enrollees under the age of 21) and Obstetric
Populations.

C.5.122.21 The Contractor shall require in its contracts with Providers that Providers shall not be
reimbursed for any of the following Never Events in any inpatient or outpatient setting:

C.5.122.21.1 Surgery performed on the Wrong Body Part;
C.5.122.21.2 Surgery performed on the Wrong Patient; and
C.5.122.21.3 Wrong surgical procedure performed on a Patient.

C.5.122.22 The Contractor is prohibited from making payment to a Provider for Provider-
preventable conditions that meet the following criteria:

C.5.122.22.1 Conditions identified in the State Plan;
C.5.122.22.2 Conditions found by the State, based upon a review of medical literature by qualified
professionals, to be reasonably preventable through the application of procedures
supported by evidence-based guidelines;
C.5.122.22.3 Conditions that have a negative consequence for the beneficiary;
C.5.122.22.4 Is able to be audited; and
C.5.122.22.5 Condition includes, at a minimum, wrong surgical or other invasive procedure
performed on a patient; surgical or other invasive procedure performed on the wrong
body part; or surgical or other invasive procedure performed on the wrong patient.

C.5.122.23 The Contractor shall provide and update disclosures relative to 42 C.F.R. §§ 1001.1001
and 1001.1051 Exclusion of Entities Owned or Controlled by a Sanctioned Person and
Individuals with ownership or control interest in Sanctioned Entities to the CA quarterly
and within five business days of the change in status of Entities Owned or Controlled by
a Sanctioned Person and Individuals with ownership of control interest in Sanctioned
Entities.

C.5.122.24 The Contractor shall provide and update disclosures relative to 42 C.F.R. §455.104,
Disclosure of Ownership, quarterly and within five business days of the change in status
of affected Contractor staff.
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C.5.122.25 Under 42 C.F.R. § 455.104, the Contractor shall provide the following to DHCF prior to
a provider submitting the provider application and implementation of a Provider
Agreement:

C.5.122.25.1 The name and address of any person (individual or corporation) with an ownership
or control interest in the Contractor. The address for corporate entities must include,
as applicable, the primary business address, the address of every business location,
and P.O. Box address;
C.5.122.25.2 Date of birth and social security number; in the case of individual;
C.5.122.25.3 Other tax identification number (in the case of a corporation) with an ownership or
control interest in the Contractor or in any Independent Contractor in which the
Contractor has a five percent (5%) or more interest;
C.5.122.25.4 Documentation outlining whether the person (individual or corporation) with an
ownership or control interest in the Contractor is related to another person with
ownership or control interest in the Contractor as a spouse, parent, child or sibling;
or whether the person (individual or corporation) with an ownership or control
interest in any Independent Contractor in which the Contractor has a five percent
(5%) or more interest is related to another person with ownership or control interest
in the Contractor as a spouse, parent, child or sibling;
C.5.122.25.5 Documentation containing the name of any other disclosing entity (Provider and/or
Independent Contractor) in which an owner of the disclosing entity (Provider and/or
Independent Contractor) has an ownership or control interest; and
C.5.122.25.6 Documentation containing the name, address, date of birth and Social Security
number of any managing employee of the Contractor.

C.5.122.26 Disclosures from the Contractor’s Providers and/or Independent Contractors or
disclosing entities must be provided at all the following times:

C.5.122.26.1 Upon the Provider or disclosing entity submitting the Provider application;
C.5.122.26.2 Upon the Provider or disclosing entity executing the Provider Agreement; and
C.5.122.26.3 Within 35 days after any change in ownership of the disclosing entity.

C.5.122.27 Disclosures from Contractor are due at the following times:

C.5.122.27.1 Upon the Contractor submitting the proposal in accordance with the District’s
Procurement process;
C.5.122.27.2 Upon the Contractor executing the contract with the District;
C.5.122.27.3 Upon exercise of an option period or extension of the contract; and
C.5.122.27.4 Within 35 days after any change in ownership of the Contractor.

C.5.122.28 The Contractor shall keep copies of all these requests and responses listed in sections
C.5.122.23., C.5.122.24., C.5.122.25., and C.5.122.26. and make them available to
DHCF and/or Secretary upon request. The Contractor shall advise DHCF when there is
no response to DHCF’s request.

C.5.122.29 The Contractor shall submit to DHCF a copy of Contractor’s Provider Agreement
Template for DHCF review and approval within 90 days of Contract Award and within
forty-eight hours of Contractor’s modification of the template.
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C.5.122.30 The Contractor shall attest to the accuracy and completeness of the information
submitted to DHCF prior to implementation of the Provider Agreement. The Contractor
shall proceed with implementing the Provider Agreement once the Contractor submits
all factual and truthful information to DHCF. Any information found to be false or
inaccurate by DHCF Division of Program Integrity may result in termination of the
Provider Agreement with the Contractor or termination of the Contractor’s contract with
the District.

C.5.123 Enrollee Lock-In Provision

C.5.123.1 The purpose of this restriction is to provide continuity of medical care for the Enrollee,
protect the Enrollee’s safety and health, and avoid inappropriate or unnecessary
utilization of services, and to educate Enrollees on effective and appropriate utilization
of health care services.

C.5.123.2 Under 42 C.F.R. § 431.54, 29 DCMR § 2712, and DHCF’s policies and procedures for
the lock-in programs the Contractor shall request that DHCF restrict an Enrollee to one
designated PCP and pharmacy when there is reason to believe that the Enrollee may be
over-utilizing services or pharmaceutical drugs. To utilize this procedure, the Contractor
shall submit a written request in advance of such lock-in to the Division of Program
Integrity and the Division of Managed Care. The selected PCP shall then be responsible
for managing the health care services of the Enrollee.

C.5.124 Provider Agreements

C.5.124.1 The Contractor shall have written Provider Agreements with all its Network Providers.
Provider Agreements shall be in effect pending the outcome of the process described in
C.5.122, of up to 120 days, but the Contractor must terminate a Network Provider
immediately upon notification from DHCF that the Network Provider cannot be
enrolled, or the expiration of one 120 period without enrollment of the Provider.

C.5.124.2 The Contractor shall notify affected Enrollees that the Network Provider has been
terminated from the Network and they must choose a new Network Provider.

C.5.124.3 Any additions or changes to the provider agreement template must be submitted to
DHCF prior to implementation. DHCF reserves the right to confirm and validate,
through the collection of information and documentation from the Contractor and on-site
visits to Network Providers, the existence of a contract between the Contractor and each
individual Provider in the Provider Network.

C.5.124.4 The Contractor shall maintain all Provider Agreements (or a copy thereof) in its District
of Columbia office or maintain electronic copies with the capability to print out a paper
file upon request by DHCF, for the term of the Contract.

C.5.124.5 In addition to the credentialing requirements described in Section C.5.122 the
Contractor’s Provider contracts shall meet the following criteria:

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C.5.124.5.1 Prohibit the Provider from seeking payment from the Enrollee for any Covered
Services provided to the Enrollee within the terms of the contract. The contract shall
require the Provider to look solely to the Contractor for compensation for services
rendered. No cost sharing or deductibles shall be collected from Enrollees;
C.5.124.5.2 Require the Provider to cooperate with the Contractor’s compliance plan and fraud,
waste and abuse efforts, CQI and utilization review activities;
C.5.124.5.3 Include provisions for the immediate transfer of Enrollees to another PCP if their
health or safety is in jeopardy;
C.5.124.5.4 Include provisions stating that Providers are not prohibited from discussing treatment
options with Enrollees that may not reflect the Contractor's position or may not be
covered by the Contractor;
C.5.124.5.5 Include provisions stating that Providers are not prohibited from advocating on
behalf of the Enrollee in any Grievance, Appeal, or utilization review process, or
individual authorization process to obtain necessary health care services;

C.5.124.6 Require Providers to meet the access requirements defined in Section C.5.93:

C.5.124.6.1 Specifically incorporate Contractor’s Provider Manual;
C.5.124.6.2 Provide for continuity of treatment in the event a Provider’s participation terminates
during the course of an Enrollee’s treatment by that Provider;
C.5.124.6.3 Prohibit the Provider from denying services to an Enrollee who is eligible for the
services;
C.5.124.6.4 Require that the Provider comply with the limitations on marketing described throughout
section C.5.10, the applicable provisions of Enrollee Services, throughout section
C.5.40, and Enrollment, Education and Outreach, section C.5.19 the applicable
provisions of C.5.10 and for Health Check and dental Providers serving as PDPs, require
that Provider present notice to the Enrollee of scheduled, due, and overdue services in
accordance with their normal operating procedures;
C.5.124.6.5 Require that the Provider comply with the District’s Communicable Disease Reporting
Requirements, as well as other applicable reporting requirements found in section
C.5.227;
C.5.124.6.6 Require that the Provider attend meetings as directed by DHCF and the Contractor;
C.5.124.6.7 Require confirmation that all Health Check Providers complete the web-based Health
Check training within 30 days of joining the Contractor’s network and at least every two
years thereafter. Compliance with Health Check training shall be a requirement for re-
credentialing with the Contractor;
C.5.124.6.8 Include a provision requiring Providers’ compliance with 42 C.F.R. Part 2, the HIPAA
Privacy and Security Rules, and the D.C. Mental Health Information Act (D.C. Code §
62001 et seq.);
C.5.124.6.9 Include a payment dispute resolution procedure that compels binding arbitration or
another mandatory form of alternative dispute resolution;
C.5.124.6.10 Describe, incorporate, and require cooperation with Contractor’s Grievances, Appeals
and Fair Hearings Process;
C.5.124.6.11 Include a clear, concise, and understandable description of the Provider’s incentive
compensation and arrangements;

C.5.124.6.12 Require that the Provider comply with the Subcontracting Clause of Section I and the
monitoring clauses found in sections C.5.178.
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C.5.124.6.13 Require that the Provider provide access to DHCF, DC Health, the HHS, and their
respective designees to Providers’ medical records to conduct fraud, waste, abuse, and
quality improvement activities.

C.5.124.7 The Contractor shall require all Network Providers who have submitted more than 100
claims to the DC Medicaid program in a previous fiscal year, or who anticipate
submitting more than 100 claims to the DC Medicaid program in the upcoming year,
shall be a participating organization in the District of Columbia Health Information
Exchange (DC HIE) as specified in 29 DCMR, Chapter 8700.

C.5.124.8 The Contractor shall provide each Provider, not chosen to participate in the Contractor’s
network, written notice of the decision.

C.5.124.9 The Contractor shall not discriminate for the participation, reimbursement, or
indemnification of any Provider who is acting within the scope of his or her license or
certification under applicable District law, solely based on that license or certification.

C.5.125 Specific Requirements for Provider Agreements for PCPs

The Contractor shall ensure that Provider Agreements with PCPs require such Providers
to screen all CASSIP Enrollees according to the EPSDT Periodicity Schedule
(Attachment J.28) and applicable federal regulations, to use the Behavioral Health
screening tools described in the EPSDT Periodicity Schedule when conducting mental
health and substance use disorder screenings, and provide or refer all CASSIP Enrollees
for Medically Necessary treatment services in accordance with EPSDT requirements.

C.5.126 Physician Incentive Plan

C.5.126.1 If the Contractor implements a physician incentive plan under 42 C.F.R. § 438.3, the
plan must comply with all applicable law, including 42 C.F.R. § 422.208 and § 422.210.
The Contractor cannot make payments under a physician incentive plan (PIP) if the
payments are designed to induce providers to reduce or limit Medically Necessary
Covered Services to Enrollees.

C.5.126.2 The PIP shall comply with § 1903(m)(A)(x) of the Act and 42 C.F.R. §§ 422.208(c) and
438.3(i).

C.5.126.3 Under 42 C.F.R. § 422.208 and for the purposes of this section only, the following
definitions apply:

C.5.126.3.1 Bonus: A payment made to a physician or physician group beyond any salary, fee-for-
service payments, capitation, or returned withhold.

C.5.126.3.2 Capitation: A set dollar payment per patient per unit of time (usually per month) paid to
a physician or physician group to cover a specified set of services and administrative
costs without regard to the actual number of services provided. The services covered
shall include the physician’s own services, referral services, or all medical services.

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C.5.126.3.3 Physician Group: A partnership, association, corporation, individual practice
association, or other group of physicians that distributes income from the practice among
members. An individual practice association is defined as a physician group for this
section only if it is composed of individual physicians and has no subcontracts with
physician groups.

C.5.126.3.4 Physician Incentive Plan: Any compensation arrangement to pay a physician or
physician group that may directly or indirectly have the effect of reducing or limiting the
services provided to any plan Enrollee.

C.5.126.3.5 Potential Payments: The maximum payments possible to physicians or physician
groups including payments for services they furnish directly, and additional payments
based on use and costs of referral services, such as withholds, bonuses, capitation, or any
other compensation to the physician or physician group. Bonuses and other
compensation that are not based on use of referrals, such as quality of care furnished,
patient satisfaction or committee participation, are not considered payments in the
determination of Substantial Financial Risk.

C.5.126.3.6 Referral Services: Any specialty, inpatient, outpatient, or laboratory services that a
physician or physician group orders or arranges but does not furnish directly.

C.5.126.3.7 Risk Threshold: The maximum risk, if the risk is based on referral services, to which a
physician or physician group may be exposed under a physician incentive plan without
being at Substantial Financial Risk. This is set at twenty-five percent (25%) risk.

C.5.126.3.8 Substantial Financial Risk: Risk for referral services that exceeds the 25% risk
threshold.

C.5.126.3.9 Withhold: A percentage of payments or set dollar amounts deducted from a physician’s
service fee, capitation, or salary payment, and that may or may not be returned to the
physician, depending on specific predetermined factors.

C.5.126.4 Under 42 C.F.R. § 417.479(d)-(g), the Contractor shall provide the capitation data
required by law, or requested by DHCF, for the previous calendar year to the District by
application/contract prior to the Contract renewal date each year. The Contractor shall
provide the information on its PIPs listed in 42 C.F.R. § 417.479(h) to any Enrollee,
upon request.

C.5.126.5 Under 42 C.F.R. § 422.208(b), any PIP that Contractor (and any of its independent
contractor arrangements) operates shall meet the following requirements:

C.5.126.5.1 The Contractor shall make no specific payment, directly or indirectly, to a physician or
physician group as an inducement to reduce or limit Medically Necessary services
furnished to any particular Enrollee. Indirect payments shall include offerings of
monetary value (such as stock options or waivers of debt) measured in the present or in
the future.

C.5.126.5.2 If the PIP places a physician or physician group at Substantial Financial Risk for
services that the physician or physician group does not furnish itself, the Contractor shall
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assure that all physicians and physician groups at Substantial Financial Risk have either
aggregate or per-patient stop-loss protection and conduct periodic surveys.

C.5.126.6 For all PIPs, the Contractor shall provide the following information, per 42 C.F.R. §
422.210, to DHCF for submission to CMS:

C.5.126.6.1 Whether services not furnished by the physician or physician group are covered by the
PIP;
C.5.126.6.2 The type or types of incentive arrangements, such as withholds, bonus, and capitation;
the percent of any withhold or bonus used by the Contractor;
C.5.126.6.3 Assurance that the physicians or physician group have adequate stop-loss
protection and the amount of that protection;
C.5.126.6.4 The patient panel size and if the Contractor uses pooling, the pooling method (as detailed
below); and
C.5.126.6.5 A summary of any required Enrollee survey results.

C.5.126.7 The Contractor shall submit its PIP on a quarterly basis. CMS may not approve
Contractor’s application for the Contract unless Contractor discloses the physician
incentive arrangements effective for that contract.

C.5.126.8 Under 42 C.F.R. § 422.208(d), the following arrangements may cause Substantial
Financial Risk if the physician panel size is not greater than 25,000 patients:

C.5.126.8.1 Withholds greater than 25% of potential payments;
C.5.126.8.2 Withholds less than 25% of potential payments if the physician or physician group is
potentially liable for amounts exceeding 25% of potential payments;
C.5.126.8.3 Bonuses greater than 33% of potential payments minus the bonus;
C.5.126.8.4 Withholds plus bonuses if the withholds plus bonuses equal more than 25% of potential
payments. The threshold bonus percentage for a particular withhold percentage shall be
calculated using the formula: (Withhold percentage (%)) = (0.75)*(Bonus percentage) +
(25 percent).

C.5.126.9 Capitation arrangements shall be made if:

C.5.126.9.1 The difference between the maximum potential payments and the minimum potential
payments is more than 25% of the maximum potential payment; or
C.5.126.9.2 The maximum and minimum potential payments are not clearly explained in the contract
with the physician or physician group.

C.5.126.10 Any other incentive arrangements that have the potential to hold a physician group liable
for more than 25% of potential payments.

C.5.126.11 The Contractor shall ensure that compensation to individuals or contractors that conduct
UM activities is not structured to provide incentives for the individual or Contractor to
deny, limit, or discontinue Medically Necessary services to any Enrollee.

C.5.126.12 The Contractor shall ensure that all physicians and physician groups at Substantial
Financial Risk have either aggregate or per-patient stop-loss protection by the following
requirements:
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C.5.126.12.1 The Contractor shall comply with §1903(m)(A)(x) of the Act, 42 C.F.R. § 417.479, and
42 C.F.R. § 434.7-(a);

C.5.126.12.2 Aggregate stop-loss protection shall cover 90% of the costs of referral services that
exceed 25% of potential payments;

C.5.126.12.3 For per-patient stop-loss protection, if the stop-loss protection provided is on a per-
patient basis, the stop-loss limit (deductible) per patient shall be determined on the same
size of the patient panel and shall be a combined policy or consist of separate policies for
professional services and institutional practices. In determining patient panel size, the
patients shall be pooled in accordance with the panel requirements; and

C.5.126.12.4 Stop-loss protection shall cover 90% of the costs of referral services that exceed the per-
patient deductible limit. The per-patient stop-loss deductible limits are as follows:

Panel Size
Single
Combined
Limit
Separate
Institutional
Limit
Separate
Professional
Limit
1-1,000 $6,000 $10,000 $3,000
1,000-5,000 $30,000 $40,000 $10,000
5,000-8,000 $40,000 $60,000 $15,000
8,000-10,000 $75,000 $100,000 $20,000
10,000-25,000 $150,000 $200,000 $25,000
>25,000 None None None

C.5.126.12.4.1 All Medically Necessary services described in Section C.5.48 without regard to
otherwise applicable limits on amount, duration and scope; and

C.5.126.12.4.2 Diagnosis and treatment of dental conditions, including dental services necessary to
treat emergencies, relieve pain and infection, restore teeth, and maintain dental
health (including Medically Necessary orthodontic services);

C.5.126.12.5 Any Contractor that meets the following pooling conditions shall pool commercial,
Medicare, and Medicaid Enrollees or the Enrollees of several Contractors with which a
physician or physician group has contracts:

C.5.126.12.5.1 It is otherwise consistent with the relevant Contracts governing the compensation
arrangements for the physician or physician group;
C.5.126.12.5.2 The physician or physician group is a risk for referral services with respect to each of
the categories of patients being pooled;
C.5.126.12.5.3 The terms of the compensation arrangements permit the physician or physician group
to spread the risk across the categories of patients being pooled;
C.5.126.12.5.4 The distribution of payments to physicians from the Risk Pool is not calculated
separately by patient category; and
C.5.126.12.5.5 The terms of risk borne by the physician or physician group are comparable for all
categories of patients being pooled.

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C.5.126.13 Under 42 C.F.R § 417.479(g), the Contractor shall conduct periodic surveys of current
and former Enrollees where Substantial Financial Risk exists. The survey results must
be distributed to DHCF within fifteen business days of completion and disclose to
beneficiaries upon request. These surveys shall include at a minimum the following:

C.5.126.13.1 Either a sample of, or all, current Medicare/Medicaid Enrollees in the Contractor’s
Organization, and individuals disenrolled in the past 12 months for reasons other than:

C.5.126.13.1.1 The loss of Medicaid or Medicare eligibility;
C.5.126.13.1.2 Relocation outside the District;
C.5.126.13.1.3 For abusive behavior; and
C.5.126.13.1.4 Retroactive disenrollment.

C.5.126.13.2 Be designed, implemented, and analyzed in accordance with accepted principles of
survey design and statistical analysis;

C.5.126.13.3 Measure the degree of Enrollee’s/Disenrollee’s satisfaction with the quality of the
services provided and the degree to which the Enrollees have or had access to services
provided by the Contractor; and

C.5.126.13.4 Be conducted no later than thirty days prior to the termination of the Contractor’s
Contract.

C.5.126.14 The Contractor shall ensure that compensation to individuals or Contractors that conduct
UM activities is not structured to provide incentives for the individual or Contractor to
deny, limit, or discontinue Medically Necessary services to any Enrollee.

C.5.126.15 If the Contractor fails to comply with the requirements of 42 C.F.R. § 422.208, the
Contractor will be subject to Intermediate Sanctions in accordance with Section G.6.7.3.

C.5.127 Disclosure of Physician Incentive Plan

C.5.127.1 Ninety days prior to the end of the Contract’s period of performance, the Contractor
shall send to the CO the information on its Physician Incentive Plans listed in 42 C.F.R.
§§ 422.208 and 422.210, as required in 42 C.F.R. § 438.3, and in accordance with
C.5.1.131, for DHCF approval. The Contractor shall ensure that incentive plans
containing compensation arrangements, where payment for designated health services
furnished to an Enrollee on the basis of a physician referral would otherwise be denied
under § 1903(s) of the Act, comply with the requirements of 42 C.F.R. §§ 422.208 and
422.210 provided to any Enrollee.

C.5.127.2 The Contractor shall make available, upon request, any physician incentive plans in
accordance with 42 C.F.R. § 438.3(i).

C.5.128 Provider Training

C.5.128.1 The Contractor shall have an organized training program for Network Providers based
upon the Contract requirements and Contractor’s monthly assessment of training needs.

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C.5.128.1.1 The Contractor shall develop an education and training plan and materials for Network
Providers and provide education and training to Network Providers and their staff
regarding key requirements of this Contract.

C.5.128.2 The Contractor shall attend and shall require that Providers attend trainings, as directed
by DHCF.

C.5.128.3 The Contractor shall conduct initial education and training to Network Providers at least
30 days prior to the start date of operations and within thirty days of a Provider joining
the Contractor’s network. The Contractor shall, at a minimum, provide training to
Network Providers on the following topics:

C.5.128.3.1 An overview of the DCHFP, CASSIP, and ICP programs, along with an overview of
DHCF’s priorities;
C.5.128.3.2 Enrollee access standards defined in sections C.5.94 and C.5.115;
C.5.128.3.3 The use of evidence-based guidelines, the Contractor’s treatment guidelines (as
described in C.5.137 and the definition of medical necessity in section C.5.144);
C.5.128.3.4 An overview of EPSDT, the periodicity schedule, compliance requirements, the Salazar
Order/Consent Decree, and subsequent court orders as identified by DHCF;
C.5.128.3.5 An overview of the IDEA and the roles and responsibilities of the schools, the EI
Program, Providers, and Contractor in sections C.5.52, C.5.110, C.5.137, and C.5.150;
C.5.128.3.6 The Contractor’s policies and procedures on Advance Directives;
C.5.128.3.7 The Contractor’s Fraud, waste, and abuse policies and procedures and Compliance Plan
as described in section C.5.182;
C.5.128.3.8 The Contractor’s CQI program and plan as described in section C.5.171;
C.5.128.3.9 Procedures for arranging referrals with other District agencies and services;
C.5.128.3.10 Cultural Competency, the availability and protocols for use of interpreters for Enrollees
who speak limited English and other skills for effective health-related cross-cultural
communication;
C.5.128.3.11 Reporting requirements, including communicable disease reporting requirements, as
described in section C.5.227;
C.5.128.3.12 Privacy and Confidentiality of Protected Health Information, including 42 C.F.R Part 2,
HIPAA Privacy and Security Rules, including, Breach Notification Rule (45 C.F.R. §§
164.400-414), and the D.C. Mental Health Information Act (D.C. Code § 6-2001 et
seq.); and
C.5.128.3.13 Manifestations of mental illness and substance use disorder, use of a DHCF approved
screening tool to identify such problems, and how to make appropriate referrals for
treatment services, including training at least annually for all PCPs so that PCPs
proactively identify Behavioral Health (mental health and substance user disorder)
Service needs at the earliest point in time and offer Enrollees referrals to Behavioral
Health (mental health and substance use disorder) Services when clinically appropriate.

C.5.128.4 The Contractor shall provide training regarding ESPDT and IDEA to all new Providers
within thirty days of Provider entering Contractor’s network and quarterly thereafter.
All Network Providers shall receive this training.

C.5.128.5 The Contractor shall participate in the District-wide on-line Provider training system for
Health Check Providers including the following:

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C.5.128.5.1 Identify and submit list of Health Check Providers to the DHCF quarterly;
C.5.128.5.2 Educate Health Check Providers regarding the requirement to complete the EPSDT
online Provider training within thirty days of joining the Contractor’s MCO network
and every two years thereafter, and in accordance with monthly reports on provider
training compliance provided by Georgetown University; and
C.5.128.5.3 The Contractor shall provide additional training to Providers as requested by DHCF at
no additional cost.

C.5.129 Provider Manual

C.5.129.1 The Contractor shall maintain and distribute to Network Providers a Provider Manual
that comprehensively documents the policies and procedures pertaining to the
Contractor’s Providers.

C.5.129.1.1 The Contractor shall submit the Provider Manual to DHCF for approval prior to the start
of the Contract within ninety days of Contract Award. All substantive subsequent
changes to the Manual must be approved by DHCF prior to implementation of the
changes.

C.5.129.1.2 The Contractor shall notify Providers thirty days in advance of change and issue updates
to the Provider Manual prior to implementing significant changes in policy or procedure.

C.5.129.1.3 The Contractor shall submit an updated Provider Manual(s) to DHCF at least annually
with the substantive changes noted.

C.5.129.2 The Provider Manual shall, at a minimum, shall address:

C.5.129.2.1 Care Coordination requirements, utilization review procedures, authorization of
services, including prior authorization requirements and Treatment Plan requirements,
described in Sections C.5.137 and C.5.150;
C.5.129.2.2 The definition of medical necessity described in C.5.142, the Contractor’s Medical
Necessity Criteria and how this definition is intended to guide Provider management of
treatment, as described in Sections C.5.48 and C.5.144;
C.5.129.2.3 The Contractor’s Provider selection, retention, and monitoring procedures, along with
the access standards and capacity restrictions described in Sections C.5.94 and C.5.115;
C.5.129.2.4 Medical record requirements, including DHCF’s and HHS’ access to these records,
along with an explanation of Advance Directive procedures described in Section
C.5.136;
C.5.129.2.5 EPSDT requirements and the Salazar Consent Decree requirements as described in
Section C.5.53, C.5.233, and Attachment J.19;
C.5.129.2.6 Protocols for fulfilling responsibilities to provide health related IDEA services as
described in Section C.5.52;
C.5.129.2.7 Grievance, Appeals, and Fair Hearing procedures, including timelines and Provider
obligations as described in section C.5.189 and C.5.200;
C.5.129.2.8 Claims submission procedures and Contractor’s prompt payment obligations as
described in section C.5.217 and C.5.218;

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C.5.129.2.9 Information about how Providers may assist Enrollees in accessing Substance Use
Disorder Services, including but not limited to services available within the scope of
benefits identified in this contract;
C.5.129.2.10 Information about how Providers may assist Enrollees in accessing behavioral health
services, including but not limited to those services within the scope of benefits
described in this contract;
C.5.129.2.11 Rights of Medicaid Enrollees (including those with limited English and those who are
Deaf and Hard of Hearing), including a description of obligations with respect to DC
Language Access Act of 2004, the ADA, and the other requirements described in C.5.8;
C.5.129.2.12 The Contractor’s credentialing and re-credentialing policies described in section C.5.122
along with the Contractor’s mandatory and optional training requirements as described
in C.5.128;
C.5.129.2.13 A comprehensive description of the Contractor’s fraud, waste, and abuse and
compliance procedures as required in section C.5.182;
C.5.129.2.14 The Contractor’s HIPAA Privacy and Security procedures and additional protections for
maintaining Enrollee’s privacy and confidentiality;
C.5.129.2.15 The District’s and DHCF’s mandatory reporting requirements, including communicable
disease reporting requirements as described in section C.5.227;
C.5.129.2.16 A description of the Contractor’s CQI Program including goals and Quality Assessment
Performance Improvement plan and Program Evaluation, along with an explanation of
the role of the EQRO as described in section C.5.170;
C.5.129.2.17 An explanation of procedures, format, and timing for collection and reporting of claims
data, Enrollee Encounter Data, and other data utilization reports as described throughout
sections C.5.207 and C.5.207.3;
C.5.129.2.18 Procedures for reporting, investigating, addressing and documenting Adverse Events as
required by section C.5.176;
C.5.129.2.19 Procedures for reporting Never Events and HCAC as described in sections C.5.122.21
and C.5.122.20;
C.5.129.2.20 Protocols for managing occurrences of HCAC and Never Events; and
C.5.129.2.21 Information related to CASSIP being a Care Management program, that Care
Management is provided to all Enrollees and how to effectively work with the
Contractor’s Care Managers.

C.5.130 Coordination with PCPs

C.5.130.1 The Contractor shall define the relative responsibilities of the PCP and other staff in
fulfilling diagnostic, planning and treatment tasks, and shall monitor treatment planning
and provision of treatment to ensure that these responsibilities are carried out.

C.5.130.2 The Contractor shall forward to the PCP any information about Enrollees’ health history
or health conditions the Contractor received from DHCF, Enrollees, or other sources
upon Enrollee enrollment, in a manner that protects the Enrollee’s confidentiality within
thirty days of Contractor’s receipt of that information so that it can be considered in the
Enrollee’s initial evaluation.

C.5.130.3 The Contractor shall ensure that, if an Enrollee has a new PCP who has not previously
cared for that Enrollee, the Enrollee receives a comprehensive initial examination,
screening for behavioral health (mental health and substance use disorder) needs using a
validated screening tool approved by DHCF prior to implementation, and referrals for
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any additional tests or examinations needed in order to complete a comprehensive
assessment of the Enrollee’s health condition.

C.5.130.4 During the initial examination and assessment of a CASSIP Enrollee, the PCP shall
perform EPSDT screening and any additional assessment needed to determine whether a
child meets the definition of a child with Special Health Care Needs and shall report this
determination to the Contractor according to the Contractor’s defined procedures.

C.5.130.5 The Contractor shall establish an effective system for PCPs to make referrals to other
network services needed by Enrollees and for authorization of services that the PCP
cannot authorize himself or herself. The Contractor shall monitor timeliness of referrals
and access to specialists.

C.5.131 Provider Relations Department

C.5.131.1 The Contractor shall maintain staff to perform Provider relations functions including:

C.5.131.1.1 Operate a toll-free telephone line for promptly answering calls in an average speed of 20
seconds or three rings. The toll-free telephone line shall receive Provider inquiries
during normal business hours as defined in C.5.6 for a minimum of eight and a half (8.5)
hours per day, Monday through Friday, and have a process in place to handle after-hours
inquiries from Providers seeking to verify enrollment for an Enrollee in need of Urgent
or Emergency Services. However, the Contractor and its Providers shall not require
such verification prior to providing Emergency Services;
C.5.131.1.2 Publish a Provider Manual(s) to be available on the Contractor’s website and available
electronically or via paper format upon request;
C.5.131.1.3 Maintain a protocol that shall facilitate communication between Providers and the
Contractor, and which shall include, but not be limited to, a Provider newsletter and
Provider meetings no less than quarterly and as required by DHCF;
C.5.131.1.4 Except as otherwise required or authorized by DHCF or by operation of law, ensure that
Providers receive 30 days advance notice in writing of policy and procedure changes,
and maintain a process to provide education and training for Providers regarding any
changes that may be implemented, prior to the policy and procedure changes taking
effect;
C.5.131.1.5 Work in collaboration with Providers to actively improve the quality of care provided to
Enrollees, consistent with the QAPI and all other requirements of this Contract;
C.5.131.1.6 Train Providers in accordance with section C.5.128 including but not limited to
Contractor’s procedures for authorization and claims payments;
C.5.131.1.7 Assisting Providers to resolve billing and other administrative problems;
C.5.131.1.8 Responding to Provider concerns about administrative processes;
C.5.131.1.9 Responding to Provider concerns about Enrollees;
C.5.131.1.10 Assisting Providers with obtaining payments from the District, when applicable due to
retroactive changes in Enrollee’s eligibility status;
C.5.131.1.11 Developing and implementing policies and procedures to notify Providers of a
retroactive change within three days of notification from the District; and
C.5.131.1.12 Providing written notice to Providers to inform them of a change in the reimbursement
process and detailed information on how to obtain reimbursement from DHCF.

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C.5.131.2 The Contractor shall submit documentation to the DHCF, in a format specified by the
DHCF, at the time the Contractor enters into a contract with the State; on a quarterly
basis, at any time there has been a material change in the Contractor’s operations that
would affect the adequacy of capacity and services including changes in the Contractors
services, benefits, geographic service area, composition of payments to it provider
network; or enrollment of a new population. Contractor shall demonstrate that it
complies with the following requirements:

C.5.131.2.1 Offers an appropriate range of preventive, primary care, specialty services, and LTSS
that is adequate for the anticipated number of enrollees for the service area.

C.5.131.2.2 Maintains a network of providers that is sufficient in number, mix, and geographic
distribution to meet the needs of the anticipated number of enrollees in the service area.

C.5.132 Provider Terminations

C.5.132.1 The Contractor shall notify DHCF, in writing, within two business days upon awareness
or receipt of termination notice from provider of contract termination of a network
provider.

C.5.132.2 The Contractor shall ensure Enrollees are notified in writing at least thirty days prior to a
provider termination when a provider serving CASSIP Enrollees is terminated from the
network. DHCF may waive the 30 day requirement for special circumstances when
member safety or other issues may warrant immediate termination.

C.5.132.3 The Contractor shall actively assist in the transition of enrollees to other health providers
when a provider servicing CASSIP enrollees is terminated.

C.5.133 Performance Reporting Requirements

The Contractor shall submit all reports in accordance with the requirements included in
section C.5.216.

C.5.134 Coordination with CFSA and the Department of Youth Rehabilitation Services

C.5.134.1 The Contractor shall be responsible for coordinating the care of Enrollees that are wards
of or under the supervision of the CFSA and the Department of Youth Rehabilitation
Services.

C.5.134.2 The Contractor shall be required to designate a contact for the CFSA and DYRS to
develop any policies and procedures needed to coordinate health care for Enrollees
affiliated with such agencies.

C.5.135 Coordination with Other Medicaid MCOs and FFS

The Contractor shall establish procedures for secure transfer of medical information,
continuity of care and for linkage of medical information of Enrollees who transfer
between Fee For Service, DC Healthy Families and CASSIP.

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C.5.136 Advanced Directives

C.5.136.1 The Contractor shall develop written policies and procedures to ensure its staff and
Network Providers comply with the requirements of 42 C.F.R. Ch. IV, Subpart I of part
489 regarding Advance Directives.

C.5.36.1.1 These policies and procedures shall apply to all adult Enrollees receiving medical care
by or through the Contractor. For purposes of this part, advance directive means a
written instruction, such as a living will or durable power of attorney for health care,
recognized under State law (whether statutory or as recognized by the courts of the
State), relating to the provision of health care when the individual is incapacitated.

C.5.136.2 The Contractor shall educate its staff about its policies and procedures on Advance
Directives, situations in which Advance Directives may be of benefit to Enrollees, and
their responsibility to educate Enrollees about this tool and assist them to make use of it.

C.5.136.3 The Contractor shall educate Enrollees about their ability to direct their care using this
mechanism and shall specifically designate which staff and Network Providers are
responsible for providing this education.

C.5.136.4 The Contractor shall inform Enrollees that Appeals concerning noncompliance with the
Advance Directive requirements shall be filed with the Health Regulation and Licensing
Administration, DC Health.

C.5.136.5 All information shall reflect changes in District laws as soon as possible, but no later
than ninety days after the effective change.

C.5.136.6 Under 42 C.F.R. § 438.3(j), the Contractor shall provide written information to
Enrollees with respect to:

C.5.136.6.1 Their rights under the law of the District of Columbia including the right to accept or
refuse medical treatment and the right to formulate Advance Directives; and
C.5.136.6.2 The Contractor’s policies regarding the implementation of the Enrollee’s rights,
including a statement of any limitation regarding the implementation of Advance
Directives as a matter of conscience.

C.5.136.7 The Contractor is prohibited from conditioning the provision of care or otherwise
discriminating against an Enrollee based on whether the Enrollee has executed an
advance directive.

C.5.137 Utilization Management

C.5.137.1 The Contractor shall develop and maintain a well-structured UM program to facilitate
Enrollees’ receipt of all appropriate health care services in a fair, impartial and
consistent manner to all CASSIP Enrollees.

C.5.137.2 The Contractor shall establish policies and procedures for UM following 42 C.F.R. §
438.210, that shall both guard against inappropriate use of high cost, high risk services
and procedures.
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C.5.137.2.1 The policies and procedures shall promote timely access to preventive treatment,
therapeutic and rehabilitation services in accordance with evidence-based standards of
health care and include safeguards to ensure that the procedures are applied in an
appropriate manner.

C.5.137.3 The Contractor shall ensure that compensation to individuals or entities that conduct UM
activities is not structured to provide incentives for the individual or entity to deny, limit,
or discontinue Medically Necessary Services to any Enrollee.

C.5.138 Utilization Management Program

C.5.138.1 The Contractor shall operate an UM program consistent with the District of Columbia
HMO Act and current NCQA “Standards and Guidelines for the Accreditation of Health
Plans,” regardless of whether the Contractor is NCQA-accredited. Included in the
Contractor’s program shall be written Medical Necessity Criteria, a Utilization Review
component, including authorization requirements, and a process for ensuring that
authorization decisions are applied fairly, impartially and consistently, and a mechanism
to test inter-rater reliability.

C.5.138.2 The Contractor shall have a written UM program description specific to the CASSIP
population, inclusive of a work plan, and conduct an annual evaluation of its program.
The Contractor shall review and/or revise the program description and annual evaluation
and submit to DHCF for approval.

C.5.138.3 The Contractor shall have processes and systems to detect both under and over
utilization of services.

C.5.138.4 The Contractor’s UM Program shall provide a structured system of operations and
monitoring of Enrollee utilization of benefits to ensure that appropriate, timely and cost
effective- care is available and provided. The goal is to assess and improve the quality
of medical care and resource allocation by utilizing nationally recognized
guidelines/criteria, best practice protocols, community standards of care, and data
analysis to demonstrate patterns of care and outcomes for children and youth with
special health care needs.

C.5.138.5 The Contractor shall comply with the performance reporting requirements specified in
section C.5.216.

C.5.138.6 In accordance with 42 C.F.R. § 438.210 (f), Beginning January 1, 2026, the contractor
must following each calendar year it has a contract with DHCF (State Medicaid agency),
the MCO, must report prior authorization data, excluding data on any and all drugs
covered by the MCO at the plan level by March 31. The MCO, must make the following
data from the previous calendar year publicly accessible by posting them on its website:

C.5.138.6.1 A list of all items and services that require prior authorization;
C.5.138.6.2 The percentage of standard prior authorization requests that were approved, aggregated
for all items and services;
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C.5.138.6.3 The percentage of standard prior authorization requests that were denied, aggregated for
all items and services;
C.5.138.6.4 The percentage of standard prior authorization requests that were approved after appeal,
aggregated for all items and services;
C.5.138.6.5 The percentage of prior authorization requests for which the timeframe for review was
extended, and the request was approved, aggregated for all items and services;
C.5.138.6.6 The percentage of expedited prior authorization requests that were approved, aggregated
for all items and services;
C.5.138.6.7 The percentage of expedited prior authorization requests that were denied, aggregated
for all items and services;
C.5.138.6.8 The average and median time that elapsed between the submission of a request and a
determination by the MCO, for standard prior authorizations, aggregated for all items
and services; and
C.5.138.6.9 The average and median time that elapsed between the submission of a request and a
decision by the MCO for expedited prior authorizations, aggregated for all items and
services.

C.5.139 Utilization Management Staffing

C.5.139.1 The Contractor shall establish an UM department that is physically located in the
District of Columbia.

C.5.139.2 The UM department shall be led by a manager with an RN or Medical Doctor (MD)
licensure in the District of Columbia.

C.5.139.2.1 The UM Manager shall maintain their certification and District licensure throughout the
life of the contract.

C.5.139.2.2 This department shall be comprised of a multidisciplinary medical and Behavioral
Health team with the appropriate skills and experience to conduct UM activities for the
provision of Covered Services and benefits.

C.5.139.3 The Contractor shall have adequate staffing and resources to ensure authorization
timeframes are met within NCQA guidelines in section C.5.170.13.4.

C.5.140 Utilization Review Process

C.5.140.1 As part of its UM program, the Contractor shall establish a Utilization Review process
following 42 C.F.R. § 438.210(b) that shall encompass, at a minimum, the following:

C.5.140.1.1 A formal UM review committee directed by the Contractor’s CMO who shall oversee
the utilization review process; review the UM program in its entirety, including its
results and activities; identify opportunities for improvement; and recommend changes
on an ongoing basis. The UM committee must be comprised of the Contractor’s staff,
including but not limited to the UM Manager and other key management staff.

C.5.140.2 The Contractor’s written UM policies and procedures shall:

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C.5.140.2.1 Define the Contractor’s prior authorization process, use of review criteria and
utilization review decision algorithm that conforms to managed health care industry
standards. The policies and procedures shall have the flexibility to efficiently
authorize Medically Necessary services and takes consideration of the special nature
and urgency of the CASSIP population;
C.5.140.2.2 Ensure the review criteria for authorization determinations are applied consistently
and require the Contractor to consult with the requesting Provider when appropriate;
C.5.140.2.3 Identify services available upon an Enrollee’s direct request;
C.5.140.2.4 Identify services that require pre-service authorization;
C.5.140.2.5 Identify services that require concurrent review;
C.5.140.2.6 Identify services that may fall outside of or exceed the Contractor’s written UM
policies and procedures and utilization limits (where appropriate) that shall be
reviewed on an individual basis for CASSIP Enrollees;
C.5.140.2.7 Indicate circumstances that warrant post-service review;
C.5.140.2.8 Are reviewed, updated (as applicable) and approved at least annually by Utilization
Review Committee;
C.5.140.2.9 Ensure that UM decisions are made by a health care professional who has experience
in serving children and youth with special health care needs and who has appropriate
clinical expertise regarding the service under review;
C.5.140.2.10 Include the Contractor’s special procedures for management of high-cost and high
risk cases; and
C.5.140.2.11 Include a clear statement that the Contractor is legally prohibited from denying
services based upon cost.

C.5.140.3 Define criteria for hospital-to-hospital transfers and discharge planning activities for
CASSIP Enrollees.

C.5.140.3.1 Provide an Enrollee, representative, and the Enrollee’s health care provider a minimum
of 24 hours (excluding weekends and legal public holidays) following an emergency
hospital admission or the provision of an emergency health care service to notify the
utilization review entity of the admission or provision of the emergency health care
service.

C.5.140.4 The Medical Necessity Criteria determinations, as described in section C.5.142, must be
incorporated into these policies and procedures. The Contractor shall not use such
policies and procedures to avoid providing Medically Necessary Covered Services.

C.5.141 DME Education

C.5.141.1 The Contractor shall develop policies and procedures for the oversight and monitoring
of an Enrollee’s DME delivery, education, use, maintenance, and repair, if applicable
and how the Contractor will integrate DME oversight into ongoing Care Management.
The Contractor shall provide such policies to DHCF within ninety days of Contract
Award, when material changes occur, and upon DHCF request.

C.5.141.2 The Contractor shall ensure that Enrollees utilizing DME or assistive technologies are
contacted by phone, home or virtual visit, by an appropriately licensed health
professional (Nurse, Occupational Therapist, Speech Language Pathologist, etc.), within
five business days of confirmed delivery of the DME. This individual shall screen the
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Enrollee to determine if additional DME related assistance is warranted (i.e. in-home
DME tutorial, maintenance education, safe use demonstration, etc.). If the health
professional contacting the Enrollee is not the assigned Care Manager, the Contractor
shall ensure the assigned Care Manager participates in the DME activities.

C.5.141.3 When an Enrollee is determined to be in need of, or requests, additional DME related
assistance, Contractor shall ensure the necessary and/or requested support is provided
within seven business days of the determination/request and is documented in the
Enrollee’s Care Plan.

C.5.141.4 The Contractor shall ensure that any disposable supplies or DME necessary to
administer or monitor an Enrollee's prescriptions, if not available at the pharmacy at the
time of the dispensing of the prescription, is received in a manner so as not to adversely
affect the health of the Enrollee, but not later than forty-eight (48) hours.

C.5.141.5 DHCF reserves the right to determine instances where Contractor shall provide a home
visit, or other contact type, prior to the five-business day timeframe.

C.5.141.6 The Contractor shall ensure that at a minimum, an appropriately licensed health
professional (Nurse, Occupational Therapist, Speech Language Pathologist, etc.)
conducts Enrollee assessments at least every six months, to monitor the safe and correct
use and maintenance of the following DME types:

C.5.141.6.1 Hospital or Pressure Reducing Beds or similar equipment;
C.5.141.6.2 Infusion pumps and supplies;
C.5.141.6.3 Power mobility devices (PMDs) which includes Power Wheelchairs (PWCs) and Power
Operated Vehicles (POVs);
C.5.141.6.4 Patient lifts; and
C.5.141.6.5 Sleep Apnea and Continues Positive Airway Pressure (CPAP) machines and
accessories.

C.5.141.7 The assessments shall be included in the Enrollee’s Care Plan and shall be conducted in
collaboration with the Enrollee’s assigned Care Manager and Provider, if warranted. If
the Contractor determines that an assessment is no longer necessary every six months
for an Enrollee, there shall be documentation in the Enrollee’s electronic health record
that supports the termination of the assessment frequency in accordance with the
Contractor’s policies and procedures.

C.5.142 Medical Necessity Criteria

C.5.142.1 The Contractor shall develop, adopt and maintain written Medical Necessity Criteria that
complies with and conforms to managed health care industry standards for children and
youth with special health care needs. The Medical Necessity Criteria and Contractor’s
guidelines for implementing the Medical Necessity Criteria shall allow Network
Providers and utilization reviewers to consider the nature of the Enrollee’s social factors
in determining what services to authorize.

C.5.142.2 The Contractor shall ensure that the Medical Necessity Criteria applicable to children
under 21 years of age, reflect EPSDT guidelines.
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C.5.142.3 The Contractor’s Medical Necessity Criteria shall be submitted to DHCF for approval
within ninety days of award date of the Contract. The Contractor shall annually review
and update, when appropriate, its Medical Necessity Criteria. Any changes to the
Contractor’s internally developed Medical Necessity Criteria shall require DHCF’s prior
approval.

C.5.142.4 The Contractor shall involve appropriate practitioners in developing,
adopting/approving, and reviewing the Medical Necessity Criteria for CASSIP
Enrollees.

C.5.142.5 The Contractor shall communicate its Medical Necessity Criteria, along with any
practice guidelines or other criteria it uses in making medical necessity determinations,
to its Network Providers and make the Medical Necessity Criteria available upon request
to whomever or whatever entity may request it.

C.5.142.6 To provide effective guidance and ensure consistency, utilization reviewers shall make
authorization determinations consistent with the Medical Necessity Criteria and, at no
time, shall any CASSIP Covered Services be denied based upon cost. The Contractor
shall evaluate the consistency with which utilization reviewers apply criteria in decision
making at least annually.

C.5.142.7 The Contractor shall provide specific Medical Necessity Criteria for authorization
decisions to DHCF upon request.

C.5.142.8 The Contractor’s Medical Necessity Criteria shall not be more restrictive than DHCF’s
criteria for medical necessity.

C.5.143 Court Orders

C.5.143.1 The Contractor shall comply with and furnish services and evaluations in a court order
applicable to the Contractor, DHCF, and/or the District.

C.5.143.2 The Contractor shall respond no later than the next business day to direct referrals from
the court system for court ordered services and ensure that appointments for Medically
Necessary services are offered by the evaluation due date specified in the Court Order
referral. If Contractor determines that services recommended under the court ordered
evaluation are not medically necessary, the Contractor shall recommend an alternative
treatment plan to address the enrollee’s needs no later than five business days.

C.5.143.3 The Contractor shall respond to direct referrals from the court system for court- ordered
evaluations and assess case management services for the enrollee. Within three business
days, Referrals shall be forwarded to appropriately qualified Providers who are able to
promptly and fully respond to the needs of the court, as defined in the court order.

C.5.143.3.1 The Contractor shall be responsible for oversight of the evaluation and for ensuring the
evaluation results are provided to the parties specified in the Court Order Referral.

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C.5.143.3.2 Unless specified in the court order, the Contractor shall ensure evaluation results are
provided to the court by the evaluation due date unless an extension is granted by the
probation officer.

C.5.143.4 The Contractor shall comply with the setting of care specified by the court (e.g., work,
school, inpatient setting, childcare, home, or other setting).

