933. BENEFICIARY REIMBURSEMENT FOR MEDICAID COVERED SERVICES

933 BENEFICIARY REIMBURSEMENT FOR MEDICAID COVERED SERVICES 933.1 Reimbursement to a Medicaid beneficiary, their authorized representative, or their family member may occur if: (a) A Medicaid covered expense was incurred and paid by or on behalf of the beneficiary, on a date of service consistent with 29 DCMR 95; and (b) The requirements for reimbursement of a Medicaid covered expense, as described in § 933.2, are met. 933.2 When reimbursement is requested, consistent with §§ 933.4 and 933.5, a beneficiary, a family member of a beneficiary, or an authorized representative of a beneficiary shall be reimbursed for covered expenses for medically necessary services under the State Medicaid Plan if: (a) The beneficiary, family member of the beneficiary, or authorized representative of the beneficiary paid out-of-pocket for