C.5.144 Medically Necessary Services

C.5.144.1 A service is Medically Necessary if a physician or other treating health Provider,
exercising prudent clinical judgment, would provide or order the service for an Enrollee
for the purpose of evaluating, diagnosing or treating illness, injury, disease, physical or
mental health conditions, or their symptoms, and the provision of the service is in
compliance with 1905(a) of the Act, 42 U.S.C. § 1396d(a), to correct or ameliorate
defects and physical and mental illnesses and conditions discovered by the screening
services, whether or not such services are covered under the State Plan. Medically
Necessary services shall be:

C.5.144.1.1 No more restrictive than those used in the Medicaid program, including quantitative and
non-quantitative treatment limits, as indicated in District statutes and regulations, the
State Plan, and other District policy and procedures;
C.5.144.1.2 Services and benefits that promote normal growth and development and prevent,
diagnose, detect, treat, ameliorate the effects or a physical, mental, behavioral, genetic,
or congenital condition, injury, or disability for CASSIP Enrollees;
C.5.144.1.3 Provided in accordance with generally accepted standards of medical practice;
C.5.144.1.4 Clinically appropriate, in terms of type, frequency, extent, site and duration, and
considered effective for the Enrollee’s illness, injury, disease, or physical or behavioral
health condition;
C.5.144.1.5 Not primarily for the convenience of the Enrollee or treating physician, or other treating
healthcare Providers, and more cost effective than an alternative service or sequence of
services, and at least as likely to produce equivalent therapeutic or diagnostic results
with respect to the diagnosis or treatment of that Enrollees illness, injury, disease or
physical or mental health condition; and
C.5.144.1.6 Specific to the Enrollee and shall take into account available clinical evidence, as well
as recommendations of the treating clinician and other clinical, educational, and social
services professionals who treat or interact with the Enrollee.

C.5.144.2 The Contractor shall cover and pay for Emergency Services, regardless of whether the
Provider that furnishes the services has a contract with the Contractor. The Contractor
shall be responsible for coverage and payment of Emergency Services and post
stabilization care services.

C.5.144.3 The Contractor shall not deny payment for treatment obtained when the Contractor’s
representative instructs the Enrollee to seek Emergency Services. Under 42 C.F.R. §
438.114(d) the Contractor shall not limit what constitutes an Emergency Medical
Condition based on lists of diagnoses or symptoms.

C.5.144.4 The Contractor shall be responsible for post-stabilization care services, following
provisions set forth at 42 C.F.R. § 422.113(c). The Contractor is financially responsible
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for post-stabilization services obtained within or outside the Contractor’s Provider
Network that are pre-approved by an inpatient Network Provider or other Contractor
representative.

C.5.144.5 The Contractor shall be financially responsible for post-stabilization care services
obtained within or outside the Contractor’s Provider Network that are not pre-approved
by an inpatient Network Provider or other Contractor representative but are administered
to maintain the Enrollee’s stabilized condition within one hour of a request to the
Contractor for pre-approval of further post-stabilization care services.

C.5.144.6 The Contractor shall be financially responsible for post-stabilization care services
obtained within or outside the Provider Network that are not pre-approved by a Network
Provider or other Contractor representative, but administered to maintain, improve, or
resolve the Enrollee’s stabilized condition if:

C.5.144.6.1 The Contractor does not respond to a request for pre-approval within one hour;
C.5.144.6.2 The Contractor cannot be contacted; or
C.5.144.6.3 The Contractor’s representative and the treating physician cannot reach an agreement
concerning the Enrollee’s care and a Network Provider is not available for consultation.
In this situation, the Contractor shall give the treating physician the opportunity to
consult with a Network Physician and the treating physician may continue with care of
the Enrollee until a Network Physician is reached.

C.5.144.7 Under 42 C.F.R. § 438.114(b)(c), the Contractor may not refuse to cover Emergency
Services based on the ER Provider, hospital or Fiscal Agent not notifying the Enrollee’s
Primary Care Provider, the Contractor, or DHCF of the Enrollee’s screening and
treatment within 10 days of presentation for Emergency Services.

C.5.144.7.1 If a health care provider certifies in writing to a utilization review entity within 72 hours
of an Enrollee’s receipt of an emergency health care service that the Enrollee’s condition
required the provision of such service, the service shall be presumed to have been
medically necessary and may be rebutted only if the utilization review entity establishes
through clear and convincing evidence that the emergency health care service was not
medically necessary.

C.5.144.8 The Contractor shall pay for treatment obtained when an Enrollee had an Emergency
Medical Condition, including cases in which the absence of immediate medical attention
would not have had the outcomes specified in 42 C.F.R. § 438.114(a) of the definition of
Emergency Medical Condition. The Contractor shall not retroactively deny a claim for
an emergency screening examination because the condition, which appeared to be an
Emergency Medical Condition under the “prudent layperson” standard, was in fact
nonemergency in nature. The Contractor may not require Prior Authorization for
Emergency Services. This applies to out-of-network, as well as to in-network services,
which an Enrollee seeks in an emergency.

C.5.144.9 Enrollee who has an Emergency Medical Condition may not be held liable for payment
of subsequent screening and treatment needed to diagnose the specific condition or
stabilize the Enrollee.

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C.5.144.10 The attending emergency physician, or the Provider actually treating the Enrollee, is
responsible for determining when the Enrollee is sufficiently stabilized for transfer or
discharge, and that determination is binding on Contractor.

C.5.144.11 The Contractor’s financial responsibility for post-stabilization care services it has not
preapproved ends when:

C.5.144.11.1 A Network Provider with privileges at the treating hospital assumes responsibility for
the Enrollee’s care;
C.5.144.11.2 A Network Provider assumes responsibility for the Enrollee’s care through transfer;
C.5.144.11.3 The Contractor’s representative and the treating physician reach an agreement
concerning the Enrollee’s care; or
C.5.144.11.4 The Enrollee is discharged.

C.5.144.12 A service is Medically Necessary if it relates to the treatment that the Enrollee was
receiving immediately prior to the Enrollee’s enrollment with the Contractor.

C.5.144.13 In the case of an Enrollee, regardless of age, who requires a health examination as a
condition of new or continuing employment, the health examination shall be considered
Medically Necessary.

C.5.144.14 Services related to screening, testing, diagnosis, counseling and treatment of HIV/AIDS
are Medically Necessary. The Contractor shall participate in the DC Health initiatives
regarding HIV/AIDS.

C.5.144.15 The Contractor shall comply with all District guidance, including all DHCF rules,
transmittals, and other guidance declared by the Mayor or city agencies throughout the
contract term.

C.5.145 Authorization Decisions

C.5.145.1 The Contractor’s CMO shall be responsible for overseeing the authorization decisions of
the UM program to ensure that decisions are based on all relevant medical,
environmental and psychosocial information available about the Enrollee and are in
accordance with evidence-based clinical practice standards promulgated by authoritative
national or international authorities.

C.5.145.2 Under 42 C.F.R. § 438.210(b), any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than requested, must be
made by an individual who has appropriate expertise in addressing the CASSIP
Enrollee's medical, behavioral health, or long-term services and supports needs.

C.5.145.3 The Contractor shall ensure authorization decisions that are denied are clearly identified
as constructive, adverse, administrative/technical, clinical and/or any other common
denial.

C.5.145.4 The UM staff shall notify Providers of occurrences of temporary or interim denials that
has the potential to be paid if the provider takes effective follow-up action or “reworks”
the denial. The Contractor shall establish procedures for reconsideration.
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C.5.145.5 The Contractor’s CMO shall be responsible for review of all denials of care based on
medical necessity (clinical denials).

C.5.145.6 The Contractor’s Chief Psychiatric Medical Officer shall review all denials of care for
Behavioral Health treatment services.

C.5.145.7 When making Authorization Decisions, Contractor’s CMO shall work in conjunction
with the Enrollee’s PCP or Specialist(s) and issue recommendations for alternative care
when appropriate.

C.5.145.8 Under 34 C.F.R. §§303.510 and 303.511, the Contractor shall be required to reimburse
OSSE if OSSE provides reimbursement for services in cases where medically necessary
IDEA-related services have been delayed due to lack of timely provision of services to
CASSIP Enrollees.

C.5.145.8.1 OSSE shall submit a claim to the Contractor for these services and the Contractor shall
be required to reimburse OSSE within thirty days of receipt of the claim.

C.5.145.9 The Contractor shall ensure that Providers provide immediate services for an Enrollee’s
Emergency Medical Condition, in accordance with the Provider’s license and scope of
practice. The Contractor’s policies and procedures shall specifically state that a Provider
is not required to verify an Enrollee’s eligibility when an Enrollee requests services for
an Emergency Medical Condition.

C.5.145.9.1 A utilization review entity may not revoke, limit, condition, or restrict approval if care is
provided within 45 business days from the date the Enrollee receives notice of the
approval; provided, that approval may be revoked or otherwise restricted in cases of
fraud.

C.5.145.10 If Contractor utilizes telephone triage, nurse lines or other demand management
systems, Contractor shall document the review and approval of qualification criteria for
staff and of clinical protocols or guidelines used in the system.

C.5.146 Authorization Decision Timeframes

C.5.146.1 The Contractor shall establish decision timeframes for:

C.5.146.1.1 Urgent Concurrent review;
C.5.146.1.2 Urgent Expedited Pre-service review;
C.5.146.1.3 Standard non-urgent pre-service review; and
C.5.146.1.4 Post-service authorization decisions.

C.5.146.2 The Contractor shall establish decision timeframes following 42 C.F.R. § 438.210(d),
the District of Columbia’s Prior Authorization Reform Amendment Act of 2023, and
NCQA Standards and Guidelines for the Accreditation of Health Plans. These
timeframes shall incorporate the following standards:

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C.5.146.2.1 For urgent concurrent authorization decisions, as expeditiously as the Enrollee’s health
condition requires and no later than 72 hours of receipt by the Contractor for the request
for service;
C.5.146.2.2 For Urgent Expedited Pre-service Authorization decisions, as expeditiously as the
Enrollee’s health condition requires and within 24 hours of receipt by the Contractor for
the request for service, with a possible extension of up to 14 days, if:

C.5.146.2.2.1 The Enrollee or the Provider requests an extension; or
C.5.146.2.2.2 The Contractor justifies to DHCF a need for additional information and how the
extension is in the Enrollee’s interest.

C.5.146.3 For Standard non-urgent pre-service authorization decisions, as expeditiously as the
Enrollee’s health condition requires and within three business days of the Contractor
receiving an electronic submission or five business days if the Contractor receives the
submission via mail, telephone, or fax. DHCF, may grant an extension of up to fourteen
days, if:

C.5.146.3.1 The Enrollee or the Provider requests an extension; or
C.5.146.3.2 The Contractor shall justify to DHCF a need for additional information and demonstrate
the extension is to the Enrollee’s interest.

C.5.146.4 For post-service authorization decisions, as expeditiously as the Enrollee’s health
condition requires and no later than fourteen days of receipt of the request for service,
with a possible extension of up to fourteen days by DHCF, if:

C.5.146.4.1 The Enrollee or the Provider requests an extension; or
C.5.146.4.2 The Contractor justifies to DHCF a need for additional information and demonstrates
that the extension is in the Enrollee’s interest.

C.5.147 Authorization Decision Notifications

C.5.147.1 The Contractor’s authorization decisions shall be communicated orally to the Provider
who requested the authorization within twenty-four hours of the decision.

C.5.147.1.1 Prior to issuing an adverse determination, the utilization review entity shall notify the
Enrollee’s health care provider that the medical necessity of the health care service is
being questioned and give the responsible physician an opportunity to provide additional
information or clarification on the medical necessity of the health care service.

C.5.147.2 Within the timeframes established by DHCF, following 42 C.F.R. § 438.404, the
Contractor shall give the Enrollee and requesting Provider written and oral notice of any
Adverse Benefit Determination.

C.5.147.3 The qualifications of the individual making the determination, includes:

C.5.147.3.1 States in which the individual is licensed; and
C.5.147.3.2 Medical specialty

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C.5.148 Second Opinions

The Contractor shall, upon Enrollee request, provide Enrollee the opportunity to have a
second opinion from a network provider. If a qualified network provider is not available,
Contractor shall arrange for the Enrollee to obtain one outside the network, at no cost to
the Enrollee per 42 C.F.R. § 438.206(b).

C.5.149 Authorization of Signed IFSP

Authorization procedures shall be coordinated with Enrollee’s other service needs,
including but not limited to IDEA service planning procedures, to facilitate authorization
of Medically Necessary IDEA services upon receipt of an approved IFSP.

C.5.150 Care Management

C.5.150.1 Enrollment in CASSIP is made with the understanding that health care services are
provided by way of a care management model of service delivery.

C.5.150.2 The Contractor shall operate a specialized, flexible and efficient Care Management
system for managing quality health care, to meet the needs/preferences of the Enrollees,
and to support the most efficient use of services through Care Coordination and Case
Management activities for all CASSIP Enrollees. The Contractor shall collect
information from the Enrollees or Enrollee representatives to guide the delivery of safe,
person-centered, value-based care, as evidenced by improved health outcomes.

C.5.150.3 Under 42 C.F.R. §438.208 and 42 C.F.R. §440.169, the Contractor shall:

C.5.150.3.1 Ensure that each Enrollee has an ongoing source of care appropriate to his or her needs
and a person or entity formally designated as primarily responsible for coordinating
services. The Contractor shall provide information to the Enrollee on how the Enrollee
can contact his/her designated person or entity responsible for coordinating care; and

C.5.150.3.2 Coordinate the services the Contractor furnishes to the Enrollee:

C.5.150.3.2.1 Between settings of care, including appropriate discharge planning for short-term
and long-term hospital and institutional stays;
C.5.150.3.2.2 With the services the Enrollee receives from any other Contractor;
C.5.150.3.2.3 With the services the Enrollee receives in FFS Medicaid; and
C.5.150.3.2.4 With the services the Enrollee receives from community and social support
providers.

C.5.151 Transitional Period

C.5.151.1 Within thirty days of award of the Contract, the Contractor shall submit a written
Care Management program description and implementation plan for approval. The
Contractor shall review and evaluate the program annually and submit the evaluation to
DHCF annually.

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C.5.151.2 The Contractor shall ensure that an Enrollee receiving on-going treatment at the time of
CASSIP enrollment may choose to continue this treatment until the course of therapy is
concluded with his/her existing Provider, regardless of whether this Provider is in the
Contractor’s Provider Network.

C.5.151.3 The Contractor shall notify the District of an Enrollee’s request to continue cancer
therapy treatment with a Non-Network Provider within five Business days of the
Contractor receiving Enrollee’s request.

C.5.151.4 The Contractor shall develop policies and procedures for transition within between
acuities, pediatric to adult care providers, into specialty care management, if warranted
and program disenrollment and include them in the Contractor’s Care Management
Program Description, Implementation Plan, and Evaluation. Such policies must also
address adult Enrollees that transfers to a Health Home.

C.5.152 Initial Screening & Assessment

C.5.152.1 In accordance with 42 C.F.R. § 438.208 the Contractor shall implement mechanisms to
comprehensively assess each Enrollee identified by the District or the Contractor as
needing LTSS or having special health care needs to identify any ongoing special
conditions of the Enrollee that require a course of treatment or regular care monitoring.
The assessment mechanisms must use appropriate providers or individuals meeting
LTSS service coordination requirements as appropriate.

C.5.152.2 The Contractor shall conduct a comprehensive assessment and a face-to-face
intervention of all CASSIP Enrollees identified within sixty (60) days of enrollment to
determine acuity. Assessments and face-to-face interventions shall be conducted by
licensed professionals as described in C.5.154.

C.5.152.3 After the initial assessment, the Contractor shall conduct face-to-face interventions as
required to assist Enrollees in reaching the Enrollee’s defined goals. Face-to-face
frequency shall be included in the Enrollees Care Plan and shall occur in accordance to
section C.5.163.

C.5.152.4 Following Initial Assessment, the Contractor shall, in consultation with Enrollee and the
Enrollee’s Natural Supports, Other District Agencies, Providers, and Community
Support Organizations (if applicable), develop and implement a Care Plan to begin no
later than the last day of the Transitional Period, if applicable.

C.5.152.5 The Contractor shall make subsequent attempts to conduct an initial screening of each
enrollee's needs if the initial attempt to contact the enrollee is unsuccessful. In addition,
unsuccessful attempts to conduct a comprehensive assessment shall be documented in
the Enrollee’s Care Plan and describe the Contractor’s strategy for engagement:

C.5.152.5.1 Share with the DHCF, Other District Agencies, Providers or other Contractors serving
the Enrollee, the results of any identification and assessment of that Enrollee’s needs to
prevent duplication of efforts.

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C.5.152.5.2 Ensure that each Provider furnishing services to Enrollees maintains and shares, as
appropriate, an Enrollee health record in accordance with professional standards to a
healthcare provider; and

C.5.152.5.3 Ensure that, in the process of coordinating care, each Enrollee’s privacy is protected in
accordance with the privacy requirements in 45 C.F.R. parts 160 and 164 subparts A and
E, to the extent that they are applicable.

C.5.152.6 Under 42 C.F.R. § 438.62, the Contractor shall develop policies and procedures, as well
as a transition of care policy, consistent with the District’s Transition of Care Policy
(Attachment J.32, DC Medicaid Care Quality Strategy) for the coordination and
continuity of care of the Enrollees.

C.5.153 Care Management and Care Coordination Program Design

C.5.153.1 The Care Management program shall be a tiered model, based on acuity, designed to
address the diversity and range of Enrollees’ health care needs based on a stratification
methodology that has been approved by the DHCF.

C.5.153.1.1 The stratification methodology shall minimally include variables predicting high cost,
high utilization, clinical pathways and high social risk factors. At least one tier must be
designed for Enrollees at the highest risk for poor health outcomes (“High Acuity/Level
Three”).

C.5.153.2 The Contractor shall develop a Comprehensive Care Management program which assess
Enrollee’s physical and Behavioral Health status including cognitive functioning and
condition-specific issues; utilization patterns; clinical history; activities of daily living;
life planning; evaluation of cultural & linguistic needs, preferences or limitations; and
caregiver resources and natural community supports.

C.5.153.3 The Contractor shall develop a Complex Case Management program in accordance with
the most recent NCQA Complex Case Management Standards and Guidelines for Health
Plan Accreditation.

C.5.153.4 The Contractor shall identify high-cost and high-risk Enrollees utilizing predictive
modeling or similar software or through development of internal criteria. Prior to
implementation, internally developed criteria shall be submitted to the DHCF for
approval.

C.5.153.5 The Contractor shall educate all participating Enrollees in self-care strategies, illness
prevention, health education and wellness activities.

C.5.153.6 The Contractor shall specifically tailor the program to offer a range of Care Management
activities to improve the health outcomes of each participating CASSIP Enrollee. The
frequency and intensity of interventions, and staff assigned to the Enrollee shall vary
based on each Enrollee’s particular needs.

C.5.153.7 The Contractor shall leverage data available through the District’s Designated HIE, in
conjunction with its internal systems, to identify high-cost and high-risk Enrollees. The
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Contractor shall develop and implement targeted care coordination and case
management strategies based on this data and submit an annual report to the Department
describing the population health methodologies and outcomes achieved.

C.5.153.8 The Contractor shall use the DC HIE to support transitions of care, including discharge
planning, care continuity, and timely follow-up using Admissions, Discharge and
transfers (ADT) data from the DC HIE.

C.5.154 Care Coordination and Case Management Staff

C.5.154.1 The Contractor shall establish a Care Management department located in the District,
under the leadership of a Manager with a LICSW, RN, or MD licensure in the District.

C.5.154.2 The Contractor’s Care Management Program shall identify a formal process for the
selection of a Care Manager who shall be designated as primarily responsible for
coordinating the services of Enrollees assigned to their caseload and how the Care
Management task are allocated.

C.5.154.3 For Enrollees that are Level Two , Three or Level Three , the Contractor shall assign a
RN or a Licensed Independent Clinical Social Worker (LICSW) as the primary care
manager, who may oversee a multidisciplinary Care Coordination team. These
individuals (RN, LICSW) must be licensed in the District of Columbia.

C.5.154.4 RESERVED

C.5.154.5 The Contractor shall designate at least one full -time Care Manager to work with
enrollees eligible for DC Medicaid through the TEFRA/Katie Beckett eligibility option.
The Care Manager can be a LICSW, or RN that is licensed in the District.

C.5.154.6 For all other CASSIP enrollees, the Contractor shall assign a Care Manager Associate
for Care Coordinator with one of the following District licensure types:

C.5.154.6.1 Licensed Graduate Professional Counselor (LGPC);
C.5.154.6.2 Licensed Professional Counselor (LPC);
C.5.154.6.3 Licensed Graduate Social Worker (LGSW);
C.5.154.6.4 Licensed Social Worker (LSW);
C.5.154.6.5 License Clinical Social Worker (LCSW);
C.5.154.6.6 Licensed Practical Nurse (LPN); or
C.5.154.6.7 Licensed Speech Language Pathologist (SLP).

C.5.154.7 The Contractor shall implement an electronic system to track, profile, report, and
manage all CASSIP Enrollees. The system shall track assessment completion, Care
Plans, ongoing interventions, including telephonic, face-to-face visits, e-mail, text, and
mail contact among the Care Manager, the Enrollee, and the Provider.

C.5.155 Care Management Staffing Based on Acuity

C.5.155.1 All Care Management staffers shall have a case load that reflects the acuity of each
Enrollee’s condition, the needs of the family, with the following stratification:
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C.5.155.1.1 Acuity Level One shall have no more than 100 CASSIP Enrollees assigned to a Care
Manager Associate or Care Coordinator (non-licensed), at any time, as outlined in
C.5.154.6.

C.5.155.1.2 Acuity Level Two shall have no more than 75 CASSIP Enrollees assigned to a Care
Manager, at any time as outlined in C.5.154.3.

C.5.155.1.3 Acuity Level Three shall have no more than 60 CASSIP Enrollees assigned to a Care
Manager at any time as outlined in C.5.154.3.

C.5.155.1.4 Acuity Level Three shall have no more than 60 CASSIP Enrollees assigned to a Care
Manager at any time; as outlined in C.5.154.3. To maximize the caseload of 60; Level
three Care Managers may be assigned Level One , and Level Two cases to reach the
maximum caseload.

C.5.155.1.5 Based on this stratification method, weighted, or combined caseload assignments of
mixed acuity of only Level One and Level Two cannot exceed 75 total per licensed Care
Manager.

C.5.155.1.5.1 Care Coordinators (unlicensed) staff may assist the Care Managers in administrative,
non-clinical care coordination needs and activities for a maximum of 300 Enrollees.

C.5.155.1.6 The Contractor shall not change its stratification and/or acuity assessment method(s)
without prior review and approval from DHCF.

C.5.155.1.7 The Contractor shall provide non-licensed staff to assist licensed Care Managers with
non-clinical care coordination and case management activities. Non-licensed support
staff such as the Care Manager Associates and Care Coordinators, shall be closely
supervised by the Care Managers, following the governing District laws, regulations,
and respective Board Licensing guidance in the District.

C.5.155.1.8 The Care Managers assigned to CFSA, DC Courts (DYRS/CSOSA) and TEFRA/Katie
Beckett cases shall be assigned one specialty-caseload category. These Care Managers
shall be designated to specialize in this specific population because of the high intensity
of medical/behavioral/social needs and services associated with involvement in those
District or Federal Agencies. These Care Managers may be assigned other non-specialty
(Level 1 and/or 2) cases to maximize their caseload; not to exceed 75.

C.5.155.1.9 If the Contractor allows the maximum care manager caseload to increase beyond the
designated limit(s), without the prior approval of DHCF, the Contractor shall be subject
to corrective action. Contractor shall make every reasonable and concerted effort to keep
caseloads manageable, so Enrollee care coordination and care management needs are
effectively and timely met without compromising quality.

C.5.155.1.10 The Care Managers assigned Specialty cases shall adhere to the following:

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C.5.155.1.10.1 At a minimum, shall be assigned to acuity level 2. The caseloads shall not exceed 75
and may be combined with any other non-specialty cases of acuity Level 1 and/or 2;
and

C.5.155.1.10.2 Specialty caseloads for Enrollees include:

C.5.155.1.10.2.1 Designated CFSA
C.5.155.1.10.2.2 Designated DC Courts (DYRS and CSOSA)
C.5.155.1.10.2.3 Designated TEFRA/Katie Beckett

C.5.156 Other Care Management Requirements

C.5.156.1 The Contractor shall implement a Provider portal or similar mechanism to enable timely
and easy sharing of Care Management activities between Providers serving CASSIP
Enrollees. This information sharing shall be implemented following HIPAA and 42
C.F.R Part II privacy and confidentiality safeguards.

C.5.156.2 The Contractor shall conduct Care Management Program Enrollee and Provider
satisfaction surveys, at least annually. Results shall be included in the annual program
evaluation provided to DHCF. The Contractor shall provide summaries of customer
satisfaction surveys following the requirements found at 42 C.F.R. §438.66 (c).

C.5.156.3 The Contractor shall implement the Care Management Program under the leadership of
a multidisciplinary medical and Behavioral Health team that includes a diverse staff with
the appropriate skills to deliver clinical and non-clinical components of the program,
including the engagement of Enrollees into the program.

C.5.157 Social Determinants of Health (SDOH)

C.5.157.1 The Contractor shall assess each CASSIP Enrollee upon enrollment to identify social
factors impacting their health and overall wellbeing. At a minimum, the Contractor
shall:

C.5.157.1.1 Establish policies and procedures, including timeliness for completion and other
resources to identify and comprehensively address SDOH or health-related social
factors. This includes assessing for any unique factors that may have a greater impact on
children and youth with special health care needs;
C.5.157.1.2 Screen for and address SDOH or health-related social factors through community
referrals, peer navigation support and other innovative strategies;
C.5.157.1.3 The Contractor shall share social needs screening and referral data with the DC HIE in a
structured format consistent with the HIE’s technical and privacy requirements;
C.5.157.1.4 Incorporate SDOH screening and/or assessment into Comprehensive Assessment and
Care Planning protocols; and
C.5.157.1.5 Focus on health outcomes and report on social factors in a format and frequency as
determined by the DHCF.

C.5.157.2 The Contractor shall use District information systems and tools as specified by the
DHCF to each screen Enrollees for SDOH or health-related social factors.

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C.5.157.3 The Contractor shall participate in District initiatives that promote opportunities to
collaboratively or independently address SDOH or health-related social factors to
provide person centered care.

C.5.157.4 The Contractor shall ensure appropriate Contractor and sub-contractor staff, and
network providers receive training on proper social needs screening documentation and
referral processes.

C.5.158 SSI/SSI Related Benefits Coordination

C.5.158.1 The Contractor shall designate at least one full -time staff person to coordinate benefits
under SSI/SSI Related eligibility categories.

C.5.158.2 The Benefits Coordinator shall minimally:

C.5.158.2.1 Assist Enrollees with the re-application and appeal processes for termination or denial of
SSI benefits as applicable;
C.5.158.2.2 Assist Enrollees with the Medicaid re-certification application process for disability
determination for the SSI Related eligibility category;
C.5.158.2.3 Assist Enrollees requiring assistance with initial SSI applications; and
C.5.158.2.4 Establish and maintain a positive working relationship with parents of minor Enrollees,
transitional aged Enrollees, SSA, attorneys, and the DHCF CA, to best support
Enrollee’s in their application for benefits and application requirements are met and
submitted timely.

C.5.158.3 Have at least three years’ experience assisting D.C. residents with applying for federal
and/or local entitlement benefits, social services, and/or human services.

C.5.158.4 The Contractor shall provide a quarterly report to DHCF on the number of:

C.5.158.4.1 Enrollees requiring assistance with initial SSI applications;
C.5.158.4.2 Enrollees requiring assistance with re-application for denied or terminated SSI or
Medicaid benefits;
C.5.158.4.3 Care coordination and/or outreach efforts/strategies used to assist Enrollees or
parent/caregivers to obtain benefits; and
C.5.158.4.4 Outcomes of all SSI related activities.

C.5.159 Identification and Engagement

C.5.159.1 Screening

C.5.159.1.1 The Contractor shall conduct an initial screening of each Enrollee’s physical, behavioral
and SDOH needs.

C.5.159.1.2 DHCF reserves the right to specify or limit which screening tool or questionnaire(s) the
Contractor shall be required to use for the initial screening.

C.5.159.1.3 The Contractor shall develop policies and procedures for the successful Outreach and
Engagement of Enrollees; this must include document all outreach attempts.
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C.5.159.1.4 The Contractor shall accept referrals for assistance and/or community-based referrals
from the Contractor’s staff, District agencies, Enrollees, other Providers, hospital
discharge planners, Network Providers, or other knowledgeable sources to support
Enrollees who are in need of coordination and/or community-based referrals. The
Contractor shall follow-up with the referring source within thirty days on the status of
the Enrollee’s referral and shall continue follow up activities until the referral is closed.

C.5.160 Care Plan Development, Implementation and Monitoring

C.5.160.1 The Contractor shall establish policies and procedures that define the requirements of
Enrollee Care Plans. The Care Plan shall specify goals agreed to by the Enrollee,
Enrollee’s family, the Enrollee’s PCP and Contractor, Medically Necessary Services,
behavioral health and substance abuse services if the Enrollee has consented to share
this information with the PCP and/or other Specialists, any support services necessary to
carry out or maintain the Care Plan, and planned Care activities.

C.5.160.2 The Contractor shall develop a specific individualized Care Plan based on the
information collected through an assessment of the Enrollee and at a minimum, shall
include the following:

C.5.160.2.1 Specifies the long and short-term goals with specific timelines and a course of action
required to manage the medical, behavioral, social, educational complexities of the
Enrollee’s health condition(s);
C.5.160.2.2 Evidence that Enrollee’s care is well coordinated and integrated with related services
provided by other District or District-Certified agencies, as applicable, such as DBH,
DCPS, OSSE, DDS, DYRS, CFSA, DC Health, Core Service Agencies (CSA), ASURS
Providers, and that continuity of care is safeguarded;
C.5.160.2.3 Consideration of the cultural values and the communication needs and preferences of the
Enrollee;
C.5.160.2.4 Activities ensuring the active participation of the Enrollee and working with Providers
(or the individual’s authorized health care decision maker) and others to develop these
goals; and
C.5.160.2.5 Refer and link the Enrollee with other programs and services (such as completing
referral forms) that are capable of providing services to address identified needs and
achieve goals that are specified in the Care Plan.

C.5.160.3 The Contractor shall identify Enrollees for whom Crisis Planning, and Advance
Directives are appropriate.

C.5.160.4 The Complete Advanced Directives are indicated, per section C.5.136. For such
Enrollees, the Care Plan shall include a plan for prevention and management of crises
that maintains health and safety, promotes maximum continuity of care, and maximizes
the least restrictive environment.

C.5.160.4.1 The Contractor shall inform Enrollees of their right to establish Advance Directives and
incorporate these Advance Directives into their Crisis Plan.

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C.5.160.5 The Contractor’s Care Managers shall work with the Enrollee, Enrollee’s representative,
and the PCP to plan care management activities. These activities shall be included in the
Care Plan:

C.5.160.5.1 Assessment of progress toward meeting established Care Plan goals;
C.5.160.5.2 Identification of barriers to meeting goals and consideration of the Enrollee’s ability to
adhere to the Care Plan;
C.5.160.5.3 Development and communication of self-management and wellness plans for Enrollees;
and
C.5.160.5.4 Behavioral Health Crisis Prevention Plan, as appropriate.

C.5.160.6 When an Enrollee’s Care Plan includes multiple services inside or outside the
Contractor’s Network, the Contractor shall establish policies and procedures for
effective communication and collaboration between Network Providers and other
Medicaid Providers inside or outside of Contractor’s Network, Contractor’s Care
Management staff (s), and non-Medicaid Providers.

C.5.160.7 The Contractor’s Case Management program may include contacts with non-
beneficiaries that are directly related to the Enrollee’s needs and care, for the purpose of
helping the Enrollee access services, identify needs and supports to assist the Enrollee in
obtaining services, provide Case Managers with useful feedback including alerts to
changes in the Enrollee’s needs.

C.5.160.8 The Contractor shall provide the Enrollee with an opportunity to sign the Care Plan
goals and activities prior to implementation of such plan and document such agreement.
Contractor is also responsible for documenting any Enrollee’s refusal to sign the Care
Plan and the Contractor’s effort to remediate any such issues.

C.5.160.9 The Contractor shall perform periodic assessments and other monitoring activities, as
indicated in the Care Plan, to determine the Enrollee’s progress toward goals, to reassess
his/her health status, and to update the Care Plan as necessary, and as the Enrollee’s care
needs change. Assessments and Care Plan updates shall minimally occur following
section C.5.160 and C.5.161 and shall determine whether the following conditions are
met:

C.5.160.9.1 Providers are furnishing services in accordance with the Enrollee’s Care Plan;
C.5.160.9.2 There are no identified gaps in care;
C.5.160.9.3 Services in the Care Plan are adequate; and
C.5.160.9.4 There are changes in the needs or status of the Enrollee.

C.5.160.10 The Contractor shall monitor and make necessary adjustments to the Care Plan and
service arrangements with Providers.

C.5.160.11 The Contractor shall make a good faith effort to include relevant District and Federal
agencies (i.e. DC Health, DDS, CFSA, OSSE, DBH, DCPS, DYRS. CSOSA) to
participate in Team Care planning and shall provide documentation of such effort in the
Enrollee’s Care Plan and other records.

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C.5.160.12 When the Enrollee is also under the custody of DYRS, DC Court System or CFSA,
Contractor shall invite a representative from the agency to participate in all aspects of
the Enrollee’s Care Planning, upon receipt and documentation of the appropriate
consent(s) or court order.

C.5.161 Care Plans Based on Acuity

C.5.161.1 After the development of the initial Care Plan the Contractor shall revise and update the
Care Plan as follows:

C.5.161.1.1 Acuity Level One will have at least one (l) assessment and revision/update of their Care
Plan per year. The Care Plan may need to be updated, more frequently, if warranted, due
to a change in the Enrollee’s medical status, Enrollee request, custody status or other
impacting circumstances.

C.5.161.1.2 Acuity Level Two will have at least two assessments and revisions/updates of the Care
Plan per year. The Care Plan may need to be updated, more frequently, if warranted, due
to a change in the Enrollee’s medical status, Enrollee request, custody status or other
impacting circumstances.

C.5.161.1.3 Acuity Level Three will have at least three assessments and revisions/updates of the
Care Plan per year. The Care Plan may need to be updated, more frequently, if
warranted, due to a change in the enrollee’s medical status, enrollee request, custody
status or other impacting circumstances.

C.5.161.1.4 Specialty Cases (CFSA, DYRS/CSOA and Katie Beckett) shall have at least two
assessments and revisions/updates of the Care Plan per year. The Care Plan may need to
be updated, more frequently, if warranted, due to a change in the Enrollee’s medical
status, Enrollee request, custody status or other impacting circumstances.

C.5.162 Ongoing Care Management Activities

C.5.162.1 The Contractor shall, at a minimum, conduct the following ongoing Care Coordination
and Care Management activities:

C.5.162.1.1 Assist in the development of an appropriate discharge plan prior to an Enrollee’s
hospital discharge or change in treatment setting, in coordination with appropriate staff,
the Enrollee’s PCP, and other Network Providers, as applicable. The Contractor’s Care
Manager shall be present at discharge planning meetings;
C.5.162.1.2 Schedule home visits and face-to-face contacts with Enrollees; and
C.5.162.1.3 Initiate activities, as indicated in the Care Plan, to ensure Enrollee’s timely and
coordinated access to primary, medical specialty, Behavioral Health care and social
needs, such as:

C.5.162.1.3.1 Reinforcement of PCP, specialists, or Network Provider instructions;
C.5.162.1.3.2 Assistance in scheduling appointments;
C.5.162.1.3.3 Well-visit and preventive care reminders;
C.5.162.1.3.4 Follow-up reminders of medical and Behavioral Health appointments and
confirming with the Enrollee that appointments have been kept;
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C.5.162.1.3.5 Referrals to community and social services;
C.5.162.1.3.6 Wellness activities (e.g., smoking cessation, weight loss,); and
C.5.162.1.3.7 Confirmation with Enrollees that they are adhering to medication recommendations
and any alternatives to recommendations.

C.5.162.2 The Contractor shall initiate activities, as indicated in the Care Plan, related to clinical
management to ensure:

C.5.162.2.1 Medication review and reconciliation;
C.5.162.2.2 Communication with other treating Providers and other supports identified by the
Enrollee;
C.5.162.2.3 Care transition planning;
C.5.162.2.4 Education of Enrollee on self-management of chronic conditions;
C.5.162.2.5 Facilitate communication among the Enrollee, the PCP, the Network Provider and other
specialty Providers, and the Enrollee’s support network, as identified by the Enrollee,
who are involved in the Enrollee’s health care, to promote service delivery coordination
and improved outcomes;
C.5.162.2.6 Collaboration with staff in other District agencies, community service organizations and
Providers who are currently involved in meeting the Enrollee’s needs or who may be
helpful in meeting those needs;
C.5.162.2.7 Monitor and track acknowledgment of receipt of the Care Plan by the Enrollee’s PCP;
C.5.162.2.8 Monitor medical and pharmacy utilization for Enrollee through claims data and
appropriately update the Care Plan and/or coordinate follow-up care, as indicated
through data the Contractor receives; and
C.5.162.2.9 Document activities related to the provision of Care Coordination and Case
Management to Enrollees and share progress reports with care team, with appropriate
consent from the Enrollee, if required.

C.5.163 Face-to-Face Visits

C.5.163.1 All CASSIP Enrollees are expected to have face-to-face visits with their assigned Care
Manager or a member of their Care Management team, as an integral part of Care
Management. Face -to -face visits may be conducted in-person or with the assistance of
a secure virtual video platform. The type of face-to-face encounter is based on the
Enrollee’s needs, preference and access.

C.5.163.2 The Contractor shall use all commercially responsible approaches, including, but not
limited to, telephonic communications, print communications, emergency contacts,
outreach team, all parties involved with the care coordination process (Providers, CFSA,
DYRS, DDS, DBH) to help make and facilitate face-to-face visits at the Enrollee’s
home and/or other community, educational or treatment setting.

C.5.163.3 If an Enrollee or their parent/caregiver refuses the face-to-face visits, the Care Manager
shall offer to have visits in the least restrictive environment for the Enrollee and
parent/caregiver, including but not limited to a secure virtual video platform, community
where the parent resides (e.g., school, library, relatives’ home or daycare center) with
the parent/caregiver’s or Enrollee’s consent.

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C.5.163.4 Parent/caregiver refusals shall be documented and submitted to the Supervisor for
review and guidance on next steps to assist the Enrollee and parent/caregivers.

C.5.163.5 Arrangements to have face to face visits with Enrollees under the care and custody of
CFSA, DYRS, and DDS shall be made between the Contractor, Enrollee (as applicable),
the District agency, parent, and court, if appropriate.

C.5.163.6 The Contractor shall make concerted and deliberate efforts to conduct face to face visits
in accordance with acuity level, so the impact of the enrollee’s environment, social
determinants of health, or other factors that are relevant to the health status of the
Enrollee, can be assessed for development of the care plan.

C.5.163.7 The Contractor shall conduct Face to Face visits as follows:

C.5.163.7.1 Acuity Level One will have at least one Face -to -Face visit per year, or more, if
warranted by a change in their medical status, Enrollee request, or custody status.

C.5.163.7.2 Acuity Level Two will have at least two Face -to -Face visits per year, or more, if
warranted by a change in their medical status, Enrollee request, or custody status.

C.5.163.7.3 Acuity Level Three will have at least three Face -to -Face visits per year, or more, if
warranted by a change in their medical status, Enrollee request, or custody status.

C.5.163.7.4 Specialty cases shall have at least three Face-to-Face visits per year, or more, if
warranted by a change in their medical status, Enrollee request, or custody status.
Visiting arrangements must be carefully coordinated with the District agencies,
attorneys, if involved, parents/caregivers and Care Managers.

C.5.164 Care Management Staff Training

C.5.164.1 The Contractor shall develop and implement a comprehensive training program for Care
Management staff. Contractor shall submit training modules, schedules, and evidence of
staff development meetings annually and upon request to DHCF for review.

C.5.164.2 Topics shall at a minimum, consist of:

C.5.164.2.1 Orientation to the Contractor’s Organization (policies/procedures/services), community
resources;
C.5.164.2.2 District Government Agencies, the services provided by these agencies and how the
Contractor interacts with such Agencies (DBH, DCPS, OSSE, DDS, ESA, DHCF,
CFSA, DYRS, DC Court system, etc.);
C.5.164.2.3 Community outreach and networking;
C.5.164.2.4 SSI disability determination process;
C.5.164.2.5 Developmental disabilities;
C.5.164.2.6 DSM-V or the most up to date version of the DSM;
C.5.164.2.7 SDOH and psychosocial factors impacting illness;
C.5.164.2.8 CFSA Mandated Reported Training;
C.5.164.2.9 Care Plan compliance;
C.5.164.2.10 Clinical and administrative documentation of work;
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C.5.164.2.11 Case Reviews and presentations; and
C.5.164.2.12 Working effectively with parents and caregivers of special needs children.

C.5.164.3 The Contractor shall provide training opportunities for Care Managers to earn
continuing education credits to be used towards professional licensure renewal.

C.5.165 Care Management Supervision

C.5.165.1 The Contractor shall develop and implement a comprehensive supervision program for
Care Management.

C.5.165.2 The Contractor shall submit to DHCF within 45 days of Contract Award, and upon
request, its roster of Care Management Supervisors to include areas of responsibility and
contact information; supervision organizational chart for care management and care
coordination. Contractor shall present its process, methods and tools used to supervise
and evaluate the work of Care Managers.

C.5.165.3 The Contractor shall develop, implement, and maintain a system of accountability for
monitoring and verifying Care Manager’s work schedule on field days and in the office.

C.5.165.4 The Case Management supervision plan shall be submitted to DHCF annually. Any
major systemic changes to the plan shall be submitted to DHCF for review, prior to
implementation.

C.5.165.5 The Contractor shall submit to DHCF, upon request, its roster of Care Management
staff, to include contact information for Case Managers.

C.5.166 Disease Management Program

C.5.166.1 The Contractor shall have in place a specialized Disease Management Program that is
detected and Provider incentive arrangements to encourage early identification among
Enrollees. integrates the use of appropriate treatment guidelines for use when a disease.

C.5.166.2 The Contractor shall have in place a Disease Management Program that addresses the
CASSIP population’s top behavioral health diagnoses and a minimum of two of the
following conditions:

C.5.166.2.1 Autism;
C.5.166.2.2 Depression;
C.5.166.2.3 HIV/AIDS;
C.5.166.2.4 Pediatric asthma;
C.5.166.2.5 Substance Use Disorder; and
C.5.166.2.6 Obesity and malnutrition in children and adolescents.

C.5.166.3 The Contractor’s Disease Management Program shall be consistent with components as
defined by the Disease Management Association of America. The Contractor shall
develop this Disease Management Program to enhance the quality of care and access to
services for CASSIP Enrollees. A Disease Management Program Plan shall be submitted
to DHCF annually.
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C.5.167 Transition Services

C.5.167.1 Transition for Enrollees Aging out of CASSIP

C.5.167.1.1 As part of its Care Management Program, Contractor shall establish a Transitions
Program that shall encompass, at a minimum, the following:

C.5.167.1.1.1 A formal set of Care Management practice guidelines for managing young adults
with special health care needs;
C.5.167.1.1.2 Written policies and procedures that describe expected outcomes for enrollees aging
out of the CASSIP population and goals of the Transition Program;
C.5.167.1.1.3 Identification of staff who are responsible for implementing Transition Program
activities; and
C.5.167.1.1.4 Workflows for referring enrollees into a District waiver program.

C.5.167.2 The Contractor shall identify Enrollees at least two years before they are scheduled to
age out of CASSIP to allow sufficient time to develop a comprehensive Transition Plan
to the District’s Managed Care program. The Contractor shall have protocols for this
transition relating, but not limited to, the following:

C.5.167.2.1 The Contractor shall perform transition related assessment and/or reassessment for each
enrollee scheduled to age out of CASSIP, at least twice per year.

C.5.167.2.2 The Contractor shall conduct as many face to face visits as necessary but shall perform
at least two transition related face to face visits per year for each Enrollee scheduled to
age out of CASSIP.

C.5.167.2.3 For enrollees assessed at Level Three/High Acuity, assigned to a Specialty Caseload, or
are identified by DHCF, the Contractor shall perform activities following Section
C.5.150.

C.5.167.2.4 The Contractor shall develop Transition Care Coordination Plans per Section C.5.167.

C.5.167.2.5 The Care Management supervisors shall closely monitor the Transition Care Plan and
Care Management activities and protocols to provide support, guidance and directives as
required.

C.5.167.2.6 The Contractor shall document this Transition Period Care Plan in the Enrollee’s
electronic health record.

C.5.167.2.7 For Enrollees scheduled to age out of CASSIP, all Transition Care Plans shall be
reviewed for comprehensive planning and implementation, appropriateness for the
Enrollee’s health care and/or social service needs and approved and signed off by a Care
Management supervisor.

C.5.167.2.8 Transition Care Plans shall be submitted to DHCF upon request.

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C.5.167.3 The Contractor shall assist the Enrollee in identifying services, locating sources of
support, and arranging for services to address the enrollee’s SDOH prior to the
Enrollee’s disenrollment from CASSIP. Contractor is responsible for documentation of
efforts in the enrollee’s electronic health record with consideration of the:

C.5.167.3.1 D.C. Department of Human Services programs, including but not limited to Child Care
Services, Emergency Rental Assistance, Emergency Shelter, Family Services and
Homeless Services;
C.5.167.3.2 D.C. Rise Center;
C.5.167.3.3 D.C. Office on Community Living and Aging; and
C.5.167.3.4 Other District and Community Based Organizations, as appropriate.

C.5.167.4 The Contractor shall identify enrollees receiving on-going treatment for chronic
conditions including chemotherapy, radiation, dialysis, oral/dental or inpatient substance
use disorder treatment 45 days prior to the enrollee’s disenrollment via a Monthly
Report that minimally details:

C.5.167.4.1 Enrollees who have a chronic condition for which they are in continuous course of
treatment that extends beyond the person’s enrollment in CASSIP;
C.5.167.4.2 Have applied for enrollment into the DC Medicaid’s EPD Waiver program or DDS’
IDD Waiver program prior to disenrollment;
C.5.167.4.3 Are within a current course of treatment with a non-network provider that is scheduled
to continue after an enrollee’s disenrollment from CASSIP;
C.5.167.4.4 Have requested to continue cancer therapy with a non-network provider;
C.5.167.4.5 Have been authorized for non-emergency ambulance transport within the last sixty (60)
days;
C.5.167.4.6 Have been and identified by the Contractor as high risk/high cost; and
C.5.167.4.7 Have been identified by Contractor as needing immediate coordination needs at the time
of transition from CASSIP.

C.5.168 Transitions between Programs, Acuity/Specialty, or Levels of Care

C.5.168.1 The Contractor shall assist and develop a Transition Plan for Enrollees transitioning
from EI Part C to Part B; Enrollees transferring in or out of acute care facilities, LTCs,
PRTFs, or other institutional care; and Enrollees entering or exiting the custody of
CFSA or DYRS.

C.5.168.2 Transition Plans between Programs or Levels of Care may supplement an ongoing Care
Plan at the discretion of Care Management supervisors but must begin no later than 60
days before the end of the Transition period.

C.5.168.3 The Enrollee’s Care Manager shall coordinate services to ensure a seamless transition
between programs and shall provide a written report to DHCF within three business
days of indication that an Enrollee’s transition includes issues or concerns related to the
transition that warrant an escalation.

C.5.168.4 For Transitions between Programs or Levels of Care, Contractor shall, in consultation
with Enrollee and the Enrollee’s Providers, develop and implement a Care Plan to begin
no later than sixty (60) days before the end of the Transition period.
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C.5.168.5 The Care Managers shall make as many face-to-face visits as necessary and facilitate as
many meetings with the Enrollee, family, and other pertinent agencies/Providers
involved with the Enrollee’s care as required to develop and implement the Transition
Plan.

C.5.168.6 The Contractor shall document this Transition Plan in the Enrollee’s electronic health
record.

C.5.168.7 All Transition Plans shall be reviewed for comprehensive planning and implementation,
appropriateness for the Enrollee’s health care and/or social service needs in accordance
with Contractor’s policies and procedures.

C.5.168.8 Transition Care Plans shall be submitted to DHCF upon request for review.

C.5.169 Oversight of Home Health Agencies (HHA)

C.5.169.1 The Contractor shall submit to DHCF annually, and within thirty days of the Contract
Award, for review and approval, all on site monitoring and evaluation tools utilized for
home health agencies by the Quality, Compliance and/or Provider Relations
Departments. Home Health monitoring and evaluation tools shall be reviewed and
revised, if necessary, at least annually and made available to DHCF upon request.

C.5.169.1.1 Home health agency contractual agreements with the Contractor, Provider Manual,
policies, and procedures shall include or be amended to include, announced and
unannounced site visits/audits, point of care home visits, personal care aide monitoring
and NPI numbers, and mandatory training that follow the Federal and Home Health
State Regulations. Updated contracts, designated Provider Manual section and
policies/procedures related to home health agencies shall be submitted to DHCF for
review and approval annually and upon request.

C.5.169.2 The Contractor shall ensure that only Medicaid and Medicare licensed home health
agencies shall provide home health services to CASSIP Enrollees.

C.5.169.2.1 For CASSIP Enrollees 0 – 18 years, the Contractor shall use a home health agency with
a pediatric Certificate of Need.

C.5.169.2.2 For CASSIP enrollees over 18 years, the Contractor may use the pediatric home health
agency as described in C.5.169.2.1 or a licensed Medicaid/Medicare adult home health
agency. The Contractor shall ensure the adult home health agencies have the needed
expertise to provide services properly and safely, to the population.

C.5.169.2.3 If a home health agency is licensed in another jurisdiction, the Contractor shall ensure
that the home health agency is a Medicaid and Medicare certified provider.

C.5.169.3 If the Contractor owns and/or otherwise operates a licensed pediatric home health
agency in the District that administers services to CASSIP Enrollees, the Contractor is
responsible for oversight of the home health agency in a transparent manner, and shall
annually submit an Attestation to DHCF attesting that oversight practices of HHA are
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the same irrespective of the Contractor owning a HHA. Contractor shall make available
its oversight policies, procedures, audits, and audit findings upon DHCF request.

C.5.169.4 The Contractor shall provide DHCF with reports on Home Health utilization and other
data, as requested.

C.5.170 Quality Assessment and Performance Improvement (QAPI)

C.5.170.1 The Contractor shall, follow Title XIX and Title XI of the Social Security Act, 42 C.F.R.
Part 438, and applicable NCQA Standards and Guidelines for the Accreditation of
Health Plans, along with other CMS and DHCF guidance related to quality improvement
activities, exhibit the commitment, knowledge, and technical capacity needed to achieve
improvements in the quality of health care services on an ongoing basis upon contract
award.

C.5.170.1.1 Under 42 C.F.R. § 438.330, and D.C. Code § 31-3406, the Contractor shall develop,
maintain, and operate a QAPI program consistent with this Contract, which shall be
reviewed and/or revised annually and submitted to DHCF for approval.

C.5.170.1.2 The Contractor shall maintain a well-defined QAPI structure that includes a planned,
systematic approach to improving clinical and non-clinical processes and outcomes. At a
minimum, the Contractor shall ensure that the QAPI Program structure:

C.5.170.1.2.1 Is organization-wide, with clear lines of accountability within the organization;
C.5.170.1.2.2 Includes a set of functions, roles, and responsibilities for the oversight of QAPI
activities that are clearly defined and assigned to appropriate individuals, including
physicians, other clinicians, and non-clinicians;
C.5.170.1.2.3 Includes annual objectives and/or goals for planned projects or activities, including
clinical and non-clinical programs or initiatives and measurement activities; and
C.5.170.1.2.4 Evaluates the effectiveness of clinical and non-clinical initiatives.

C.5.170.2 The Contractor shall submit a QAPI Program Annual Summary in a format and
timeframe specific by DHCF or its designee. The written summary shall describe how
the Contractor:

C.5.170.2.1 Analyzes the processes and outcomes of care using currently accepted standards from
recognized medical authorities;
C.5.170.2.2 Analyzes data, including social determinants of health, to determine differences in
quality of care and utilization, as well as the underlying reasons for variations in the
provision of care to Enrollees;
C.5.170.2.3 Develops system interventions to address the underlying factors of disparate utilization,
health-related behaviors, and health outcomes, including but not limited to how they
relate to high utilization of Emergency Services; and
C.5.170.2.4 Uses measures to analyze the delivery of services and quality of care, over and
underutilization of services, disease management strategies, and outcomes of care.

C.5.170.2.5 The Contractor shall keep participating physicians and other Network Providers
informed about the QAPI Program and related activities and include in Provider
contracts a requirement securing cooperation with the QAPI.
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C.5.170.2.6 The Contractor shall integrate Behavioral Health into its QAPI Program and include a
systematic and ongoing process for monitoring, evaluating, and improving the quality
and appropriateness of Behavioral Health Services provided to beneficiaries.

C.5.170.2.7 The Contractor shall collect data, monitor, and evaluate for improvements of the
physical health outcomes resulting from Behavioral Health integration into the
Enrollee’s overall care.

C.5.170.2.8 The Contractor shall ensure the QAPI program include mechanisms to assess the quality
and appropriateness of care furnished to Children with Special Health Care Needs and
Adults with Special Health Care Needs.

C.5.170.2.9 The Contractor shall include mechanisms to assess the quality and appropriateness of
care furnished to enrollees using LTSS, including:

C.5.170.2.9.1 An assessment of care between care settings;
C.5.170.2.9.2 A comparison of services and supports received with those set forth in the Enrollee’s
Care Plan; and
C.5.170.2.9.3 Ensure the QAPI program include participation in efforts by the District to prevent,
detect, and remediate critical incidents (consistent with assuring beneficiary health and
welfare that are based, at a minimum, on the requirements on the District’s home and
community-based waiver programs.

C.5.170.3 The QAPI program shall be consistent with the following requirements, but not limited
to:

C.5.170.3.1 The Contractor shall at least annually, collect, and submit performance measurement
data following 42 C.F.R. § 438.330(c) and 42 C.F.R. § 438.350; and
C.5.170.3.2 The Contractor shall use performance measures including, but not limited to HEDIS®,
Consumer Assessment of Health Plans Studies (CAHPS®), Provider surveys,
satisfaction surveys, CMS-specified Core Measures, EPSDT, Clinical and Non-Clinical
Initiatives, Practice Guidelines, Focused Studies, Adverse Events, and all External
Quality Review Organization (EQRO) activities as part of its QAPI program.

C.5.170.3.3 The Contractor shall use mechanisms to assess the quality and appropriateness of care
furnished to enrollees using long-term services and supports, including assessment of care
between care settings and a comparison of services and supports received with those set
forth in the enrollee's treatment/service plan, if applicable.

C.5.170.3.4 The Contractor shall include participation in efforts by the District to prevent, detect,
and remediate critical incidents (consistent with assuring enrollee health and welfare that
are based at a minimum, on requirements on the District for home and community-based
waiver programs.

C.5.170.4 The Contractor shall use mechanisms to detect both underutilization and overutilization
of services.

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C.5.170.5 The Contractor shall ensure that all agreements (or provision of an agreement) with the
Providers contain a requirement to allow DHCF, or its designee, reasonable access to
records or files for CQI activities.

C.5.170.6 The Contractor shall integrate the following Program Descriptions/Strategies into the
QAPI:

C.5.170.6.1 Case Management and Care Coordination;
C.5.170.6.2 UM; and
C.5.170.6.3 Provider Network Management.

C.5.170.7 The Contractor shall use the results of these performance measures and any other
performance measures specified by DHCF to assess the effectiveness of its QAPI
program. The QAPI program shall include iterative processes for assessing and
monitoring quality performance, including but not limited to: barrier analysis;
identifying opportunities for improvement; implementing targeted and system
interventions; and regularly monitoring for effectiveness utilizing CQI.

C.5.170.8 The Contractor shall maintain an organizational structure, lines of authority and
accountability for CQI functions within the QAPI including, but not limited to
responsibilities of the CQO; and CMO. The Contractor shall designate a senior
executive responsible for the QAPI Program and the CMO must have substantial
involvement in QAPI Program activities.

C.5.170.9 The Contractor shall maintain a Quality Management Committee (QMC) for purposes of
reviewing the QAPI program, its results and activities, and recommending changes on
an ongoing basis. The QMC must be comprised of key management staff, as well as
health professionals providing care to Enrollees.

C.5.170.10 The Contractor shall conduct performance improvement projects (PIPs) that are
designed to achieve, through ongoing measurements and interventions, improvement,
sustained over time in clinical and nonclinical areas that are expected to have a favorable
effect on health outcomes and Enrollee satisfaction. If CMS specifies performance
measures and PIPs following 42 C.F.R. § 430.330(a), the Contractor shall report such
performance measures to DHCF and conduct such PIPs.

C.5.170.11 The Contractor shall report the status and the results of each PIP to DHCF at least
annually in a format as determined by DHCF.

C.5.170.12 The Contractor shall adhere to the following practices as part of its QAPI program, and
include the following elements in performance improvement projects:

C.5.170.12.1 Objective quality indicators must be used to measure performance;
C.5.170.12.2 Establish performance goals and identify benchmarks;
C.5.170.12.3 Plan and initiate activities for increasing or sustaining improvement;
C.5.170.12.4 Implement system interventions to achieve improvement in the access to; availability of
and quality of care; and
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C.5.170.12.5 Systems shall be in place to evaluate the effectiveness of each intervention based on the
performance measures.

C.5.170.13 NCQA Accreditation

C.5.170.13.1 If the Contractor is not accredited for its DHCF Medicaid Managed Care Program at the
Operational Start Date of this Contract, the Contractor shall obtain the National NCQA,
Health Plan Accreditation and Case Management Accreditation within 12 months of the
Start Date and shall maintain such accreditation thereafter. Failure to obtain the
specified NCQA accreditation and failure to maintain such accreditation thereafter may
be considered a material breach of this Contract and may result in an immediate freeze
of enrollment with the Contractor and may result in termination of this Contract.

C.5.170.13.2 If the Contractor has obtained NCQA Health Plan Accreditation and Case Management
Accreditation for its DHCF Medicaid Managed Care Program as of the start date of this
Contract, the Contractor shall maintain such NCQA accreditation throughout the period
of performance of this Contract. Failure to maintain such accreditation may be
considered a material breach of this Contract and shall result in immediate freezing of
enrollment with the Contractor.

C.5.170.13.3 Under 42 C.F.R. §§ 438.332, the Contractor shall authorize private accreditation
organizations, such as NCQA, to provide DHCF with a copy of the Contractor’s most
recent accreditation review, including accreditation status, survey type, and level (as
applicable), accreditation results, included recommended actions or improvements,
CAPs, summaries of findings, and expiration date of accreditation.

C.5.170.13.4 The Contractor shall provide DHCF with a copy of all NCQA Accreditation findings
within seven days of Contractor receipt from NCQA.

C.5.170.13.5 Achievement of provisional NCQA accreditation status shall require the Contractor to
submit a CAP to DHCF within thirty days of receipt of notification from NCQA. The
Contractor’s failure to submit a CAP within the specified timeframe may result in
freezing enrollment with the Contractor’ or termination of this Contract.

C.5.171 CQI Plan

C.5.171.1 The Contractor shall implement a CQI Plan as part of its QAPI program compliant with
42 C.F.R. § 438.330 and D.C. Code § 31-3406.

C.5.171.2 The Contractor’s CQI Plan shall include the use of health information exchange and
other tools to access clinical and Enrollee Encounter Data. These tools should include
the capacity for, but not limit to the following:

C.5.171.2.1 Systematic collection and desired frequency of performance data, health care quality and
Enrollee outcomes;
C.5.171.2.2 Sharing performance data, health care quality and Enrollee outcomes to Network
Providers; and
C.5.171.2.3 Making necessary changes to the Contractor’s operations, policies, and procedures to
improve health care quality.
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C.5.171.3 The CQI plan shall be reviewed, and/or revised at least annually and submitted to DHCF
for approval. The evaluation of the CQI plan shall include, but not be limited to, the
results of activities that demonstrate the Contractor’s assessment of the clinical quality
of physical and Behavioral Health care rendered, and related accomplishments,
compliance and/or deficiencies.

C.5.171.4 The Contractor’s CQI Plan shall include the Contractor’s performance plan for:

C.5.171.4.1 Improving health care quality due to information obtained through analysis of, including
but not limited to: HEDIS® performance measures; performance improvement projects;
any CMS specified Core measures; survey results, including CAHPS® surveys; adverse
events; and chart/file reviews;
C.5.171.4.2 Reducing racial, socioeconomic and ethnic disparities in health care utilization and in
health outcomes;
C.5.171.4.3 Comparing health care utilization data for Enrollees by Enrollee subgroups, such as,
race/ethnicity, language, and by DC Ward against prior year performance, and, where
possible, against regional and national benchmarks;
C.5.171.4.4 Improving performance in response to information obtained through the EQRO reports;
and
C.5.171.4.5 Implementing a schedule for system and targeted quality improvement activities.

C.5.171.5 The Contractor shall monitor Provider/Practitioner performance using performance
measures that reflect currently accepted standards of evidence-based care and clinical
practice guidelines, and provide feedback, and/or offer per programs or other APM to
Providers based on performance.

C.5.172 Quality Improvement Staff

C.5.172.1 The Contractor’s qualifications, staffing level and available resources shall be sufficient
to meet the goals and objectives of the QAPI program, CQI plan, and the Contractor’s
related activities. Such activities include but are not limited to the Contractor’s ability
to: obtain or maintain NCQA Accreditation; monitor and evaluate services; assess
satisfaction; monitor Provider performance; involve Enrollees in CQI initiatives,
conduct performance improvement projects; and related quantitative and qualitative data
and statistical analyses.

C.5.172.2 The Contractor shall have written documentation listing staff resources that are directly
under the organizational control of the CQO and are dedicated to implementation of a
QAPI program (including total FTEs, percent of time dedicated to QAPI for this
Contract, educational background, professional and clinical quality management
experience, and clearly defined roles and responsibilities for this Contract) that shall be
made available to DHCF and the EQRO upon request. Any changes to this staffing plan
must be approved by DHCF.

C.5.172.3 The Contractor shall designate a CQO to be accountable for the administrative success
of the QAPI program and CQI plan for this Contract. The CQO shall work in
collaboration with the CMO.

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C.5.172.4 The CQO shall be accountable for the CQI activities of the Contractor’s Network and
Non-Network Providers, as well as the subcontracted or delegated Providers.

C.5.172.5 The CQO or designee shall be responsible for development, implementation, and
evaluation of the QAPI program and the CQI plan under the guidance of the CQO.

C.5.172.6 The CQO shall participate in monthly and/or quarterly CQI meetings with DHCF and/or
the EQRO.

C.5.172.7 The Contractor shall send staff with an appropriate level of decision-making authority,
based on the Contractor’s determination, to participate in planning meetings that may
involve DHCF; other Contractors; other District agencies; the DHCF Advisory Groups;
and other stakeholders.

C.5.173 Performance Measures

C.5.173.1 The Contractor shall directly contract with a NCQA certified HEDIS® auditor and
CAHPS® vendor.

C.5.173.2 The Contractor shall submit all performance measures required by DHCF in accordance
with the DHCF specifications and timeliness requirements. CAHPS ® survey results
shall be submitted to NCQA Quality Compass and to the National CAHPS ®
Benchmarking Database.

C.5.173.3 The Contractor shall have systems in place for analyzing its performance measures and
shall report to DHCF any CQI activities.

C.5.173.4 The Contractor shall conduct at least one survey per year of Enrollees using the
CAHPS® 3.0 Child Survey instrument, including the Children with Chronic Conditions
(CCC) set.

C.5.173.4.1 The Contractor shall conduct the Agency for Healthcare Research and Quality (AHRQ)
Experience of Care and Health Outcomes (ECHO) survey each year. The ECHO
accesses the experiences of adults and children who have received mental health or
SUDS.

C.5.173.4.2 The Contractor shall include any additional questions requested by DHCF and the
EQRO in the surveys.

C.5.173.5 To assess Provider/Practitioner satisfaction, the Contractor shall conduct a
Provider/Practitioner satisfaction survey annually.

C.5.173.6 The Contractor shall conduct an Enrollee access and availability survey at least annually
to assess compliance with the Contract standards for access to Covered Services,
CASSIP Covered Services, and appointment times.

C.5.173.7 The Contractor shall identify disparities in health services and health outcomes between
subpopulations/groups (race/ethnicity, language, and disability); identify social
determinants of health; and identify the causes for health disparities.
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C.5.173.7.1 The Contractor shall develop a plan of action and a timeline to remediate the SDOH and
health disparities identified through targeted interventions and include this plan and
timeline in the Contractor’s QAPI program and CQI plan submissions to DHCF.

C.5.173.7.2 This plan of action shall include a performance measurement and evaluation component,
in coordination with section C.5.173.

C.5.173.8 The Contractor shall submit HEDIS® reports to DHCF annually.

C.5.174 Provider Performance Requirement

C.5.174.1 The Contractor shall measure the performance of Providers quarterly utilizing a Provider
profiling and report card system. The Contractor’s system shall consist of, but not be
limited to Provider profiling activities for PCPs, Behavioral Health Providers and, as
directed by DHCF, other high Provider utilizer types, at least annually. As part of its
quality activities, the Contractor shall describe the methodology it uses to identify which
and how many Providers to profile and to identify measures to use for profiling such
Providers. The Contractor’s Provider profiling activities shall include, but are not
limited to:

C.5.174.1.1 Developing Provider-specific reports that include a multi-dimensional assessment of a
Provider’s performance using clinical, administrative, and Enrollee satisfaction
indicators of care that are accurate, measurable, and relevant to the enrolled population;
C.5.174.1.2 Establishing Provider, group, or regional benchmarks for areas profiled, where
applicable, including DHCF Medicaid-specific benchmarks, if any;
C.5.174.1.3 Providing feedback to Providers, at least quarterly, regarding the results of their
performance and the overall performance of the Provider Network and the Contractor
shall submit copies of this feedback to DHCF, upon request;
C.5.174.1.4 Designing and implementing QIPs for Providers who receive a relatively high denial
rate for pre-service, concurrent, or post-service authorization requests, including referral
of these Providers to the Network management staff for education and TA; and
C.5.174.1.5 Using the results of its Provider profiling activities to identify areas of improvement for
Providers, and/or groups of Providers, utilize benchmarking data to identify and manage
outliers.

C.5.174.2 The Contractor shall:

C.5.174.2.1 Establish Provider-specific quality improvement goals for priority areas in which a
Provider or Providers do not meet established Contractor standards or improvement
goals and take appropriate action when the Contractor determines the Provider’s
performance is non-compliant;
C.5.174.2.2 Recommend appropriate action to correct identified deficiencies and monitor corrective
action by Providers;
C.5.174.2.3 Develop and implement incentives, which may include financial and non-financial
incentives, such as APMs to motivate Providers to improve performance on profiled
measures;
C.5.174.2.4 Conduct on-site visits to Network Providers for quality improvement purposes; and
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C.5.174.2.5 At least annually, identify, establish improvement goals, with periodic measurement and
report to DHCF on the Provider Network’s progress, or lack of progress, towards
meeting such improvement goals.

C.5.175 Clinical and Non-Clinical Initiatives

C.5.175.1 As part of its QAPI Program, the Contractor shall undertake clinical and non-clinical
initiatives that address the following, but are not limited to:

C.5.175.1.1 Low Acuity Non-Emergent ED Visit (LANE);
C.5.175.1.2 Potentially Preventable Admissions (PPA);
C.5.175.1.3 30 Day All Cause Re-Admission;
C.5.175.1.4 48-hour Follow-up Post ED and Inpatient Admissions; and
C.5.175.1.5 Other clinical and non-clinical areas as determined by DHCF or EQRO.

C.5.175.2 All initiatives shall be developed using a scientifically sound research design,
methodology, and analytical framework. Establish goals to measure improvement and
identify benchmarks.

C.5.176 Adverse Events

C.5.176.1 The Contractor shall have policies and procedures for documenting, reporting,
investigating, and addressing Adverse Events as defined in section C.2 including
responsible parties for performing each activity. These policies and procedures shall be
reviewed and approved by DHCF and included in the Contractor’s Provider Manual.

C.5.176.2 The Contractor shall notify DHCF of all Adverse Events described in C.5.176 occurring
within each calendar month via reporting mechanisms and processes set by DHCF.

C.5.176.3 The Contractor shall notify DHCF within 24 hours of occurrence or knowledge of
occurrence of an Adverse Event that require DHCF’s immediate attention based on the
severity and potential implications of the event (e.g. unforeseen death or reported abuse
or neglect of an Enrollee under age 21, Adverse Event involving criminal activity).

C.5.176.4 The Contractor shall designate a multi-disciplinary committee under the leadership of
the CMO to review Adverse Events as described in section C.5.176 as they occur, as
well as to review summary reports on a quarterly basis. The committee shall order, and
monitor needed corrective actions, if the action is remediable and issue protocols
designed to guide Providers/practitioners in preventing or providing appropriate
responses to commonly experienced events or identified trends warranting opportunities
for improvement activities.

C.5.177 EQRO Activities

Under 42 C.F.R. §§ 438.350 and 438.358, the Contractor shall fully cooperate and
collaborate with all DHCF’s EQRO activities, personnel, any requests for
data/documentation/reports, as well as any DHCF staff or contractors who are assisting
DHCF in its EQRO and CQI efforts.

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C.5.178 Auditing and Monitoring

C.5.178.1 Under Section E, DHCF, its designee, and/or the EQRO may perform off-site and on-
site quality improvement audits to ensure that Contractor is compliant with the
requirements set forth in this Contract. The reviews and audits may include: on-site
visits; staff and Enrollee interviews; medical record reviews (paper or electronic);
Claims payment systems; care/case management software systems; customer relations
system; review of CQI policies and procedures; reports; committee activities;
credentialing and re-credentialing activities; adverse benefit determinations; Grievances
and Appeals activities; corrective action and follow-up plans; review of survey results;
and staff and Provider qualifications.

C.5.178.2 Under 42 C.F.R. § 438.3(h), the Contractor shall allow the District, CMS, OIG, the
Comptroller General, and their designees to inspect and audit any of the Contractor’s
records or documents at any time.

C.5.178.3 The District, CMS, the OIG, the Comptroller General, and their designees have the right
to audit records or documents of the Contractor for 10 years from the final date of the
contract period or from the date of completion of any audit, whichever is later.

C.5.179 Mortality Reviews

C.5.179.1 The Contractor shall conduct a mortality review on all CASSIP Enrollees, 0-20 years of
age, regardless of whether the death is deemed an Adverse Event and the Contractor
shall notify DHCF within twenty-four hours of the occurrence or knowledge of the
occurrence. Should the event occur on a Friday, during the weekend or a District
holiday, notification shall be conveyed on the first business day after the event.

C.5.179.2 The Contractor shall designate a multi-disciplinary Committee under the leadership of
the CQO to review Adverse Events as described in section C.5.176 as they occur, as
well as to review summary reports on a quarterly basis. The Committee shall order, and
monitor needed corrective actions, if the action is remediable and issue protocols
designed to guide Providers in preventing or providing appropriate responses to
commonly experienced events or identified trends warranting opportunities for
improvement activities.

C.5.180 Sanctions

C.5.180.1 Under 42 C.F.R. § 438.700 et seq.., DHCF shall employ Contract remedies and/or
sanctions to address any Contractor noncompliance with the Contract and poor
performance including, but not limited to:

C.5.180.1.1 Failure to take corrective action or adhere to a CAP;
C.5.180.1.2 Misrepresenting or falsifying information provided to the DHCF;
C.5.180.1.3 Failure to comply with any reporting requirement and timely submission;
C.5.180.1.4 Failure to submit any DHCF requested performance measure and data analysis; and
C.5.180.1.5 Additional areas of noncompliance for which DHCF may impose remedies and
sanctions to the extent include, but are not limited to:

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C.5.180.1.5.1 Marketing Practices;
C.5.180.1.5.2 Member Services;
C.5.180.1.5.3 Provision of Medically Necessary Covered Services;
C.5.180.1.5.4 Enrollment Practices, including but not limited to, discrimination based on health
status or need for health services;
C.5.180.1.5.5 Provider Networks;
C.5.180.1.5.6 Provider Payments;
C.5.180.1.5.7 Financial Requirements including but not limited to, failure to comply with
Physician Incentive Plan requirements or imposing charges that are in excess of
charges permitted under the Medicaid program;
C.5.180.1.5.8 Enrollee Satisfaction;
C.5.180.1.5.9 Performance Standards included in the Contract;
C.5.180.1.5.10 NCQA Accreditation; and
C.5.180.1.5.11 Violating any of the other applicable requirements of §§ 1903(m) or 1932 of the Act
and any implementing regulations.

C.5.180.2 DHCF shall utilize a variety of means to assure compliance with Contract requirements.
DHCF will pursue remedial actions or improvement plans for the Contractor to
implement to resolve outstanding requirements. If remedial action or improvement plans
are not appropriate or are not successful, Contract sanctions will be implemented. DHCF
may utilize intermediate sanctions as described in 42 C.F.R.§ 438.700 et seq.

C.5.181 Corrective Action

C.5.181.1 DHCF shall require that Contractor develop a CAP for any case of non-compliance or
poor performance under the Contract, including but not limited to instances where
DHCF believes that Contractor’s quality improvement efforts are inadequate.

C.5.181.2 The Contractor shall be required to submit a CAP for approval within ten Business
Days of DHCF’s request.

C.5.181.3 The CAP shall include, at a minimum:

C.5.181.3.1 Stated Goal;
C.5.181.3.2 Definition of the problem;
C.5.181.3.3 Identified Barriers;
C.5.181.3.4 Contractor’s proposed course of action(s) for eliminating the barriers;
C.5.181.3.5 Timeframes from beginning and completing the identified course of action(s);
C.5.181.3.6 An explanation of how to sustain compliance or improvement;
C.5.181.3.7 Assigned Responsibility Parties;
C.5.181.3.8 Deliverables; and
C.5.181.3.9 Outcomes/Results.

C.5.182 Program Integrity

C.5.182.1 The Contractor shall comply with all District and federal laws and regulation relating to
fraud, waste, and abuse. The Contractor shall cooperate and assist the District and any
District or federal agency charged with the duty of identifying, investigating, or
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prosecuting suspected fraud, waste, or abuse. The Contractor shall provide originals
and/or copies (at no charge) of all records and information requested.

C.5.182.2 The Contractor shall permit DHCF and/or its authorized agent(s), the HHS, Office of
Inspector General (OIG), CMS, Federal Bureau of Investigation, and the District’s
Medicaid Fraud Control Unit (MFCU) reasonable access to its records, facilities and
personnel, including contractors and Independent Contractors, if applicable. Such access
shall be immediate, unless the Contractor can demonstrate good cause otherwise
determined by the aforementioned entities.

C.5.182.3 The Contractor, subcontractor and Providers, whether contract or non-contract, shall,
upon request and as required by this Contract or District and/or federal law, make
available to the Federal and District agencies, any and all administrative, financial and
medical records relating to the delivery of items or services for which Federal and
District monies are expended. Such records will be made available at no cost to the
requesting agency. In addition, the District’s MFCU, and other District agencies shall,
as required by this Contract or District and/or federal law, be allowed access to the
place of business and to all CASSIP or Non-CASSIP records of any contractor,
subcontractor or Provider, whether contract or non-contract, during normal business
hours, except under special circumstances when after-hour admission shall be allowed.
Special circumstances shall be determined by the District’s MFCU, DHCF/Division of
Program Integrity, and Department of Human Services/Economic Security
Administration.

C.5.182.4 Under the PPACA and District policy and procedures, the Contractor shall report
overpayments made by the District’s CASSIP to the Contractor as well as overpayments
made by the Contractor to a Provider and/or subcontractor.

C.5.182.5 The Contractor shall have a mechanism for a Network Provider to report to the
Contractor when it has received an overpayment, return the overpayment to the
Contractor within sixty (60) days after the date on which the overpayment was
identified, and notify the Contractor in writing of the reason for the overpayment.

C.5.182.6 The Contractor shall report all overpayments identified or recovered, specifying the
overpayments due to potential fraud, waste, and abuse to the DHCF.

C.5.182.7 The Contractor shall submit monthly reports and a comprehensive annual report in a
format determined by DHCF, on its recovery of overpayments, following 42 C.F.R. §
438.608(d).

C.5.182.8 The Contractor shall have retention policies for the treatment of recoveries of all
overpayments from the Contractor to a Provider, including specifically a retention policy
for the treatment of recoveries of overpayments due to fraud, waste, or abuse following
42 C.F.R. § 438.608(d). Retention policies shall include the process, timeframes, and
documentation required for reporting the recovery of all overpayments.

C.5.183 Prohibiting Affiliations with Individuals Debarred by Federal Agencies

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C.5.183.1 Under the Act § 1932(d) and 42 C.F.R. § 438.610, the Contractor shall not knowingly
have a relationship with: an individual or entity that is debarred, suspended, or
otherwise excluded from participating in procurement activities under the Federal
Acquisition Regulation or from participating in non-procurement activities under
regulations issued under Executive Order No. 12549 or under guidelines implementing
Executive Order No. 12549; an individual or entity who is an affiliate, as defined in the
Federal Acquisition Regulation at 48 C.F.R. § 2.101, of a person described in subpart of
this paragraph. The Contractor shall not have a relationship with an individual or entity
that is excluded from participation in any Federal health care program under sections
1128 or 1128A of the Act. This prohibition applies to:

C.5.183.1.1 A Director, Officer, or Partner of Contractor;
C.5.183.1.2 A person with beneficial ownership of five percent (5%) or more of the Contractor;
C.5.183.1.3 A person with an employment, consulting, or other arrangement with the Contractor for
the provision of items and services that are significant and material to Contractor’s
obligations under the Contract;
C.5.183.1.4 Network provider who is (or is affiliated with a person/entity); and
C.5.183.1.5 Subcontractor or Subcontractor’s affiliate of the Contractor as governed by 42 C.F.R §
438.230.

C.5.183.2 The Contractor shall notify the DHCF within three days of the time it receives notice
that action is being taken against the Contractor or any person defined in C.5.183 above
or under the provisions of § 1128(a) or (b) of the Act (42 U.S.C. § 1320a- 7) or any
Independent Contractor which could result in exclusion, debarment, or suspension of
the Contractor or an Independent Contractor from the Medicaid program, or any
program listed in Executive Order 12549.

C.5.183.3 If DHCF learns that the Contractor has a prohibited relationship with an individual or
entity that is debarred, suspended, or otherwise excluded from participating in
procurement activities following 42 C.F.R. §438.610 (d) FAR or from participating in
procurement activities under regulations issued under Executive Order No. 12549 or
under guidelines implementing Executive Order No. 12549, or if the Contractor has
relationship with an individual who is an affiliate of such an individual, the District:

C.5.183.3.1 Must notify the Secretary of the noncompliance;
C.5.183.3.2 May continue an existing agreement with the Contractor unless the Secretary directs
otherwise; and
C.5.183.3.3 May not renew or otherwise extend the duration of an existing agreement with the
Contractor unless the Secretary provides to the District and to Congress a written
statement describing compelling reasons that exist for renewing or extending the
agreement despite the prohibited affiliations. Nothing in Section C.5.183 shall be
construed to limit or otherwise affect any remedies available to the U.S. under sections
1128, 1128A or 1128B of the Act.

C.5.184 Program Integrity Compliance Program

C.5.184.1 Under 42 C.F.R. §§ 456.3, 456.4, 456.23, and 42 C.F.R. § 438.608(a), the Contractor
shall have a Compliance Program that includes administrative and management
arrangements or procedures, including a mandatory Compliance Plan, designed to guard
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against fraud, waste, and abuse. The Compliance Plan must address all 7 elements of an
effective Compliance program. The Contractor shall submit an annual compliance plan
document and any updates or modifications prior to making them effective to the CA
and the Division of Program Integrity for approval.

C.5.184.2 The Contractor’s Compliance Program and its fraud, waste, and abuse prevention
policies shall comply with 42 C.F.R. § 438.610 and all relevant District and Federal
laws, regulations, policies, procedures, and guidance, including updates and
amendments (including CMS’ Guidelines for Constructing a Compliance Program for
Medicaid MCOs) issued by DHCF, HHS, CMS, and the OIG.

C.5.184.3 Under 42 C.F.R. § 438.608(a), the Contractor shall designate a Chief Compliance
Officer and Regulatory Compliance Committee that have the responsibility and
authority for carrying out the provisions of the Compliance Program. These individuals
shall be accountable to the Board of Directors and report to the Board of Directors and
senior management.

C.5.184.4 The Chief Compliance Officer has the direct responsibility and authority for overseeing
the Compliance Program. The Chief Compliance Officer shall be responsible for
developing and implementing policies, procedures, and practices designed to ensure
compliance with the requirements of the Contract and shall report directly to the CEO
and the Board of Directors. The Contractor shall notify the CA of the Chief Compliance
Officer’s contact information and any changes thereto.

C.5.184.5 The Regulatory Compliance Committee shall be charged with overseeing the
Contractor’s compliance program and its compliance with the requirements under the
Contract, including the Chief Compliance Officer.

C.5.184.6 The Contractor shall have adequate staffing and resources to investigate unusual
incidents and develop and implement CAPs to assist the Contractor in preventing and
detecting potential fraud and abuse activities.

C.5.184.7 The Contractor shall be prohibited from taking any action to recoup or withhold
improperly paid funds already paid or potentially due to a Provider when the issues,
services, or Claims upon which the recoupment or withholding meet one or more of the
following criteria:

C.5.184.7.1 The improperly paid funds have already been recovered by the District, either by DHCF
directly or as part of a resolution of a District or by a federal investigation, review and/or
lawsuit, including but not limited to False Claims Act cases;
C.5.184.7.2 The improperly paid funds have already been recovered by the District’s Recovery
Audit Contractor (RAC); or
C.5.184.7.3 The issues, services, or Claims that are the basis of the recoupment or withhold are
currently being investigated or reviewed by the District, are the subject of pending
federal, District, or state litigation or investigation, or are being audited by the RAC.

C.5.184.8 The Contractor shall discuss with the DHCF Division of Program Integrity before
initiating any recoupment or withholding any program integrity related funds to ensure
that the recoupment or withhold is permissible. In the event that the Contractor obtains
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funds in cases where recoupment or withhold is prohibited under this section, the
Contractor shall return the funds to the Provider within thirty days of the Contractor
being notified or the Contractor discovering the prohibited recoupment or withhold.

C.5.184.9 The Contractor shall comply with all federal and District requirements regarding fraud
and abuse, including but not limited to, sections 1128, 1156, and 1902(a)(68) of the Act.

C.5.184.10 The Contractor shall promptly refer any potential fraud the Contractor identifies to the
Division of Program Integrity within 24 hours of identifying a potential credible
allegation of fraud.

C.5.184.11 The Contractor shall suspend all payments to a Network Provider for which DHCF
determines there is a credible allegation of fraud under 42 C.FR § 455.23.

C.5.185 Compliance Plan

C.5.185.1 As part of its Compliance Program, the Contractor shall develop a Compliance Plan.
The Contractor shall submit the Compliance Plan to the DHCF within ninety days of
Contract Award. The Contractor shall submit any updates or modifications to the DHCF
for approval prior to the updates or modifications taking effect. At its sole discretion,
DHCF may require that the Contractor modify its Compliance Plan.

C.5.185.2 At a minimum, the Contractor’s Compliance Plan shall incorporate the following:

C.5.185.2.1 Written policies, procedures, and standards of conduct that articulate the Contractor’s
commitment to comply with all applicable requirements and standards under the
Contract, and all federal and District standards designed to prevent and detect potential
or suspected fraud, waste and abuse in the administration and delivery of services under
the Contract;
C.5.185.2.2 Establish effective lines of communication between the Chief Compliance Officer and
the Contractor’s employees that the Contractor shall enforce through well-publicized
disciplinary guidelines;
C.5.185.2.3 Procedures for ongoing monitoring and auditing of the Contractor’s systems, including
but not limited to, Claims processing, billing and financial operations, enrollment
functions, Enrollee services, CQI activities, and Provider activities; and
C.5.185.2.4 Establishment and implementation of procedures and a system with dedicated staff for
routine internal monitoring and auditing of compliance risks; prompt response to
compliance issues, as they are raised; investigation of potential compliance problems, as
identified in the course of self-evaluation and audits; correction of such problems
promptly and thoroughly (or coordination of suspected criminal acts with law
enforcement agencies) to reduce the potential for recurrence; and ongoing compliance
with the requirements under the Contract.

C.5.185.3 The Contractor shall verify, by sampling or other methods, whether services that have
been represented to have been delivered by Network Providers were received by
Enrollees and the application of such verification processes on a regular basis.

C.5.185.4 The Contractor shall establish provisions, such as a hotline, for the confidential reporting
of Contractor violations, and a clearly designated individual, such as the Chief
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Compliance Officer, to receive them. The Contractor shall create several independent
reporting paths to report fraud so that such reports cannot be diverted by supervisors or
other personnel; and

C.5.185.5 Provisions for internal monitoring and auditing reported fraud, waste, and abuse per 42
C.F.R. § 438.608(a); including:

C.5.185.5.1 A description of the specific controls in place for prevention and detection of potential
or suspected fraud, waste and abuse, such as:

C.5.185.5.1.1 Automated pre-payment Claims edits;
C.5.185.5.1.2 Automated post-payment Claims edits;
C.5.185.5.1.3 Desk audits on post-processing review of Claims;
C.5.185.5.1.4 Reports of Provider profiling and credentialing used to aid program and payment
integrity reviews;
C.5.185.5.1.5 Surveillance and/or UM protocols used to safeguard against unnecessary or
inappropriate use of Medicaid services;
C.5.185.5.1.6 Provisions in the subcontractor and Provider agreements that ensure the integrity of
Provider credentials; and
C.5.185.5.1.7 References in Provider and member material regarding fraud and abuse referrals.

C.5.185.6 The Contractor shall provide a list of edits, audits, reports, protocols, provisions, or
references employed for specific controls identified in C.5.185 to the DHCF, upon
request.

C.5.185.7 The Contractor shall provide protections to ensure that no individual who reports
Contractor violations or suspected fraud, waste, and abuse is retaliated against and the
Contractor protects the confidentiality, to the extent possible, of individuals reporting
violations of the Compliance Plan:

C.5.185.7.1 Provisions for a prompt response to detected offenses and development of corrective
action initiatives related to the Contract per 42 C.F.R. § 438.608(a);
C.5.185.7.2 Well-publicized disciplinary procedures that apply to employee who violate
Contractor’s compliance program;
C.5.185.7.3 Training for officers, directors, managers, and employees (as described below) to ensure
that they know and understand the provisions of Contractor’s Compliance Plan; and
C.5.185.7.4 An outline of activities proposed for the next reporting year to educate Providers on
federal and District laws and regulations related to fraud, waste and abuse and
identification of patterns of incorrect billing practices and/or overpayments.

C.5.186 Compliance Training

C.5.186.1 In accordance with 42 C.F.R. § 438.608(a), the Contractor shall establish a system of
effective training and education of the Compliance Officer, senior management, the
Contractor’s employees, and Key Personnel. The Contractor shall conduct or arrange for
compliance training within 90 days of hire and annually thereafter of all employees,
contractors, and staff regarding:

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C.5.186.1.1 Federal and District fraud, waste, and abuse laws, regulations, and policies applicable to
the D.C. Medicaid Managed Care Program and CASSIP;
C.5.186.1.2 DHCF’s fraud, waste, and abuse policies and procedures; and
C.5.186.1.3 Contractor’s Compliance Program and Plan.

C.5.187 Reporting of Fraud, Waste and Abuse

C.5.187.1 Under 42 C.F.R. §§ 455.1(a) and 455.17, the Contractor shall be responsible for
referring potential fraud, reporting violation of the terms of the Contract, taking prompt
corrective action, and cooperating with DHCF in its investigation of the matter(s).
Additionally, the Contractor shall promptly report to the DHCF if it discovers that any
of its Providers have been excluded, suspended, or debarred from any District, or federal
health care benefit program within three Business days. Reporting on waste, abuse, and
complaints or tips will be provided in monthly reports to the DHCF.

C.5.187.2 The Contractor shall provide reports using forms or formats identified by DHCF, or such
other forms as may be deemed satisfactory by the agency to which the report is made
under the terms of this Contract. The Contractor shall provide periodic reports
summarizing required reporting for identified time periods when directed by the DHCF.

C.5.187.3 The fraud, waste, and abuse information that the Contractor shall report to the DHCF
must include:

C.5.187.3.1 The name and I.D. number of the suspected offender, the source of the complaint, the
type of provider, the nature of the complaint, the approximate number of dollars
involved, summary of any follow-up, and any associated documentation; and
C.5.187.3.2 The legal and administrative disposition of the case, if known.

C.5.187.4 After receiving the Contractor’s potential fraud referrals, the DHCF will conduct any
additional investigation necessary to determine if a credible allegation of fraud exists
and inform the Contractor of the status of referred cases.

C.5.187.5 The Contractor shall report all tips, confirmed or suspected fraud, waste or abuse to
DHCF and the appropriate agency as follows:

C.5.187.5.1 The Contractor shall report suspected credible allegations of fraud after investigation to
the DHCF within twenty-four hours of the Contractor completing the related
investigation using the DHCF on-line Compliant Form at
https://dhcf.isight.com/external/case/new;
C.5.187.5.2 Suspected fraud and abuse in the administration of the program shall be reported to
DHCF within five days of discovery using the on-line Compliant Form at
https://dhcf.isight.com/external/case/new;
C.5.187.5.3 All audits or other cases involving suspected or confirmed Provider waste and abuse,
including overpayment determinations and recoupments shall be reported to DHCF in
the monthly Program Integrity report;
C.5.187.5.4 All complaints/tips shall be reported to DHCF in the monthly Program Integrity report;
and
C.5.187.5.5 Confirmed or suspected Enrollee fraud and abuse shall be reported to DHCF using the
online Compliant Form, with the exception of eligibility fraud and abuse which shall be
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reported to the DHS and also listing the Enrollee information in the monthly Program
Integrity report to the DHCF.

C.5.187.6 Any case opened by Contractor’s program integrity department shall be reported to the
DHCF in the monthly Program Integrity report.

C.5.187.7 The Contractor shall promptly perform a preliminary investigation of all incidents of
suspected fraud and abuse.

C.5.187.8 Unless prior written approval is obtained from the District agency that received the
incident report (or written approval is obtained from another District agency that was
designated by the District agency that received the incident report), after reporting
suspected or confirmed fraud or abuse, the Contractor shall not take any of the following
actions as they specifically relate to CASSIP Claims:

C.5.187.8.1 Contact the subject of the investigation about any matters related to the investigation;
C.5.187.8.2 Enter into or attempt to negotiate any settlement or agreement regarding the incident; or
C.5.187.8.3 Accept any monetary or other thing of valuable consideration offered by the subject of
the investigation in connection with the incident.

C.5.187.9 The Contractor shall promptly notify the DHCF when contacted by law enforcement or
other agencies on program integrity related matters and include the DHCF in any
communications.

C.5.187.10 The Contractor shall notify the DHCF when it receives information about a change in a
Network Provider's circumstances that may affect the Network Provider's eligibility to
participate in the managed care program, including the termination of the Provider
agreement with the Contractor.

C.5.187.11 The Contractor’s failure to report potential or suspected fraud, waste, or abuse may
result in sanctions and penalties to the extent allowed by section G.6.7, including but not
limited to, termination of the Contract.

C.5.188 Whistleblower Protections

C.5.188.1 The Contractor shall ensure that no individual who reports Compliance Plan violations
or suspected fraud and abuse is retaliated against by anyone who is employed by or
contracts with the Contractor. Anyone who believes that he or she has been retaliated
against may report a violation to the DHCF and/or the U.S. DHHS, OIG.

C.5.188.2 Under 42 C.F.R. § 455.1(a), the Contractor shall have a method to verify that services
provided under the Contract are actually provided.

C.5.188.3 Following § 6032 of the Deficit Reduction Act of 2005, the Contractor shall:

C.5.188.3.1 Establish written policies for all employees, subcontractors, and agents of the Contractor
to provide detailed information about the False Claims Act established under 31 U.S.C.
§§ 3729 -3733, administrative remedies for false claims and statements under Chapter
38 of Title 31 of the U.S. Code, any District laws pertaining to civil or criminal
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penalties for false claims or statements and whistleblower protection under such laws,
with respect to the role of such laws in preventing and detecting fraud, waste, and abuse
in Federal health care programs;

C.5.188.3.2 Include, as part of the written policies, detailed provisions regarding the Contractor’s
policies and procedures for detecting and preventing fraud, waste, and abuse; and

C.5.188.3.3 Include in the Contractor’s employee handbook, a specific discussion of the laws
described in C.5.188.3.1, the rights of the employees to be protected as whistleblowers,
and the Contractor’s policies and procedures for detecting fraud, waste, and abuse.

C.5.189 Enrollee Grievances and Appeals

C.5.189.1 The Contractor shall have in place an internal Grievance and Appeal System that
complies with relevant sections of the Act, 42 USC § 1396a, 42 C.F.R. §§ 438.400 -
438.424, District of Columbia’s Prior Authorization Reform Amendment Act of 2023,
as well as D.C. Code § 44-301.06. The Contractor’s Grievance and Appeal system shall
include a grievance process that contains only one level of appeal and the system shall
provide access to the District’s process for administrative Fair Hearings. To the extent
that the applicable federal and District laws grant the Contractor discretion to make
certain decisions pertaining to the design of its Grievance and Appeal process, prior to
implementation, the Contractor’s decisions shall be subject to DHCF’s approval.

C.5.189.2 The Contractor shall establish and maintain internal policies and procedures for the
resolution of CASSIP Enrollee Grievances and Appeals.

C.5.189.3 The Contractor shall submit to the CA or other DHCF designee for approval, within
ninety days after the Date of Award of the Contract and upon DCHF request thereafter,
a copy of policies and procedures for the Grievance and Appeal System that complies
with sections C.5.189 and C.5.200.

C.5.189.4 These policies and procedures shall be administered according to the requirements of 42
C.F.R. §§ 438.400 - 438.424 and any other applicable federal or District laws and DHCF
guidance.

C.5.190 Requirements for Notice of Adverse Benefit Determination

C.5.190.1 The Contractor shall issue timely and adequate notice of an Adverse Benefit
Determination, in writing, that meets the requirements set forth in C.5.8, 42 C.F.R. §
438.10(c) and (d), and § 438.404.

C.5.190.2 A utilization review entity shall provide an Enrollee with at least 15 days from the date
the Enrollee receives notice of an adverse determination to appeal the decision via the
utilization review entity’s website, facsimile, or mail; provided, that an appeal submitted
by mail shall be considered timely if postmarked within 15 days of the Enrollee
receiving notice.

C.5.191 When Notice Is Required

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C.5.191.1 The Contractor shall give notice of Adverse Benefit Determination by the date of the
action when any of the following occur:

C.5.191.1.1 The Enrollee has died;
C.5.191.1.2 The Enrollee of legal age of consent, or their parent or guardian, submits a signed
written statement requesting service termination;
C.5.191.1.3 The Enrollee of legal age of consent, or their parent or guardian, submits a signed
written statement including information that requires service termination or reduction
and indicates that he/she understands that service termination or reduction result;
C.5.191.1.4 The Enrollee has been admitted to an institution in which she/he is ineligible for
Medicaid services, if applicable;
C.5.191.1.5 The Enrollee’s address is determined unknown based on returned mail with no
forwarding address;
C.5.191.1.6 The Enrollee is accepted for Medicaid services by another local jurisdiction, state,
territory, or commonwealth;
C.5.191.1.7 A change in the level of medical care is prescribed by the Enrollee’s physician;
C.5.191.1.8 The notice involves an Adverse Benefits Determination regarding preadmission
screening requirements; or
C.5.191.1.9 The transfer or discharge from a facility will occur in an expedited fashion, as described
in 42 C.F.R. § 483.15.

C.5.192 Timeframes for Delivery of Notice

C.5.192.1 Under 42 C.F.R. § 438.404(c), the Contractor shall issue the Notice of Adverse Benefit
Determination within the following timeframes:

C.5.192.1.1 For termination, suspension, or reduction of previously authorized Medicaid services,
the timeframes specified in 42 C.F.R. §§ 431.211, 431.213, and 431.214, as amended,
and all other regulatory or statutory regulatory requirements;
C.5.192.1.2 For denial of payment, at the time of the Adverse Benefit Determination affecting the
Claim;
C.5.192.1.3 For standard Service Authorization decisions that deny or limit services, within the
timeframe specified in section C.5.146;
C.5.192.1.4 If the Contractor meets the criteria set forth for extending the timeframe for standard
service authorization decisions consistent with 42 C.F.R. § 438.210(d)(ii), it must:

C.5.192.1.4.1 Give the Enrollee written notice of the reason for the decision to extend the timeframe
and inform the Enrollee of the right to file a grievance if he or she disagrees with that
decision; and
C.5.192.1.4.2 Issue and carry out its determination as expeditiously as the Enrollee's health
condition(s) requires and no later than the date the extension expires.

C.5.192.1.5 For Service Authorization decisions not reached within the timeframes specified in
section C.5.146 (which constitute a denial and is thus an Adverse Benefit
Determination), on the date that the timeframes expire;
C.5.192.1.6 For urgent expedited Service Authorization decisions, within the timeframe specified in
section C.5.146; and
C.5.192.1.7 If the Contractor extends the timeframe in accordance with section C.5.146.2.1 and
C.5.146.3 the Contractor shall:
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C.5.192.1.7.1 Give the Enrollee written notice of the reason for the decision to extend the timeframe
and inform the Enrollee of the right to file a grievance if he or she disagrees with that
decision; and
C.5.192.1.7.2 Issue and carry out its determination as expeditiously as the Enrollee’s health condition
requires and no later than the date the extension expires.

C.5.192.2 The Contractor shall mail the notice of Adverse Benefit Determination no later than five
days prior to the date of action if the Contractor has facts indicating that action should be
taken because of probable fraud by the beneficiary, and the facts have been verified, if
possible, through secondary sources.

C.5.193 Content of Notice of Adverse Benefit Determination

C.5.193.1 The Notice of Adverse Benefit Determination shall meet the requirements of 42 C.F.R. §
438.404 and 42 C.F.R. § 431.210 and the District of Columbia’s Prior Authorization
Reform Amendment Act of 2023. The Contractor shall submit to DHCF for approval a
template that includes, at a minimum, the following information:

C.5.193.1.1 The reason(s) for the Adverse Benefit Determination;
C.5.193.1.2 The Enrollee’s right to file an Appeal with Contractor;
C.5.193.1.3 The Enrollee's right to request an appeal of the Contractor’s Adverse Benefit
Determination, including information on exhausting the Contractor’s one level of appeal
described at 42 C.F.R. § 438.402(b) and the right to request a District Fair Hearing
consistent with 42 C.F.R. § 438.402(c);
C.5.193.1.4 The procedures for exercising the Enrollee’s Appeal or Fair Hearing rights;
C.5.193.1.5 The circumstances under which an expedited resolution of the Adverse Benefit
Determination is permitted and how to request it;
C.5.193.1.6 The Enrollee’s right to have his or her benefits continued pending resolution of the
Appeal or Fair Hearing, if the conditions specified in section C.5.200 are met;
C.5.193.1.7 The Enrollee’s right to receive assistance from the Ombudsman and how to contact the
Ombudsman; and
C.5.193.1.8 The Enrollee’s right to obtain free copies of certain documents, including the Enrollee’s
medical records used to make the decision and the Medical Necessity Criteria,
referenced in the Adverse Benefit Determination.

C.5.193.2 The Contractor shall provide the following Grievance, Appeal and Fair Hearing
procedures and timeframes to all Providers, independent contractors, and those under a
Single Case Agreement at the time they enter a contract:

C.5.193.2.1 The Enrollee’s right to file Grievances and Appeals and the requirements and
timeframes for filing;
C.5.193.2.2 The Enrollee’s right to a District Fair Hearing, how to obtain a hearing and
representation rules at a hearing;
C.5.193.2.3 The availability of the Contractor to assist the Enrollee at all stages of the Grievance and
Appeals process;
C.5.193.2.4 The toll-free numbers to file oral Grievances and Appeals; and
C.5.193.2.5 The Enrollee’s right to have his or her benefits continued during an appeal or a District
Fair Hearing if the conditions in section C.5.200 are met.
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C.5.194 Grievance and Appeals System Requirements

C.5.194.1 The Contractor shall have an identifiable person or persons who can impartially provide
assistance to CASSIP Enrollees throughout the Grievance and Appeals process, as well
as, the steps required to request a Fair Hearing.

C.5.194.2 The Contractor shall identify a contact person employed by or contracted with the
Contractor to receive Grievances and Appeals and be responsible for routing processing.

C.5.194.3 The Contractor shall record and preserve all communications, written and oral
(telephonic, virtual or in-person), with Enrollees.

C.5.194.4 The Contractor shall maintain a record keeping and tracking system to document all
Adverse Benefit Determinations, Appeals, and Grievances. The system shall be
accurately maintained in a manner accessible to the District and available upon request
to CMS along with any underlying documentation. The record shall not contain any
information other than that related to Adverse Benefit Determinations, Appeals and
Grievances for CASSIP Enrollees, as these terms are defined herein. This record shall
document:

C.5.194.4.1 Whether the matter was a Grievance or Appeal;
C.5.194.4.2 The subject and general description of each Grievance or Appeal;
C.5.194.4.3 The Enrollee’s PCP and the Provider involved in the Grievance or Appeal (if different
from the PCP);
C.5.194.4.4 How the matter was resolved;
C.5.194.4.5 What, if any, corrective action was taken by the Contractor;
C.5.194.4.6 The date the Contractor received the Grievance or Appeal;
C.5.194.4.7 The date of each review or, if applicable, review meeting;
C.5.194.4.8 Date of resolution at each level, if applicable; and
C.5.194.4.9 Name of the covered person for whom the Appeal or Grievance was filed.

C.5.194.5 The Contractor shall not penalize any Enrollee who files a Grievance, Appeal, or
requests a Fair Hearing.

C.5.194.6 The Contractor shall not take any retaliatory action against a Provider who acts on
behalf of, or as the authorized representative of, an Enrollee in a Grievance, Appeal, or
Fair Hearing.

C.5.195 Grievance and Appeal Procedures

C.5.195.1 The Contractor shall render assistance at all stages in the Grievance and Appeal process,
including auxiliary aids and services upon request including, but not limited to, the
provision of interpreter/translator services, toll-free numbers that have adequate
TTY/TDD, Sorenson Video Relay or similar capabilities, and interpreter capability in
accordance with section C.5.8.

C.5.195.2 Following 42 C.F.R. § 438.402, any of the following individuals may invoke the
Grievance and Appeal procedure:
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C.5.195.2.1 The Enrollee affected by the determination;
C.5.195.2.2 If the Enrollee is a minor child, the Enrollee’s parent, Guardian, or authorized
representative;
C.5.195.2.3 In the case of a Grievance, an authorized representative, including but not limited to, an
Attorney and a Provider or other non-legal advocate, acting on behalf of the Enrollee;
and
C.5.195.2.4 In the case of an Appeal, a Provider acting on behalf of the Enrollee and with the
Enrollee’s written consent.

C.5.195.3 Under 42 C.F.R. § 438.406(b), the Contractor’s Appeal process shall:

C.5.195.3.1 Provide that oral inquiries seeking to appeal an Adverse Benefit Determination are
treated as Appeals. The Contractor shall treat any ambiguous communication as a
Grievance;
C.5.195.3.2 Provide the Enrollee a reasonable opportunity to present evidence and allegations of fact
or law, in person, as well as in writing. The Contractor shall inform the Enrollee of the
limited time available for this in the case of an expedited resolution; and
C.5.195.3.3 Provide the Enrollee and his or her representative the opportunity, before and during the
Appeal process, to examine the Enrollee’s case file, including Medical Records and any
other documents and records considered during the Appeal process. This information
must be provided free of charge and sufficiently in advance of the resolution timeframe
for appeals as specified in 42 C.F.R. §§ 438.408(b) and (c).

C.5.195.4 Include as parties to the Appeal:

C.5.195.4.1 The Enrollee and his or her representative; or
C.5.195.4.2 The legal representative of a deceased Enrollee’s estate.

C.5.196 Filing Timeframes for Grievances and Appeals

C.5.196.1 An Enrollee or authorized representative, with the Enrollee’s written consent, may file a
grievance with the Contractor, either orally or in writing, at any time.

C.5.196.2 An Enrollee or authorized representative, with the Enrollee’s written consent, may file
an Appeal with the Contractor, either orally or in writing, within 60 days from the date
of the notice of Adverse Benefit Determination.

C.5.196.3 An oral or written Appeal shall trigger the start of the Contractor’s time limits for
resolving an Appeal under both section C.5.198.5 (standard Appeal) and section
C.5.199.

C.5.196.4 The Contractor shall issue a written acknowledgement of an Appeal or a Grievance
within two Business days of receipt.

C.5.197 Grievance and Appeal Committee

C.5.197.1 The Contractor shall appoint a Grievance and Appeal Committee to review all
Grievances and Appeals for CASSIP Enrollees.
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C.5.197.2 At a minimum, the Grievance and Appeal Committee shall include:

C.5.197.2.1 The CMO;
C.5.197.2.2 A Provider working within the scope of his or her practice with the skills and credentials
relevant to the specific Grievance or Appeal at hand;
C.5.197.2.3 Any other individual with experience in CQI;
C.5.197.2.4 Other medical and clinical staff as needed to substitute for a staff member involved in
the matter in dispute or to provide needed specialty expertise; and
C.5.197.2.5 All appeals are reviewed by a physician who possesses a current and valid non-restricted
license to practice medicine in the District, Maryland, or Virginia.

C.5.197.3 A Provider or other individual against whom the Grievance or Appeal has been brought
may not sit as part of the Grievance and Appeal Committee.

C.5.197.4 The Contractor shall ensure that all Grievances and Appeals are reviewed by appropriate
pediatric, adolescent, or adult specialists and subspecialists with at least five years of
practicing experience and is knowledgeable of, and have experience providing, the care
service on appeal.

C.5.197.5 The Contractor shall ensure that persons who make decisions on Grievances and
Appeals are individuals who were neither involved in any previous level of review or
decision making nor subordinate to a previous reviewer or decision-maker;

C.5.197.6 The Contractor shall ensure that persons who make decisions on Grievances and
Appeals take into account all comments, documents, records, and other information
submitted by the Enrollee or their representative without regard to whether such
information was submitted or considered in the initial Adverse Benefit Determination;
and

C.5.197.7 Are health care professionals with the appropriate clinical expertise, as determined by
DHCF, in treating the Enrollee’s condition or disease, if deciding any of the following:

C.5.197.7.1 An Appeal of a Denial that is based on lack of medical necessity;
C.5.197.7.2 A Grievance regarding denial of an expedited resolution of an Appeal; or
C.5.197.7.3 A Grievance or Appeal that involves clinical issues.

C.5.198 Resolution and Notification Timeframes for Grievances and Appeals

C.5.198.1 Under 42 C.F.R. § 438.408, the Contractor shall dispose of each Grievance and resolve
each Appeal and provide notice, as expeditiously as the Enrollee’s health condition
requires, within the timeframes set forth in this section.

C.5.198.2 The Contractor shall dispose of the Grievance and notify the Enrollee or the Enrollee’s
designee in writing of the decision no later than ninety days from the date the
Contractor receives the Grievance.

C.5.198.3 The Contractor shall notify an Enrollee of the resolution of a Grievance and ensure that
such methods meet, at a minimum, the standards described at 42 C.F.R. § 438.10.
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C.5.198.4 For all Appeals, the Contractor shall provide written notice of resolution of the appeals
process and include the results of the appeal resolution and the date it was completed in
a format and language that, at a minimum, meet the standards described at 42 C.F.R. §
438.10.

C.5.198.4.1 At minimum, the qualifications of the physician reviewing the appeal shall include:

C.5.198.4.1.1 The grounds for the physician’s decision under the utilization review entity's prior
authorization requirements;
C.5.198.4.1.2 States in which the physician is licensed;
C.5.198.4.1.3 Status of their medical licenses;
C.5.198.4.1.4 Their medical specialty;
C.5.198.4.1.5 Years of practice in that specialty; and
C.5.198.4.1.6 The grounds for the physician’s decision under the utilization review entity's prior
authorization requirements.

C.5.198.5 The Contractor shall resolve standard Appeals not later than thirty days after receipt of
the Appeal, whether the Appeal is oral or written.

C.5.198.6 For expedited resolution of an Appeal and notice to affected parties, the Contractor shall
resolve the Appeal within seventy-two hours from the date that it receives the Appeal.

C.5.198.7 For notice of an expedited resolution, the Contractor shall make reasonable efforts to
provide oral notice.

C.5.198.8 The Contractor may extend timeframes in section C.5.198 by up to fourteen days if any
of the following are met:

C.5.198.8.1 The Enrollee or the Enrollee’s representative requests the extension; or
C.5.198.8.2 The Contractor shows to the satisfaction of DHCF that there is need for additional
information and the delay is in the Enrollee’s interest.

C.5.198.9 If the Contractor extends the timeframe for any extension not requested by the Enrollee,
it shall complete the following:

C.5.198.9.1 Make reasonable efforts to give the Enrollee prompt oral notice of the delay;
C.5.198.9.2 Within two days give the Enrollee written notice of the reason for the decision to extend
the timeframe and inform the Enrollee of the right to file a Grievance if he or she
disagrees with that decision; and
C.5.198.9.3 Resolve the Appeal as expeditiously as the Enrollee's health condition requires and no
later than the date the extension expires.

C.5.198.10 If the Contractor fails to adhere to the notice and timing requirements in accordance with
42 C.F.R. § 438.408, the enrollee is deemed to have exhausted the Contractor’s appeals
process, and the enrollee may initiate a District fair hearing

C.5.199 Expedited Resolution of Appeals

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C.5.199.1 Under 42 C.F.R. § 438.410, the Contractor shall establish and maintain an expedited
review process for Appeals.

C.5.199.2 The Enrollee or Provider may file a request for an expedited Appeal either orally or in
writing. No additional Enrollee follow-up shall be required.

C.5.199.3 The Contractor shall inform the Enrollee of the limited time available for the Enrollee to
present evidence and allegations of fact or law, in person and in writing, in the case of
expedited resolution.

C.5.199.4 The expedited review process shall be available when:

C.5.199.4.1 Enrollee requests an Appeal and the Contractor determines that taking the time for a
standard resolution could seriously jeopardize the Enrollee’s life or health or ability to
attain, maintain, or regain maximum function; or
C.5.199.4.2 The Provider indicates, in making the request on behalf of an Enrollee or in supporting
the Enrollee’s request, that taking the time for a standard resolution could seriously
jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum
function.

C.5.199.5 The Contractor shall ensure that punitive action is not taken against a Provider who
requests an expedited Appeal or supports an Enrollee’s Appeal.

C.5.199.6 If the Contractor denies a request for an expedited resolution of an Appeal, it shall:

C.5.199.6.1 Transfer the Appeal to the timeframe for standard resolution of an Appeal following 42
C.F.R. § 438.408(b); and
C.5.199.6.2 Make reasonable efforts to give the Enrollee prompt oral notice of the Denial and follow
up within two days with a written notice informing the Enrollee the right to file a
grievance if he or she does not agree with the decision to deny the request for an
expedited resolution of an Appeal.

C.5.200 District of Columbia Fair Hearings

C.5.200.1 Under 42 U.S.C. § 1396a(a), 42 C.F.R. § 431.220, § 438.402 and § 438.408, D.C. Code
§ 4-210.01 et seq., the District shall grant an Enrollee who is the subject of an Adverse
Benefit Determination an opportunity for a Fair Hearing after receiving the final notice
of Adverse Benefit Determination. A final notice of Adverse Benefit Determination is
the Contractor’s decision after the Appeal as described in 42 C.F.R. § 438.408(e).

C.5.200.2 The Contractor shall notify the Enrollee or the Enrollee’s designee of the right to a Fair
Hearing at the time of any Adverse Benefit Determination affecting an Enrollee’s claim.

C.5.200.3 For Appeals not resolved wholly in favor of the Enrollee, Contractor shall inform the
Enrollee of:

C.5.200.3.1 The Enrollee’s right to request a District Fair Hearing and how to do so; and
C.5.200.3.2 The Enrollee’s right to request and receive benefits while the Fair Hearing is pending
and how to make the request for continuation of benefits.
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C.5.200.4 If an Enrollee wants to request a Fair Hearing, an Enrollee shall request a Fair Hearing
no later than 120 days from the date of the Contractor’s final notice of Adverse Benefit
Determination. The Contractor shall assist the Enrollee with filing a Fair Hearing
request, and the Contractor shall send a copy of the filed request to the Enrollee’s home
address.

C.5.200.5 Under 42 C.F.R. § 438.408(f), the parties to a District Fair Hearing include the
Contractor as well as the Enrollee and his or her representative or the representative of a
deceased Enrollee’s estate. The Contractor shall designate an individual responsible for
the Contractor’s defense of the Adverse Benefit Determination at issue.

C.5.200.6 The Contractor shall provide each Enrollee with a written notice of Adverse Benefit
Determination, as described in section C.5.193, inclusive of the Enrollee’s rights to
request a Fair Hearing. The Contractor shall ensure this written notice contains the
following information:

C.5.200.6.1 The Enrollee is entitled to a Fair Hearing under § 1902(a) of the Act, 42 C.F.R. USC §
1396a(a), 42 C.F.R. § 431.220;
C.5.200.6.2 The timeframes by which an Enrollee may request a fair hearing;
C.5.200.6.3 Explain the method by which an Enrollee may obtain such a hearing;
C.5.200.6.4 The right of the Enrollee to represent himself or herself or to be represented by his or her
family caregiver, legal counsel or other representative;
C.5.200.6.5 If the Enrollee wishes to continue his or her benefits, the Enrollee must request a Fair
Hearing on or before the later of the following:

C.5.200.6.5.1 Within ten days of the date on the Notice of Adverse Benefit Determination; or
C.5.200.6.5.2 The intended effective date of the Contractor’s proposed Adverse Benefit
Determination; and
C.5.200.6.5.3 The availability of accommodations for CASSIP Enrollees and on behalf of Non-
CASSIP Enrollees.

C.5.200.7 The Contractor shall ensure that this notice is written:

C.5.200.7.1 In a manner and format which may be easily understood by an Enrollee in accordance
with section C.5.8; and
C.5.200.7.2 In each language which is spoken as a primary language by the Enrollees.

C.5.201 Fair Hearing Procedures

C.5.201.1 The Contractor shall submit all documents regarding the Contractor’s Adverse Benefit
Determination and the Enrollee’s dispute to DHCF no later than five days from the date
the Contractor receives notice from DHCF that a Fair Hearing request has been filed.

C.5.201.2 When the Contractor is notified of the District Office of Administrative Hearings
decision to reverse an Adverse Benefit Determination, the Contractor shall authorize or
provide the service no later than two Business days after reversal or notification of
reversal from the District. In cases involving an expedited Appeal, the Contractor shall
provide services within 24 hours of the reversal.
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C.5.201.3 Under 42 C.F.R. § 438.424(a), where the Contractor or the District Office of
Administrative Hearings reverses a decision to deny, limit, or delay services that were
not furnished while the Appeal was pending, the Contractor shall authorize or provide
the disputed services promptly and as expeditiously as the Enrollee’s health condition
requires and no later than 72 hours from the date the Contractor receives notice
reversing the determination.

C.5.201.4 Under 42 C.F.R. § 438.424(b), where the Contractor or the District Office of
Administrative Hearings reverses a decision to deny authorization of services and the
Enrollee received the disputed services while the Appeal was pending, the Contractor
shall pay for the services provided during the pending Appeal and/or Fair Hearing.

C.5.201.5 The Contractor is prohibited from recovering payment for continuation of benefits
during a pending Appeal or District Fair Hearing.

C.5.202 The Contractor Notification of the District’s Fair Hearing Procedures

C.5.202.1 Under 42 C.F.R. § 431.244 and 1 DCMR § 2821, Fair Hearing decisions shall be based
exclusively on evidence introduced at the Fair Hearing.

C.5.202.2 The Office of Administrative Hearing must reach its decisions within the specified
timeframes in accordance with 42 C.F.R. § 431.244.

C.5.203 Continuation of Benefits During Pending Appeals and District Fair Hearings

C.5.203.1 Under 42 C.F.R. § 438.420 (b), the Contractor shall continue the Enrollee's benefits if all
the following occur:

C.5.203.1.1 The Enrollee files the request for an Appeal timely following 42 C.F.R. §
438.402(c)(ii) and (c)(ii);
C.5.203.1.2 The Appeal involves the termination, suspension, or reduction of previously authorized
services;
C.5.203.1.3 The services were ordered by an authorized Provider;
C.5.203.1.4 The period covered by the original authorization has not expired; and
C.5.203.1.5 The Enrollee timely files for continuation of benefits.

C.5.203.2 While the Enrollee’s Appeal, in accordance with circumstances set forth in section
C.5.203 is pending, the Enrollee’s benefits shall continue until one of the following
occurs:

C.5.203.2.1 The Enrollee withdraws the Appeal;
C.5.203.2.2 Ten days following the date the Contractor mails the notice providing the resolution of
the Appeal against the Enrollee, unless the Enrollee, within the ten day timeframe, has
requested a District Fair Hearing;
C.5.203.2.3 The District Office of Administrative Hearings issues a Fair Hearing decision adverse to
the Enrollee; or
C.5.203.2.4 The period or service limits of a previously authorized service has been met.

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C.5.203.3 Under 42 C.F.R. § 431.230, if the Contractor mails the Notice of Adverse Benefit
Determination, as required under Section C.5.190, and the Enrollee requests a Fair
Hearing before the effective date of the Adverse Benefit Determination, the Contractor
may not terminate or reduce services until a decision has been rendered after the Fair
Hearing unless:

C.5.203.3.1 It is determined at the Fair Hearing that the sole issue is one of federal or District law or
policy; and
C.5.203.3.2 The Contractor promptly informs the Enrollee in writing that services are to be
terminated or reduced pending the Fair Hearing decision.

C.5.204 Training

The Contractor shall conduct monthly training for its staff regarding the Grievance,
Appeal, and Fair Hearing policies and procedures and Contractor’s procedures for
implementing the requirements in Sections C.5.189 and C.5.200.

C.5.205 Grievance and Appeal Reporting Requirements

C.5.205.1 The Contractor shall submit the following reports to DHCF on Grievances, Appeals, and
Fair Hearings:

C.5.205.1.1 A monthly Grievances and Appeals report which includes, at a minimum:

C.5.205.1.1.1 The number of Grievances filed categorized by type and disposition;
C.5.205.1.1.2 The number of Appeals filed categorized by type and resolution;
C.5.205.1.1.3 The number of Expedited Appeals filed categorized by type and resolution; and
C.5.205.1.1.4 Percentage (%) of Expedited Appeals processed within 72 hours.

C.5.205.2 A monthly report on the number of Fair Hearings categorized by type and resolution;
and

C.5.205.3 A monthly summary of all Grievances, Appeals, and Fair Hearings categorized by type
and resolution.

C.5.206 Debts of Contractor

C.5.206.1 Under 42 C.F.R. § 438.116(a), Contractor shall ensure through its Contracts,
subcontracts and in any other appropriate manner that neither Enrollees nor the District
are held liable for Contractor’s debts in the event of Contractor’s insolvency.

C.5.206.2 Any cost sharing imposed on Enrollees shall follow 42 C.F.R §§ 447.50 through 447.60
and shall be approved by DHCF prior to implementation.

C.5.207 Equity Balance, Solvency, and Financial Reserves

C.5.207.1 Under 42 C.F.R. § 438.116 and the Balanced Budget Act of 1997, the Contractor shall
maintain a positive net worth, and insolvency reserves or deposits that equal or exceed
the minimum requirements established by the DISB as a condition for maintaining a
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certificate of authority to operate a health maintenance organization in the District. This
includes Contractor’s provision against the risk of insolvency to ensure that its Enrollees
shall not become liable for Contractor’s debts if Contractor becomes insolvent.
Federally Qualified MCOs, as defined in Section 1310 of the Public Health Service Act,
are exempt from this requirement.

C.5.207.2 The Contractor shall otherwise have demonstrated ability to maintain a strong financial
position to provide a sound financial foundation for its operations and to ensure the
provision of high-quality medical care. The foregoing shall be the sole manner of
regulation of the Contractor’s solvency relative to the performance of the Contract.

C.5.207.3 Under 42 C.F.R. § 438.116(b), the solvency standards in this section do not apply to an
MCO or PIHP that meets any of the following conditions:

C.5.207.3.1 Does not provide both inpatient hospital and physician services;
C.5.207.3.2 Is a public entity;
C.5.207.3.3 Is (or is controlled by) one or more Federally Qualified Health Centers and meets the
solvency standards established by the District for those centers; and
C.5.207.3.4 Has its solvency guaranteed by the District.

C.5.207.4 The Contractor shall cover continuation of services to Enrollees for duration of period
for which payment has been made, as well as for inpatient admissions up until discharge,
during periods of Contractor insolvency.

C.5.208 Fiduciary Relationship

C.5.208.1 Any director, officer, employee, or partner of the Contractor who receives, collects,
disburses, or invests funds in connection with the activities of such the Contractor shall
be responsible for such funds in a fiduciary relationship to Contractor.

C.5.208.2 The Contractor shall maintain in force and provide evidence within thirty days of
Contract award of a fidelity bond in an amount of not less than one million dollars
($1,000,000) per person for each officer and employee who has a fiduciary
responsibility or fiduciary duty to the organization.

C.5.209 Provider Payment Arrangement

The Contractor shall make its provider rates and payment agreements available to DHCF
upon DHCF’s request.

C.5.210 Special Provider Payment Arrangements

C.5.210.1 TPL and Coordination of Benefits

C.5.210.1.1 The Contractor shall comply with all applicable federal statutes and regulations
including Section 1902(a)(25) of the Social Security Act, 42 C.F.R. Part 433, Subpart D,
and the Health Care Assistance Reimbursement Act of 1984 (D.C. Law 5-86: D.C. Code
Section 3-501 et seq.).

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C.5.210.1.2 The Contractor shall be responsible for the identification and collection of all third-party
sources available for payment of Covered Services described in the Contract and
rendered to Enrollees, including court-ordered medical support available from a third
party. All funds recovered by Contractor shall be retained by Contractor and considered
income.

C.5.210.1.3 The Contractor is responsible for obtaining from Enrollees any third-party payment
source to the Contractor pursuant to notification of this responsibility as outlined in the
Enrollees’ written Evidence of Coverage. This includes but is not limited to the
following types of resources: health insurance, casualty and torts settlements or claims,
and worker’s compensation benefits.

C.5.210.1.4 The Contractor shall not consider an Enrollee with an IEP or an IFSP to be an Enrollee
with third party coverage.

C.5.210.1.5 Per Section 1902(a)(25) of the Social Security Act, DHCF will take all reasonable
measures to ascertain the legal liability of third parties and monitor Contractor’s
collections of third-party liability contributions.

C.5.210.1.6 The Contractor shall submit monthly Third-Party Liability Reports in a format to be
prescribed by DHCF by the 10th day of the month following the end of each month.

C.5.210.1.7 The Contractor shall provide a copy of all third-party liability reports to the Office of
Program Integrity on a monthly basis by the tenth (10th) of each month.

C.5.211 Financial Statements

C.5.211.1 The Contractor shall submit financial statements in compliance with the National
Association of Insurance Commissioners (NAIC) guidelines audited by an independent
certified public accountant to DISB and the CA within one hundred twenty (120) days of
the close of Contractor's fiscal year. The financial statements shall clearly show both
total expenses, revenues and the expenses and revenues attributable to CASSIP
Enrollees, including all direct medical expenses and administrative costs charged to
Contractor.

C.5.211.2 Under 42 C.F.R. § 438.6(g), upon the District’s written request, the Contractor shall
permit and assist the federal government, its agents, or the District, in the inspection and
audit of any financial records of Contractor or its Subcontractors.

C.5.212 Medical Loss Ratio (MLR)

C.5.212.1 In accordance with Section C.5.2 Contractor shall submit copies to DHCF of its
quarterly and annual financial statements and any other financial reports requested by
DHCF. These reports shall include a report to DHCF that calculates the Contractor’s
MLR for CASSIP, following 42 C.F.R. § 438.8 and as described in Section H.30.2.

C.5.212.2 If the Contractor’s MLR is less than the target MLR as described in Section H.30.2, at
DHCF’s discretion Contractor may be required to:

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C.5.212.2.1 Contract with a DHCF-approved contractor, at the Contractor’s expense, to study what
has caused the Contractor’s MLR to fall below the target MLR established during rate
setting;
C.5.212.2.2 Take corrective action, including developing a CAP, to ensure that the Contractor’s
MLR does not fall below the target; and
C.5.212.2.3 DHCF will, at its discretion, require that, in accordance with Sections G.3 or G.4,
Contractor pay a civil monetary penalty for:

C.5.212.2.3.1 Failing to provide Covered Services;
C.5.212.2.3.2 Failing to adhere to acceptable financial practices and standards for operating a health
plan in the District;
C.5.212.2.3.3 Discriminating against Enrollees in violation of Section C.5.22 and
C.5.212.2.3.4 Failing to operate an Enrollee Services department adequate to provide Covered
Services.

C.5.212.3 The Contractor shall maintain Risk-Based Capital (RBC) or the minimum required
liquid reserved at a level that is no less than two hundred percent (200%), the proxy
level established by DHCF. If Contractor’s RBC is less than two hundred (200%),
indicating less than enough capital to sustain operating losses, it will result in a freeze of
all enrollment (voluntary) or suspension of all new enrollment, including default or auto-
enrollment, after the effective date of the sanction, in accordance with section G.6.7.

C.5.212.4 The Contractor shall have the sanction referenced in section C.5.212.3 terminated at any
time once DHCF has received confirmation that the capital required to increase the RBC
above two hundred percent (200%) has been deposited.

C.5.212.5 The Contractor shall cover continuation of services to Enrollees for duration of the
period for which payment has been made, as well as for inpatient admissions through up
until discharge, during periods of Contractor insolvency.

C.5.213 MLR Reporting

C.5.213.1 The MLR report the Contractor shall submit to DISB and DHCF for each reporting year
shall include:

C.5.213.1.1 Total incurred Claims;
C.5.213.1.2 Expenditures on quality improving activities;
C.5.213.1.3 Expenditures related to activities compliant with 42 C.F.R. § 438.608(a) through , , (8)
and (b);
C.5.213.1.4 Non-Claims costs;
C.5.213.1.5 Premium revenue;
C.5.213.1.6 Taxes, licensing, and regulatory fees;
C.5.213.1.7 Methodology(ies) for allocation of expenditures;
C.5.213.1.8 Any credibility adjustment applied;
C.5.213.1.9 The calculated MLR;
C.5.213.1.10 A comparison of the information reported in this paragraph with the audited financial
report required under 42 C.F.R. § 438.3(m);
C.5.213.1.11 A description of the aggregation method used to calculate incurred Claims;
C.5.213.1.12 The number of member months; and
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C.5.213.1.13 Any other reporting requirements, as determined by DHCF and DISB.

C.5.213.2 The Contractor shall submit the MLR report required in section C.5.213 to DHCF and
DISB quarterly and annual in a format determined by the District.

C.5.213.3 The Contractor shall require any third-party vendor providing Claims adjudication
activities to provide all underlying data associated with MLR reporting to the Contractor
within 180 days of the end of the MLR reporting year or within 30 days of being
requested by the Contractor, whichever comes sooner, regardless of current contractual
limitations, to calculate and validate the accuracy of MLR reporting.

C.5.213.4 Under 42 C.F.R. § 438.8(m), in any instance where DHCF makes a retroactive change to
the capitation payments for a MLR reporting year where the report has already been
submitted to the DHCF, the Contractor shall re-calculate the MLR for all MLR reporting
years affected by the change and shall submit a new report meeting the requirements in
section C.5.213.

C.5.213.5 The Contractor shall attest to the accuracy of the calculation of the MLR in accordance
with requirements of 42 C.F.R. § 438.8 when submitting the report required under 42
C.F.R. § 438.8 (k).

C.5.214 Risk Corridor for CASSIP

C.5.214.1 The DHCF and Contractor agree to enter a risk sharing arrangement to limit the
financial gains and losses for this risk contract. The risk corridor will apply to the base
year and each option year of the Contract. This arrangement falls under the definition of
a Risk Corridor as defined in 42 C.F.R. § 438.6(a).

C.5.214.2 The arrangement sets risk corridors around a target MLR. For each rating year, the
target MLR will be evaluated in conjunction with capitation premium development and
shall be set by DHCF consistent with the percentage of the rates associated with service
expenses and care management included in the capitation rates. The target MLR will
vary for each contract year based on the rating assumptions. The target MLR is included
in Schedule B of this Contract and will also be documented in the annual Rate
Certification materials. The Contractor shall calculate, and report aggregate MLR on an
annual basis aligned to the rating year on two bases as follows:

C.5.214.3 The Contractor shall calculate the CMS-defined MLR experience in a MLR reporting
year as defined in 42 C.F.R. § 438.8.

C.5.214.4 The numerator of the contractor’s CMS-defined MLR for a MLR reporting year shall be
defined as the sum of the contractor’s incurred claims, expenditures for activities that
improve healthcare quality, and the lesser of expenditures for fraud reduction activities
or fraud reduction recoveries as defined in 42 C.F.R. § 438.8(e).

C.5.214.5 The denominator of the contractor’s CMS-defined MLR for a MLR reporting year shall
equal the contractor’s adjusted premium revenue. The adjusted premium revenue shall
be defined as the contractor’s premium revenue minus the contractor’s federal, state, and
local taxes and licensing and regulatory fees as defined in 42 C.F.R. § 438.8(f).
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C.5.214.6 The CMS-defined MLR calculation may consider any applicable credibility adjustment
per 42 C.F.R. § 438.8(g).

C.5.214.7 The Contractor shall calculate the DHCF-defined MLR experience in a MLR reporting
year as the ratio of the numerator and denominator.

C.5.214.8 The numerator of the DHCF-defined MLR shall be calculated in a manner similar to the
CMS-defined MLR with the following adjustments:

C.5.214.8.1 For purposes of this contract, medical claims will be calculated according to the
contractor’s fee schedule for services provided to non-related parties. If DHCF
identifies, through the development of Capitation Rates, review of Provider Agreements,
program integrity reviews, or through other monitoring activities, related parties to
whom the Contractor makes payments, DHCF and its Actuary will assess the
reasonableness of the related-party payments. For services with a DHCF Medicaid Fee
Schedule rate, DHCF and its Actuary will determine the ratio of the related-party
payments to the claims priced at the DHCF Medicaid Fee Schedule. DHCF and its
Actuary will compare this ratio for the related-party claims to the ratio of non-related
party payments to the non-related party claims priced at the DHCF Medicaid Fee
Schedule for similar services to assess reasonableness. For services without a DHCF
Medicaid Fee Schedule rate, DHCF and its Actuary will compare the related-party
payments to non-related party payments for the same or similar services to assess
reasonableness. If DHCF and its Actuary determine that these related-party payment
arrangements are unreasonable when compared to reimbursement rates to non-related
parties or the broader healthcare market, as identified by the Contractor and acceptable
to DHCF, the Contractor shall reflect the related-party services priced at reasonable rates
for non-related parties for similar services in the numerator.

C.5.214.9 The denominator of the DHCF-defined MLR shall be calculated consistent with the
CMS defined MLR.

C.5.214.10 Credibility adjustments as described in 42 C.F.R. § 438.8(g) are not allowed for the
DHCF defined MLR calculation.

C.5.214.11 The DHCF-defined MLR shall be determined to four decimal places (e.g., 89.4321%).

C.5.214.12 For purposes of this Contract, medical claims will be calculated according to
Contractor’s fee schedule. The District retains the right to audit medical claims as part
of the settlement process described in Section B. DHCF requires medical claims
performed by related parties to be priced and reported at comparable market rates for the
DHCF-defined MLR in C.5.212. If during audit DHCF determines Contractor’s
payments to related party providers have not been priced and reported in the DHCF-
defined MLR calculation at comparable market rates paid by the Contractor to unrelated
providers providing similar services, DHCF retains the right to reduce any loss sharing
amount owed to Contractor by an amount equal to the difference between the actual rate
used by the Contractor in the DHCF-defined MLR calculation and the market rate.

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C.5.214.13 For purposes of this Contract, Care Management Expenses will be calculated based on
annual performance of the following activities:

C.5.214.13.1 Outreach activities that educate Enrollees as to how they can access covered benefits and
services efficiently; and promote Enrollee health;
C.5.214.13.2 UM activities that manage medically necessary covered benefits and services, including:

C.5.214.13.2.1 Nurse advice lines;
C.5.214.13.2.2 Prospective and concurrent utilization review;
C.5.214.13.2.3 Case Management services provided to Enrollees with high-cost medical conditions
to improve continuity and quality of care in a cost-effective manner;
C.5.214.13.2.4 Disease Management services that, through a process of coordinated health care
interventions that emphasize prevention and management, intensively manage the
care of Enrollees with specific conditions; and
C.5.214.13.2.5 Quality Management activities designed to achieve optimal health outcomes in a
cost-effective manner.

C.5.214.14 Any other activities that meet the definition of Activities that improve health care
quality as defined in 42 C.F.R. § 438.8(g).

C.5.214.15 If the DHCF-defined MLR calculated by the contractor based on C.5.212 differs from
the target MLR established during capitation premium development, the differential is
shared between the parties as follows:

C.5.214.15.1 Any portion of the contractor’s MLR between the target MLR plus-or-minus 2% is
100% the responsibility of the contractor; no DHCF payment will be made within this
range.
C.5.214.15.2 Any portion of the contractor’s MLR between the target MLR plus 2% to plus 11% is
shared 50% between DHCF and the contractor, with DHCF payment to the contractor.
C.5.214.15.3 Any portion of the contractor’s MLR between the target MLR minus 2% to minus 11%
is shared 50% between DHCF and the contractor, with payment to DHCF.
C.5.214.15.4 Any portion of the contractor’s MLR of greater than the target MLR plus 11% is covered
100% by DHCF, with DHCF payment to contractor.
C.5.214.15.5 Any portion of the Contractor’s MLR of less than the target MLR minus 11% is returned
100% to DHCF, with payment to DHCF.

C.5.214.16 If the DHCF-defined MLR exceeds the target MLR by more than twenty-five percent
(25%) of capitation revenue, FFP may be limited.

C.5.214.17 If the actual MLR based on the DHCF-defined MLR differs from the target MLR, the
shared risk is calculated using the appropriate risk corridors which may be more than
one risk corridor.

C.5.215 Settlement Process

C.5.215.1 The risk sharing arrangement shall include a settlement process. The settlement will be
based on the MLR calculated in accordance with the DHCF definition in C.5.212 on the
basis of claims incurred in the Contract year and paid by the Contractor no later than one
hundred and eighty (180) days after the end of the Contract year.
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C.5.215.2 To facilitate the settlement, the Contractor shall comply with an audit of the medical
claims incurred in the Contract Year no later than two-hundred and forty (240) days
after the end of the Contract Year.

C.5.215.3 Based on the audit, the actual MLR will be compared to the target MLR to determine
whether a risk corridor settlement is necessary given the provision outlined in C.5.214.
DHCF retains the right to adjust loss sharing amounts owed to the Contractor based on
results of audit, as noted in Section C.5.214.12.

C.5.215.4 The settlement process shall be based on claims incurred during the Contract Year or
applicable rating period selected by DHCF. Settlement procedures shall be completed
within three-hundred and sixty-five (365) days following the end of the Contract Year.
Based on the percent of risk assumed by each party as described in Section C.5.214,
Contractor shall issue a credit to DHCF for any amount owed to the DHCF during the
term of the Contract (and a check for any amount owed thereafter), and the DHCF will
issue a check to the Contractor for any amount owed to the Contractor

C.5.216 Financial Functions

C.5.216.1 Financial Management and Operations

C.5.216.1.1 The Contractor shall maintain a system of financial management that is sufficient to
support the Contractor’s operations, including the ability to separately account for and
track CASSIP and any other D.C. Medicaid Program (as applicable) operations, and
ensure timely payment of Claims. This system shall be fully operational prior to DHCF
enrolling Enrollees with the Contractor.

C.5.216.1.2 The Contractor shall have written internal control policies and procedures that safeguard
against loss or theft of CASSIP and Non-CASSIP funds and shall submit to DHCF for
review within ninety days of Contract award.

C.5.216.1.3 The Contractor’s internal controls shall include controls to ensure that revenue and
expenses for the CASSIP are separately identifiable from other lines of business and
from each other.

C.5.216.1.4 The Contractor shall comply with all DISB licensing requirements and DHCF
requirements regarding financial solvency and reserves, including but not limited to the
submission of complete, accurate and timely reports as required by DISB and/or DHCF.

C.5.216.1.5 The Contractor shall, follow DISB and/or DHCF requirements, and undergo an audit by
an independent auditor. The Contractor shall submit a copy of its audited financial
reports on to DHCF upon completion.

C.5.216.1.6 The Contractor shall, on a quarterly basis, submit to DHCF a copy of its financial
reporting statements that are submitted to DISB. The Contractor shall include a cover
letter that provides the Contractor’s MLR calculated in accordance with NAIC
standards. This information shall be utilized to monitor the Contractor’s Risk Corridor
as specified in C.5.214.
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C.5.216.1.7 On a monthly basis, the Contractor shall submit unaudited financial statements and bank
reconciliations to DHCF.

C.5.216.1.8 The Contractor shall submit copies of any other DISB reports or any financial reports to
DHCF upon request.

C.5.216.1.9 The Contractor shall provide written notice to the CA within two Business days of:

C.5.216.1.9.1 Actions taken by DISB that may adversely affect the Contractor’s license or authority to
operate in the District of Columbia;
C.5.216.1.9.2 Any investigations or findings of the Contractor’s fraud, waste, or abuse conducted by
DISB, HHS, CMS, or OIG; and
C.5.216.1.9.3 Any actions taken by any state licensing authority against the Contractor to limit, reduce
or terminate the Contractor’s license or authority to operate in that state.

C.5.217 Claims Payment Capacity

C.5.217.1 The Contractor shall pay all Claims for properly accessed and authorized (if necessary)
CASSIP and D.C. Medicaid Covered services provided to Enrollees for dates of service
in which the Enrollees are assigned to the Contractor unless the services are excluded
under D.C. Medicaid or CASSIP.

C.5.217.2 The Contractor shall have written policies and procedures for processing Claims
submitted for payment from any source and shall monitor its compliance with these
procedures. The procedures shall, at a minimum, specify timeframes for:

C.5.217.2.1 Submission of Claims;
C.5.217.2.2 Date stamping Claims when received;
C.5.217.2.3 Determining, within a specific number of days from receipt whether a Claim is a Clean
Claim or not;
C.5.217.2.4 Payment of Clean Claim in accordance with the Prompt Payment Act, D.C. Code
§313132;
C.5.217.2.5 Follow-up of pending Claims to obtain additional information;
C.5.217.2.6 Reaching a determination following receipt of additional information; and
C.5.217.2.7 Payment of Claims following receipt of additional information.

C.5.217.3 The Contractor shall accept Network and Non-Network Providers’ initial Claim(s) for all
services rendered within three hundred sixty-five (365) days from the date of service.

C.5.217.4 The Contractor’s Claims payment system shall use standard Claims forms that have
been approved by DHCF. In addition, the Contractor shall have the capability to
electronically accept and adjudicate Claims, while complying with current HIPAA
requirements.

C.5.217.5 The Contractor’s Claims processing system shall ensure that duplicate Claim
submissions are denied.

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C.5.217.6 The Contractor shall verify that reimbursed services were provided to Enrollees by
Providers and Independent Contractors.

C.5.217.7 The Contractor shall provide the DHCF with information thirty days prior to
implementation of any changes to the software system to be used to support the claims
processing function as described in the Contractor’s proposal and incorporated by
reference in the Contract.

C.5.217.8 The Contractor shall require that Providers bill the Contractor using the same format and
coding instructions as required for the Medicaid FFS programs. The Contractor may not
require Providers to complete additional fields on the electronic forms that are not
specified under the Medicaid FFS policy and Provider manuals unless prior approval by
DHCF for Respite and Home Modification & Environmental Accessibility related
claims only.

C.5.217.9 The Contractor shall ensure that no Medicaid payments may be made to entities located
outside the United States.

C.5.217.10 The Contractor shall ensure that the NPI number is included on each Provider claim
form, including all ordering, and referring providers enrolled with DHCF as Medicaid
providers.

C.5.217.11 Furnished by an individual or entity to whom the state has failed to suspend payments
during any period when there is a pending investigation of a credible allegation of fraud
against the individual or entity, unless the state determines there is good cause not to
suspend such payments.

C.5.217.12 With respect to any amount expended for which funds may not be used under the
Assisted Suicide Funding Restriction Act of 1997.

C.5.217.13 For home health care services provided by an agency or organization, unless the agency
provides the state with a surety bond as specified in Section 1861(o) of the Act.

C.5.217.14 With respect to any amount expended for roads, bridges, stadiums, or any other item or
service not covered under the Medicaid State Plan.

C.5.218 Processing of Claims

C.5.218.1 Providers shall submit Claims to Contractor no later than three hundred sixty-five (365)
days from date of service.

C.5.218.2 The Contractor’s failure to pay or deny claims following sections C.5.218.3 and
C.5.218.4 may result in DHCF freezing all of the Contractor’s enrollment or suspending
of all new enrollment after the effective date of the sanction, in accordance with G.6.7.

C.5.218.3 The Contractor shall pay or deny ninety percent (90%) of all Clean Claims within thirty
days of receipt, consistent with the Claims payment procedures described in
§1902(a)(37)(A) of the Act and D.C. Code § 31-3132.

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C.5.218.3.1 The Contractor shall adhere to these Claim payment procedures unless the Provider and
Contractor agree, in writing, to an alternative payment schedule.

C.5.218.3.2 If the Contractor fails to comply with this requirement, the Contractor shall be required
to pay interest to Providers per D.C. Code § 31-3132(c).

C.5.218.3.3 The Contractor shall report its Clean Claim payments to DHCF monthly, including the
percentage of Clean Claims paid within 30 days of receipt.

C.5.218.4 Under 42 C.F.R. §§ 447.45 and 447.46, the Contractor shall pay ninety-nine percent
(99%) of Clean Claims within ninety days of receipt. The date of receipt is the date
Contractor receives the Claim, as indicated by its date stamp on the Claim, and the date
of payment is the date of the check or other form of payment.

C.5.218.4.1 The Contractor shall adhere to these Claim payment procedures, unless the Providers
and the Contractor agree to an alternative payment schedule in writing.

C.5.218.5 The Contractor shall submit a monthly claims payment report to the DHCF in a format
specified by the District and supplied to the Contractor.

C.5.218.6 The Contractor shall submit a quarterly performance report financial statement in a
format specified by the District and supplied to the Contractor.

C.5.218.7 The Contractor shall pay all other Claims within twelve (12) months of the date of
receipt, except in the following circumstances per 42 C.F.R § 447.45:

C.5.218.7.1 This time limitation does not apply to retroactive adjustments paid to Providers who are
reimbursed under a retrospective payment system, as defined in 42 C.F.R. § 447.272;
C.5.218.7.2 If a Claim for payment under Medicare has been filed in a timely manner, the
Contractor may pay a Medicaid Claim relating to the same services within 6six months
after the Contractor or the Provider receives notice of the disposition of the Medicare
Claim;
C.5.218.7.3 The time limitation does not apply to Claims from Providers under investigation for
fraud or abuse; and
C.5.218.7.4 DHCF may make payments at any time in accordance with a court order, to carry out
hearing decisions, or in accordance with corrective action taken to resolve a dispute, or
to extend the benefits of a hearing decision, corrective action, or court order to Enrollees
in the same situation as those Enrollees directly affected by it.

C.5.218.8 The date of receipt is the date DHCF receives the Claim, as indicated by its date stamp
on the Claim.

C.5.218.9 The date of payment is the date of the check or other form of payment.

C.5.218.10 The Contractor shall utilize a post-payment review methodology to ensure Claims have
been paid in accordance with the terms of this Contract and all applicable laws. The
Contractor shall complete post-payment reviews for individuals disenrolled by DHCF
within ninety days of the date that DHCF notifies the Contractor of the disenrollment.

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C.5.218.11 The Contractor shall remain responsible for Enrollees’ Covered Services until the date
of disenrollment from the Contractor. DHCF shall not retroactively recoup any
capitation payments resulting from retroactive eligibility changes.

C.5.219 Reimbursement to Hospital Providers

C.5.219.1 The Contractor shall negotiate contracted rates with District hospitals for inpatient
services at a minimum reimbursement level of the fee-for-service reimbursement rate
established under the Medicaid State Plan (which aims to reimburse at 98% of costs)
minus the DME add-on payment that is paid retrospectively by DHCF.

C.5.219.1.1 The Contractor shall reimburse District hospitals a minimum of 100% of the Medicaid
APR-Diagnostic Related Group (DRG) fee schedule for services provided to DCHFP
enrollees only, per the DHCF FFS rate methodologies determined by DRG base rates,
DC Medicaid FFS case weights and outlier methodologies. The results of the annual rate
analysis will be reviewed as a part of annual rate development and will be addressed in
the final capitation rates per consideration of final hospital reimbursement requirements.
This provision does not apply to ICP enrollees.

C.5.219.2 The Contractor shall negotiate contracted rates with District hospitals for outpatient
services at a minimum reimbursement of 100% of the DC Medicaid fee-for-service
EAPG conversion factor.

C.5.219.2.1 The Contractor shall reimburse outpatient services no less than 100% of the DC
Medicaid EAPG rate methodology for services provided to DCHFP enrollees only. This
provision does not apply to ICP enrollees.

C.5.219.3 The Contractor shall reimburse all District inpatient and outpatient hospital an uniform
increase above negotiated contract rates that ensures total inpatient and outpatient
reimbursement at the average commercial rate, as determined by DHCF. This
reimbursement will be quarterly or within a timeframe determined by DHCF, via lump
sum payment, based on the claims incurred during that quarter or an estimate of claims
as determined by DHCF. This provision does not apply to public Institutions for Mental
Diseases as defined in Section 1905(i) of the Social Security Act.

C.5.219.4 On a quarterly and annual basis, the Contractor shall implement a reconciliation process
for payments made in accordance with C.5.219.1 accounting for lagged claims not
included in the quarterly directed payment calculations and directed payments made for
individuals retroactively disenrolled during the rate year. The Contractor shall make
available evidence that payments have been made to the Hospitals, as requested by
DHCF.

C.5.219.5 The Contractor shall pay out-of-network hospital Providers for all emergencies and
authorized Covered Services provided outside of the established network. Out-of-
network hospital Provider Claims shall be paid at the established Medicaid rate in effect
on the date of service for participating Medicaid Providers. Out-of-Network hospital
provider payments shall include payment for the DRGs, as defined in the Medicaid
Institutional Provider Chapter IV), outliers, as applicable, and capital costs, at the per-
discharge rate.
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C.5.219.6 For non-emergent services, the Contractor may reimburse an Out-of-Network Provider
if an Enrollee cannot obtain services through a Network Provider.

C.5.220 Payment Resolution Process

The Contractor shall develop and maintain an effective process to promptly resolve
Provider billing disputes. This process shall include a provision for binding arbitration
or other alternative dispute resolution processes between the parties.

C.5.221 Financial Performance Reporting Requirements

C.5.221.1 The Contractor shall submit Claims Payment and financial performance reports to
DHCF in accordance with section C.5.227, which shall include at a minimum:

C.5.221.1.1 A Claims Payment Performance Report for CASSIP services, monthly; and
C.5.221.1.2 A monthly report of Claims incurred but not paid, separately described for CASSIP and
Non-CASSIP Programs.

C.5.222 Enrollees Held Harmless

C.5.222.1 Enrollees shall not be held liable for any of the following provisions consistent with 42
C.F.R. §§ 438.106 and 438.116:

C.5.222.1.1 Contractor’s debts, in case of insolvency;
C.5.222.1.2 Covered Services under the Contract provided to the Enrollee for which the District does
not pay Contractor;
C.5.222.1.3 Covered Services provided to the Enrollee for which the District or the Contractor does
not pay the Provider due to contractual, referral or other arrangement; or
C.5.222.1.4 Payments for Covered Services furnished under a Contract, referral, or other
arrangement, to the extent that those payments are in excess of the amount that the
Enrollee would owe if Contractor provided the services directly.

C.5.222.2 The Contractor or its Providers may not require any co-payments, patient-pay amounts,
or other cost-sharing arrangements, unless authorized by DHCF. The Contractor’s
Providers shall not bill Enrollees for the difference between the Provider’s charge and
the Contractor’s payment for Covered Services. The Contractor’s Providers shall not
seek nor accept additional or supplemental payment from the Enrollee, his/her family, or
representative, in addition to the amount paid by Contractor, even when the Enrollee has
signed an agreement to do so. These provisions also apply to Out-of-Network
Providers.

C.5.222.3 The Contractor or its Providers shall exempt Native Americans/Indigenous Americans
from payment of a deductible, coinsurance, copayment, or similar charge for any item or
service covered by Medicaid if the Indian is furnished the item or service directly by an
Native American/Indigenous American health care Provider, I/T/U or through CHS.

C.5.223 Health Information Technology and Encounter Data

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C.5.223.1 The Contractor shall be a participating organization in the District’s Health Information
Exchange (DC HIE) as specified in 29 DCMR Chapter 87.

C.5.223.2 The Contractor shall maintain a health information system that collects, analyzes,
integrates, and reports data and can achieve the objectives of 42 C.F.R. § 438.242. The
system must provide information on the areas including, but not limited to utilization,
Claims, grievance and appeals as well as enrollment and disenrollment for reasons other
than loss of Medicaid eligibility.

C.5.223.3 The Contractor shall provide complete Enrollee Encounter Data for all Covered Services
in the format specified by DHCF including the method of transmission and the
submission schedule. The submission of Enrollee Encounter Data transmissions must
include all Enrollee Encounter Data and Enrollee Encounter Data adjustments processed
by the Contractor. Enrollee Encounter Data quality validation shall incorporate
assessment standards developed jointly by the Contractor and DHCF.

C.5.223.3.1 Upon request by DHCF, Contractor shall provide all Provider claims, both denied and
paid to DHCF based on requested reporting requirements.

C.5.223.4 The Contractor, following 42 C.F.R. §438.242(c), shall provide for:

C.5.223.4.1 Collection and maintenance of sufficient Enrollee Encounter Data to identify the
Provider who delivers any item(s) or service(s) to Enrollees;
C.5.223.4.2 Submission of Enrollee Encounter Data to the DHCF at a frequency and level of detail
to be specified by the District, based on program administration, oversight, and program
integrity needs;
C.5.223.4.3 Submission of all Enrollee Encounter Data, including the allowed amount and paid
amount, that the District is required to report to CMS under 42 C.F.R. §438.818; and
C.5.223.4.4 Specifications for submitting Enrollee Encounter Data to the District in standardized
ASC X12N 837 and NCPDP formats and the ASC X12N 835 format, as appropriate.

C.5.223.5 The Contractor shall maintain the ability to submit all Encounter and Claims data
electronically in accordance with HIPAA and specifications supplied by DHCF.

C.5.223.6 The Contractor shall implement an Application Programming Interface (API) that meets
the criteria specified at 42 C.F.R. 431.60 and include(s):

C.5.223.6.1 Data concerning adjudicated claims, including claims data for payment decisions that
may be appealed, were appealed, or are in the process of appeal, and provider
remittances and beneficiary cost sharing pertaining to such claims, no later than one
business day after a claim is processed.
C.5.223.6.2 Clinical data, including laboratory results, if the Contractor maintains any such data, no
later than one business day after the data is received by the District.
C.5.223.6.3 Information about covered outpatient drugs and updates.
C.5.223.6.4 Implement and maintain a publicly accessible standards-based API described in 42
C.F.R. §431.70, which must include all information specified in § 438.10(h) and of this
chapter.
C.5.223.7 The Contractor shall implement and maintain a publicly accessible standards-based API
as described in 42 C.F.R. 431.70, which shall include all of the provider directory
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information specified in 42 C.F.R. 438.10(h).

C.5.223.8 The Contractor shall ensure data accuracy, completeness, and consistency through
routine internal validation and quality assurance procedures.

C.5.223.9 The Contractor shall submit all required data in accordance with the timeframes and
formats specified and defined in the DHCF Managed Care Program Reports Manual.

C.5.223.9.1 The Contractor shall ensure that all submitted data is compliant with HIPAA and CMS
standards.

C.5.223.10 The Contractor shall ensure that all submitted data is compliant with HIPAA and CMS
standards.

C.5.223.11 The Contractor shall implement data backup, disaster recovery, and business continuity
protocols to maintain system functionality and data integrity.

C.5.223.12 The Contractor shall respond to reports issued by DHCF identifying data discrepancies,
including data errors or formatting inconsistencies, within three business days of receipt
of notification. The Contractor may request an extension of two days and proactively
identify and correct any such issues in submitted information, notifying DHCF of
material problems within two business days of discovery.

C.5.224 District Review and Validation of Enrollee Encounter Data

C.5.224.1 The Contractor shall validate the completeness and accuracy of the reported Enrollee
Encounter Data and validate that it precisely reflects the services provided to the
Enrollees under this Contract.

C.5.224.2 The Contractor shall ensure timely submission of data, in the format and timeframe
specified by DHCF.

C.5.224.3 The Contractor shall have policies and procedures in place to monitor data
completeness, consistency, and validity, including an attestation process.

C.5.224.4 The Contractor shall comply with Section 6504 (a) of the Affordable Care Act (ACA),
which requires that the Contractor’s Claims Processing and retrieval systems collect data
elements necessary to enable the mechanized Claims processing and information
retrieval systems and operation by the DHCF to meet the requirements of Section 1903
(r)(F) of the Act.

C.5.224.5 The Contractor shall have internal procedures to ensure that data reported to DHCF is
valid and is routinely tested for validity, accuracy, and consistency. At a minimum, the
Contractor shall:

C.5.224.5.1 Verify the accuracy and timeliness of reported data Verify the accuracy and timeliness
of reported data including data from network providers the Contractor is compensating
based on capitation payments;
C.5.224.5.2 Screen the data for completeness, logic, and consistency; and
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C.5.224.5.3 Collect service information in standardized formats, approved by DHCF, to the extent
feasible and appropriate.

C.5.224.6 The Contractor shall cooperate in data validation activities that may be conducted by
DHCF, and make available medical records, Claims records, and other data as specified
by DHCF.

C.5.224.7 The Contractor shall ensure its MIS is capable of allowing the Contractor to comply
with the requirements of section C, including but not limited to the Performance
Reporting Requirements in section C.5.133 and the Financial Performance Reporting
Requirements in section C.5.221.

C.5.224.8 The Contractor shall ensure the MIS is capable of collecting, analyzing, integrating,
preserving, safeguarding, and reporting data following 42 C.F.R. § 438.242(a).

C.5.224.9 The Contractor’s data collection, analysis, integration, and reporting shall comply with
Federal and DHCF reporting requirements, including CMS reporting requirements and
data specifications.

C.5.224.10 The Contractor shall have a MIS capable of documenting administrative and clinical
procedures, while maintaining the privacy and confidentiality of protected health
information, following HIPAA, the District’s Mental Health Information Act, and 42
C.F.R. Part 2, including special privacy and confidentiality provisions related to people
with HIV/AIDS, mental illness, and substance use disorders.

C.5.224.11 The Contractor shall develop and implement required corrective action activity,
including CAPs in accordance with section C.5.181, to correct data problems.

C.5.224.12 The Contractor shall develop an MIS disaster recovery plan. The Contractor shall submit
the plan to DHCF within ninety days of the Contract award and annually thereafter.

C.5.225 Eligibility Data

C.5.225.1 At the time of service, the Contractor or its subcontractors shall verify every Enrollee’s
eligibility through the eligibility verification system operated by DHCF.

C.5.225.2 The Contractor shall notify DHCF whenever an Enrollee reports a change in
demographics, (e.g., changes names, phone numbers, language spoken, and addresses
procedures or other such changes).

C.5.225.3 The Contractor shall maintain Enrollee information for whom accurate addresses or
current locations cannot be determined and shall document the action that has been
taken to locate the Enrollee. This information shall be available upon request by DHCF.

C.5.225.4 The Contractor shall, within two Business days, notify DHCF and the Pharmacy of the
death of any Enrollee accordingly.

C.5.226 Encounter and Claims Records

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C.5.226.1 The Contractor shall comply with the requirements set forth in the MCO Instruction
Manual for Encounter Data Submission, attached as Attachment J.21.

C.5.226.2 The Contractor shall use a standardized methodology capable of supporting CMS
reporting categories for collecting service event data and costs associated with each
category of service. The Enrollee Encounter Data reporting system shall assure the
ability to generate aggregated, unduplicated service counts provided across service
categories, Enrollee demographic and health characteristics, Provider types, and
treatment facilities.

C.5.226.3 The Contractor shall collect and submit service specific data in the appropriate HIPAA
compliant ASC X12N 837 format or an alternative format, if approved by DHCF.

C.5.226.4 The Contractor shall submit, in the next week’s scheduled submission day(s),
adjustments to previous records that are deemed to be reparable denials by DHCF’s
Fiscal Agent. More frequent submissions may be allowed with prior approval from
DHCF. The data shall include all services reimbursed by the Contractor, including
services reimbursed at $0.

C.5.226.5 The Contractor shall submit to DHCF the following data:

C.5.226.5.1 Encounter data in the form and manner described in 42 C.F.R. § 438.818;
C.5.226.5.2 Data based on which the DHCF certifies the actuarial soundness of capitation rates to
the Contractor under 42 C.F.R. § 438.4, including base data described in 42 C.F.R. §
438.5(c) that is generated by the Contractor;
C.5.226.5.3 Data based on which DHCF determines the compliance of the Contractor with the MLR
requirement described in 42 C.F.R. § 438.8; and
C.5.226.5.4 Data based on which DHCF determines that the Contractor has made adequate provision
against the risk of insolvency as required under 42 C.F.R. § 438.116:

C.5.226.5.4.1 Documentation described in 42 C.F.R. § 438.207(b) on which DHCF bases its
certification that the Contractor has complied with the State's requirements for
availability and accessibility of services, including the adequacy of the provider network,
as set forth in § 438.206;
C.5.226.5.4.2 Information on ownership and control described in 42 C.F.R. § 455.104 from the
Contractor, and subcontractors, as governed by 42 C.F.R. § 438.230; and
C.5.226.5.4.3 The annual report of overpayment recoveries, as required in § 438.608(d).

C.5.226.5.5 The Contractor or the District will retain the overpayment recoveries depending on
which entity identified the overpayment. Under this arrangement, if the Contractor
identifies the overpayments through its own data analysis or other program integrity
activities, the Contractor can retain the recoveries. Alternatively, if the District identifies
overpayments by analyzing the Contractor’s payment data and the Contractor has not yet
identified the overpayments, the District can require the Contractor to recover the
overpayment and refund the overpayment to the District.

C.5.227 Reporting Requirements

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C.5.227.1 This section sets forth reporting requirements applicable to the Contractor performance
and establishes a series of reporting requirements related to reportable and notifiable
events, including, the results of interactions between the Contractor, Providers and
Enrollees assigned to the Contractor.

C.5.227.2 All reporting requirements shall be carried out in accordance with DHCF’s policies and
procedures, including any subsequent amendments thereto. The Contractor shall comply
with relevant privacy and confidentiality standards, HIPAA, and any electronic
formatting specifications when fulfilling the requirements of this section.

C.5.227.3 DHCF may request that the Contractor attend meetings to explain or provide additional
information regarding reports the Contractor has submitted. The Contractor shall be
required to send appropriate staff to such meetings, as required by DHCF.

C.5.228 Encounter Data and Pharmacy Data

C.5.228.1 The Contractor shall submit Encounter Data in a specified format and frequency as
determined by DHCF, which shall be provided to the Contractor within thirty days of
award of this Contract. DHCF reserves the right to change MIS and/or reporting
specification and format.

C.5.228.2 The Contractor shall report complete, accurate and timely data regarding
pharmaceuticals in a format specified by DHCF.

C.5.228.3 The Contractor shall have internal procedures to ensure that data reported to DHCF are
Valid and to test validity, accuracy, and consistency on a regular basis. At a minimum,
Contractor shall verify the accuracy and timeliness of reported data; shall screen the data
for completeness, logic, and consistency; and shall collect service information in
standardized formats to the extent feasible and appropriate. Contractor shall ensure that
reportable data reflects a sufficient sample size to accurately reflect the Enrollee
population.

C.5.229 Reporting Attestation

C.5.229.1 By submitting a report or Deliverable, the Contractor represents that, to the best of its
knowledge, it has performed the associated tasks in a manner that shall, in concert with
other tasks, meet the objectives stated or referred to in the Contract. Under 42 C.F.R. §
438.606, the Contractor shall, provide an attestation/certification to DHCF, based on
best information, knowledge, and belief that the data, documentation, and information
are accurate.

C.5.229.2 The Contractor’s CEO, CFO, CMO or an individual who reports directly to the CEO,
CFO, or CMO with delegated authority to sign for the CEO or CFO (the CEO or CFO is
ultimately responsible for the certification), must certify the data, documentation, or
information submitted by the Contractor to the District.

C.5.230 Reportable Health Conditions

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C.5.230.1 The Contractor shall report specific conditions and diseases in accordance with D.C.
Code §§ 7- 131, 132, and Title 22 DCMR.

C.5.230.2 Infants, Toddlers, and School-Age Children Experiencing Developmental Delay

C.5.230.2.1 The Contractor shall report to the DC Strong Start EI Program/ OSSE and to the DHCF
Enrollees who are infants, toddlers, and school-age children, whose developmental
assessment components of their EPSDT periodic or interperiodic exams reveal evidence
of developmental delay.

C.5.230.3 Enrollees with Vaccine – Preventable Disease

C.5.230.3.1 The Contractor shall report on all CASSIP Enrollees with vaccine-preventable diseases.
Reports shall be submitted to the HIV/AIDS, Hepatitis, STD, and TB Administration
(HAHSTA), DC Health.

C.5.230.4 Sexually Transmitted and other Communicable Diseases

C.5.230.4.1 The Contractor shall report Enrollees with sexually transmitted and other communicable
diseases, including HIV. Reports of sexually transmitted diseases must be submitted to
the HAHSTA, DC Health.

C.5.230.5 Tuberculosis

C.5.230.5.1 Within 48 hours of identification, the Contractor shall report Enrollees diagnosed with
or suspected as being infected with tuberculosis to the HAHSTA.

C.5.230.5.2 The Contractor shall provide periodic reports on Enrollees in treatment and notify
HAHSTA of Enrollees absent from treatment more than thirty days.

C.5.230.6 Blood Lead Levels among all CASSIP Enrollees Under the Age of Six

C.5.230.6.1 Following the District’s Childhood Lead Poisoning Screening and Reporting Legislative
Review Emergency Act of 2002, D.C. Code § 7-871.03, the Contractor shall report, and
require that its independent contractors, including contracted laboratories report, results
of all blood lead screening tests to DHCF and the Mayor, District Department of Energy
and Environment, Childhood Lead Prevention Program within seventy-two hours after
identification.

C.5.230.7 The Contractor shall refer a child identified for assessment of developmental delay and
shall coordinate services required to treat the exposed child with lead inspection and
abatement services.

C.5.230.8 The Contractor shall comply with the reporting requirements of the District registries
and programs, including but not limited to, the Cancer Control Registry.

C.5.230.9 The Contractor shall report to the District all identified provider-preventable conditions,
as defined in C.F.R. § 447.26 (b), within 24 hours of identification.

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C.5.230.10 The Contractor shall require Providers to report Provider-preventable conditions
associated with claims for payment or Enrollee treatments for which payment would
otherwise be made.

C.5.231 Reporting to DISB

C.5.231.1 Following D.C. Code § § 31-301 et seq.; D.C. Code §§ 31-1901 et seq.; D.C. Code §§
31-1401 et seq.; D.C. Code §§ 31-701 et. seq.; and D.C. Code §§ 31-2101 et seq., The
Contractor shall submit reports in compliance with the DISB, requirements as
appropriate. The Contractor shall submit reports to the DHCF according to the timelines
described in section F.3.

C.5.231.2 The Contractor shall comply with any changes, additions, or deletions to these laws
and/or timelines as directed by DISB.

C.5.231.3 Failure to submit timely, accurate reports may result in fines, penalties, and Sanctions, to
the extent allowed by Section G.6.7.

C.5.232 Protection of Confidential Information

C.5.232.1 The Contractor shall ensure that any reports that contain information about individuals
which are protected by privacy laws, including the HIPAA, Standards for Privacy of
Individually Identifiable Health Information, 45 C.F.R. §§ 160-164 (The HIPAA
Privacy and Security Rules), the District of Columbia Mental Health Information Act,
D.C. Code §§ 7-1201.01 – 7-1208.07, and the Confidentiality of Alcohol and Drug
Abuse Patient Records, 42 C.F.R. Part 2 et seq., shall be prominently marked as
“Confidential” and submitted to DHCF in a fashion that ensures that unauthorized
individuals do not have access to the information. The Contractor shall not make reports
available to the public.

C.5.232.2 The Contractor shall conduct annual risk assessments, and annual audits of cloud-based
services to meet the requirement for managing protected health information and
compliance with HIPAA regulations associated with the collection of Enrollee
information.

C.5.232.3 The contractor shall report any use or disclosure of PHI not permitted or required by this
Contract or attachment J.11 (BAA), and any incident or condition arising out of the
Privacy Security Rule, including breaches of unsecured PHI as required at 45 C.F.R §
164.410, to dhcfprivacy@dc.gov within 24 hours or the next business day. The
Contractor shall report to the DHCF any HIPAA incident of which it becomes aware,
including any attempts to access ePHI, whether those attempts were successful or not.

C.5.232.4 The Contractor shall have resources to investigate incidents arising out of the Privacy
and Security Rules, and develop CAPs as requested to assist the Contractor in
preventing re-occurrences/breaches of unsecured PHI.

C.5.232.5 The Contractor shall provide reports of its investigation using forms or formats
identified by DHCF. The HIPAA information that the Contractor shall report to the
DHCF shall include at a minimum:
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C.5.232.5.1 The nature of the incident;
C.5.232.5.2 How many individuals were involved;
C.5.232.5.3 What information was involved;
C.5.232.5.4 When did the incident happen;
C.5.232.5.5 What did the contractor do to prevent further harm; and
C.5.232.5.6 Summary of any follow-up.

C.5.232.6 Additionally, in accordance with 45 C.F.R. §§ 164.402. when applicable, the
information should demonstrate that there is a low probability the PHI has been
compromised and submit findings to DHCF, no later than 72 hours after the initial
report.

C.5.223.5.7 Upon request, provide a log of HIPAA incidents, including documented breaches, risk
assessments, and any additional requested information demonstrating compliance with
HIPAA regulations

C.5.232.8 The Contractor’s failure to report incidents involving the use or disclosure of PHI not
listed in the contract or Attachment J.11 (BAA) may result in sanctions and penalties to
the extent allowed by section G.6.7, including but not limited to, termination of the
Contract.

C.5.233 Reporting Requirements Table

C.5.233.1 The table in section F.3 lists the reporting requirements under this Contract in addition
to reporting requirements identified throughout this Contract. All reports, Deliverables,
policies, procedures, documents, notifications, and attestations listed in the table shall be
submitted to DHCF in accordance with the application section(s) and section F.3, unless
otherwise specifically noted by DHCF. The table is organized by type of document and
divided, as in section C, with a citation to the location in section C. Additional
information about Deliverables is found in section F.3.

C.5.233.2 The Contractor shall be required to comply with all requirements imposed by court order
or a court monitor, including but not limited to District mediation efforts, settlement
agreements, and other judiciary proceedings related to Salazar v. District of Columbia.

C.5.233.3 In addition to the data, documentation, and information specified in Section F.3 the
Contractor is required to submit, the Contractor shall submit all other data,
documentation, and information relating to the performance of the Contractor’s
obligations under this Contract, as required by the District or the Secretary. The
Contractor shall submit certification/attestation concurrently with the submission of data
and documentation of other information, as required in 42 C.F.R. § 438.604(a).

C.5.234 Recordkeeping Requirements

C.5.234.1 In accordance with Contractor shall reimburse hospitals per the DHCF FFS rate
methodologies determined by DRG base rates, Medicaid FFS case weights and outlier
methodologies. The results of the annual rate analysis will be reviewed as a part of
annual rate development, and will be addressed in the final capitation rates per
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consideration of final hospital reimbursement requirements, the Contractor shall retain,
and require subcontractors to retain, as applicable, the following information:

C.5.234.1.1 Enrollee Grievance and Appeal records per 42 C.F.R. § 438.416;
C.5.234.1.2 Base data (rate development) per 42 C.F.R. § 438.5(c);
C.5.234.1.3 MLR reports per 42 C.F.R. § 438.8(k) and DHCF requirements; and
C.5.234.1.4 The data, information, and documentation specified in 42 C.F.R. §§ 438.604, 438.606,
438.608, and 438.610 for a period of no less than 10 years.

C.5.235 Primary Care Rates

C.5.235.1 In accordance with the ACA § 1902(a)(13) and 42 C.F.R. § 447.405, the Contractor
shall reimburse qualified Primary Care Providers, OB/GYNs, psychiatrists and nurse
Practitioners for certain primary care and vaccine administration services at 100% of the
applicable Enhanced Medicare rates, which is the Medicare Part B schedule rate
applicable to a non-facility site of service.

C.5.235.2 The Contractor shall ensure that qualified Providers, as determined by DHCF, within the
Contractor’s Provider network receive the direct benefit of the Enhanced Medicare rate
for all eligible primary care and vaccine administration services.

C.5.235.3 Qualified primary care and vaccine administration services include Evaluation and
Management (E&M) under the Healthcare Common Procedure Coding System
(HCPCS); and Current Procedural Terminology (CPT) codes related to immunization
administration for vaccines and toxoids, as determined and approved by DHCF.

C.5.235.4 The Contractor shall ensure that each Qualified Provider receiving an increased payment
for primary care and vaccine administration payments submits a written self-attestation
that he/she is Board-certified in family medicine, internal medicine,
obstetrics/gynecology or pediatric medicine or in a subspecialty within those
designations as determined by the American Board of Medical Specialists (ABMS), the
American Board of Physician Specialists (ABPS), the American Board of Obstetrics and
Gynecology, the American Board of Psychiatry and Neurology (ABPN), and the
American Osteopathic Association (AOA).

C.5.235.5 A physician who is not Board-certified in family medicine, general medicine, obstetrics
and gynecology or pediatric medicine or a designated subspecialty must self-attest that
he/she has furnished the approved evaluation and management services and vaccine
administration services codes that equals at least 60 percent (60%) of the Medicaid
codes he or she has billed during the most recently completed calendar year, or for a
physician enrolled in Medicaid for less than a full calendar year, the month prior to the
month the self-attestation form is completed.

C.5.235.6 Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PA) who are
practicing under the direct supervision of a physician are also eligible to receive an
increase in reimbursement, provided the physician meets the eligibility requirements of
section C.5.94, has assumed professional responsibility for the services provided by the
APRN or PA, and has submitted a self-attestation form that identifies the APRN or PA
as a practitioner under the physician’s direct supervision.
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C.5.235.7 Each physician’s self-attestation must be completed on a form prescribed by DHCF.

C.5.235.8 Physicians who participates in multiple Contractor Provider Networks are only required
to complete and submit one form.

C.5.235.9 DHCF shall provide the Contractor with a list of physicians and non-physician
practitioners who have qualified to receive the Enhanced Medicare rate and who have
indicated that they participate in the Contractor’s network. The Contractor is responsible
for verifying that each listed practitioner is a member of the Contractor’s Provider
Network.

C.5.235.9.1 The Contractor shall refer interested providers in their network who are not on the list of
qualified providers to DHCF.

C.5.235.10 Payments under the ACA § 1902(a)(13) and 42 C.F.R. § 447.405 shall commence from
the effective date determined and approved by DHCF.

C.5.235.11 The Contractor shall be responsible for reimbursement of all eligible primary care and
vaccine administration services rendered by a qualified physician, APRN or PA.

C.5.235.12 DHCF shall publish the applicable rates for eligible primary care and vaccine
administration services each calendar year on its website at www.dhcf.dc.gov/.

C.5.235.13 The Contractor shall submit a report to DHCF on a quarterly basis, using a template
provided by DHCF.

C.5.235.14 Annually, DHCF will undertake a review to verify that physicians and other
practitioners are receiving enhanced Medicare rate payments pursuant to requirements
outlined in this section.

C.5.235.15 The Contractor shall provide information to allow DHCF, to validate the appropriate and
timely enhanced payments to Qualified Providers.

C.5.235.16 The Contractor shall recoup and repay to DHCF any payments made to a Provider in
violation of the provisions of this Contract and DHCF rules.

C.5.235.17 Exclusions

Qualified primary care service Providers receiving payment through another Provider,
such as a hospital, clinic or FQHC, are not eligible for the increased payment.

C.5.236 Value Based Purchasing (VBP)

C.5.236.1 The DHCF seeks to advance its mission to improve health outcomes and promote the
goals and objectives of the District’s Quality Strategy by providing access to
comprehensive, cost-effective and quality healthcare services for residents of the District
of Columbia and to ensure that payments to providers are increasingly focused on
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population health, appropriateness of care and other measures related to value to achieve
The Triple Aim framework as described in Section C.2.276.

C.5.236.1.1 Use of VBP and Provider Incentive Programs shall align financial incentives and
accountability with the total cost of care and overall health outcomes and ensure that
Contractors and Network Providers are recognized and rewarded for delivering high
quality care through innovative and cost-effective reimbursement strategies.

C.5.236.1.2 The Contractor shall participate in DHCF-funded TA programs, collaboratives,
outreach, and webinars which support provider-organizations' participation in VBP
arrangements.

C.5.236.1.3 The VBP arrangement must have a connection to quality performance, but can
incorporate foundational and infrastructure payments (e.g., care coordination fees) and
pay for reporting components. Qualifying VBP arrangements in pediatrics, maternal
health, and primary care must comply with DHCF's preferred measures requirements in
C.5.236.5.2

C.5.236.1.4 The Contractor shall have an IT infrastructure and data analytic capabilities to support
the DHCF’s vision in moving toward value-based payment, have systems that can
support alternative payment arrangement models which require shared savings and/or
risk-sharing across different provider types, care settings and locations. These systems
must have mechanisms to measure quality and costs across attributed populations, share
actionable administrative and clinical data with providers in these VBP arrangements,
and process payments to providers based on the terms of the contract.

C.5.236.2 Value-Based Purchasing Strategies

C.5.236.2.1 A VBP model aligns payment more directly to the quality and efficiency of care by
rewarding Providers for improved performance within the quality metrics outlined in the
DHCF Quality Strategy located at https://dhcf.dc.gov/managed-care-qualitystrategy.
VBP strategies may include any combination of the following payment model
classifications as defined by the LAN-APM framework:

C.5.236.2.1.1 Category 2C (Pay for Performance) link to Quality and Value per calendar year, as
defined by DHCF.
C.5.236.2.1.2 Category 3 APM Built on Fee-For Service Architecture
C.5.236.2.1.3 Category 4 Population Based Payment

C.5.236.3 Value-Based Purchasing Requirements

C.5.236.3.1 The Contractor shall incorporate VBP initiatives with its Network Providers. IT
infrastructure shall also include Contractor’s ability to share attributed patient panels
with the DC HIE for provider organizations in VBP arrangements. The Contractor shall
meet the benchmarks relative to the percentage of the total medical expenditures under
VBP strategies as outlined in the DC Medicaid VBP Framework (2026-2030).

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C.5.236.3.1.1 The Contractor shall complete an APM assessment based on the categories developed by
HCP-LAN by the end of each Contract Year. DHCF will provide specifications on the
assessment methodology upon Contract Award.

C.5.236.3.1.2 DHCF shall use the APM assessment to demonstrate compliance with section C.5.236.3.
For each Contract Year, Contractors shall annually document progress for each of the
VBP models. Starting in Contract Year 2, the Contractor shall compare documented
progress to the Contractors APM strategy as well as performance against VBP results in
the previous Contract Year. The Contractor’s evaluation of VBP performance shall
include lessons learned, best and promising practices and a plan to improve the process
for the upcoming Contract Year.

C.5.236.3.1.3 The Contractor shall report the results of the APM assessment within three months after
the end of each Contract Year.

C.5.236.3.1.4 To ensure the Contractor’s response aligns with the DHCF Quality Strategy which seeks
to achieve the Triple Aim framework and reduce health disparities, the Contractor shall
provide a description of its Value-Based Purchasing initiatives at the start of each
Contract Year.

C.5.236.3.1.5 DHCF will approve/disapprove all proposed VBP/APM models submitted by the
Contractor for each Contract Year.

C.5.236.3.2 Failure to meet the minimum target as noted in section C.5.236.3.1 will result in a CAP
and/or sanctions as determined by DHCF.

C.5.236.3.3 DHCF reserves the right to amend or adjust the Contractors VBP requirements in any
Contract Year.

C.5.236.4 VBP Reporting Requirements

C.5.236.4.1 The Contractor shall submit an annual report of all implemented VBP initiatives as
required in Section C.5.236.5.2 to DHCF using the VBP report template provided by
DHCF.

C.5.236.5 VBP Provider Terms of Performance

C.5.236.5.1 The Contractor shall use the same terms of performance to a class of providers providing
services under the Provider Agreement.

C.5.236.5.2 The Contractor shall use a common set of performance measures across all like Network
Providers participating in the Contractor’s VBP arrangements, as required annually via
DHCF’s preferred measure list.

C.5.237 Implementation of Contract

C.5.237.1 The Contractor shall develop and submit to DHCF an Implementation Plan at the time of
the award of a Contract under this RFP within 30 days of the date of award of this
Contract. This Implementation Plan shall include:
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C.5.237.1.1 A comprehensive plan for the provision of transitional services to Enrollees;
C.5.237.1.2 A clear description of staff responsibilities for implementing the Contract; and
C.5.237.1.3 Sufficient resources to carry out the Implementation Plan and clearly defined milestones
appropriate to meet the goals and objectives of the implementation.

C.5.237.2 The Contractor shall designate an implementation planning group to direct the
implementation of all required functions under the Contract and to develop and carry out
the Implementation Plan.

C.5.237.3 The Implementation Planning Group shall be comprised of individuals with knowledge
of and/or experience with managed care, pediatric & adolescent clinical care, MIS,
Medicaid managed care, mental health care and substance use disorders, EPSDT,
District of Columbia’s health system, and other functions for successful implementation.

C.5.237.4 The Contractor shall submit to DHCF, as part of its Implementation Plan, the documents
stated in Section C.5.237.

C.5.237.5 The Contractor shall fully cooperate with DHCF in its Readiness Assessment, which
shall be conducted prior to implementation of the Contract. As part of the Readiness
Assessment, the Contractor shall provide the additional information described in section
H.12.

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SECTION D: PACKAGING AND MARKING

D.1 The packaging and marking requirements for this contract shall be governed by clause number ,
Shipping Instructions-Consignment, of the Government of the District of Columbia's Standard
Contract Provisions for use with Supplies and Services Contracts, dated July 2010. (Attachment
J.1)

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SECTION E: INSPECTION AND ACCEPTANCE

E.1 The inspection and acceptance requirements for this contract shall be governed by clause
number six , Inspection of Services of the Government of the District of Columbia's Standard
Contract Provisions for use with Supplies and Services Contracts, dated July 2010. (Attachment
J.1)

E.2 Inspection and Acceptance-Destination Inspection and acceptance of the supplies/services to be
furnished hereunder shall be made at a DHCF destination specified by the CA or his/her duly
authorized representative.

E.3 Right to Enter Premises

E.3.1 In accordance with 42 C.F.R. § 438.3(h), DHCF, OCP, HHS including CMS, the City Auditor,
the U.S. Government Accountability Office (GAO), the Office of the Inspector General, the
Comptroller General, and their designees may, at any time inspect the premises, physical
facilities, and equipment where Medicaid-related activities or work is conducted. The right to
audit under this section exists for 10 years from the final date of the contract period or from the
date of completion of any audit, whichever is later. The Contractor and all subcontractors shall
provide reasonable access to all facilities. All inspections and evaluations shall be performed in
such a manner to not unduly delay work.

E.3.2 The Contractor shall provide direct access upon request to DHCF, OCP, HHS including CMS,
the City Auditor, the GAO, the Office of the Inspector General, the Comptroller General, to the
Contractor’s:

E.3.2.1 Claims Information;
E.3.2.2 Encounter Information;
E.3.2.3 Financial Records;
E.3.2.4 CQI Information;
E.3.2.5 Provider Files; and
E.3.2.6 Enrollee records.

E.4 Monitoring of Performance

E.4.1 The District shall utilize a variety of methods to determine the Contractor’s compliance with
Contract requirements and measure the quality of the Contractor’s performance.

E.4.2 The District may employ fines, remedies, and sanctions to address issues of Contractor’s
noncompliance and poor performance. These methods include but are not limited to:

E.4.2.1 Fines, as described in section G.6.6;
E.4.2.2 Sanctions, as described in section G.6.7;
E.4.2.3 Suspension or freezing of enrollment with Contractor;
E.4.2.4 Withholding part or all of Contractor’s Capitation payment, as described in section G.6.4;
E.4.2.5 Corrective Action;
E.4.2.6 Termination of the Contract; and
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E.4.2.7 Disqualification from participation with the DCHFP and other District health care benefit
programs.

E.4.3 The District may employ remedies and sanctions to address issues of the Contractor’s
noncompliance and issues of Contractor’s poor performance, including but not limited to,
the following reasons:
E.4.3.1 Violation of the terms and conditions or poor performance of the Contract;
E.4.3.2 Violation of applicable law or policy;
E.4.3.3 Failure to provide Medically Necessary Covered Services;
E.4.3.4 Failure to take corrective action or adhere to a CAP;
E.4.3.5 Engaging in inappropriate or impermissible marketing practices, as defined in section
C.5.15;
E.4.3.6 Engaging in inappropriate enrollment practices, including but not limited to, policies or
practices that lead to discouraging enrollment or discrimination on the basis of health status,
pregnancy status, or need for health services;
E.4.3.7 Failure to adhere the Enrollee services requirements including but not limited to, violations
of the requirements of the Language Access Act;
E.4.3.8 Failure to adhere to the Provider relations management, capacity, and access requirements,
including but not limited to, the following requirements:

E.4.3.8.1 Provider payment requirements, including delays in payments to Providers;
E.4.3.8.2 Access to covered services and wait times for appointments;
E.4.3.8.3 Provider credentialing requirements; and
E.4.3.8.4 A sufficient Provider Network.

E.4.3.9 Failure to comply with reporting requirements, including but not limited to:
E.4.3.9.1 Failure to submit information or a report at DHCF’s request;
E.4.3.9.2 Failure to submit information or a report in a timely manner;
E.4.3.9.3 Failure to submit all requested HEDIS® performance measures, including but not limited to,
HEDIS® and CAHPS® measures;
E.4.3.9.4 Failure to submit its MLR; and
E.4.3.9.5 Failure to submit a report.

E.4.3.10 Misrepresenting or falsifying information provided to the District, DHCF, HHS, or CMS;

E.4.3.11 Misrepresenting or falsifying information provided to Enrollees, potential Enrollees, or
Providers; and

E.4.3.12 Failure to comply with applicable Court Orders.

E.4.4 Additional State Monitoring Procedures. In accordance with 42 C.F.R. § 438.66, DHCF shall
have in effect procedures for monitoring Contractor’s operations, including, at a minimum,
operations related to:

E.4.4.1 Enrollment and Disenrollment;
E.4.4.2 Processing of Grievances and Appeals;
E.4.4.3 Violations subject to Intermediate Sanctions;
E.4.4.4 Violations of the conditions for FFP, set forth in 42 C.F.R. Part 438, Subpart J; and
E.4.4.5 All other provisions of the Contract, as appropriate.
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SECTION F: PERIOD OF PERFORMANCE AND DELIVERABLES

F.1 TERM OF CONTRACT

The term of the contract shall be for a period of one year from the date of award.

F.2 OPTION TO EXTEND THE TERM OF THE CONTRACT

F.2.1 The District may extend the term of this contract for a period of four one-year option periods, or
successive fractions thereof, by written notice to the Contractor before the expiration of the
contract; provided that the District will give the Contractor preliminary written notice of its
intent to extend at least 30 days before the contract expires. The preliminary notice does not
commit the District to an extension. The exercise of this option is subject to the availability of
funds at the time of the exercise of this option. The Contractor may waive the 30-day
preliminary notice requirement by providing a written waiver to the Contracting Officer prior to
expiration of the contract.

F.2.2 If the District exercises this option, the extended contract shall be considered to include this option
provision.

F.2.3 The price for the option period shall be as specified in Section B of the contract.

F.2.4 The total duration of this contract, including the exercise of any options under this clause, shall
not exceed five years.

F.3 DELIVERABLES

The Contractor shall perform the activities required to successfully complete the District’s
requirements and submit each deliverable to the Contract Administrator (CA) identified in
section G.9 in accordance with the following:

Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
1
Contractor’s
Implementation
Plan for operating
and participating in
the District’s
Managed Care
program. (C.5.237)
1 Word Document or
PDF/Electronic
Within 30 days of
Contract Award
2
Change in Place of
Business and Hours
of Operation (C.5.6)
Varies Word Document or
PDF/Electronic
At least 90 days before
proposed change
3
Minutes of Advisory
Committee
Meetings
(Enrollee and
Provider)
Varies Word Document or
PDF
Within Three
Business Days After
Advisory Committee
Meeting
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
(C.5.7.3)
4
Agenda and
Meeting
Information of
Advisory
Committee Meeting
(Enrollee and
Provider)
(C.5.7.4)
Varies Word Document or
PDF
Within Three
Business Days of Any
Advisory Committee
Meeting
5
Notice of Removal
of Key Personnel
(C.5.5.2.3)
Varies PDF Within Two Business
Days of the Decision
6
Investigational or
Experimental
Treatment
Request (C.5.82.5)
Varies
Word Document or
PDF/Electronically
or DHCF Secure
Email
Within 24 hours of
identifying or receiving
a request

Enrollment and Eligibility
7
Pregnancy and
Prenatal Care report
to DHCF
(C.5.28.6.2)
1 Excel Report/
Electronically
Quarterly (January 30,
April 30, July 31, and
October 31)
8
Submit to DHCF the
Deemed Newborn
Form, VOB, and
Log (C.5.28.1)
1 Word Document or
PDF/Electronically
Within 10 business
days of a new birth
9
Newborn Home
Visit Outreach
Report (C.5.30)
1 Excel Report/
Electronically Monthly
10
Disenrollment
Report regarding the
Number of
Enrollees (C.5.38)
1 per
Month
Excel Report/
Electronically
Monthly, by the 10th
for enrollee
disenrollment by the
end of the same month
end
11
Notification of
Enrollee
Eligibility
Misclassification
(C.5.20)
Varies
Word Document on
DHCF Secure
Email
Within two Business
Days of Contractor’s
Awareness of an
Enrollee’s
Misclassified
Eligibility
12 CASSIP New
Member
1 per
week
Word Document or
PDF/Electronically
Weekly. Reports
submitted by the 15th
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
Enrollment Report
(C.5.38.3)
or DHCF Secure
Email
of the month; the
enrollment will become
effective the following
month.
13
Enrollment Policies,
Procedures and
Related Materials
(C.5.38)
1 Word Document or
PDF
Within 30 days of
Contract Award
14 Enrollment
Report (C.5.38)
1 per
month
Excel Report/
Electronically

By the 15th of each
month
15
Any requests for
disenrollment due to
termination of a
Network Provider or
an Enrollee’s
inability or
unwillingness to
Select a New
PCP/PDP
Following a
Provider’s
Termination
(C.5.46.4)
Varies
Word Document or
PDF/Electronically
or DHCF Secure
Email
Within five Business
Days of Any Requests
for Disenrollment
Network Adequacy
16
Written Policies and
Procedures ensuring
that Contractor’s
Network
Providers have not
been excluded,
suspended or
debarred from
participating in any
District, state, or
Federal health care
benefit program.
(C.5.122.5)
1 within
90 days
of
Contract
award
and 1 per
quarter
Word Document or
PDF/Electronically
Within 90 days of
Contract award and
quarterly (January 30,
April 30, July 31, and
October 31) thereafter.
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
17 Provider Directory
(C.5.114)
1 within
90 days
of
Contract
award
and 1 per
month
Electronically
Within 90 days of
Contract award and
Annually thereafter for
the paper format.
Within 30 days after
Contractor receives
updated Provider
information.
18
Evidence of
compliance with the
requirements
Mileage and Travel
Time Standards.
(C.5.100.1)
1 within
90 days
of
Contract
award
and 1 per
quarter
Excel Report/
Electronically
At least 30 days prior to
the Start Date of the
Contract, quarterly, and
as requested by DHCF
19
Geographic Access
analysis that clearly
indicates the percent
of Enrollees who do
not have Provider
access as defined by
Mileage and Time
Standards.
(C.5.100.2)
1 per
quarter
Software or
PDF/Electronically
Quarterly (January 30,
April 30, July 31, and
October 31).
20
Report on all
Network Providers
with open panels or
not accepting new
patients. (C.5.100.4)
1 per
quarter
Excel Report/
Electronically
Quarterly (January 30,
April 30, July 31, and
October 31).
21
Written protocols
for access to
screening, diagnosis
and referral, and
appropriate
treatment for those
conditions and
Covered Services
under CASSIP to
DHCF.
(C.5.119.1.1)
1 within
90 days
of
Contract
award
and 1
per
quarter
Word Document or
PDF/Electronically
Within 90 days of
Contract award and
quarterly thereafter
(January 30, April 30,
July 31, and October
31)
22 Provider Manual
(C.5.129) 1 Word Document or
PDF/Electronically
Within 90 days of
Contract award and at
least once annually with
substantive changes
noted.
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
23
Any Termination of
a Contract with a
Network Provider
(C.5.132.1)
Varies Word Document or
PDF/Electronically
Within two Business
Days
24
Copy of Policies
and Procedures
regarding Enrollee
referral for a second
medical opinion
(C.5.117)
1 Word Document or
PDF/Electronically
30 days after Date of
Award
25
Written copy and
description of
Physician Incentive
Plans (C.5.126.6)
1 Word Document or
PDF/Electronically
30 days after Date of
Award and 90) days
prior to end of Contract
Term
26 Dental Providers
(C.5.70) 1 Word Document or
PDF/Electronically Quarterly
27
Evaluation, Training
and Monitoring
Tools for Home
Health Agencies
(C.5.169.1)
1 Word Document or
PDF/Electronically
Within 30 days of
Contract Award and
Annually by March
31st
28
Fair Home Health
Agency Oversight
Attestation
(C.5.169.3)
1 per
year PDF/Electronically Annually by March
31st
29 Delegated Entity
Listing (H.11.2.4.1) 1 Word Document or
PDF/Electronically
Within 90 days of
Contract award and
within 60 days of
executing or
terminating a
delegation agreement
30
Policies and
procedures on
Termination of the
Enrollee/Provider
Relationship
(C.5.33.5)
1 Word Document or
PDF/Electronically
Within 30 days
from date of Contract
Award
31
Revised Delegated
Entity Listing
(H.11.2.4.1)
1 Excel Report/
Electronically
Within 60 days of a
change, either the
addition of a new
delegated entity or
termination.
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
32
Pre-Delegation
Review Report
(H.12.3.2)
1 Word Document or
PDF/Electronically
Within 45 days of the
Contractor conducting
the pre-delegation
review
33
Delegation
Oversight
Review Report
(H.12.3.3)
1 Word Document or
PDF/Electronically
Annually within 45
days of the Contractor
conducting the annual
oversight review.
Fraud, Waste and Abuse Compliance
34 Compliance Plan
(C.5.185.1) 1 Word Document or
PDF/Electronically
Within 90 days of
Contract award
35
List of edits, audits,
reports, protocols,
provisions, or
references employed
for specific controls.
(C.5.185.6)
1 Word Document or
PDF/Electronically
Upon request from the
CA or Division of
Program Integrity.
36 Program Integrity
Reports. (C.5.187) Varies Word Document or
PDF/Electronically Upon DHCF request.
37
Confirmed
violations of
Fraud, Waste and
Abuse
(C.5.187)
Varies Word Document or
PDF/Electronically
Within 24 hours of the
violation confirmed by
the Contractor
Grievance and Appeals
38
Grievance and
Appeals System
Policies and
Procedures
(C.5.189.3)
1 Word Document or
PDF/Electronically
Within 90 days of the
date of award and upon
DHCF request.
39
Grievances and
Appeals Report
(C.5.205)
1 per
month
Excel Report/
Electronically Each month by the 25th
40
Submit all tips,
confirmed or
suspected fraud and
abuse to DHCF and
the appropriate
agency (C.5.187.5)
1 per
reported
violation
Word Document or
PDF/Electronically
Within 24 hours of a
report of a violation.
Language Access & Cultural Competency
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
41
Usage of Language
Assistive
Services and/or
Devices (C.5.9.4)
1 per
quarter
Excel Report/
Electronically
Quarterly on January
15, April 15, July 15,
and October 15
Marketing, Outreach and Health Education
42 Marketing Plan
(C.5.11.1) 1 Word Document or
PDF/Electronically
45 business days prior
to October 1, annually.
43
Submit all
marketing, outreach,
health education and
promotion, and
other similar
materials to DHCF
for review and
approval. (C.5.13.1)
1 Word Document or
PDF/Electronically
At a minimum of 30
business days prior to
distribution.
44
Marketing,
outreach, health
education, and
promotion activities
Report. (C.5.13.2)
Varies Excel Report/
Electronically
Monthly no later than
the 15th of the month
prior to the month of
the scheduled
activities.
45 Incentive Report.
(C.5.14.3.4) 1 Excel Report/
Electronically
Quarterly on January
15, April 15, July 15,
and October 15.
46 Enrollee Handbook
(C.5.25.4) 1 Word Document or
PDF/Electronically
Within 30 days of
Operational Start Date,
Before the intended
effective date of a
Material Change, and
Annually thereafter by
March 31st.
Pharmacy
47
Prior authorization
process for covered
outpatient drugs.
(C.5.78.1)
1 Word Document or
PDF/Electronically
Within 90 days of Start
Date.
48 Drug Utilization
Data (C.5.77.5) 1 Excel Report/
Electronically
Within 45 days of each
quarterly rebate period
49 Description of DUR
activities (C.5.77.3)
1 per
quarter
Word Document or
PDF/Electronically
Quarterly on January
15,
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
April 15, July 15, and
October 15
50
Prescription Drug
Formulary Report
(C.5.77.5)
1 per
quarterly
rebate
period
Excel Report/
Electronically
Within 45 days after the
end of each quarterly
rebate period
51
PBM Agreement
Pricing
Transparency
(C.5.80.2)

1
Excel Report/
Electronically or
Word Document or
PDF
A format and frequency
as determined by
DHCF to be provided
during the Contractor’s
Readiness Meeting
52
Internal control
policies and
procedures that
safeguard against
loss or theft of
Medicaid funds.
(C.5.216.1.2)
1 Word Document or
PDF/Electronically
Within ninety days of
Contract award and
annually thereafter.
53
Audited Financial
Reporting
Statement.
1 per
quarter
Word Document or
PDF/Electronically
Quarterly on January
15, April 15, July 15,
and October 15.
54
Unaudited financial
statements and bank
reconciliations.
(C.5.216.1.7)
1 per
month
Word Document or
PDF/Electronically
Each month by the 25th
day of the month.
55
Written notice of
any actions taken by
DISB that may
adversely affect
Contractor’s license
or ability to operate
in the District.
(C.5.216.1.9)
1 Word Document or
PDF/Electronically
Within two business
days of notice from
DISB.
56
Certificate of
Authority to
Operate a Health
Maintenance
Organization in the
District from DISB.
(C.5.2)
1 Word Document or
PDF/Electronically
Within in one business
day of DISB notifying
Contractor or in
accordance with DISB
timeframes.
57
Financial Reporting
Statements and
MLR (C.5.216.1.6)
1 Word Document or
PDF/Electronically
Quarterly on January
15, April 15, July 15,
and October 15.
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
58
Contractor Provider
rate and payment
agreements
(C.5.209)
1 Word Document or
PDF/Electronically Upon DHCF request
59
Description and
Information on
PIPs. (C.5.170.10)
1 Word Document or
PDF/Electronically
Within 90 days of
Contract award and
October 1st annually
thereafter.
60 PIPs Report
(C.5.170.10) 1 Word Document or
PDF/Electronically
Quarterly on January
15, April 15, July 15,
and October 15.
61
Encounter Data for
all Covered
Services. (C.5.93.7)
1 Excel Report/
Electronically
Frequency to be
determined by DHCF
(frequency will be
provided to the
Contractor during the
Readiness Review).
62
Performance report
financial statement.
(C.5.216.1)
1 per
quarter
Word Document,
Excel Report or
PDF/Electronically
Quarterly on January
15, April 15, July 15,
and October 15.
63 Claims Payment
Report.(C.5.218.5)
1 per
month
Excel Report
/Electronically
Each month, by the 25th
day of the following
month
64
MIS disaster
recovery plan.
(C.5.224.13)
1 Word Document or
PDF/Electronically
Within 90 days of
Contract award.
65
Written notice that
Contractor has the
technical capacity to
electronically
approve all
enrollment
information,
including an
explanation of
procedures used to
substantiate the
enrollment process
(C.5.27.8)
1 Word Document or
PDF/Electronically
Within 30 Days of
Contract Award
66
Written notice of
any change(s) to the
technical capacity to
electronically
approve all
enrollment
Varies Word Document or
PDF/Electronically As Warranted
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
information
(C.5.27.9)
67
Care Management
Program
Description and
Implementation
Plan
(C.5.151.1)
1 Word Document or
PDF/Electronically
Within 30 days of
Contract Award
68
Submission of
Contractor’s referral
procedures
regarding
Enrollee second
opinion for DHCF
approval. (C.5.148)
1 Word Document or
PDF/Electronically
Within 90 days of the
Contract award and
annually thereafter by
January 31st.
69
Care Management
Program
Description and
Program
Evaluation
(C.5.156.2)
1 per
year
Word Document Or
PDF/Electronically
Annually on March
31st.
70
Care Management
Practice Guidelines
(C.5.87.9)
1 Word Document Or
PDF/Electronically
Within 45 Days of
Contract Award, and
when requested,
thereafter
71
Care Management
Enrollee
Survey (C.5.156.2)
1 per
year
Word Document Or
PDF/Electronically
Annually by January
31st
72
Benefits
Coordination Report
(C.5.158.4)
1 per
quarter
Excel Report/
Electronically
Quarterly on January
15th, April 15th, July
15th, & October 15th.
73
Care Management
Training Binder
(C.5.164.1)
1 per
year Varies Annually by January
31st
74
Care Management
Supervision
Structure/Roster
(C.5.165.2)
1
Word Document,
PDF or
Electronically
Within 45 Days of
Contract Award, and
upon request thereafter
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
75
Case Management
Supervision Plan
(C.5.165.4)
1
Word Document,
PDF or
Electronically
Annually by January
31st
76
Transition Report on
Enrollees
transitioning out of
CASSIP within next
three months.
(C.5.167)
1 per
month
Excel Report/
Electronically
Monthly by the tenth
10th
77
Disease
Management
Program Plan
(C.5.166.3)
1 per
year
Word Document,
PDF or
Electronically
Annually by March 31st
78
Social Determinants
of
Health Reporting
(C.5.157.1.4)
1
Word Document,
Excel Report or
PDF/Electronically
In a method and
manner as determined
by DHCF
79
Escalation of
Enrollee Transitions
(C.5.168.3)
Varies
Word Document,
PDF or
Electronically
DHCF secure email
Within three Days of
Indication, and as
warranted thereafter
80 TPL Report
(C.5.210.1.6)
1 per
month
Excel Report
Electronically
Monthly (by the tenth
(10th) day of the month
following the end of
each month)
81
UM Program
Description and
Program Evaluation
(C.5.138.2)
1 Word Document or
PDF/Electronically
Annually on March
31st.
82
Policies and
procedures that
define Contractor’s
prior approval and
Utilization Review
criteria for
Authorization
Decisions
(C.5.140.2.1)
1 Word Document or
PDF/Electronically
30 days after the Date
of Award
83
Notification of
disagreement
between PCP and
Contractor
regarding Level of
Care or other
Varies Word Document or
PDF/Electronically
Within Two Business
Days
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
Coverage disputes
(C.5.86)
84
Enrollee’s Request
to
Continue Cancer
Therapy
Treatment with a
Non-
Network Provider
(C.5.167.4)
Varies
Word Document
or
PDF/Electronically
Within five Business
days of the Contractor
receiving Enrollee’s
Request
85
DME Policies and
Procedures
(C.5.141.1)
Varies Word Document or
PDF
Within 90 days of
Contract Award, when
Material Changes
Occur, and upon DHCF
Request.
86 Medical Necessity
Criteria (C.5.142.3) 1 Word Document or
PDF/Electronically
Within 90 days of
Contract award.
87
Adverse Benefit
Determination
Letter Template
(F.3)
1 Word Document or
PDF/Electronically
Within 90 days
Contract award
88 Respite Utilization
Report (C.5.62)
1 per
quarter;
and 1
per year
Excel Report/
Electronically
Quarterly on January
15th, April 15th, July
15th, & October 15th
Annually by January
15th
89
All coverage denials
for
EI Service
(C.5.52.4)
Varies
Word Document,
Excel Report or
PDF/Electronically
Within three days of
Denial or Exclusion
90
NCQA
Accreditation
Report
(C.5.170.13.8)
1
Word Document
or
PDF/Electronically
Within 7 days of
Contractor receipt from
NCQA.
91
QAPI Program
Description and
Program evaluation
(C.5.171.3)
1 Word Document or
PDF/Electronically
Annually on March
31st.
92
HEDIS®
Performance
Measures
(C.5.173.2)
1 per
quarter
Excel Report/
Electronically
Quarterly on January
15th, April 15th, July
15th & October 15th.
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
93 HEDIS® Audit
Report (C.5.173.8) 1 Word Document or
PDF/Electronically
Annually, within seven
days of Contractor
receipt from NCQA
approved HEDIS®
Auditor.
94
CAHPS® Survey
Results
(C.5.170.3.2)
1 Word Document or
PDF/Electronically Annually on June 15th.
95 Health-Check
Utilization (F.3)
1 per
quarter
Excel Report/
Electronically
Quarterly (2nd Friday of
October, January, April,
July)
96
Health-Check
Outreach (C.5.54.3)

1 per
quarter
Excel Report/
Electronically
Quarterly (2nd Friday of
October, January, April,
July)
97 Dental Provider
Report (C.5.71)
1 per
quarter
Excel Report/
Electronically
Quarterly (2nd Friday of
October, January, April,
July)
98 MCO 416
(C.5.50.3) Varies Excel Report/
Electronically
Quarterly (4th Friday of
October, January, April,
July) and Annual (4th
Friday of March)
Three Prior Draft Runs
Dates Vary
99
MCO-416
Supplemental
Data (C.5.50.3)
Varies Excel Report/
Electronically
Quarterly (4th Friday of
October, January, April,
July) and Annual (4th
Friday of March)
Three Prior Draft Runs
Dates Vary
100
MCO-416 Non-
Compliant
Members (C.5.50.3)
Varies Excel Report/
Electronically
Quarterly (4th Friday of
October, January, April,
July) and Annual (4th
Friday of March)
Three Prior Draft Runs
Dates Vary
101
EPSDT CAP/Work
Plan
(C.5.50.3)
1 per
quarter Word Document
Quarterly (Dates Vary
Within - October,
March, April, July)
102 Annual Blood Lead
Report (C.5.230.6)
1 per
year
Excel Report/
Electronically
Annually on January
31st
103
EI Report
(C.5.52.11)

1 per
quarter
Excel Report/
Electronically
Quarterly (January 30,
April 30, July 30, and
October 30)
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Deliverable
No. Deliverable Quantity Format/Method of
Delivery Due Date
104
EI Report –
Quarterly Summary
(C.5.52.6)
1 per
quarter
Excel Report/
Electronically
Quarterly (4th Friday of
October, January, April,
July)
105
Biannual Dental
Provider Report
(C.5.71.1.1)
2 per
year
Excel Report/
Electronically
Biannually (1st Friday
in June and 1st Friday in
December)
106
Current Dental
Terminology
(CDT) Procedure
Code Report
(C.5.71.1.2)
1 per
year
Excel Report/
Electronically
Annually the 4th Friday
in September
107
Dental Prior
Authorization
Report (C.5.71.1.3)
1 per
quarter
Excel Report/
Electronically
Quarterly (January 30,
April 30, July 30, and
October 30)
108
Number of Calls
Received
(C.5.43.2.3)
1 quarter Excel Report/
Electronically
Quarterly (January 30,
April 30, July 30, and
October 30)
109
Select a screening
tool for Behavioral
Health in primary
care settings and for
children with
Special Health Care
Needs. (C.5.51.1)
1 Word Document or
PDF/Electronically
Within 90 days of
Contract Award
110
Monthly Behavioral
Health Report
(C.5.57.10)
1 per
month
Excel Report/
Electronically Monthly by the 30th
111
Enrollee
Admissions to
PRTFs, Nursing
Facilities, Skilled
Nursing Facilities,
and ICF/IIDs by age
and gender
((C.5.5.57.11)
1 per
month;
and 1
annually
Excel Report/
Electronically
Monthly by the 30th,
and annually by
December
31st
11
Alternative Care
Monthly Report
(C.5.57.12)
1 per
month
Excel Report/
Electronically Monthly by the 30th

F.3.1 For contracts subject to the 51% District Residents New Hires Requirements and First Source
Employment Agreement requirements, the Contractor shall submit to the Contract
Administrator, as a deliverable, the compliance report or a waiver of compliance with its final
request for payment.

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SECTION G: CONTRACT ADMINISTRATION
G.1 INVOICE PAYMENT

G.1.1 The District will make payments to the Contractor, upon the submission of proper invoices, at
the prices stipulated in this contract, for supplies delivered and accepted or services performed
and accepted, less any discounts, allowances or adjustments provided for in this contract.

G.1.2 The District will pay the Contractor on or before the 30th day after receiving a proper invoice
from the Contractor.

G.2 INVOICE SUBMITTAL

G.2.1 The Contractor shall create and submit payment requests in an electronic format through the DC
Vendor Portal, https://vendorportal.dc.gov
G.2.2 The Contractor shall submit proper invoices on a monthly basis or as otherwise specified in
Section G.4.
G.2.3 To constitute a proper invoice, the Contractor shall enter all required information into the Portal
after selecting the applicable purchase order number which is listed on the Contractor’s profile.

G.3 FIRST SOURCE AGREEMENT REQUEST FOR FINAL PAYMENT

G.3.1 For contracts subject to the 51% District Residents New Hires Requirements and First Source
Employment Agreement requirements, final request for payment must be accompanied by the
compliance report or a waiver of compliance.

G.3.2 The District may impose monetary fines for willful breach of the employment agreement or
failure to submit the compliance report.

G.4 PAYMENT

G.4.1 The District shall pay Contractor a prospective monthly capitation rate for each Enrollee that is
enrolled with Contractor on the first (1st) day of each month.

G.4.2 In accordance with 42 C.F.R.§ 438.60, DHCF shall ensure that no payment is made to a
Provider other than the through the Contractor for services available under the Contract between
the District and Contractor, except when these payments are provided for in Title XIX of the
Act, in 42 C.F.R chapter IV., or when DHCF makes direct payments to network providers for
Graduate Medical Education (GME).

G.4.3 In accordance with 42 C.F.R.§ 438.4, if the District makes payments to Providers for GME
costs under an approved State Plan, the District shall adjust the actuarially sound capitation rates
to account for the GME payments to be made on behalf of Enrollees covered under the Contract,
not to exceed the aggregate amount that would have been paid under the approved State Plan for
DC Medicaid FFS Program. The District makes payments to Providers for the Direct Medical
Expense add-on payments related to Inpatient services under the approved State Plan. The
District shall ensure the actuarially sound capitation rates exclude the GME payments to be
made on behalf of Enrollees covered under the Contract.
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G.4.4 As a condition of receiving payment under the CASSIP, Contractor shall comply with the
applicable certifications, program integrity, and prohibited affiliation requirements of 42 C.F.R.
Part 438.

G.4.5 If an Enrollee’s coverage ends under the Contract or an Enrollee is disenrolled for any reason,
the District shall terminate payments to Contractor for that Enrollee effective on the last day of
the month in which the Enrollee’s status change becomes effective.

G.4.6 If an Enrollee reaches a birthday that results in a change in the Enrollee’s rate cohort, the
Enrollee’s new rates shall begin in the month following the Enrollee’s birthday.

G.4.7 Except as discussed in section G.4.2, because the capitation payments shall be calculated based
on the number of Enrollees on the first (1st) day of each month, no adjustments shall be made
for Enrollees who are enrolled after the beginning of the month’s payment cycle or disenrolled
after the beginning of the month’s payment cycle. Adjustments will occur at the mid-month
Capitation cycle.

G.4.8 Actuarially Sound

In accordance with 42 C.F.R. § 438.4, all CASSIP payments to the Contractor under contract
shall be actuarially sound.

G.4.9 Electronic Payments

G.4.9.1 The District reserves the option to make payments to Contractor by wire, National
Automated Clearing House Association (NACHA), or electronic transfer and shall provide
Contractor at least a 30 day notice prior to the effective date of any such change.

G.4.9.2 Where payments are made by electronic funds transfer, the District shall not be liable for
any error or delay in transfer or indirect or consequential damages arising from the use of
the electronic funds transfer process. Any charges or expenses imposed by the bank for
transfers or related actions shall be borne by the Contractor.

G.4.9.3 In accordance with 42 C.F.R. 438.3(c), capitation payments may only be made by the
District and retained by the Contractor for Medicaid-eligible enrollees.

G.5 ASSIGNMENT OF CONTRACT PAYMENTS

G.5.1 In accordance with 27 DCMR 3250, the Contractor may assign to a bank, trust company, or
other financing institution funds due or to become due as a result of the performance of this
contract.

G.5.2 Any assignment shall cover all unpaid amounts payable under this contract, and shall not be made
to more than one party.

G.5.3 Notwithstanding an assignment of contract payments, the Contractor, not the assignee, is
required to prepare invoices. Where such an assignment has been made, the original copy of the
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invoice must refer to the assignment and must show that payment of the invoice is to be made
directly to the assignee as follows:

“Pursuant to the instrument of assignment dated ___________, make payment of this invoice to
(name and address of assignee).”

G.6 THE QUICK PAYMENT ACT

G.6.1 Interest Penalties to Contractors

G.6.1.1 The District will pay interest penalties on amounts due to the Contractor under the Quick
Payment Act, D.C. Official Code § 2-221.01 et seq., as amended, for the period beginning
on the day after the required payment date and ending on the date on which payment of the
amount is made. Interest shall be calculated at the rate of at least 1% per month. No interest
penalty shall be paid if payment for the completed delivery of the item of property or service
is made on or before the required payment date. The required payment date shall be:

G.6.1.1.1 The date on which payment is due under the terms of this contract;
G.6.1.1.2 Not later than 7 calendar days, excluding legal holidays, after the date of delivery of
meat or meat food products;
G.6.1.1.3 Not later than 10 calendar days, excluding legal holidays, after the date of delivery of a
perishable agricultural commodity; or
G.6.1.1.4 30 calendar days, excluding legal holidays, after receipt of a proper invoice for the
amount of the payment due.

G.6.1.2 No interest penalty shall be due to the Contractor if payment for the completed delivery of
goods or services is made on or before:

G.6.1.2.1 3rd day after the required payment date for meat or a meat product;
G.6.1.2.2 5th day after the required payment date for an agricultural commodity; or
G.6.1.2.3 15th day after any other required payment date.

G.6.1.3 Any amount of an interest penalty which remains unpaid at the end of any 30-day period
shall be added to the principal amount of the debt and thereafter interest penalties shall
accrue on the added amount.

G.6.2 Payments to Subcontractors

G.6.2.1 The Contractor shall take one of the following actions within seven days of receipt of any
amount paid to the Contractor by the District for work performed by any subcontractor
under the contract:

G.6.2.1.1 Pay the subcontractor(s) for the proportionate share of the total payment received from the
District that is attributable to the subcontractor(s) for work performed under the contract; or

G.6.2.1.2 Notify the CO and the subcontractor(s), in writing, of the Contractor’s intention to withhold
all or part of the subcontractor’s payment and state the reason for the nonpayment.

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G.6.2.2 The Contractor shall pay subcontractors or suppliers interest penalties on amounts due to the
subcontractor or supplier beginning on the day after the payment is due and ending on the
date on which the payment is made. Interest shall be calculated at the rate of at least 1% per
month. No interest penalty shall be paid on the following if payment for the completed
delivery of the item of property or service is made on or before the:

G.6.2.2.1 3rd day after the required payment date for meat or a meat product;
G.6.2.2.2 5th day after the required payment date for an agricultural commodity; or
G.6.2.2.3 15th day after any other required payment date.

G.6.2.3 Any amount of an interest penalty which remains unpaid by the Contractor at the end of any
30-day period shall be added to the principal amount of the debt to the subcontractor and
thereafter interest penalties shall accrue on the added amount.

G.6.2.4 A dispute between the Contractor and subcontractor relating to the amounts or entitlement of
a subcontractor to a payment or a late payment interest penalty under the Quick Payment
Act does not constitute a dispute to which the District is a party. The District may not be
interpleaded in any judicial or administrative proceeding involving such a dispute.

G.6.3 Subcontract requirements

G.6.3.1 The Contractor shall include in each subcontract under this contract a provision requiring the
subcontractor to include in its contract with any lower-tier subcontractor or supplier the
payment and interest clauses required under paragraphs and of D.C. Official Code § 2-
221.02(d).

G.6.3.2 The Contractor shall include in each subcontract under this contract a provision that
obligates the Contractor, at the election of the subcontractor, to participate in negotiation or
mediation as an alternative to administrative or judicial resolution of a dispute between
them.

G.6.4 Right to Withhold Payment

G.6.4.1 Pursuant to 42 C.F.R. §§ 438.6 and 438.608, the District reserves the right to withhold or
recoup funds from Contractor in addition to any other remedies allowed under the Contract
or any policies and procedures.

G.6.4.2 The District may withhold portions of capitation payments from Contractor or impose
sanctions as provided in section G.7.

G.6.5 Co-Payment Prohibition

The Contractor shall not impose co-payment requirements or other fees on Enrollees, except as
directed to do so by DHCF, in accordance with the District’s approved Medicaid State Plan.

G.6.6 Fines

G.6.6.1 The Contractor shall be responsible for any fines levied against the District by HHS, CMS,
or an administrative body as a result of Contractor’s performance under the Contract.
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G.6.6.2 The Contractor shall be responsible for any fines or sanctions imposed upon the District by
the courts when a court determines that Contractor has failed to adequately perform under
the Contract or meet the requirements of a court order, including but not limited to Salazar
v. The District of Columbia et al.

G.6.7 Sanctions

G.6.7.1 General Sanctions

G.6.7.1.1 In addition to any other remedies available to the District, the District may impose
sanctions against the Contractor for noncompliance with Contract terms by the
Contractor or its subcontracted Providers in accordance with 29 DCMR § 5320.

G.6.7.1.2 The Contractor shall be responsible for any recoupment of funds or sanctions imposed
by the federal government to the District that are related to Contractor’s non-compliance
of any part of the Contract.

G.6.7.2 Intermediate Sanctions

G.6.7.2.1 Basis for Imposition of Intermediate Sanctions

G.6.7.2.1.1 The District shall establish intermediate sanctions, as specified in 42 C.F.R. § 438.702
and shall base its determinations on findings from onsite surveys, complaints filed by an
Enrollee or an Enrollee representative, financial status, or any other source.

G.6.7.2.1.2 The Contractor shall be found to be non-compliant if the District determines that
Contractor has failed to comply with the terms of the Contract, and any applicable
federal law as specified in §§ 1903(m)(5)(A) and 1932(e) of the Act and 42 C.F.R. §§
422.208210, and 438.700-702, including:

G.6.7.2.1.2.1 Substantially failing to provide Medically Necessary Services that Contractor is required
to provide under law or under the Contract to an Enrollee covered under the Contract;

G.6.7.2.1.2.2 Imposing on Enrollees premiums or charges that are in excess of the premiums or
charges permitted under the Medicaid program;

G.6.7.2.1.2.3 Acting to discriminate among Enrollees on the basis of their health status or need for
health care services. This includes termination of enrollment or refusal to reenroll a
beneficiary, except as permitted under the Medicaid program, or any practice that would
reasonably be expected to discourage enrollment by beneficiaries whose medical
condition or history indicates probable need for substantial future medical services;

G.6.7.2.1.2.4 Misrepresenting, failing to provide, or falsifying information Contractor furnishes to
CMS or the District;

G.6.7.2.1.2.5 Misrepresenting or falsifying information Contractor furnishes to an Enrollee, potential
Enrollee, or health care Provider;

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G.6.7.2.1.2.6 Failing to comply with requirements for Physician Incentive Plans as set forth in 42
C.F.R. §§ 422.208 and 422.210 (as in section H.14);

G.6.7.2.1.2.7 Distributing directly or indirectly through any agent or Independent Contractor,
Marketing Materials that have not been approved by the District or that contain false or
materially misleading information;

G.6.7.2.1.2.8 Violating any of the other applicable requirements of §§ 1903(m) or 1932 of the Act and
any implementing regulations; and

G.6.7.2.1.2.9 Violating any District of Columbia law, regulation, or court order, including failure to
comply with the Corrective Action imposed by DHCF (as described in section C.5.31),
as a result of Salazar v. The District of Columbia et al.

G.6.7.3 Types of Intermediate Sanctions

G.6.7.3.1 The types of intermediate sanctions the District may impose include the following:

G.6.7.3.1.1 Civil money penalties in the amounts specified in 42 C.F.R. § 438.704;

G.6.7.3.1.2 Appointment of temporary management for Contractor as provided in 42 C.F.R. §
438.706;

G.6.7.3.1.3 Granting Enrollees the right to terminate enrollment without cause and the District must
notify the affected Enrollees of their right to disenroll;

G.6.7.3.1.4 Suspension of all new enrollment, including default enrollment, after the date the
Secretary or DHCF notifies the Contractor of the determination of the violation of any
requirement under section 1903(m) or 1932 of the Act; and

G.6.7.3.1.5 Suspension of payment for beneficiaries enrolled after the effective date of the sanction
and until CMS or the District is satisfied that the reason for imposition of the sanction no
longer exists and is not likely to recur.

G.6.7.3.2 The District retains authority to impose additional sanctions under 29 DCMR § 5320 that
address areas of noncompliance specified in 42 C.F.R. § 438.700, as well as additional
areas of noncompliance. Nothing in this section prevents the District from exercising
that authority.

G.6.7.4 Amounts of Civil Money Penalties

G.6.7.4.1 The limit on, or the maximum civil money penalty, varies depending on the nature of
Contractor’s action or failure to act.

G.6.7.4.2 Specific Limits

G.6.7.4.2.1 42 C.F.R. § 438.704 outlines the maximum civil money penalty specific limits. The limit
is twenty-five thousand dollars ($25,000) for each determination in accordance with 42
C.F.R. §§ 438.700(b)(1), (b)(5) and (b)(6):
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G.6.7.4.2.1.1 Fails substantially to provide Medically Necessary services that the Contractor is
required to provide under law or under this Contract with the District to an enrollee
covered under this Contract;

G.6.7.4.2.1.2 Misrepresents or falsifies information that it furnishes to an Enrollee, Potential enrollee,
or health care Provider;

G.6.7.4.2.1.3 Fails to comply with the requirements for Physician Incentive Plans, as set forth (for
Medicare) in 42 C.F.R. §§ 422.208 and 422.210; and

G.6.7.4.2.1.4 Distributes directly, or indirectly through any agent or independent contractor,
Marketing materials that have not been approved by the District or that contain false or
materially misleading information.

G.6.7.4.2.2 The limit is one-hundred thousand dollars ($100,000) for each determination in
accordance with 42 §§ C.F.R.438.700 (b)(3) or (b)(4):

G.6.7.4.2.2.1 Acts to discriminate among Enrollees based on their health status or need for health care
services. This includes termination of enrollment or refusal to reenroll beneficiaries,
except as permitted under the Medicaid program, or any practice that would reasonably
be expected to discourage enrollment by beneficiaries whose medical condition or
history indicates probable need for substantial future medical services.

G.6.7.4.2.2.2 Misrepresents or falsifies information the Contractor furnishes to CMS or to the District.

G.6.7.4.2.2.3 The limit is fifteen thousand dollars ($15,000) for each Enrollee the District determines
was not enrolled because of a discriminatory practice in accordance with 42 C.F.R §
438.700(b)(3) (This is subject to the overall limit of $100,000 under section
G.6.2.8.4.2.2).

G.6.7.4.3 Specific Amount

For premiums or charges in excess of the amounts permitted under the Medicaid
program, the maximum amount of the sanction is twenty-five thousand dollars ($25,000)
or double the amount of the excess charges, whichever is greater. The District shall
deduct from the penalty the amount of overcharge and return it to the affected Enrollees.

G.6.7.5 Special Rules for Temporary Management

G.6.7.5.1 The District may impose temporary management only if it finds (through onsite survey,
enrollee complaints, financial status, or any other source) that:

G.6.7.5.1.1 There is continued egregious behavior by the Contractor, including but not limited to
behavior that is described in 42 C.F.R. § 438.700, or that is contrary to any requirements
of §§ 1903(m) and 1932 of the Act; or

G.6.7.5.1.2 There is substantial risk to Enrollees' health; or

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G.6.7.5.1.3 The sanction is necessary to ensure the health of Contractor’s Enrollees:

G.6.7.5.1.3.1 While improvements are made to remedy violations under 42 C.F.R. § 438.700; or

G.6.7.5.1.3.2 Until there is an orderly termination or reorganization of the Contractor.

G.6.7.5.2 The District shall impose temporary management (regardless of any other sanction that
may be imposed) if it finds that Contractor has repeatedly failed to meet substantive
requirements in §§ 1903(m) or 1932 of the Act or 42 C.F.R. § 438 Subpart I. The
District will grant Enrollees the right to terminate enrollment without cause, as described
in 42 C.F.R. § 438.702(a)(3) and shall notify the affected Enrollees of their right to
terminate enrollment.

G.6.7.5.3 The District shall not delay imposition of temporary management to provide a hearing
before imposing this sanction.

G.6.7.5.4 The District may not terminate temporary management until it determines that
Contractor can ensure that the sanctioned behavior will not recur.

G.6.7.6 Termination of Contractor’s Contract

G.6.7.6.1 The Contractor shall not terminate without the authorization of the CO. Notwithstanding
terms in the Standard Contract Provision, the District has the authority to terminate
Contractor’s Contract and enroll Contractor’s Enrollees in other Contractors, or provide
their Medicaid benefits through other options included in the District State Plan, if the
District determines that Contractor has failed to do either of the following:

G.6.7.6.1.1 Carry out the substantive terms of the Contract; or

G.6.7.6.1.2 Meet applicable requirements in §§ 1932, 1903(m), and 1905(t) of the Act.

G.6.7.7 Notice of Sanction and Pre-termination Hearing

G.6.7.7.1 Except as provided in 42 C.F.R. § 438.706(c), before imposing any of the intermediate
sanctions specified in this section, the District shall give Contractor timely written notice
that explains the following:

G.6.7.7.1.1 The basis and nature of the sanction.

G.6.7.7.1.2 Any other appeal rights that the District elects to provide.

G.6.7.7.2 Before terminating the Contract under 42 C.F.R. § 438.708, the District shall provide the
Contractor a pre-termination hearing, including:

G.6.7.7.2.1 Give Contractor written notice of its intent to terminate, the reason for termination, and
the time and place of the hearing;

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G.6.7.7.2.2 After the hearing, give the Contractor written notice of the decision affirming or
reversing the proposed termination of the Contract and, for an affirming decision, the
effective date of termination; and

G.6.7.7.2.3 Give Enrollees of the Contractor notice of the termination and information, consistent
with 42 C.F.R. § 438.10, on their options for receiving Medicaid services following the
effective date of termination.

G.6.7.7.3 At the same time DHCF sends notice to the Contractor under 42 C.F.R. § 438.730, CMS
forwards a copy of the notice to the OIG.

G.6.7.8 Disenrollment during Termination Hearing Process

G.6.7.8.1 After the District notifies Contractor that it intends to terminate the Contract, the District
may do the following:

G.6.7.8.1.1 Give Contractor’s Enrollees written notice of the District’s intent to terminate the
Contract; and

G.6.7.8.1.2 Allow Enrollees to disenroll immediately without cause.

G.6.7.9 Notice to CMS

G.6.7.9.1 The District shall give the CMS Regional Office written notice whenever it imposes or
lifts a sanction for one of the violations listed in 42 C.F.R. § 438.700.

G.6.7.9.2 The written notice shall:

G.6.7.9.2.1 Be given no later than thirty (30) days after the District imposes or lifts a sanction; and

G.6.7.9.2.2 Specify the affected Contractor, the kind of sanction, and the reason for the District's
decision to impose or lift a sanction.

G.6.7.10 Monitoring Violations

G.6.7.10.1 In accordance with 42 C.F.R. § 438.726(a), the District shall develop and implement a
plan to monitor for violations that involve the actions and failures to act as specified 42
C.F.R. § 438.726 and to implement the provisions of 42 C.F.R. § 438.726.

G.6.7.10.2 Contract shall provide that payments provided under the Contract shall be denied for
new Enrollees when and for so long as, payment for those Enrollees is denied by CMS
under 42 C.F.R. § 438.730(e).

G.6.7.10.3 The District shall recommend that CMS impose the denial of payment sanction on
Contractor if the District determines that Contractor acts or fails to act as specified in 42
C.F.R. § 438.700(b)(1) through (b)(6).

G.6.7.10.4 CMS retains the right to independently perform the functions assigned to DHCF under
42 C.F.R. §438.730 (a) through (d).
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G.6.7.11 Effect of a Determination

G.6.7.11.1 In accordance with 42 C.F.R. § 438.730(b), the District’s determination becomes CMS’
determination for purposes of § 1903(m)(5)(A) of the Act unless CMS reverses or
modifies it within fifteen (15) days.

G.6.7.11.2 When the District decides to recommend imposing the sanction, this recommendation
becomes CMS' decision, for purposes of § 1903(m)(5)(B)(ii) of the Act, unless CMS
rejects this recommendation within fifteen (15) days.

G.6.7.12 Notice of Sanction

G.6.7.12.1 If the District's determination becomes CMS’ determination under section G.6.2.8.11.1,
the District shall take the following actions in accordance with 42 C.F.R. § 438.730(c):

G.6.7.12.1.1 Give the Contractor written notice of the nature and basis of the proposed sanction;

G.6.7.12.1.2 Allow the Contractor fifteen (15) days from the date it receives the notice to provide
evidence that it has not acted or failed to act in the manner that is the basis for the
recommended sanction;

G.6.7.12.2 The District may extend the initial fifteen (15) day period for an additional fifteen (15)
days if:

G.6.7.12.2.1 Contractor submits a written request that includes a credible explanation of why it needs
additional time;

G.6.7.12.2.2 The request is received by CM S before the end of the initial period; and

G.6.7.12.2.3 CMS has not determined that the Contractor's conduct poses a threat to an Enrollee's
health or safety.

G.6.7.13 Informal Reconsideration

G.6.7.13.1 If the Contractor submits a timely response to the notice of sanction, the District shall, in
accordance with 42 C.F.R. § 438.730(d):

G.6.7.13.1.1 Conduct an informal reconsideration that includes review of the evidence by a District
agency official who did not participate in the original recommendation;

G.6.7.13.1.2 Give the Contractor a concise written decision setting forth the factual and legal basis for
the decision; and

G.6.7.13.1.3 Forward the decision to CMS.

G.6.7.13.2 The District’s decision under G.6.2.8.11.3.1.2 shall become CMS’ decision unless CMS
reverses or modifies the decision within fifteen (15) days from the date of receipt by
CMS.
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G.6.7.13.3 If CMS reverses or modifies the District’s decision, the District shall send the Contractor
a copy of CMS' decision.

G.6.7.14 Denial of Payment

G.6.7.14.1 CMS, based upon the recommendation of DHCF, may deny payment to the District for
new Enrollees of Contractor under § 1903(m)(5)(B)(ii) of the Act in the following
situations, in accordance with 42 C.F.R. § 438.730(e):

G.6.7.14.1.1 If a CMS determination that the Contractor has acted or failed to act, as described in of
42 C.F.R. §§ 438.700(b)(1) through (b)(6), is affirmed on review under section
G.6.2.8.11.4; and

G.6.7.14.1.2 If a CMS determination is not contested in a timely manner by the Contractor.

G.6.7.14.2 Under 42 C.F.R § 438.726(b), CMS’ denial of payment for new Enrollees automatically
results in a denial of District payments to the Contractor for the same Enrollees.

G.6.7.15 Effective Date of Sanction

G.6.7.15.1 If Contractor does not seek reconsideration, a sanction is effective fifteen (15) days after
the date Contractor is notified under section G.6.2.8.11.2 of the decision to impose the
sanction.

G.6.7.15.2 If Contractor seeks reconsideration, the following rules apply:

G.6.7.15.2.1 Except as specified in 42 C.F.R. § 438.730(d), the sanction is effective on the date
specified in CMS’ reconsideration notice.

G.6.7.15.2.2 If CMS, in consultation with the District, determines that the Contractor’s conduct poses
a serious threat to an Enrollee's health or safety, the sanction may be made effective
earlier than the date of the District’s reconsideration decision under section
G.6.2.8.14.1.2.

G.6.7.16 Health Insurance Providers Fee

G.6.7.16.1 DHCF must calculate payment for the Medical Assistance impact of the Health
Insurance Providers Fee (HIPF) under Section 9010 of the PPACA, when the fee is
applicable. If the HIPF is under moratorium and therefore not applicable, no
consideration of HIPF will be made in the rates for the respective fee year.

G.6.7.16.2 If the Contractor has a liability for payment of the HIPF, the DHCF contracted Actuary
intends to recognize the costs associated with this fee as “reasonable, appropriate and
attainable costs” to be considered in actuarially sound payments to the Contractor. The
HIPF due each year (the “fee year”) is calculated by the IRS from information on net
premiums written for the prior calendar year (the “data year”) filed by the insurers on
Form 8963.

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G.6.7.16.3 DHCF will make payments to each Contractor that are appropriate for the specific level
of the HIPF’s tax expense. The amount of fee year HIPF incurred by the impacted
Contractor will vary as a percentage of their capitation payments or fee year premium
revenue. The standard HIPF exemptions impact Contractors differently and corporate
income tax amounts may vary by Contractor.

G.6.7.16.4 Rather than include a preliminary estimate of HIPF prospectively in capitation rate
development and reconcile to final HIPF amounts due from each Contractor when the
IRS provides it on August 31 of the fee year, DHCF will make a retrospective
adjustment to the capitation rates after the HIPF amounts for each Contractor is known.
DHCF’s contracted Actuary will adjust either the base year or fee year rates. This
approach will adjust the capitation rates to what they would have been had each
Contractor’s actual HIPF rate been known when the capitation rates were initially
developed.

G.6.7.16.5 The Contractor shall, at a minimum, be responsible for adhering to the following criteria
and reporting requirements:

G.6.7.16.5.1 Provide DHCF with a copy of the final Form 8963 submitted to the IRS within 5
business days of submission to the IRS. In the case that adjustments to the original Form
8963 are appropriate, the Contractor shall provide any adjusted Form 8963 within 5
business days of the amended filing. The Contractor will also provide DHCF with any
supporting detail regarding the breakout of the amounts reported by the Contractor in the
8963, as requested by DHCF.

G.6.7.16.5.2 Provide DHCF with the preliminary calculation of the HIPF as determined by the IRS,
and all applicable federal and state tax information within 5 business days of receipt
from the IRS.

G.6.7.16.5.3 Provide DHCF with the final calculation of the HIPF as determined by the IRS within 5
business days of receipt from the IRS.

G.6.7.16.5.4 DHCF will provide the Contractor with the estimated impact of the HIPF calculated by
DHCF’s Actuary using the preliminary HIPF calculation provided by the IRS. The
Contractor must review and notify DHCF of any discrepancies within 10 business days.

G.6.7.16.5.5 DHCF will make payment to the Contractor based upon the final HIPF amount provided
by the IRS and calculated by DHCF’s contracted Actuary, by the end of the fiscal year.

G.7 CONTRACTING OFFICER (CO)

Contracts will be entered into and signed on behalf of the District only by contracting officers.
The contact information for the Contracting Officer is:

Tracy Williams
Office of Contracting and Procurement
tracy.williams2@dc.gov

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G.8 AUTHORIZED CHANGES BY THE CONTRACTING OFFICER (CO)

G.8.1 The CO is the only person authorized to approve changes in any of the requirements of this
contract.

G.8.2 The Contractor shall not comply with any order, directive or request that changes or modifies
the requirements of this contract, unless issued in writing and signed by the CO.

G.8.3 In the event the Contractor effects any change at the instruction or request of any person other
than the CO, the change will be considered to have been made without authority and no
adjustment will be made in the contract price to cover any cost increase incurred as a result
thereof.

G.9 CONTRACT ADMINSTRATOR (CA)

G.9.1 The CA is responsible for general administration of the contract and advising the CO as to
the Contractor’s compliance or noncompliance with the contract. The CA has the
responsibility of ensuring the work conforms to the requirements of the contract and such
other responsibilities and authorities as may be specified in the contract. These include:

G.9.1.1 Keeping the CO fully informed of any technical or contractual difficulties encountered during
the performance period and advising the CO of any potential problem areas under the contract;
G.9.1.2 Coordinating site entry for Contractor personnel, if applicable;
G.9.1.3 Reviewing invoices for completed work and recommending approval by the CO if the
Contractor’s costs are consistent with the negotiated amounts and progress is satisfactory
and commensurate with the rate of expenditure;
G.9.1.4 Reviewing and approving invoices for deliverables to ensure receipt of goods and services.
This includes the timely processing of invoices and vouchers in accordance with the
District’s payment provisions; and
G.9.1.5 Maintaining a file that includes all contract correspondence, modifications, records of
inspections (site, data, equipment) and invoice or vouchers. G.9.2. The address and
telephone number of the CA is:

Oluwatobi Oni
Department of Health Care Finance
Oluwatobi.oni@dc.gov

G.9.3 The CA shall NOT have the authority to:

1. Award, agree to, or sign any contract, delivery order or task order. Only the CO shall make
contractual agreements, commitments or modifications;
2. Grant deviations from or waive any of the terms and conditions of the contract;
3. Increase the dollar limit of the contract or authorize work beyond the dollar limit of the
contract,
4. Authorize the expenditure of funds by the Contractor;
5. Change the period of performance; or
6. Authorize the use of District property, except as specified under the contract.

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G.9.4 The Contractor will be fully responsible for any changes not authorized in advance, in writing,
by the CO; may be denied compensation or other relief for any additional work performed that
is not so authorized; and may also be required, at no additional cost to the District, to take all
corrective action necessitated by reason of the unauthorized changes.

G.10 ORDERING CLAUSE

G.10.1 Any supplies and services to be furnished under this contract must be ordered by issuance of
delivery orders or task orders by the CO. Such orders may be issued during the term of this
contract.
G.10.2 All delivery orders or task orders are subject to the terms and conditions of this contract. In
the event of a conflict between a delivery order or task order and this contract, the contract
shall control.
G.10.3 If mailed, a delivery order or task order is considered "issued" when the District deposits the
order in the mail. Orders may be issued by facsimile or by electronic commerce methods.

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SECTION H: SPECIAL CONTRACT REQUIREMENTS

H.1 HIRING OF DISTRICT RESIDENTS AS APPRENTICES AND TRAINEES

H.1.1 For all new employment resulting from this contract or subcontracts hereto, as defined in
Mayor’s Order 83-265 and implementing instructions, the Contractor shall use its best
efforts to comply with the following basic goal and objectives for utilization of bona fide
residents of the District of Columbia in each project’s labor force:

H.1.1.1 At least fifty-one (51) percent of apprentices and trainees employed shall be residents of the
District of Columbia registered in programs approved by the District of Columbia
Apprenticeship Council.

H.1.2 The Contractor shall negotiate an Employment Agreement with the Department of
Employment Services (DOES) for jobs created as a result of this contract. The DOES shall
be the Contractor’s first source of referral for qualified apprentices and trainees in the
implementation of employment goals contained in this clause.

H.1.3 If a contractor has one or more contracts to provide information technology work to the
District valued at $500,000 or more during a 12-month period, the contractor is required to
register an apprenticeship program with the DC Apprenticeship Council through the DOES
Office of Apprenticeship. The prime contractor shall include this provision its subcontracts
under those contracts.

H.2 DEPARTMENT OF LABOR WAGE DETERMINATIONS

The Contractor shall be bound by the Wage Determination No. 2015-4281, Revision No. 35,
dated December 3, 2025, issued by the U.S. Department of Labor in accordance with the
Service Contract Act, 41 U.S.C. § 351 et seq., and incorporated herein as Section J.2. The
Contractor shall be bound by the wage rates for the term of the contract subject to revision as
stated herein and in accordance with clause 24 of the SCP. If an option is exercised, the
Contractor shall be bound by the applicable wage rates at the time of the exercise of the option.
If the option is exercised and the CO obtains a revised wage determination, the revised wage
determination is applicable for the option periods and the Contractor may be entitled to an
equitable adjustment.

H.3 PREGNANT WORKERS FAIRNESS

H.3.1 The Contractor shall comply with the Protecting Pregnant Workers Fairness Act of 2016, D.C.
Official Code § 32-1231.01 et seq. (PPWF Act).

H.3.2 The Contractor shall not:

(a) Refuse to make reasonable accommodations to the known limitations related to pregnancy,
childbirth, related medical conditions, or breastfeeding for an employee, unless the Contractor
can demonstrate that the accommodation would impose an undue hardship;

(b) Take an adverse action against an employee who requests or uses a reasonable
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accommodation in regard to the employee's conditions or privileges of employment, including
failing to reinstate the employee when the need for reasonable accommodations ceases to the
employee's original job or to an equivalent position with equivalent:

Pay;
Accumulated seniority and retirement;
Benefits; and
Other applicable service credits;

(c) Deny employment opportunities to an employee, or a job applicant, if the denial is based on
the need of the employer to make reasonable accommodations to the known limitations related
to pregnancy, childbirth, related medical conditions, or breastfeeding;

(d) Require an employee affected by pregnancy, childbirth, related medical conditions, or
breastfeeding to accept an accommodation that the employee chooses not to accept if the
employee does not have a known limitation related to pregnancy, childbirth, related medical
conditions, or breastfeeding or the accommodation is not necessary for the employee to perform
her duties;

(e) Require an employee to take leave if a reasonable accommodation can be provided; or

(f) Take adverse action against an employee who has been absent from work as a result of a
pregnancy-related condition, including a pre-birth complication.

H.3.3 The Contractor shall post and maintain in a conspicuous place a notice of rights in both English
and Spanish and provide written notice of an employee's right to a needed reasonable
accommodation related to pregnancy, childbirth, related medical conditions, or breastfeeding
pursuant to the PPWF Act to:

(a) New employees at the commencement of employment;
(b) Existing employees; and
(c) An employee who notifies the employer of her pregnancy, or other condition covered by the
PPWF Act, within 10 days of the notification.

H.3.4 The Contractor shall provide an accurate written translation of the notice of rights to any non-
English or non-Spanish speaking employee.

H.3.5 Violations of the PPWF Act shall be subject to civil penalties as described in the Act.

H.4 UNEMPLOYED ANTI-DISCRIMINATION

H.4.1 The Contractor shall comply with the Unemployed Anti-Discrimination Act of 2012, D.C.
Official Code § 32-1361 et seq.

H.4.2 The Contractor shall not:

(a) Fail or refuse to consider for employment, or fail or refuse to hire, an individual as an
employee because of the individual's status as unemployed; or

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(b) Publish, in print, on the Internet, or in any other medium, an advertisement or announcement
for any vacancy in a job for employment that includes:

(1) Any provision stating or indicating that an individual's status as unemployed disqualifies
the individual for the job; or

(2)Any provision stating or indicating that an employment agency will not consider or hire
an individual for employment based on that individual's status as unemployed.

H.4.3 Violations of the Unemployed Anti-Discrimination Act shall be subject to civil penalties as
described in the Act.

H.5 51% DISTRICT RESIDENTS NEW HIRES REQUIREMENTS AND FIRST SOURCE
EMPLOYMENT AGREEMENT

Delete Article 35, 51% District Residents New Hires Requirements and First Source
Employment Agreement, of the Standard Contract Provisions dated July 2010 for use with
District of Columbia Government Supplies and Services Contracts and substitute the following
Section H.5 51% DISTRICT RESIDENTS NEW HIRES REQUIREMENTS AND FIRST
SOURCE EMPLOYMENT AGREEMENT in its place:

H.5 51% DISTRICT RESIDENTS NEW HIRES REQUIREMENTS AND FIRST SOURCE
EMPLOYMENT AGREEMENT

H.5.1 For contracts for services in the amount of $300,000 or more, the Contractor shall comply with
the First Source Employment Agreement Act of 1984, as amended, D.C. Official Code § 2-
219.01 et seq. (First Source Act).

H.5.2 The Contractor shall enter into and maintain during the term of the contract, a First Source
Employment Agreement (Employment Agreement) with the District of Columbia Department
of Employment Service’s (DOES), in which the Contractor shall agree that:

(a) The first source for finding employees to fill all jobs created in order to perform the
contract shall be the First Source Register; and
(b) The first source for finding employees to fill any vacancy occurring in all jobs covered by
the Employment Agreement shall be the First Source Register.

H.5.3 The Contractor shall not begin performance of the contract until its Employment Agreement has
been accepted by DOES. Once approved, the Employment Agreement shall not be amended
except with the approval of DOES.

H.5.4 The Contractor agrees that at least 51% of the new employees hired to perform the contract shall
be District residents.

H.5.5 The Contractor’s hiring and reporting requirements under the First Source Act and any rules
promulgated thereunder shall continue for the term of the contract.

H.5.6 The CO may impose penalties, including monetary fines of 5% of the total amount of the direct
and indirect labor costs of the contract, for a willful breach of the Employment Agreement,
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failure to submit the required hiring compliance reports, or deliberate submission of falsified
data.

H.5.7 If the Contractor does not receive a good faith waiver, the CO may also impose an additional
penalty equal to 1/8 of 1% of the total amount of the direct and indirect labor costs of the
contract for each percentage by which the Contractor fails to meet its hiring requirements.

H.5.8 Any contractor which violates, more than once within a 10-year timeframe, the hiring or
reporting requirements of the First Source Act shall be referred for debarment for not more than
five years.

H.5.9 The contractor may appeal any decision of the CO pursuant to this clause to the D.C. Contract
Appeals Board as provided in clause 14 of the SCP, Disputes.

H.5.10 The provisions of the First Source Act do not apply to nonprofit organizations which employ 50
employees or less.

H.6 RESERVED

H.7 RESERVED

H.8 RESERVED

H.9 SUBCONTRACTING REQUIREMENTS

Delete Article 45, Subcontracting Requirements, of the Standard Contract Provisions dated July
2010 for use with District of Columbia Government Supplies and Services Contracts and
substitute the following Section H.9 SUBCONTRACTING REQUIREMENTS in its place:

H.9 SUBCONTRACTING REQUIREMENTS

H.9.1 Mandatory Subcontracting Requirements

H.9.1.1 For all contracts in excess of $250,000, at least 4.1% of the dollar volume of the contract
shall be subcontracted to qualified small business enterprises (SBEs).

H.9.1.2 If there are insufficient SBEs to completely fulfill the requirement of paragraph H.9.1.1, then
the subcontracting may be satisfied by subcontracting 4.1% of the dollar volume to any
qualified certified business enterprises (CBEs); provided, however, that all reasonable efforts
shall be made to ensure that SBEs are significant participants in the overall subcontracting
work.

H.9.1.3 A prime contractor that is certified by DSLBD as a small, local or disadvantaged business
enterprise shall not be required to comply with the provisions of sections H.9.1.1 and H.9.1.2.

H.9.1.4 Except as provided in H.9.1.5 and H.9.1.7, a prime contractor that is a CBE and has been
granted a proposal preference pursuant to D.C. Official Code § 2-218.43, or is selected
through a set-aside program, shall perform at least 35% of the contracting effort with its own
organization and resources and, if it subcontracts, 35% of the subcontracting effort shall be
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with CBEs. A CBE prime contractor that performs less than 35% of the contracting effort
shall be subject to enforcement actions under D.C. Official Code § 2-218.63.

H.9.1.5 If the prime contractor is a certified joint venture and has been granted a bid preference
pursuant to D.C. Official Code § 2-218.43, or is selected through a set-aside program, the
CBE member of the certified joint venture shall perform at least 50% of the contracting effort
with its own organization and resources and, if it subcontracts, 35% of the subcontracting
effort shall be with CBEs. If the CBE member of the certified joint venture prime contractor
performs less than 50% of the contracting effort, the certified joint venture shall be subject to
enforcement actions under D.C. Official Code § 2-218.63.

H.9.1.6 Each CBE utilized to meet these subcontracting requirements shall perform at least 35% of
its contracting effort with its own organization and resources.

H.9.1.7 A prime contractor that is a CBE and has been granted a proposal preference pursuant to D.C.
Official Code § 2-218.43, or is selected through a set-aside program, shall perform at least
50% of the on-site work with its own organization and resources if the contract is $1 million
or less.

H.9.2 Subcontracting Plan

If the prime contractor is required by law to subcontract under this contract, it must subcontract
at least 35% of the dollar volume of this contract in accordance with the provisions of section
H.9.1 of this clause. The plan shall be submitted as part of the proposal and may only be
amended after award with the prior written approval of the CO and Director of DSLBD. Any
reduction in the dollar volume of the subcontracted portion resulting from an amendment of the
plan after award shall inure to the benefit of the District.

Each subcontracting plan shall include the following:

(1) The name and address of each subcontractor;
(2) A current certification number of the small or certified business enterprise;
(3) The scope of work to be performed by each subcontractor; and
(4) The price that the prime contractor will pay each subcontractor.

H.9.3 Copies of Subcontracts

Within twenty-one days of the date of award, the Contractor shall provide fully executed copies
of all subcontracts identified in the subcontracting plan to the CO, CA, District of Columbia
Auditor and the Director of DSLBD.

H.9.4 Subcontracting Plan Compliance Reporting

H.9.4.1 If the Contractor has a subcontracting plan required by law for this contract, the Contractor
shall submit a quarterly report to the CO, CA, District of Columbia Auditor and the Director
of DSLBD. The quarterly report shall include the following information for each
subcontract identified in the subcontracting plan:

(A) The price that the prime contractor will pay each subcontractor under the subcontract;
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(B) A description of the goods procured or the services subcontracted for;
(C) The amount paid by the prime contractor under the subcontract; and
(D) A copy of the fully executed subcontract, if it was not provided with an earlier
quarterly report.

H.9.4.2 If the fully executed subcontract is not provided with the quarterly report, the prime
contractor will not receive credit toward its subcontracting requirements for that subcontract.

H.9.5 Annual Meetings

Upon at least 30-days written notice provided by DSLBD, the Contractor shall meet annually
with the CO, CA, District of Columbia Auditor and the Director of DSLBD to provide an
update on its subcontracting plan.

H.9.6 Notices

The Contractor shall provide written notice to the DSLBD and the District of Columbia Auditor
upon commencement of the contract and when the contract is completed.

H.9.7 Enforcement and Penalties for Breach of Subcontracting Plan

H.9.7.1 A contractor shall be deemed to have breached a subcontracting plan required by law, if the
contractor (i) fails to submit subcontracting plan monitoring or compliance reports or other
required subcontracting information in a reasonably timely manner; (ii) submits a
monitoring or compliance report or other required subcontracting information containing a
materially false statement; or (iii) fails to meet its subcontracting requirements.

H.9.7.2 A contractor that is found to have breached its subcontracting plan for utilization of CBEs in
the performance of a contract shall be subject to the imposition of penalties, including
monetary fines in accordance with D.C. Official Code § 2-218.63.

H.9.7.3 If the CO determines the Contractor’s failure to be a material breach of the contract, the CO
shall have cause to terminate the contract under the default provisions in clause 8 of the
SCP, Default.

H.10 FAIR CRIMINAL RECORD SCREENING

H.10.1 The Contractor shall comply with the provisions of the Fair Criminal Record Screening
Amendment Act of 2014, effective December 17, 2014 (D.C. Law 20-152) (the “Act” as
used in this section). This section applies to any employment, including employment on a
temporary or contractual basis, where the physical location of the employment is in whole or
substantial part within the District of Columbia.

H.10.2 Prior to making a conditional offer of employment, the Contractor shall not require an
applicant for employment, or a person who has requested consideration for employment by
the Contractor, to reveal or disclose an arrest or criminal accusation that is not then pending
or did not result in a criminal conviction.

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H.10.3 After making a conditional offer of employment, the Contractor may require an applicant to
disclose or reveal a criminal conviction.

H.10.4 The Contractor may only withdraw a conditional offer of employment, or take adverse
action against an applicant, for a legitimate business reason as described in the Act.

H.10.5 This section and the provisions of the Act shall not apply:

(a) Where a federal or District law or regulation requires the consideration of an applicant’s
criminal history for the purposes of employment;
(b) To a position designated by the employer as part of a federal or District government
program or obligation that is designed to encourage the employment of those with
criminal histories;
(c) To any facility or employer that provides programs, services, or direct care to, children,
youth, or vulnerable adults; or
(d) To employers that employ less than 11 employees.

H.10.6 A person claiming to be aggrieved by a violation of the Act may file an administrative
complaint with the District of Columbia Office of Human Rights, and the Commission on
Human Rights may impose monetary penalties against the Contractor.

H.11 DISTRICT RESPONSIBILITIES

H.11.1 Enrollment Notification Schedule

H.11.1.1 The following describes the schedule for notification and enrollment for CASSIP:

H.11.1.1.1 One month after the Start Date of the Contract, the DHCF shall send a notification letter
to all CASSIP eligible individuals. The letter shall inform Enrollees of the following:

H.11.1.1.1.1 The District shall notify all Enrollees of their CASSIP eligibility and option to enroll
into the CASSIP Contractor or remain in FFS. Enrollees shall have 10 days from the
date of the letter to enroll with the Contractor.

H.11.1.1.1.2 The District shall disenroll an Enrollee due to loss of eligibility under the following
circumstances:

H.11.1.1.1.2.1 If the Enrollee is no longer eligible for CASSIP, the Enrollee’s disenrollment shall
be effective no later than the first (1st) day of the first (1st) full month following the
loss of eligibility; or
H.11.1.1.1.2.2 If the Enrollee ages out of the CASSIP, the disenrollment shall be effective the first
day of the following month of their loss of eligibility.

H.11.1.2 DHCF may restrict the number of Enrollees in or assigned to a Contractor, if DHCF
determines that Contractor or its Provider Network do not have adequate capacity to serve
additional Enrollees, or if DHCF imposes Intermediate Sanctions under section G.6.7.
Families enrolled with Contractor shall still be given the opportunity to enroll with
Contractor, even if DHCF restricts Contractor’s enrollment under this provision.

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H.11.2 Readiness Assessment

H.11.2.1 DHCF shall conduct a Readiness Assessment of the Contractor selected for award of this
Contract. Contractor shall fully comply with DHCF’s Readiness Assessment and Review
procedures, including providing DHCF or its Contractors with access to documents, staff,
and facilities.

H.11.2.2 General Subcontract Requirements

H.11.2.2.1 The requirements of 42 C.F.R. § 438.230, shall apply to any contract or written
arrangement/agreement that the Contractor has with any subcontractor.

H.11.2.2.2 The Contractor shall maintain ultimate responsibility for adhering to and otherwise fully
complying with all terms and conditions of its Contract with the District.

H.11.2.2.3 The Contractor shall ensure that all activities carried out by any subcontractor conform
to the provisions of the Contract with the District and be clearly specified in the
subcontract. The Contractor shall include in all of its contracts and subcontracts a
requirement that the subcontractor look solely to the Contractor for payment for services
rendered.

H.11.2.2.4 The terms of any subcontracts involving the provision or administration of medical
services shall be subject to DHCF approval via the CO prior to implementation or
application.

H.11.2.2.5 It is the responsibility of the Contractor to ensure that its subcontractors are fully capable
of meeting all reporting requirements outlined in the Contract, including the ability to
accurately report data that pertains exclusively to the District population. The Contractor
must verify that its subcontractors have the necessary systems, processes, and expertise
to segregate and provide data that reflects District-specific metrics. If a subcontractor
lacks the ability to isolate and report data relevant only to the District, this does not
absolve the Contractor of its obligation to fulfill all reporting requirements. The
Contractor remains fully accountable for delivering comprehensive and compliant
reports as required under the terms of the Contract.

H.11.2.3 Sub-contractual Relationships and Delegation

H.11.2.3.1 All contracts or written arrangements/agreements between the Contractor and any
subcontractor must meet the requirements of 42 C.F.R. §438.230(c).

H.11.2.3.2 The subcontractor agrees to comply with all applicable Medicaid laws, regulations,
including applicable sub-regulatory guidance and contract provisions.

H.11.2.3.3 The subcontractor agrees that:

H.11.2.3.3.1 The District, CMS, the HHS Inspector General, the Comptroller General, or their
designees have the right at any time to audit, evaluate, and inspect all documents
records, contracts, computer or other electronic systems of the subcontractor, or of the
subcontractor’s contractor, that pertain to any aspect of services and activities
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performed, or determination of amounts payable under the Contractor’s Contract with
the District;
H.11.2.3.3.2 The subcontractor will make available, for purposes of an audit, evaluation, or
Inspection, under section C.5.40.4 its premises, physical facilities, equipment,
documents, records, contracts, computer, or other electronic systems relating to
Medicaid Enrollees;
H.11.2.3.3.3 The right to audit under section C.5.40.4 will exist through 10 years from the final date
of the contract period or from the date of completion of any audit, whichever is later; and
H.11.2.3.3.4 If the District, CMS, or the HHS Inspector General determines that there is a reasonable
possibility of fraud or similar risk, the District, CMS, or the HHS Inspector General may
inspect, evaluate, and audit the subcontractor at any time.

H.11.2.3.4 The District shall ensure, through its contracts, that before any delegation to an
independent contractor, the Contractor shall:

H.11.2.3.4.1 Oversee and be accountable for any functions and responsibilities that it delegates to any
independent contractor;
H.11.2.3.4.2 Evaluate the prospective independent contractor’s ability to perform the activities to be
delegated before a written agreement is executed; and

H.11.2.3.4.3 Meet the following specific conditions:

H.11.2.3.4.3.1 The Contractor has a written agreement that specifies the activities and reporting
responsibilities delegated to the independent contractor;
H.11.2.3.4.3.2 The written agreement provides for revoking delegation or imposing other sanctions if
the independent contractor’s performance is inadequate;
H.11.2.3.4.3.3 The Contractor shall monitor the independent contractor’s performance on an ongoing
basis and subject it to formal review according to a periodic schedule established by
the District, consistent with industry standards, or DISB laws and regulations; and
H.11.2.3.4.3.4 If Contractor identifies deficiencies or areas for improvement, the Contractor and the
subcontractor shall take corrective action.

H.11.2.3.5 The Contractor shall adhere to 42 C.F.R. § 438.6 contract requirements, 42 C.F.R. Part
489; DCMR Title 29, Chapters 53, 54, and 55, and D.C. Code §44-551 and 552 et seq.,
along with any other applicable Federal and District laws.

H.11.2.3.6 In accordance with 42 C.F.R. § 438.6(k), all subcontractors must fulfill the requirements
that are appropriate to the service or activity delegated under the subcontract.

H.11.2.3.7 Subcontracts do not terminate Contractor’s legal responsibilities for performance under
the Contract.

H.11.2.4 Sub-contractual Relationships and Delegation Reporting

H.11.2.4.1 The Contractor shall provide to the DHCF a complete listing of the delegated entities
within 90 days of the date of Contract award and provide a subsequent updated listing
within 60 days of executing or terminating a delegation agreement that includes a
description of core functions and activities delegated to the subcontractor

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H.11.2.4.2 The Contractor shall provide to the District a copy of the pre-delegation review report
within 45 days of the Contractor conducting the review.

H.11.2.4.3 The Contractor shall provide to the District a copy of the annual delegation review
reports with 45 days of the Contractor conducting the review.

H.11.2.4.4 Contractor shall notify the District in writing of any corrective action taken in
accordance with section C.5.181.

H.11.2.5 Timing

DHCF will conduct a Readiness Assessment after the Contract award is announced and prior
to enrollment of any Enrollees.

H.11.2.6 Content of Readiness Assessment

The Readiness Assessment shall include but is not limited to: site visits, interviews with key
personnel, and review of documentation and deliverables that are required prior to
enrollment. Areas of special emphasis for the Readiness Assessment may include, but are
not limited to, EPSDT; behavioral health care; Enrollee outreach; Care Coordination and
Case Management procedures; financial operations; UM and CQI management; network
adequacy and capacity; Enrollment Activities; provisions for monitoring the transition of
Enrollees with children with special health care needs; claims payment procedures; and
reporting.

H.11.2.7 Readiness Assessment and Corrective Action

If DHCF determines that any potential Contractor has not met the criteria for readiness,
DHCF shall notify the Contractor and the Contractor shall be required to develop a CAP
acceptable to DHCF and in accordance with section C.5.181. Following the implementation
of the CAP, DHCF has the right to conduct site visits to Contractor’s office to verify
implementation of the CAP. DHCF shall approve Contractor for enrollment once DHCF
verifies that the CAP has been implemented to its satisfaction.

H.11.2.8 Readiness Assessment Certification

DHCF shall complete and submit a Certification of Readiness indicating the Contractor’s
successful fulfillment of the contents of the Readiness Assessment, as described in section
H.11.2, 30 days before Start Date. The Readiness Assessment Certification shall be signed
by the Contractor’s authorized representative, the CA, and the CO prior to the Contractor’s
acceptance of Enrollees in CASSIP.

H.11.2.9 Establishing Community Standards

H.11.2.9.1 When establishing community standards DHCF will consider:

H.11.2.9.1.1. Relevant federal statutes, regulations, and policy;
H.11.2.9.1.2. Relevant District of Columbia statutes, regulations, and policy;
H.11.2.9.1.3. Relevant federal and District court cases;
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H.11.2.9.1.4. The opinion of health care Providers and professionals who practice in the District and,
where appropriate, practice primarily within a specific subset of the District’s population
or geography; and
H.11.2.9.1.5. Valid, reliable research generalizable to the District of Columbia and any population
within the District and any population within the District of Columbia of interest.

H.11.2.9.2 If Contractor disagrees with DHCF’s definition of a community standard, the Contractor
may submit an alternative community standard definition to DHCF for consideration,
along with an explanation of how Contactor established the standard prior to applying
that standard for analysis.

H.11.2.9.3 By approving a report or Deliverable, DHCF represents only that it has received and
reviewed the report or Deliverable.

H.11.2.9.4 The CA acceptance of a report or Deliverable is equivalent to DHCF’s acceptance of
that report. Another District agency’s acceptance of a report or Deliverable does not
discharge any of Contractor’s contractual obligations with respect to its reporting
requirements, or to the quality, comprehensiveness, functionality, effectiveness, or
acceptance by the CA or DHCF as a whole

H.11.3 Reporting Requirements

H.11.3.1 DHCF shall provide the Contractor templates for the reports required in sections C.5.216
and F.3 following the Start Date.

H.11.3.2 DHCF shall publicly highlight the performance of Contractor on the performance measures
described in, but not limited to, section C.5.170 and the other performance reports described
in section F.3.

H.11.4 Enrollee Handbook

DHCF shall provide Contractor a standard Enrollee Handbook Template within 15 days of
the date of Contract Award.

H.11.5 Non-Financial Performance Incentives

H.11.5.1 DHCF may, at its discretion, utilize Contractor’s performance on the performance measures
described in section C.5.170 to develop Performance Report Cards, which present a
summary of the Contractor’s performance, and DHCF will distribute to Enrollees, Providers,
and other stakeholders. The Report Card will provide Enrollees and the public with
consistent and transparent information regarding the performance of the Contractor.

H.11.5.2 DHCF, at its discretion, may publicly highlight the performance of Contractor on the
performance measures described in section C.5.170 and other performance reports described
within section C, including through published summaries, reports, and documents
distributed to the public.

H.11.6 Performance-Based Incentive Program

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H.11.6.1 Providing incentives to Contractors for high quality performance is an important component
of DHCF’s overall strategy to improve the quality of care received by Enrollees. DHCF may
utilize financial performance-based incentives to encourage CQI and, therefore,
improvement in quality of care received by Enrollees. If financial performance-based
incentives are utilized, DHCF may periodically modify the type of incentives and the
structure of the performance-based incentive program over the course of the Contract period.

H.11.6.2 All Contractors shall participate in the Performance-Based Incentive Program.

H.11.6.3 Performance Based Incentive Measurements

H.11.6.4 The following lists examples of measures that shall be used as part of the Performance
Based Incentive Program:

H.11.6.4.1. LANE Utilization;
H.11.6.4.2. Potentially Preventable Admissions (PPA); and
H.11.6.4.3. Plan All-Cause Readmissions (PCR)

H.11.7 Performance Evaluation

H.11.7.1 DHCF shall make performance incentive payments according to criteria and standards
established by DHCF. These criteria include measurement of performance in clinical quality
of care. Examples of the evaluation methods and scoring for the Performance Based
Incentives are described in the scoring Algorithm in Attachment J.32, DC Medicaid Care
Quality Strategy. DHCF may modify the type of performance measures, and performance
incentives used over the course of the Contract period.

H.11.7.2 Contractor shall not be eligible for a performance incentive payment when fines, sanctions,
or damages are imposed due to continuous egregious behavior by the Contractor, including
but not limited to behavior that is described in 42 C.F.R § 438.700, or that is contrary to any
requirements of §§ 1903 (m) and 1932 of the Act.

H.11.7.3 If DHCF, at its sole discretion, eliminates any of the performance measures, Contractor shall
be scored based on an adjusted assessment of the remaining performance measures as
described in Attachment J.29.

H.11.7.4 As described in the scoring algorithm at Attachment J.32, DHCF will evaluate Contractor’s
performance on the selected measures as compared to benchmarks, which shall vary
depending on the measure.

H.11.7.5 In accordance with 42 C.F.R § 438.6 (b) (), performance incentive awards under this section,
shall not exceed 105% of the capitation payments approved by CMS that are attributable to
the Enrollees and Covered Services.

H.12 CONTRACTOR RESPONSIBILITIES

H.12.1 The Contractor shall provide sufficient staff devoted to delivering the requirements outlined
in this contract. The Contractor shall ensure that its staff responds to the CA requests for
documents and information. The Contractor’s staff shall respond to the CA’s questions and
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requests in a timely and efficient manner.

H.12.2 All deliverables, materials or other submissions provided by the Contractor must meet the
requirements specified in Section F.3. Such deliverables or other materials are subject to
DHCF approval.

H.12.3 If DHCF rejects a deliverable, the Contractor will have a resolution period beginning with
notice from DHCF that the deliverable is not approved. The resolution period will last for 10
business days from the notice of deliverable rejection. If, at the end of the specified time, the
deliverable(s) submitted by the Contractor are not approved by DHCF, DHCF may, at its
sole discretion, withhold all or part of the next monthly payment and any subsequent
payments until the deliverable(s) are acceptable to DHCF.

H.12.4 Prohibited Information and Activities

H.12.4.1 The Contractor shall not violate applicable Federal law as specified in Sections 1903(m)(A)
and 1932(e) of the Social Security Act (C.2.1 Applicable Document #4) and 42 CFR
422.208-210, §438.700-702, and 45 CFR 92.36(i), including:

H.12.4.1.1. Acting to discriminate among Beneficiaries on the basis of their health status or need for
health care services;
H.12.4.1.2. Misrepresenting or falsifying information the Contractor furnishes to CMS or the District;
H.12.4.1.3. Misrepresenting or falsifying information that the Contractor furnishes to a Beneficiary or
health care provider;
H.12.4.1.4. Distributing directly or indirectly through any Agent or independent Contractor, materials
that have not been approved by the District or that contain false or materially misleading
information;
H.12.4.1.5. Violating any of the other applicable requirements of sections 1903(m) or 1932 of the
Social Security Act and any implementing regulations; and
H.12.4.1.6. Violating District of Columbia law; or regulations or court orders.

H.13 DIVERSION, REASSIGNMENT AND REPLACEMENT OF KEY PERSONNEL

The key personnel specified in the contract are essential to the work being performed hereunder.
Prior to diverting any of the specified key personnel for any reason, the Contractor shall notify
the CO at least 30 calendar days in advance and shall submit justification, including proposed
substitutions, in sufficient detail to permit evaluation of the impact upon the contract. The
Contractor shall obtain written approval of the CO for any proposed substitution of key
personnel.

H.14 ADVISORY AND ASSISTANCE SERVICES

This contract is a “nonpersonal services contract”. The Contractor and the Contractor’s
employees: shall perform the services specified herein as independent contractors, not as
employees of the government; shall be responsible for their own management and
administration of the work required and bear sole responsibility for complying with any and all
technical, schedule, financial requirements or constraints attendant to the performance of this
contract; shall be free from supervision or control by any government employee with respect to
the manner or method of performance of the service specified; but shall, pursuant to the
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government’s right and obligation to inspect, accept or reject work, comply with such general
direction of the CO, or the duly authorized representative of the CO as is necessary to ensure
accomplishment of the contract objectives.

H.15 HIPAA BUSINESS ASSOCIATE COMPLIANCE

Any contractor with access to or responsibility for creating, transmitting, receiving, accessing,
or maintaining protected health information (PHI) on behalf of the District of Columbia must
comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as
amended, and its implementing regulations at 45 CFR Parts 160, 162, and 164. This includes
adherence to the HIPAA Privacy Compliance Business Associate Agreement and the Business
Associate HIPAA Compliance Questionnaire. These requirements apply to all contracts where
the contractor qualifies as a Business Associate, as defined under HIPAA regulations.

H.16 CRIMINAL BACKGROUND AND TRAFFIC RECORDS CHECKS FOR
CONTRACTORS THAT PROVIDE DIRECT SERVICES TO CHILDREN OR YOUTH

H.16.1 A contractor that provides services as a covered child or youth services provider, as defined
in section 202 of the Child and Youth, Safety and Health Omnibus Amendment Act of 2004,
effective April 13, 2005 (D.C. Law 15-353; D.C. Official Code § 4-1501.01 et seq.), as
amended (in this section, the “Act”), shall obtain criminal history records to investigate
persons applying for employment, in either a compensated or an unsupervised volunteer
position, as well as its current employees and unsupervised volunteers. The Contractor shall
request criminal background checks for the following positions identified in section C.5.5.3.

H.16.2 The Contractor shall also obtain traffic records to investigate persons applying for
employment, as well as current employees and volunteers, when that person will be required
to drive a motor vehicle to transport children in the course of performing his or her duties.
The Contractor shall request traffic records for the following positions identified in section
C.5.5.3.

H.16.3 The Contractor shall inform all applicants requiring a criminal background check that a
criminal background check must be conducted on the applicant before the applicant may be
offered a compensated position or an unsupervised volunteer position.

H.16.4 The Contractor shall inform all applicants requiring a traffic records check that a traffic
records check must be conducted on the applicant before the applicant may be offered a
compensated position or a volunteer position.

H.16.5 The Contractor shall obtain from each applicant, employee and unsupervised volunteer:

(A) a written authorization which authorizes the District to conduct a criminal background
check;
(B) a written confirmation stating that the Contractor has informed him or her that the
District is authorized to conduct a criminal background check;
(C) a signed affirmation stating whether or not they have been convicted of a crime,
pleaded nolo contendere, are on probation before judgment or placement of a case
upon a stet docket, or have been found not guilty by reason of insanity, for any sexual
offenses or intra-family offenses in the District or their equivalent in any other state or
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territory, or for any of the following felony offenses or their equivalent in any other
state or territory:

(i) Murder, attempted murder, manslaughter, or arson;
(ii) Assault, assault with a dangerous weapon, mayhem, malicious disfigurement, or
threats to do bodily harm;
(iii) Burglary;
(iv) Robbery;
(v) Kidnapping;
(vi) Illegal use or possession of a firearm;
(vii) Sexual offenses, including indecent exposure; promoting, procuring, compelling,
soliciting, or engaging in prostitution; corrupting minors (sexual relations with
children); molesting; voyeurism; committing sex acts in public; incest; rape;
sexual assault; sexual battery; or sexual abuse; but excluding sodomy between
consenting adults;
(viii) Child abuse or cruelty to children; or
(ix) Unlawful distribution of or possession with intent to distribute a controlled
substance;

(D) a written acknowledgement stating that the Contractor has notified them that they are
entitled to receive a copy of the criminal background check and to challenge the
accuracy and completeness of the report; and
(E) a written acknowledgement stating that the Contractor has notified them that they
may be denied employment or a volunteer position or may be terminated as an
employee or volunteer based on the results of the criminal background check.

H.16.6 The Contractor shall inform each applicant, employee and unsupervised volunteer that a
false statement may subject them to criminal penalties.

H.16.7 Prior to requesting a criminal background check, the Contractor shall provide each
applicant, employee, or unsupervised volunteer with a form or forms to be utilized for the
following purposes:

(A) To authorize the Metropolitan Police Department (MPD), or designee, to conduct the
criminal background check and confirm that the applicant, employee, or unsupervised
volunteer has been informed that the Contractor is authorized and required to conduct
a criminal background check;
(B) To affirm whether or not the applicant, employee, or unsupervised volunteer has been
convicted of a crime, has pleaded nolo contendere, is on probation before judgment or
placement of a case upon a stet docket, or has been found not guilty by reason of
insanity for any sexual offenses or intra-family offenses in the District or their
equivalent in any other state or territory of the United States, or for any of the felony
offenses described in paragraph H.16.5(C);
(C) To acknowledge that the applicant, employee, or unsupervised volunteer has been
notified of his or her right to obtain a copy of the criminal background check report
and to challenge the accuracy and completeness of the report;
(D) To acknowledge that the applicant may be denied employment, assignment to, or an
unsupervised volunteer position for which a criminal background check is required
based on the outcome of the criminal background check; and
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(E) To inform the applicant or employee that a false statement on the form or forms may
subject them to criminal penalties pursuant to D.C. Official Code § 22-2405.

H.16.8 The Contractor shall direct the applicant or employee to complete the form or forms and
notify the applicant or employee of when and where to report to be fingerprinted.

H.16.9 Unless otherwise provided herein, the Contractor shall request criminal background checks
from the Chief, MPD (or designee), who shall be responsible for conducting criminal
background checks, including fingerprinting.

H.16.10 The Contractor shall request traffic record checks from the Director, Department of Motor
Vehicles (DMV) (or designee), who shall be responsible for conducting traffic record
checks.

H.16.11 The Contractor shall provide copies of all criminal background and traffic check reports to
the CA within one business day of receipt.

H.16.12 The Contractor shall pay for the costs for the criminal background and traffic record checks,
pursuant to the requirements set forth by the MPD and DMV. The District shall not make
any separate payment for the cost of criminal background and traffic record checks.

H.16.13 The Contractor may make an offer of appointment to, or assign a current employee or
applicant to, a compensated position contingent upon receipt from the CO of the CA’s
decision after his or her assessment of the criminal background or traffic record check.

H.16.14 The Contractor may not make an offer of appointment to an unsupervised volunteer whose
position brings him or her into direct contact with children until it receives from the
contracting officer the CA’s decision after his or her assessment of the criminal background
or traffic record check.

H.16.15 The Contractor shall not employ or permit to serve as an unsupervised volunteer an
applicant or employee who has been convicted of, has pleaded nolo contendere to, is on
probation before judgment or placement of a case on the stet docket because of, or has been
found not guilty by reason of insanity for any sexual offenses involving a minor.

H.16.16 Unless otherwise specified herein, the Contractor shall conduct periodic criminal
background checks upon the exercise of each option year of this contract for current
employees and unsupervised volunteer in the positions listed in sections H.16.1 and H.16.2.

H.16.17 An employee or unsupervised volunteer may be subject to administrative action including,
but not limited to, reassignment or termination at the discretion of the CA after his or her
assessment of a criminal background or traffic record check.

H.16.18 The CA shall be solely responsible for assessing the information obtained from each
criminal background and traffic records check report to determine whether a final offer may
be made to each applicant or employee. The CA shall inform the CO of its decision, and the
CO shall inform the Contractor whether an offer may be made to each applicant.

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H.16.19 If any application is denied because the CA determines that the applicant presents a present
danger to children or youth, the Contractor shall notify the applicant of such determination
and inform the applicant in writing that she or he may appeal the denial to the Commission
on Human Rights within 30 days of the determination.

H.16.20 Criminal background and traffic record check reports obtained under this section shall be
confidential and are for the exclusive use of making employment-related determinations.
The Contractor shall not release or otherwise disclose the reports to any person, except as
directed by the CO.

H.17 FRAUD, WASTE AND ABUSE PROVISIONS AND PROTECTIONS

H.17.1 Cooperation with the District

H.17.1.1 The Contractor is subject to all state and Federal laws and regulations relating to fraud,
waste and abuse in health care and the Medicaid program.

H.17.1.2 The Contractor shall cooperate and assist the District of Columbia, and any State or Federal
agency charged with the duty of identifying, investigating, or prosecuting suspected fraud,
waste and abuse.

H.17.1.3 The Contractor shall provide all records and information requested and allow the CA, CMS,
the U.S. Department of Health and Human Services, FBI and the District's Medicaid Fraud
Control Unit access to the Contractor's premises and provide records to. All copies of
records shall be provided free of charge.

H.17.1.4 The Contractor shall be responsible for promptly reporting suspected fraud, abuse, or
violation of the terms of the Contract to the CA, Office of Program Integrity and the
Contracting Officer, taking prompt corrective actions consistent with the terms of any
subcontract, and cooperating with District investigations.

H.17.1.5 The Contractor shall allow the District of Columbia Medicaid Fraud Control Unit or its
representatives to conduct private interviews of Contractor's employees, subcontractors, and
their employees, witnesses, and patients. The Contractor shall honor requests for information
in the form and the language specified.

H.17.1.6 The Contractor shall ensure that its staff and its subcontractors and their staff shall cooperate
fully and be available in person for interviews, consultation grand jury proceedings, pre-trial
conference, hearings, trials, and in any other process.

H.17.2 Federal False Claims Act

In accordance with Section 6032 of the Deficit Reduction Act, the Contractor shall:

(1) Establish written policies for all employees of the entity (including management), and of
any Contractor or agent of the entity, that provide detailed information about the False
Claims Act established under sections 3729 through 3733 of Title 31, United States Code,
administrative remedies for false claims and statements established under chapter 38 of Title
31, United States Code, any state laws pertaining to civil or criminal penalties for false
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claims and statements, and whistleblower protections under such laws, with respect to the
role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care
programs (as defined in section 1128B(f) of the Social Security Act);

(2) Include as part of such written policies, detailed provisions regarding the entity's policies
and procedures for detecting and preventing fraud, waste, and abuse; and

(3) Include in any employee handbook for the entity, a specific discussion of the laws described
in subparagraph (A), the rights of employees to be protected as whistleblowers, and the
entity's policies and procedures for detecting and preventing fraud, waste, and abuse.

H.18 CMS REQUIRED PROVISIONS

H.18.1 The state or local government will have all ownership rights in software or modifications
thereof and associated documentation designed, developed or installed with federal financial
participation (FFP). [45 CFR 95.617(a)]

H.18.2 The Federal government reserves a royalty-free, non-exclusive, and irrevocable license to
reproduce, publish, or otherwise use and to authorize others to use for Federal government
purposes, such software, modifications, and documentation. [45 CFR 95.617(b)]

H.18.3 Proprietary operating/contractor software packages which are provided at established catalog
or market prices and sold or leased to the general public shall not be subject to the ownership
provisions in paragraphs (a) and (b) of this section. FFP is not available for proprietary
applications software developed specifically for the public assistance programs covered
under this subpart. [45 CFR 95.617(c)]

H.18.4 Contractor is not permitted to use program data for independent projects without prior written
permission from the state. [SMM 2083.5] CW118651– Provider Data Management System &
Services O&M

H.18.5 The right of HHS (CMS) to conduct evaluation of services performed by the contractor and
for audit and inspection of contractor records. [SMM 2080.9]

H.18.6 No subcontract terminates the legal responsibility of the (prime) contractor to the agency to
assure that all activities under the contract are carried out. [42 CFR 434.6 (c) & SMM
2081.2]

H.18.7 Contract includes termination procedures that require the contractor to promptly supply all
materials necessary for continued operation of systems, including:

H.18.7.1 computer programs
H.18.7.2 data files user and operations manuals
H.18.7.3 system and program documentation
H.18.7.4 training programs related to the operation and maintenance of the system [42 CFR 434.10 (b)
& SMM 2082.2]

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H.19 FNS REQUIRED PROVISIONS

H.19.1 Compliance with Executive Order 11246 related to Equal Employment Opportunity

H.19.2 Compliance with Clean Air Act:

Clean Air Act (42 U.S.C. 7401-7671q.) and the Federal Water Pollution Control Act (33
U.S.C. 1251-1387), as amended. Contracts and subgrants of amounts in excess of $150,000
must contain a provision that requires the non-Federal award to agree to comply with all
applicable standards, orders or regulations issued pursuant to the Clean Air Act (42 U.S.C.
7401-7671q) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251-
1387). Violations must be reported to the Federal awarding agency and the Regional Office
of the Environmental Protection Agency (EPA). (2 CFR 200, Subpart F, Appendix II).

H.19.3 Compliance with the Clean Water Act (33 U.S.C. 1251-1387)

H.19.4 Compliance with “Anti-Kickback” Act, 40 USC §276c and 18 USC §874 The Copeland:

The “Anti-Kickback” section of the Act precludes a contractor or sub-contractor from
inducing an employee to give up any part of the compensation to which he or she is entitled
under his or her contract of employment. The Act also requires the contractor and sub-
contractor to submit a weekly statement of the wages paid to each employee performing on
covered work during the preceding payroll period.

H.19.5 Compliance with the Anti-Lobbying Act:

This Act prohibits the recipients of Federal contracts, grants, and loans from using
appropriated funds for lobbying the Executive or Legislative branches of the Federal
government in connection with a specific contract, grant, or loan. As required by Section
1352, Title 31 of the U.S. Code and implemented at 2 CFR 200, Subpart F, Appendix II, for
persons entering into a grant or cooperative agreement over $100,000, as defined at 31 U.S.C.
1352, the applicant certifies that:

H.19.5.1 No federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee
of any agency, a member of Congress, an officer or employee of Congress, or an employee
of a member of Congress in connection with the making of any federal grant, the entering
into of any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any federal grant or cooperative agreement.

H.19.5.2 If any funds other than federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
member of Congress, an officer or employee of Congress, or an employee of a member of
Congress in connection with this federal grantor o cooperative agreement, the undersigned
shall complete and submit Standard Form – LLL, “Disclosure Form to Report Lobbying,” in
accordance with its instructions.

H.19.5.3 The undersigned shall require that the language of this certification be included in the award
documents for all sub-awards at all tiers (including sub-grants, contracts under grants and
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cooperative agreements, and subcontracts) and that all sub-recipients shall certify and
disclose accordingly.

H.19.6 Compliance with Americans with Disabilities Act:

This Act (28 CFR Part 35, Title II, Subtitle A) prohibits discrimination on the basis of
disability in all services, programs, and activities provided to the public and State and local
governments, except public transportation services.

H.19.7 Compliance with Drug-Free Workplace requirements:

The Federal government implemented 41 U.S. Code § 8103, Drug-free workplace
requirements for Federal grant recipients in an attempt to address the problems of drug abuse
on the job. It is a fact that employees who use drugs have less productivity, a lower quality of
work, higher absenteeism, and are more likely to misappropriate funds or services. From this
perspective, the drug abuser may endanger other employees, the public at large, or
themselves. Damage to property, whether owned by this entity or not, could result from drug
abuse on the job. All these actions might undermine public confidence in the services this
entity provides. Therefore, in order to remain a responsible source for government contracts,
the following guidelines have been adopted:

H.19.7.1 The unlawful manufacture, distribution, dispensation, possession or use of a controlled
substance is prohibited in the workplace.

H.19.7.2 Violators may be terminated or requested to seek counseling from an approved rehabilitation
service.

H.19.7.3 Employees must notify their employer of any conviction of a criminal drug statute no later
than five days after such conviction.

H.19.7.4 Contractors of federal agencies are required to certify that they will provide drug-free
workplaces for their employees.

H.19.8 Transactions subject to the suspension/debarment rules (covered transactions) include grants,
subgrants, cooperative agreements, and prime contracts under such awards. Subcontracts are
not included. Also, the dollar threshold for covered procurement contracts is $25,000.
Contracts for Federally required audit services are covered regardless of dollar amount.

H.19.9 Compliance with suspension/debarment requirements:

Debarment and Suspension (Executive Orders 12549 and 12689)—A contract award (see 2
CFR 180.220) must not be made to parties listed on the government wide exclusions in the
System for Award Management (SAM), in accordance with the OMB guidelines at 2 CFR
180 that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689 (3
CFR part 1989 Comp., p. 235), “Debarment and Suspension.” SAM Exclusions contain the
names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties
declared ineligible under statutory or regulatory authority other than Executive Order 12549.
(2 CFR 200, Subpart F, Appendix II)

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H.19.10 FNS has royalty-free rights to use software and documentation developed (2 CFR
200.315 Intangible property):

H.19.10.1 Title to intangible property (see §200.59 Intangible property) acquired under a Federal
award vests upon acquisition in the non-Federal entity. The non-Federal entity must use that
property for the originally authorized purpose and must not encumber the property without
approval of the Federal awarding agency. When no longer needed for the originally
authorized purpose, disposition of the intangible property must occur in accordance with the
provisions in §200.313 Equipment paragraph (e).

H.19.10.2 The non-Federal entity may copyright any work that is subject to copyright and was
developed, or for which ownership was acquired, under a Federal award. The Federal
awarding agency reserves a royalty-free, nonexclusive, and irrevocable right to reproduce,
publish, or otherwise use the work for Federal purposes, and to authorize others to do so.

H.19.10.3 The non-Federal entity is subject to applicable regulations governing patents and inventions,
including government wide regulations issued by the Department of Commerce at 37 CFR
Part 401, “Rights to Inventions Made by Nonprofit Organizations and Small Business Firms
Under Government Awards, Contracts and Cooperative Agreements.”

H.19.10.4 The Federal Government has the right to:

H.19.10.4.1 Obtain, reproduce, publish, or otherwise use the data produced under a Federal award;
and
H.19.10.4.2 Authorize others to receive, reproduce, publish, or otherwise use such data for Federal
purposes.

H.19.11 Required Federal Assurances of FNS Handbook 901. For reference, Appendix F in FNS
Handbook 901 provides the Federal clauses: https://fns-
prod.azureedge.net/sites/default/files/resource-files/HB901v2.4.pdf

H.20 INTELLECTUAL PROPERTY

The Contractor shall comply with CMS’ grantor agency requirements and regulations pertaining
to reporting and patient rights and of CMS requirements and regulations pertaining to copyrights
and rights in data.

H.21 ENERGY EFFICIENCY

The Contractor shall recognize mandatory standards and policies related to energy efficiency
which are contained in the District’s energy conservation plan issued in compliance with the
Energy Policy and Conservation Act (Public Law 94-165, 42 U.S.C. § 6-201 et seq.).

H.22 SPECIAL INDEMNIFICATION

The Contractor shall fully indemnify, defend, and hold harmless the District of Columbia, its
officers, employees, and agents from and against any and all losses, liabilities, damages, penalties,
fines, costs, and expenses (including reasonable attorneys’ fees) incurred by the District that are
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directly or indirectly attributable to, or arise out of, the Contractor’s defective performance of its
obligations under this Contract.

In the event the federal government reduces, withholds, or recoups all or any portion of the
Federal Medical Assistance Percentage (FMAP) for Medicaid—currently set at seventy-five
percent (75%)—provided to the District, and such reduction, withholding, or recoupment is
determined by the federal government, the District, or any court of competent jurisdiction to be
the result of the Contractor’s acts, omissions, negligence, willful misconduct, or failure to comply
with applicable federal or District laws, rules, regulations, or contractual requirements, the
Contractor shall be liable for, and shall reimburse the District for, the full amount of the reduction,
withholding, or recoupment, together with any associated interest, penalties, and administrative
costs.

H.23 DISCLOSURE OF INFORMATION

H.23.1 In accordance with Federal Regulation 42 CFR 455.104, the Contractor must disclose the
following information to DHCF:

(1) The name and address of each person (individual or corporation) with an ownership or
control interest in the Contractor or in any subcontractor in which the Contractor has
direct or indirect ownership of 5 percent or more. The address for corporate entities
must include as applicable primary business address, every business location, P.O. Box
address, and Federal Tax Identification Number;
(2) Whether any of the persons (individual or corporation) with an ownership or control
interest in the disclosing entity (or fiscal agent) is related to another person with
ownership or control interest in the disclosing entity as a spouse, parent, child, or
sibling; or whether the person (individual or corporation)with an ownership or control
interest in any subcontractor in which the disclosing entity (or fiscal agent) has a 5
percent or more interest is related to another person with ownership or control interest
in the disclosing entity as a spouse, parent, child, or sibling;
(3) The name of any other disclosing entity in which an owner of the disclosing entity has
an ownership or control interest; and
(4) The name, address, date of birth, and Social Security Number of any managing
employee of the disclosing entity.

H.23.2 In accordance with Federal Regulation 42 CFR 455.106, before DHCF enters into or renews
an CASSIP agreement, or at any time upon written request by DHCF, the Contractor must
disclose to DHCF the identity of any person who:

(1) Has ownership or control interest in the Contractor, or is an agent or managing employee
of the Contractor; and
(2) Has been convicted of a criminal offense related to that person's involvement in any
program under Medicare, Medicaid, or Title XX of the Social Security Act since the
inception of those programs.

H.23.3 When the disclosures must be provided. The disclosures are due at any of the following
times:

(1) Prior to the Contractor entering into a contractual agreement to provide CASSIP services;
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(2) Upon the Contractor executing the contract to provide CASSIP services;
(3) Upon request of the DHCF during the contract renewal process; and
(4) Within 35 days after any change in ownership of the Contractor.

H.24 BUSINESS TRANSACTIONS

In accordance with Federal Regulation 42 CFR 455.105, the Contractor must furnish DHCF,
within 35 days of the date on a request, full and complete information related to business
transactions about:

(1) The ownership of any subcontractor with whom the Contractor has had business transactions
totaling more than $25,000 during the 12-month period ending on the date of the request;
and
(2) Any significant business transactions between the Contractor and any wholly owned
supplier, or between the Contractor and any subcontractor, during the 5- year period ending
on the date of the request.

H.25 PUBLICITY

The Contractor shall at all times obtain the prior written approval from the Contracting Officer
before it, any of its officers, agents, employees or subcontractors, either during or after
expiration or termination of the contract, make any statement, or issue any material, for
publication through any medium of communication, bearing on the work performed or data
collected under this contract.

H.26 CONFLICT OF INTEREST

H.26.1 In accordance with 45 C.F.R. § 92.36, no employee, officer, or agent of Contractor shall
participate in the selection, award, or administration of the Contract if a real or apparent
conflict of interest would be involved.

H.26.2 A conflict of interest arises when the employee, officer, or agent, or any member of his or
her immediate family, his or her partner, or an organization which employs or is about to
employ any of the parties indicated herein, has a financial or other interest in the firm
selected for an award.

H.26.3 The officers, employees, and agents of Contractor shall neither solicit nor accept gratuities,
favors, or anything of monetary value from Contractors, or parties to subcontracts. However,
Contractor may set standards for situations in which the financial interest is not substantial,
or the gift is an unsolicited item of nominal value. The standards of conduct shall provide for
disciplinary actions to be applied for violations of such standards by officers, employers, or
agents of the beneficiaries.

H.26.4 Contractor represents and covenants that it presently has no interest and shall not acquire
any interest, direct or indirect, which would conflict in any manner or degree with the
performance of its services hereunder. Contractor further covenants that, in the performance
of the Contract, no person having any such known interests shall be employed.

H.26.5 No official or employee of the District of Columbia or the federal government who exercises
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any functions or responsibilities in the review or approval of the undertaking or carrying out
of the Contract shall, prior to the termination of the Contract, voluntarily acquire any
personal interest, direct or indirect, in the Contract or proposed Contract. (D.C. Procurement
Practices Act of 1985, D.C. Law 6-85 and Chapter 18 of the D.C. Personnel Regulations).

H.26.6 In accordance with 42 C.F.R. § 438.58, as a condition of contracting with MCOs, the
District shall have in effect safeguards against conflict of interest on the part of the District
and local officers, employees, and agents of the District who have responsibilities relating to
the Contractors, contracts, or the default enrollment process specified in 42 C.F.R. § 438.54,
which states:

H.26.6.1 For beneficiaries who do not choose a Contractor during their enrollment period, the District
shall have a default enrollment process for assigning those beneficiaries to a Contractor;

H.26.6.2 The process must seek to preserve existing Provider-Enrollee relationships and relationships
with Providers that have traditionally served Medicaid beneficiaries. If that is not possible,
the District shall distribute the beneficiaries equitably among qualified Contractors available
to enroll them, excluding those subjects to sanction as described in 42 C.F.R. § 438.702(a);

H.26.6.3 An “existing Provider-patient relationship” is one in which the Provider was the main source
of services for the beneficiary during the previous year. This may be established through
District records of previous managed care enrollment or fee-for-service experience or
through contact with the beneficiary; and

H.26.6.4 A Provider is considered to have “traditionally served” beneficiaries if it has experience in
serving the DCHFP, Alliance, CASSIP or population.

H.27 FINANCIAL DISCLOSURE

H.27.1 In accordance with § 1903(m)(A) of the Act, non-Federally Qualified Contractors shall
report a description of certain transactions with Parties in Interest. Contractor shall report to
the District within 60 days when it has identified the capitation payments or other payments
in excess of amounts specified in this Contract. As defined in § 1318(b) of the Act, for
purposes of this section, a Party in Interest is: Any director, officer, partner, or employee
responsible for management or administration of a Contractor and health insuring
organization; any person who is directly or indirectly the beneficial owner of more than five
percent (5%) of the equity of the Contractor; any person who is the beneficial owner of a
mortgage, deed of trust, note, or other interest secured by, and valuing more than five
percent (5%) of the Contractor; or, in the case of a Contractor organized as a non-profit
corporation, an incorporator or member of such corporation under applicable District
corporation law;

H.27.2 Any organization in which a person is a director, officer or partner, has (directly or
indirectly) a beneficial interest of more than five-percent (5%) of the equity of the
Contractor; or has a mortgage, deed of trust, note, or other interest valuing more than five-
percent (5%) of the assets of the Contractor;

H.27.3 Any person directly or indirectly controlling, controlled by, or under common control with a
Contractor; or
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H.27.4 Contractor shall make any reports of transactions between the Contractor and parties in
interest that are provided to the District or other agencies available to the Contractor’s
Enrollees upon reasonable request.

H.28 TRANSACTION DISCLOSURE

H.28.1 In accordance with § 1318(b) of the Act, business transactions which shall be disclosed
include:

H.28.1.1 Any sale, exchange, or lease of any property between the Contractor and a Party in Interest;
H.28.1.2 Any lending of money or other extension of credit between the Contractor and a party in
interest; and
H.28.1.3 Any furnishing for consideration of goods, services (including management services), or
facilities between the Contractor and the party in interest. This does not include salaries paid
to employees for services provided in the normal course of their employment.

H.28.2 The information, which shall be disclosed for each such business transaction, includes the
name of the party in interest, a description of the transaction and quantity or units involved,
the accrued dollar value during the fiscal year, and justification for the reasonableness of the
transaction.

H.28.3 If the Contract is being renewed or extended, Contractor shall disclose information on the
business transactions which occurred during the prior contract period. If the Contract is an
initial contract with the District, but Contractor has operated previously in the commercial or
Medicare markets, information, or business) transactions for the entire year proceeding the
initial contract period shall be disclosed.

H.28.4 The business transactions Contractor shall report under this section H.21 are not limited to
transactions related to serving the Medicaid population. All of Contractor’s business
transactions that meet fulfill the requirements of this section H.21 shall be reported.

H.28.5 Entities Located Outside the United States (U.S.)

H.28.6 Contractor shall operate all business functions within the U.S. and no claims paid by the
Contractor to the Network Provider, Out of Network Provider, subcontractor or financial
institution located outside of the U.S. are considered in the development of actuarially sound
capitation rates, in accordance with 42 C.F.R. § 438.602(i).

H.29 DEBARMENT AND SUSPENSION (Executive Orders 12549 AND 12689)

In accordance with 42 C.F.R.§ 438.610 and 45 C.F.R. § 455.436, certain contracts shall not be
made to parties listed on the non-procurement portion of the General Services Administration’s
“Lists of Parties Excluded from Federal Procurement or Non-Procurement Programs” in
accordance with Executive Orders 12549 and 12689, “Debarment and Suspension.” This list
contains the names of parties debarred, suspended, or otherwise excluded by agencies and
contractors declared ineligible under statutory authority other than E.O. 12549. Contractors with
awards that exceed the simplified acquisition threshold of $100,000 shall provide the required
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certification regarding their exclusion status and that of their principals prior to the Date of
Award of the Contract.

H.30 SECURITY REQUIREMENTS

H.30.1 In accordance with D.C. Code § 44-552, Contractor shall not employ or contract with any
unlicensed person until a criminal background check has been conducted for that person.
Contractor shall inform each prospective employee or contract worker that Contractor is
required to conduct a criminal background check before employing or contracting with an
unlicensed person. Contractor shall include in any Provider agreement the requirements of
D.C. Code § 44-552.

H.30.2 All criminal records received by Contractor for the purposes of employing a person who is
not a licensed professional pursuant to this section shall be kept confidential and shall be
used solely by Contractor. The criminal records shall not be released or otherwise disclosed
to any person except to:

H.30.2.1 The Mayor or the Mayor's designee during an official inspection or investigation of the
facility;
H.30.2.2 The person whose background is being investigated;
H.30.2.3 Comply with an order of a court; or
H.30.2.4 Any person with the written consent of the person being investigated.

H.30.3 All criminal records received by Contractor shall be destroyed after one year from the end
of employment of the person to whom the records relate.

H.30.4 Contractor shall not employ or contract with any unlicensed person if, within the seven
years preceding a criminal background check conducted pursuant to this section, that person
has been convicted in the District of Columbia, or in any other state or territory of the
United States where such person has worked or resided, of any of the offenses enumerated
in D.C. Code § 44-552(e) or their equivalent in another state or territory.

H.30.5 Contractor may obtain a criminal background check from the Metropolitan Police
Department, the U.S. Department of Justice, or from a private agency. Contractors shall pay
the fee that is established and charged by the entity that provides the criminal background
check results. Nothing in this section shall preclude Contractor from seeking reimbursement
of the fee paid for the criminal background check from the applicant for employment or
contract work.

H.30.6 The requirements of this section shall not apply to persons employed on or before July 23,
2001, persons licensed under Chapter 12 of Title 3 of the D.C. Code, or to a person who
volunteers services to a facility and works under the direct supervision of a person licensed
pursuant to Chapter 12 of Title 3 of the D.C. Code.

H.30.7 Except as provided in section H.23.1, Contractor may opt to conduct a criminal background
check on any employee or volunteer who provides services at the facility.

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H.30.8 Contractor must require its employees to disclose to the DHCF any arrests or convictions
that may occur subsequent to employment. Any conviction or arrest of Contractor’s
employees shall determine the employee’s suitability for continued employment.

H.30.9 Contractor must require that employees not bring into Contractor’s facilities any form of
weapons or contraband; shall be subject to search; shall conduct themselves in a professional
manner at all times; and shall not cause any disturbance; and shall be subject to all other
rules and regulations of Contractor and DHCF. Contractor shall ensure that each employee
is issued a copy of Contractor’s rules and signs a statement acknowledging the receipt of
said rules. Contractor shall maintain the acknowledgement of receipt in the employee’s
personnel file.

H.31 BYRD ANTI-LOBBYING AMENDMENT

H.31.1 In accordance with 45 C.F.R. Appendix A, contractors who apply or bid for an award of
more than $100,000 shall file the required certification. Each tier certifies to the tier above
that it shall not and has not used federal appropriated funds to pay any person or
organization for influencing or attempting to influence an officer or employee of any federal
agency, a member of Congress or an employee of a member of Congress in connection with
obtaining any federal contract, grant or other award covered by 31 U.S.C. § 1352.

H.31.2 Each tier shall disclose any lobbying with non-federal funds that takes place in connection
with obtaining any federal award. Such disclosures are forwarded from tier to tier up to
Contractor.

H.32 INDEPENDENT AUDIT

H.32.1 Contractor shall obtain the services of an independent audit firm at the Contractor’s expense
to assess the Contractor’s internal accounting controls and procedures to perform the
administration of the CASSIP. The independent audit firm shall determine whether the audit
revealed any conditions that presented a material weakness in the overall administration of
CASSIP and the Contractor’s accounting and financial practices, consistent with sound
business principles and generally accepted accounting procedures.

H.32.2 The Contractor shall provide the initial Independent Audit Findings to the CA within 60
days from the date of Contract award. The Independent Audit Findings shall include, at a
minimum, details of the independent auditor’s assessment of the Contractor’s internal
accounting controls and procedures. The Independent Audit Findings shall include
statements from the auditor confirming that no material weaknesses in the Contractor’s
internal controls and procedures exist and that Contractor’s accounting and financial
practices are consistent with sound business principles and generally accepted accounting
procedures.

H.32.3 The Contractor shall submit subsequent Independent Audit findings for the review and
approval of the CA, as determined by the District. Standards, orders, or regulations issued
pursuant to the Clean Air Act, Pollution Control Act, 42 U.S.C. §§ 7401 et seq., and the
Federal Water Pollution Control Act, as amended 33 U.S.C. §§ 1251 et seq.

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H.32.4 Violations shall be reported to the HHS and the appropriate Regional Office of the
Environmental Protection Agency. Contractor shall comply with all applicable standards,
orders or requirements issued under § 306 of the Clean Air Act (42 U.S.C. §1857(h)), § 508
of the Clean Water Act (33 U.S.C. § 1368) Executive Order 11738, and Environmental
Protection Agency regulations (40 C.F.R. § 15).

H.33 SCOPE OF WORK NO LONGER AUTHORIZED BY LAW

H.33.1 Should any part of the scope of work under this contract relate to a District program that is
no longer authorized by law (e.g., which has been vacated by a court of law, or for which
CMS has withdrawn federal authority, or which is the subject of a legislative repeal), the
Contractor must do no work on that part after the effective date of the loss of program
authority.

H.33.2 The District must adjust either capitation rates if using risk-based contract or payments if
using a non-risk contract to remove costs that are specific to any program or activity that is
no longer authorized by law.

H.33.3 If the Contractor works on a program or activity no longer authorized by law after the date
the legal authority for the work ends, the Contractor will not be paid for that work.

H.33.4 If the District paid the Contractor in advance to work on a no-longer-authorized program or
activity and under the terms of this contract the work was to be performed after the date the
legal authority ended, the payment for that work should be returned to the District. However,
if the Contractor worked on a program or activity prior to the date legal authority ended for
that program or activity, and the District included the cost of performing that work in its
payments to the Contractor, the Contractor may keep the payment for that work even if the
payment was made after the date the program or activity lost legal authority.

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SECTION I: CONTRACT CLAUSES

I.1 APPLICABILITY OF STANDARD CONTRACT PROVISIONS

The Standard Contract Provisions for use with District of Columbia Government Supplies and
Services Contracts dated July 2010 (“SCP”) are incorporated as part of the contract. To obtain
a copy of the SCP go to http://ocp.dc.gov, under Quick Links click on “Required Solicitation
Documents”.

I.2 CONTRACTS THAT CROSS FISCAL YEARS

Continuation of this contract beyond the current fiscal year is contingent upon future fiscal
appropriations.

I.3 CONFIDENTIALITY OF INFORMATION

The Contractor shall keep all information relating to any employee or customer of the District
in absolute confidence and shall not use the information in connection with any other matters;
nor shall it disclose any such information to any other person, firm or corporation, in
accordance with the District and federal laws governing the confidentiality of records.

I.4 TIME

Time, if stated in a number of days, will include Saturdays, Sundays, and holidays, unless
otherwise stated herein.

I.5 RIGHTS IN DATA

Delete Article 42, Rights in Data, of the Standard Contract Provisions dated July 2010 for use
with District of Columbia Government Supplies and Services Contracts and substitute the
following Article 42, Rights in Data) in its place:

A. Definitions

1. “Products” - A deliverable under any contract that may include commodities, services and/or
technology furnished by or through Contractor, including existing and custom Products,
such as, but not limited to: a) recorded information, regardless of form or the media on
which it may be recorded; b) document research; c) experimental, developmental, or
engineering work; d) licensed software; e) components of the hardware environment; f)
printed materials (including but not limited to training manuals, system and user
documentation, reports, drawings); g) third party software; h) modifications, customizations,
custom programs, program listings, programming tools, data, modules, components; and i)
any intellectual property embodied therein, whether in tangible or intangible form, including
but not limited to utilities, interfaces, templates, subroutines, algorithms, formulas, source
code, and object code.

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2. “Existing Products” - Tangible Products and intangible licensed Products that exist prior to
the commencement of work under the contract. Existing Products must be identified on the
Product prior to commencement of work or else will be presumed to be Custom Products.

3. “Custom Products” - Products, preliminary, final or otherwise, which are created or
developed by Contractor, its subcontractors, partners, employees, resellers or agents for the
District under the contract.

4. “District” – The District of Columbia and its agencies.

B. Title to Project Deliverables

The Contractor acknowledges that it is commissioned by the District to perform services
detailed in the contract. The District shall have ownership and rights for the duration set
forth in the contract to use, copy, modify, distribute, or adapt Products as follows:

1. Existing Products: Title to all Existing Licensed Product(s), whether or not embedded in,
delivered or operating in conjunction with hardware or Custom Products, shall remain with
Contractor or third party proprietary owner, who retains all rights, title and interest
(including patent, trademark or copyrights). Effective upon payment, the District shall be
granted an irrevocable, non-exclusive, worldwide, paid-up license to use, execute,
reproduce, display, perform, adapt (unless Contractor advises the District as part of
Contractor’s bid that adaptation will violate existing agreements or statutes and Contractor
demonstrates such to the District’s satisfaction), and distribute Existing Product to District
users up to the license capacity stated in the contract with all license rights necessary to fully
effect the general business purpose of the project or work plan or contract. Licenses shall be
granted in the name of the District. The District agrees to reproduce the copyright notice and
any other legend of ownership on any copies authorized under this paragraph.

2. Custom Products: Effective upon Product creation, Contractor hereby conveys, assigns, and
transfers to the District the sole and exclusive rights, title and interest in Custom Product(s),
whether preliminary, final or otherwise, including all patent, trademark and copyrights.
Contractor hereby agrees to take all necessary and appropriate steps to ensure that the
Custom Products are protected against unauthorized copying, reproduction and marketing by
or through Contractor.

C. Transfers or Assignments of Existing or Custom Products by the District

The District may transfer or assign Existing or Custom Products and the licenses thereunder
to another District agency. Nothing herein shall preclude the Contractor from otherwise
using the related or underlying general knowledge, skills, ideas, concepts, techniques and
experience developed under a project or work plan in the course of Contractor’s business.

D. Subcontractor Rights

Whenever any data, including computer software, are to be obtained from a subcontractor
under the contract, the Contractor shall use this clause, Rights in Data, in the subcontract,
without alteration, and no other clause shall be used to enlarge or diminish the District’s or
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the Contractor’s rights in that subcontractor data or computer software which is required for
the District.

E. Source Code Escrow

1. For all computer software furnished to the District with the rights specified in section B.2,
the Contractor shall furnish to the District, a copy of the source code with such rights of the
scope as specified in section B.2 of this clause. For all computer software furnished to the
District with the restricted rights specified in section B.1 of this clause, the District, if the
Contractor either directly or through a successor or affiliate shall cease to provide the
maintenance or warranty services provided the District under the contract or any paid-up
maintenance agreement, or if the Contractor should be declared insolvent by a court of
competent jurisdiction, shall have the right to obtain, for its own and sole use only, a single
copy of the current version of the source code supplied under the contract, and a single copy
of the documentation associated therewith, upon payment to the person in control of the
source code the reasonable cost of making each copy.

2. If the Contractor or Product manufacturer/developer of software furnished to the District
with the rights specified in section B.1 of this clause offers the source code or source code
escrow to any other commercial customers, the Contractor shall either: provide the District
with the source code for the Product; place the source code in a third party escrow
arrangement with a designated escrow agent who shall be named and identified to the
District, and who shall be directed to release the deposited source code in accordance with a
standard escrow arrangement acceptable to the District; or will certify to the District that the
Product manufacturer/ developer has named the District as a named beneficiary of an
established escrow arrangement with its designated escrow agent who shall be named and
identified to the District, and who shall be directed to release the deposited source code in
accordance with the terms of escrow.

3. The Contractor shall update the source code, as well as any corrections or enhancements to
the source code, for each new release of the Product in the same manner as provided above,
and certify such updating of escrow to the District in writing.

F. Indemnification and Limitation of Liability

The Contractor shall indemnify and save and hold harmless the District, its officers, agents
and employees acting within the scope of their official duties against any liability, including
costs and expenses, (i) for violation of proprietary rights, copyrights, or rights of privacy,
arising out of the publication, translation, reproduction, delivery, performance, use or
disposition of any data furnished under this contract, or (ii) based upon any data furnished
under this contract, or based upon libelous or other unlawful matter contained in such data.

I.6 OTHER CONTRACTORS

The Contractor shall not commit or permit any act that will interfere with the performance of
work by another District contractor or by any District employee.

I.7 SUBCONTRACTS

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a. The Contractor hereunder shall not subcontract any of the Contractor’s work or services
to any subcontractor without the prior written consent of the CO. Any work or service
so subcontracted shall be performed pursuant to a subcontract agreement, which the
District will have the right to review and approve prior to its execution by the
Contractor. Any such subcontract shall specify that the Contractor and the subcontractor
shall be subject to every provision of this contract. Notwithstanding any such
subcontract approved by the District, the Contractor shall remain liable to the District for
all Contractor's work and services required hereunder.

b. The Contractor shall ensure that its subcontractors at all times meet the criteria for
responsibility as described in D.C. Official Code §2-353.01

I.8 INSURANCE

A. GENERAL REQUIREMENTS. The Contractor at its sole expense shall procure and
maintain, during the entire period of performance under this contract, the types of insurance
specified below. The Contractor shall submit a Certificate of Insurance to the Contracting
Officer (CO) giving evidence of the required coverage prior to commencing performance
under this contract. In no event shall any work be performed until the required Certificates
of Insurance signed by an authorized representative of the insurer(s) have been provided to,
and accepted by, the CO.

If the Contractor and/or its subcontractors maintain broader coverage and/or higher limits
than the minimums shown below, the District requires and shall be entitled to the broader
coverage and/or the higher limits maintained by the Contractor and subcontractors.

B. INSURANCE REQUIREMENTS

1. Commercial General Liability Insurance (“CGL”) - The Contractor shall provide
evidence satisfactory to the CO with respect to the services performed that it carries a
CGL policy, written on an occurrence (not claims-made) basis, on Insurance Services
Office, Inc. (“ISO”) form CG 00 01 04 13 (or another occurrence-based form with
coverage at least as broad and approved by the CO in writing), covering liability for all
ongoing and completed operations of the Contractor and under all subcontracts, covering
claims for bodily injury, including without limitation sickness, disease or death and
mental anguish of any persons, broad form property damage, including loss of use
resulting therefrom, personal and advertising injury, and including coverage for liability
arising out of an Insured Contract (including the tort liability of another assumed in a
contract) and acts of terrorism (whether caused by a foreign or domestic source). Such
coverage shall have limits of liability of not less than $1,000,000 for each occurrence,
$2,000,000 general aggregate, $2,000,000 products and completed operations aggregate,
and $1,000,000 personal and advertising injury aggregate limit.

The Commercial General Liability shall be further endorsed to:

a) To the fullest extent permitted by law, provide additional insured coverage using ISO
form CG 2010 0413 and CG2037 04 13 (or its equivalent) to The Government of the
District of Columbia
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b) Coverage available to the additional insureds shall apply on a primary and non-
contributing basis as respects any other insurance, deductibles, or self-insurance
available to the additional insureds
c) A waiver of subrogation in favor of The Government of the District of Columbia
d) Any Annual Aggregate shall apply on a per location or per project basis
e) Defense costs shall be in addition to and not erode the limits of liability

2. Automobile Liability Insurance - The Contractor shall provide evidence satisfactory to
the CO of commercial (business) automobile liability insurance written on ISO form CA
00 01 10 13 (or another form with coverage at least as broad and approved by the CO in
writing) including coverage for all owned, hired, borrowed and non-owned vehicles and
equipment used by the Contractor in connection with work under this agreement, with a
minimum combined single limit of $1,000,000. Such policy or policies of automobile
liability insurance shall be written on an "occurrence" (as opposed to a "claims made")
basis.

The Commercial Auto Liability policy shall be further endorsed to:

a) To the fullest extent permitted by law, provide additional insured coverage to The
Government of the District of Columbia
b) Coverage available to the additional insureds shall apply on a primary and non-
contributing basis as respects any other insurance, deductibles, or self-insurance
available to the additional insureds
c) A waiver of subrogation in favor of The Government of the District of Columbia
d) Defense costs shall be in addition to and not erode the limits of liability
e) If applicable, include Form CA 99 48 03 06 Pollution Liability - Broadened
Coverage for Covered Autos - Business Auto, Motor Carrier, and Truckers (or its
equivalent)
f) Moving and Storage Companies shall be required to provide evidence of BMC91 or
BMC91X filing

For Contractors providing transportation:

Contractors providing transportation must additionally comply with the following:
a) Operators holding a restricted WMATC Certificate of Authority must have a single
limit of $1.5 million in combined (bodily injury and physical damage) coverage, or
b) Operators holding an unrestricted WMATC Certificate of Authority must have a
single limit of $5M in combined (bodily injury and physical damage) coverage.

In addition, both types of WMATC certificate holders must have in place the following
Licensing Requirements as applicable:

a) Commercial Driver’s License (CDL) with the following endorsements:
i) P (Passenger): All drivers MUST have a P endorsement enabling them to
transport passengers (16 or more).
ii) S (School Bus): All drivers operating school buses (flashing lights, swing arm
w/stop sign) must also have an S endorsement. Please note that driver credentials
for any vehicles that are converted school buses must have S.
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b) Valid (unexpired) US Department of Transportation Medical Examiner Certification
(“Medical Card”).

For Contractors using District Government-Owned Vehicles:

Agencies that provide Contractors with District Government-owned or leased motor
vehicles are responsible for ensuring that such vehicles are used only for the
performance under this Contract. Contractor and its subcontractors are prohibited from
using such vehicles for home-to-work transportation unless specifically provided for
under the terms of the contract and approved in writing by the Contracting Officer or
otherwise provided by law. Contractor shall obtain automobile liability insurance with a
minimum combined single limit of $1,000,000 to cover bodily injury and property
damage to protect the Contractor and the District Government against third-party claims
arising from the use of District Government-owned vehicles. The Commercial Auto
Liability Policy shall be endorsed to include:

a) To the fullest extent permitted by law, provide additional insured coverage to The
Government of the District of Columbia;
b) Coverage available to the additional insureds shall apply on a primary and non-
contributing basis as respects any other insurance, deductibles, or self-insurance
available to the additional insureds; and
c) A waiver of subrogation in favor of The Government of the District of Columbia.

In the event of loss, destruction, or damage to any government-owned vehicles used in
the performance of contact, Contractor shall be liable for full cost of repair or
replacement of lost, destroyed, or damaged vehicle.

3. Workers’ Compensation Insurance - The Contractor shall provide evidence satisfactory
to the CO of Workers’ Compensation insurance in accordance with the statutory
mandates of the District of Columbia or the jurisdiction in which the contract is
performed.

Employer’s Liability Insurance - The Contractor shall provide evidence satisfactory to
the CO of employer’s liability insurance as follows: $500,000 per accident for injury;
$500,000 per employee for disease; and $500,000 for policy disease limit.

The Workers Compensation and Employers Liability shall be further endorsed to:

a) Include a Waiver of Subrogation in favor of The Government of the District of
Columbia.
b) Where applicable, include United States Longshore and Harbor Workers
Compensation Act (USL&H)
c) Where applicable, include Jones Act Coverage for seamen or crew members on an
“if any” basis.

4. Media Liability and Network Security/Privacy (Cyber) Liability Insurance – The
Contractor shall provide covering acts, errors, omissions, and violation of any consumer
protection laws arising out of Contractor’s operations or services with a limit of
$5,000,000 per claim and in the aggregate. Such coverage shall include but not be
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limited to, third party and first party coverage for loss or disclosure of any data,
including personally identifiable information and payment card information, network
security failure, violation of any consumer protection laws, unauthorized access and/or
use or other intrusions, infringement of any intellectual property rights (except patent),
negligence or breach of duty to use reasonable care, breach of any duty of
confidentiality, invasion of privacy, or violations of any other legal protections for
personal information, defamation, libel, slander, commercial disparagement, negligent
transmission of computer virus, or use of computer networks in connection with denial
of service attacks. Such coverage shall include regulatory defense and fines/penalties in
any jurisdiction anywhere in the world. Such coverage shall include contractual privacy
coverage for data breach response and crisis management costs that would be incurred
by Contractor on behalf of The Government of the District of Columbia in the event of a
data breach including legal and forensic expenses, notification costs, credit monitoring
costs, and costs to operate a call center. Contractor shall maintain coverage in force
during the term of this Agreement and for an extended reporting period of not less than
two years after.

5. Commercial Umbrella or Excess Liability - The Contractor shall provide evidence
satisfactory to the CO of commercial umbrella with minimum limits of $5,000,000 per
occurrence and $5,000,000 in the annual aggregate. Coverage must excess of required
commercial general liability, commercial auto liability, and employers’ liability. The
insurance required under this paragraph shall be written in a form that annually reinstates
all required limits. Coverage shall be primary to any insurance, self-insurance or
reinsurance maintained by The Government of the District of Columbia and the “other
insurance” provision must be amended in accordance with this requirement and
principles of vertical exhaustion.

6. Medical Professional Liability - The Contractor shall provide evidence satisfactory to the
CO of a Medical Professional Liability policy with limits of not less than $1,000,000 for
each incident and $3,000,000 in the annual aggregate. The definition of insured shall
include the Contractor and all Contractor’s employees and agents. The policy shall be
either written on an occurrence basis or written on a claims-made basis. If the coverage
is on a claims-made basis, Contractor hereby agrees that prior to the expiration date of
Contractor’s current insurance coverage, Contractor shall purchase, at Contractor’s sole
expense, either a replacement policy annually thereafter having a retroactive date no
later than the effective date of this Contract or unlimited tail coverage in the above stated
amounts for all claims arising out of this Contract.

7. Sexual/Physical Abuse & Molestation - The Contractor shall provide evidence
satisfactory to the CO with respect to the services performed that it carries $1,000,000
per occurrence limits; $2,000,000 aggregate of affirmative abuse and molestation
liability coverage. Coverage should include physical abuse, such as sexual or other
bodily harm and non-physical abuse, such as verbal, emotional, or mental abuse; any
actual, threatened or alleged act; errors, omission or misconduct. This insurance
requirement will be considered met if the general liability insurance includes an
affirmative sexual abuse and molestation endorsement for the required amounts or
through a separate stand-alone sexual abuse and molestation policy with confirmation
there are no exclusions for abuse or assault & battery under the General Liability. So
called “silent” coverage or “shared” limits under a commercial general liability or
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professional liability policy will not be acceptable. Limits may not be shared with other
lines of coverage. The applicable policy may need to be submitted to the Office of Risk
Management for compliance review.

C. SUBCONTRACTOR INSURANCE REQUIREMENTS. Any and all subcontractors
engaged by Contractor for work under this agreement shall be required to have the same
insured required of Contractor. Should the Contractor wish to propose different insurance
requirements for the subcontractor than the ones outlined in the Contract, then, prior to
commencement of work by the subcontractor, the Contractor shall submit in writing the
name and brief description of work to be performed by the subcontractor to the CO. The CO
will promptly provide in writing to the Contractor with a decision regarding the insurance
requirements applicable to the subcontractor. When requested by the CO, the Contractor
must provide proof of the subcontractor's required insurance prior to commencement of
work by the subcontractor.

D. PRIMARY AND NONCONTRIBUTORY INSURANCE. The insurance required herein
shall be primary to and will not seek contribution from any other insurance, reinsurance or
self-insurance including any deductible or retention, maintained by the Government of the
District of Columbia.

E. DURATION. The Contractor shall carry all required insurance until all contract work is
accepted by The Government of the District of Columbia and shall carry listed coverages for
ten years for construction projects following final acceptance of the work performed under
this contract and two years for non-construction related contracts.

F. LIABILITY. These are the required minimum insurance requirements established by The
Government of the District of Columbia. However, it is understood that The Government of
the District of Columbia does not in any way represent that the insurance or the limits of
insurance specified herein are sufficient or adequate to protect your interests or liabilities
and will not in any way limit the contractor’s liability under this contract.

G. CONTRACTOR’S PROPERTY. The Contractor and subcontractors are solely
responsible for any loss or damage to their personal property, including but not limited to
tools and equipment, scaffolding, and temporary structures, rented machinery, or owned and
leased equipment. A waiver of subrogation shall apply in favor of The Government of the
District of Columbia.

H. MEASURE OF PAYMENT. The Government of the District of Columbia shall not make
any separate measure or payment for the cost of insurance and bonds. The Contractor shall
include all the costs of insurance and bonds in the contract price.

I. NOTIFICATION. The Contractor shall ensure that all policies provide that the CO shall
be given thirty days prior written notice in the event of cancellation, non-renewal, or
material changes to the extent such cancellation or material changes results in Contractor no
long complying with the above requirements. The Contractor shall provide the CO with ten
days’ prior written notice in the event of non-payment of premium. The Contractor will also
provide the CO with an updated Certificate of Insurance should its insurance coverages
renew during the contract. The Government of the District of Columbia may reasonably
change the above insurance coverage requirements during the Term by giving Contractor at
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least 30 days’ notice of the change. Contractor must comply, at your expense, and deliver to
the CO evidence of compliance before the change becomes effective.

J. CERTIFICATES OF INSURANCE. The Contractor must send to CO, at least 10 days
after execution of this Agreement, certificates of insurance evidencing the required
insurance coverage and endorsements required herein. Contractor must also provide us with
evidence of renewal before the expiration date of each insurance policy. Contractor is
responsible for providing us with 30 days advanced written notice if the certificate of
insurance by the insurer has been canceled, reduced in coverage, or otherwise altered.
Certificates of insurance must reference the corresponding contract number. Evidence of
insurance shall be submitted to:

The Government of the District of Columbia
And mailed to the attention of:

Tracy Williams, Contracting Officer
Office of Contracting and Procurement
441 4th Street, NW, Suite 300S
Washington, DC 20001
(202) 899-3657
tracy.williams2@dc.gov

The CO may request, and the Contractor shall promptly deliver updated certificates of
insurance, endorsements indicating the required coverages, and/or certified copies of the
insurance policies. If the insurance initially obtained by the Contractor expires prior to
completion of the contract, renewal certificates of insurance and additional insured and other
endorsements shall be furnished to the CO prior to the date of expiration of all such initial
insurance. For all coverage required to be maintained after completion, an additional
certificate of insurance evidencing such coverage shall be submitted to the CO on an annual
basis as the coverage is renewed (or replaced).

K. DISCLOSURE OF INFORMATION. The Contractor agrees that The Government of the
District of Columbia may disclose the name and contact information of its insurers to any
third party which presents a claim against The Government of the District of Columbia for
any damages or claims resulting from or arising out of work performed by the Contractor, its
agents, employees, servants or subcontractors in the performance of this contract.

L. CARRIER RATINGS. All Contractor’s and its subcontractors’ insurance required in
connection with this contract shall be written by insurance companies with an A.M. Best
Insurance Guide rating of at least A- VII or better (or the equivalent by any other rating
agency) and licensed in the District of Columbia.

M. WARRANTIES. When applicable, the Contractor should be named as an additional
insured on the applicable manufacturer’s/distributer’s Commercial General Liability policy
using Insurance Services Office, Inc. (“ISO”) form CG 20 15 04 13 (or another occurrence-
based form with coverage at least as broad). CO should collect, review for accuracy, and
maintain all warranties for goods and services.

I.9 EQUAL EMPLOYMENT OPPORTUNITY
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In accordance with the District of Columbia Administrative Issuance System, Mayor’s Order
85-85 dated June 10, 1985, the forms for completion of the Equal Employment Opportunity
Information Report are incorporated herein as Section J.3. An award cannot be made to any
offeror who has not satisfied the equal employment requirements.
I.10 ORDER OF PRECEDENCE
The contract awarded because of RFP Doc808208 will contain the following clause:

ORDER OF PRECEDENCE

A conflict in language shall be resolved by giving precedence to the document in the highest
order of priority that contains language addressing the issue in question. The following
documents are incorporated into the contract by reference and made a part of the contract in the
following order of precedence:

(1) An applicable Court Order, if any
(2) Contract document
(3) Standard Contract Provisions
(4) Contract attachments other than the Standard Contract Provisions
(5) RFP, as amended
(6) BAFOs (in order of most recent to earliest)
(7) Proposal

I.11 DISPUTES

Delete Article 14, Disputes, of the Standard Contract Provisions dated July 2010 for use with
District of Columbia Government Supplies and Services Contracts and substitute the following
Article 14, Disputes, in its place:
14. Disputes
All disputes arising under or relating to the contract shall be resolved as provided herein:

(a) Claims by the Contractor against the District: Claim, as used in paragraph (a) of this
clause, means a written assertion by the Contractor seeking, as a matter of right, the payment
of money in a sum certain, the adjustment or interpretation of contract terms, or other relief
arising under or relating to the contract. A claim arising under a contract, unlike a claim
relating to that contract, is a claim that can be resolved under a contract clause that provides
for the relief sought by the claimant

(1) All claims by a Contractor against the District arising under or relating to a contract shall
be in writing and shall be submitted to the CO for a decision. The Contractor’s claim
shall contain at least the following:

(i) A description of the claim and the amount in dispute;
(ii) Data or other information in support of the claim;
(iii) A brief description of the Contractor’s efforts to resolve the dispute prior to filing
the claim; and
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(iv) The Contractor’s request for relief or other action by the CO.

(2) The CO may meet with the Contractor in a further attempt to resolve the claim by
agreement.

(3) The CO shall issue a decision on any claim within 120 calendar days after receipt of the
claim. Whenever possible, the CO shall take into account factors such as the size and
complexity of the claim and the adequacy of the information in support of the claim
provided by the Contractor.

(4) The CO’s written decision shall do the following:

(i) Provide a description of the claim or dispute;
(ii) Refer to the pertinent contract terms;
(iii) State the factual areas of agreement and disagreement;
(iv) State the reasons for the decision, including any specific findings of fact, although
specific findings of fact are not required and, if made, shall not be binding in any
subsequent proceeding;
(v) If all or any part of the claim is determined to be valid, determine the amount of
monetary settlement, the contract adjustment to be made, or other relief to be
granted;
(vi) Indicate that the written document is the CO’s final decision; and
(vii) Inform the Contractor of the right to seek further redress by appealing the decision
to the Contract Appeals Board.

(5) Failure by the CO to issue a decision on a contract claim within 120 days of receipt of
the claim will be deemed to be a denial of the claim, and will authorize the
commencement of an appeal to the Contract Appeals Board as provided by D.C. Official
Code § 2-360.04.

If a contractor is unable to support any part of its claim and it is determined that the
inability is attributable to a material misrepresentation of fact or fraud on the part of the
Contractor, the Contractor shall be liable to the District for an amount equal to the
unsupported part of the claim in addition to all costs to the District attributable to the
cost of reviewing that part of the Contractor’s claim. Liability under this paragraph (a)
shall be determined within six years of the commission of the misrepresentation of fact
or fraud.

Pending final decision of an appeal, action, or final settlement, the Contractor shall
proceed diligently with performance of the contract in accordance with the decision of
the CO.

(b) Claims by the District against the Contractor: Claim as used in paragraph (b) of this
clause, means a written demand or written assertion by the District seeking, as a matter of
right, the payment of money in a sum certain, the adjustment of contract terms, or other
relief arising under or relating to the contract. A claim arising under a contract, unlike a
claim relating to that contract, is a claim that can be resolved under a contract clause that
provides for the relief sought by the claimant.

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(1) The CO shall decide all claims by the District against a contractor arising under or
relating to a contract.

(2) The CO shall send written notice of the claim to the contractor. The CO’s written
decision shall do the following:

(i) Provide a description of the claim or dispute;
(ii) Refer to the pertinent contract terms;
(iii) State the factual areas of agreement and disagreement;
(iv) State the reasons for the decision, including any specific findings of fact,
although specific findings of fact are not required and, if made, shall not be
binding in any subsequent proceeding;
(v) If all or any part of the claim is determined to be valid, determine the amount of
monetary settlement, the contract adjustment to be made, or other relief to be
granted;
(vi) Indicate that the written document is the CO’s final decision; and
(vii) Inform the Contractor of the right to seek further redress by appealing the decision
to the Contract Appeals Board.

(3) The CO shall support the decision by reasons and shall inform the Contractor of its
rights as provided herein.

(4) Before or after issuing the decision, the CO may meet with the Contractor to attempt to
resolve the claim by agreement.

(5) The authority contained in this paragraph (b) shall not apply to a claim or dispute for
penalties or forfeitures prescribed by statute or regulation which another District agency
is specifically authorized to administer, settle or determine.

(6) This paragraph shall not authorize the CO to settle, compromise, pay, or otherwise
adjust any claim involving fraud.

(c) Decisions of the CO shall be final and not subject to review unless the Contractor timely
commences an administrative appeal for review of the decision, by filing a complaint with
the Contract Appeals Board, as authorized by D.C. Official Code § 2-360.04.

(d) Pending final decision of an appeal, action, or final settlement, the Contractor shall proceed
diligently with performance of the contract in accordance with the decision of the CO.

I.12 CHANGES

Delete clause 15, Changes, of the Standard Contract Provisions dated July 2010 for use with
District of Columbia Government Supplies and Services Contracts and substitute the following
clause 15, Changes in its place:
15. Changes:

(a) The CO may, at any time, by written order, and without notice to the surety, if any, make
changes in the contract within the general scope hereof. If such change causes an increase
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or decrease in the cost of performance of the contract, or in the time required for
performance, an equitable adjustment shall be made. Any claim for adjustment for a change
within the general scope must be asserted within ten days from the date the change is
ordered; provided, however, that the CO, if he or she determines that the facts justify such
action, may receive, consider and adjust any such claim asserted at any time prior to the date
of final settlement of the contract. If the parties fail to agree upon the adjustment to be
made, the dispute shall be determined as provided in clause 14 Disputes.

(b) The District shall not require the Contractor, and the Contractor shall not require a
subcontractor, to undertake any work that is beyond the original scope of the contract or
subcontract, including work under a District-issued change order, when the additional work
increases the contract price beyond the not-to-exceed price or negotiated maximum price of
this contract, unless the CO:

(1) Agrees with Contractor, and if applicable, the subcontractor on a price for the additional
work;
(2) Obtains a certification of funding to pay for the additional work;
(3) Makes a written, binding commitment with the Contractor to pay for the additional work
within 30-days after the Contractor submits a proper invoice; and
(4) Provides the Contractor with written notice of the funding certification.

(c) The Contractor shall include in its subcontracts a clause that requires the Contractor to:

(1) Within 5 business days of its receipt of notice the approved additional funding, provide
the subcontractor with notice of the amount to be paid to the subcontractor for the
additional work to be performed by the subcontractor;
(2) Pay the subcontractor any undisputed amount to which the subcontractor is entitled for
the additional work within 10 days of receipt of payment from the District; and
(3) Notify the subcontractor and CO in writing of the reason the Contractor withholds any
payment from a subcontractor for the additional work.

(d) Neither the District, Contractor, nor any subcontractor may declare another party to be in
default, or assess, claim, or pursue damages for delays, until the parties to agree on a price
for the additional work.

I.13 NON-DISCRIMINATION CLAUSE

Delete clause 19, Non-Discrimination Clause, of the Standard Contract Provisions dated July
2010 for use with District of Columbia Government Supplies and Services Contracts and
substitute the following clause 19, Non-Discrimination Clause, in its place:
19. Non-Discrimination Clause:

(a) The Contractor shall not discriminate in any manner against any employee or applicant for
employment that would constitute a violation of the District of Columbia Human Rights
Act, effective December 13, 1977, as amended (D.C. Law 2-38; D.C. Official Code § 2-
1401.01 et seq.) (“Act”, as used in this clause). The Contractor shall include a similar clause
in all subcontracts, except subcontracts for standard commercial supplies or raw materials.
In addition, the Contractor agrees, and any subcontractor shall agree, to post in conspicuous
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places, available to employees and applicants for employment, a notice setting forth the
provisions of this non-discrimination clause as provided in section 251 of the Act.

(b) Pursuant to Mayor’s Order 85-85, (6/10/85), Mayor’s Order 2002-175 (10/23/02), Mayor’s
Order 2011-155 (9/9/11) and the rules of the Office of Human Rights, Chapter 11 of Title 4
of the D.C. Municipal Regulations, the following clauses apply to the contract:

(1) The Contractor shall not discriminate against any employee or applicant for employment
because of actual or perceived: race, color, religion, national origin, sex, age, marital
status, personal appearance, sexual orientation, gender identity or expression, family
responsibilities, genetic information, disability, matriculation, political affiliation, or
credit information. Sexual harassment is a form of sex discrimination which is
prohibited by the Act. In addition, harassment based on any of the above protected
categories is prohibited by the Act.

(2) The Contractor agrees to take affirmative action to ensure that applicants are employed,
and that employees are treated during employment, without regard to their actual or
perceived: race, color, religion, national origin, sex, age, marital status, personal
appearance, sexual orientation, gender identity or expression, family responsibilities,
genetic information, disability, matriculation, political affiliation, or credit information.
The affirmative action shall include, but not be limited to the following:

(a) employment, upgrading or transfer;
(b) recruitment, or recruitment advertising;
(c) demotion, layoff or termination;
(d) rates of pay, or other forms of compensation; and
(e) selection for training and apprenticeship.

(3) The Contractor agrees to post in conspicuous places, available to employees and
applicants for employment, notices to be provided by the contracting agency, setting
forth the provisions in paragraphs 19(b) and (b) concerning non-discrimination and
affirmative action.

(4) The Contractor shall, in all solicitations or advertisements for employees placed by or on
behalf of the Contractor, state that all qualified applicants will receive consideration for
employment pursuant to the non-discrimination requirements set forth in paragraph
19(b).

(5) The Contractor agrees to send to each labor union or representative of workers with
which it has a collective bargaining agreement or other contract or understanding, a
notice to be provided by the contracting agency, advising the said labor union or
workers’ representative of that contractor’s commitments under this nondiscrimination
clause and the Act, and shall post copies of the notice in conspicuous places available to
employees and applicants for employment.

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(6) The Contractor agrees to permit access to its books, records, and accounts pertaining to
its employment practices, by the Chief Procurement Officer or designee, or the Director
of the Office of Human Rights or designee, for purposes of investigation to ascertain
compliance with the Act, and to require under terms of any subcontractor agreement
each subcontractor to permit access of such subcontractors’ books, records, and accounts
for such purposes.

(7) The Contractor agrees to comply with the provisions of the Act and with all guidelines
for equal employment opportunity applicable in the District adopted by the Director of
the Office of Human Rights, or any authorized official.

(8) The Contractor shall include in every subcontract the equal opportunity clauses, i.e.,
paragraphs 19(b) through (b) of this clause, so that such provisions shall be binding
upon each subcontractor.

(9) The Contractor shall take such action with respect to any subcontract as the CO may
direct as a means of enforcing these provisions, including sanctions for noncompliance;
provided, however, that in the event the Contractor becomes involved in, or is threatened
with, litigation with a subcontractor or vendor as a result of such direction by the
contracting agency, the Contractor may request the District to enter into such litigation
to protect the interest of the District.

I.14 COST AND PRICING DATA

Delete Article 25, Cost and Pricing Data, of the Standard Contract Provisions dated July 2010
for use with District of Columbia Government Supplies and Services Contracts.

I.15 SPECIAL PROVISION RELATED TO CITY ADMINISTRATOR’S ORDER 2022-3

Contractors who provide goods or perform services in person in District of Columbia facilities
or worksites shall ensure that each of their employees, agents, subcontractors, and supervised
volunteers comply with City Administrator’s Order 2022-3, Mask Requirements Inside Certain
District Government Buildings and Offices, dated April 14, 2022, and all substantially similar
mask requirements including any modifications to the Order, unless and until they are
rescinded.

I.16 CAMPAIGN FINANCE REFORM

I.16.1 Mandatory Certification

I.16.1.1 The Contractor shall certify that it has read and is in compliance with the Campaign Finance
Reform Amendment Act of 2018, effective March 13, 2019 (D.C. Law 22-250; D.C.
Official Code § 1-1001.03 et seq.). This certification is included in the Bidder/Offeror
Certification Form.

I.16.1.2 The Contractor shall re-certify prior to the exercise of any option period that it has read and
is in compliance with the Campaign Finance Reform Amendment Act of 2018, effective
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March 13, 2019 (D.C. Law 22-250; D.C. Official Code § 1-1001.03 et seq.). This
certification is included in the Bidder/Offeror Certification Form.

I.16.2 Reporting Contractor’s Principals

Contractors shall inform the contracting officer of any change to its principals during the term
of the contract within thirty days of its occurrence.

I.16.3 Prohibited Contributions

I.16.3.1 For contracts with a maximum aggregate value (the total sum of the contract ceiling for the
base period and any subsequent option periods) of between $250,000 and up to and
including $1,000,000 and a base period of performance of 1 year or less, neither the
Contractor nor any of its principals may make any contribution to the Mayor, any candidate
for Mayor, any political committee affiliated with the Mayor or a candidate for Mayor, or
any constituent-service program affiliated with the Mayor for the period from the date of
contract award through one year after the contract ends or is terminated.

I.16.3.2 For contracts with a maximum aggregate value (the total sum of the contract ceiling for the
base period and any subsequent option periods) of over $1,000,000 or with a base period of
longer than 1 year, neither the Contractor nor any of its principals may make any
contribution to the Mayor, any candidate for Mayor, any political committee affiliated with
the Mayor or a candidate for Mayor, any constituent-service program affiliated with the
Mayor, any Councilmember, any candidate for Councilmember, any political committee
affiliated with a Councilmember or a candidate for Councilmember, or any constituent-
service program affiliated with a Councilmember for the period from the date of contract
award through one year after the contract ends or is terminated.
I.17 AMERICANS WITH DISABILITIES ACT of 1990 (ADA)

During the performance of the contract, the Contractor and all of its subcontractors shall comply
with the ADA. The ADA makes it unlawful to discriminate in employment against a qualified
individual with a disability. Contractors providing public transportation shall comply with Title
II of the ADA. Contractors providing public accommodations shall comply with Title III of the
ADA. Contractors providing telecommunication shall comply with Title IV of the ADA. See 42
U.S.C. § 12101 et seq.

I.18 CONTINUITY OF SERVICES

I.18.1 The Contractor recognizes that the services provided under this contract are vital to the District
and must be continued without interruption and that, upon contract expiration or termination, a
successor, either the District or another contractor, at the District’s option, may continue to
provide these services. To that end, the Contractor agrees to:

I.18.1.1 Furnish phase-out, phase-in (transition) training; and
I.18.1.2 Exercise its best efforts and cooperation to effect an orderly and efficient transition to a
successor.

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I.18.2 The Contractor shall, upon the CO’s written notice:

I.18.2.1 Furnish phase-in, phase-out services for up to 90 days after this contract expires and
I.18.2.2 Negotiate in good faith a plan with a successor to determine the nature and extent of phase-
in, phase-out services required. The plan shall specify a training program and a date for
transferring responsibilities for each division of work described in the plan, and shall be
subject to the CO’s approval.

I.18.3 The Contractor shall provide sufficient experienced personnel during the phase-in, phase-out
period to ensure that the services called for by this contract are maintained at the required level
of proficiency.

I.18.4 The Contractor shall allow as many personnel as practicable to remain on the job to help the
successor maintain the continuity and consistency of the services required by this contract. The
Contractor also shall disclose necessary personnel records and allow the successor to conduct
on-site interviews with these employees. If selected employees are agreeable to the change, the
Contractor shall release them at a mutually agreeable date and negotiate transfer of their earned
fringe benefits to the successor.

I.18.5 Only in accordance with a modification issued by the CO, the Contractor shall be reimbursed
for all reasonable phase-in, phase-out costs (i.e., costs incurred within the agreed period after
contract expiration that result from phase-in, phase-out operations) and a fee (profit) not to
exceed a pro rata portion of the fee (profit) under this contract.

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SECTION J: ATTACHMENTS

The following attachments are incorporated into the solicitation and resulting contract by reference:

Attachment
Number Document
J.1
Government of the District of Columbia Standard Contract Provisions for
Use with the Supplies and Services Contracts (2010) available at
https://ocp.dc.gov/, under Quick Links click on “Required Solicitation
Documents”
J.2 U.S. Department of Labor Wage Determination No. 2015-4281, Revision No.
35, dated December 3, 2025
J.3
Office of Local Business Development Equal Employment Opportunity
Information Report and Mayor’s Order 85-85 available at https://ocp.dc.gov/,
under Quick Links click on “Required Solicitation Documents”
J.4
Department of Employment Services First Source Initial Employment Plan
available at https://ocp.dc.gov/, under Quick Links click on “Required
Solicitation Documents”
J.5
Department of Employment Services First Source Employment Agreement
available at https://ocp.dc.gov/, under Quick Links click on “Required
Solicitation Documents”
J.6
Way to Work Amendment Act of 2006 - Living Wage Notice
available at https://ocp.dc.gov/, under Quick Links click on “Required
Solicitation Documents”
J.7
Way to Work Amendment Act of 2006 - Living Wage Fact Sheet
available at https://ocp.dc.gov/, under Quick Links click on “Required
Solicitation Documents”
J.8 Tax Certification/Affidavit available at https://ocp.dc.gov/, under Quick
Links click on “Required Solicitation Documents”
J.9 Notice of Prohibition of Sexual Harassment in the Workplace
J.10 Bidder/Offeror Certification Form available at https://ocp.dc.gov/, under
Quick Links click on “Required Solicitation Documents”
J.11 Subcontracting Plan available at https://ocp.dc.gov/, under Quick Links click
on “Required Solicitation Documents”
J.12 HIPAA Privacy Compliance Business Associate Agreement (BAA),
Department of Health Care Finance
J.13 Business Associate HIPAA Compliance Questionnaire
J.14 Past Performance Evaluation Form available at https://ocp.dc.gov/, under
Quick Links click on “Required Solicitation Documents”
J.15 Certificate of Clean Hands available at http://mytax.dc.gov
J.16 Cost/Price Disclosure Certification available at https://ocp.dc.gov/, under
Quick Links click on “Required Solicitation Documents”
J.17 Business License available at https://dlcp.dc.gov, DC Department of
Licensing and Consumer Protection
J.18 Capitation Rate Report for CASSIP) prepared on November 7, 2025, is
incorporated and made a part of the contract.
J.19 Salazar Consent Decree (Salazar v. the district of Columbia)
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Attachment
Number Document
J.20 IVR Instructions
J.21 MCO Instruction Manual for Encounter Data Submission
J.22 Settlement Order (MCO Responsibilities under the Consent Decree)
J.23 Language Access Act of 2004
J.24
Final Guidance to Federal Financial Assistance Recipients Regarding Title
VI Prohibition Against National Origin Discrimination Affecting Limited
English Proficient Persons
J.25 CASSIP New Enrollee Log
J.26 Reconciliation of Newborn Monthly Report
J.27 SSA’s Presumptive Premature Newborn Eligibility Criteria
J.28 DC Medicaid HeatlhCheck Periodicity Schedule
J.29 DC Medicaid HeatlhCheck Dental Periodicity Schedule
J.30 Covered Outpatient Drugs – Supplement 1 to Attachment 3.1
J.31 Gender Reassignment Policy
J.32 DC Medicaid Managed Care Quality Strategy
J.33 CASSIP Disenrollment Log
J.34 Cell and Gene Therapy Exclusions Transmittal 25-12 & 25-13
J.35
U.S. Department of Health and Human Services Office of Civil Rights -
HIPAA Administrative Simplification available at
https://www.hhs.gov/sites/default/files/hipaa-simplification-201303.pdf
J.36 Salazar Settlement Agreement
J.37 HSCSN’s Technical Proposal
J.38 HSCSN’s Price Proposal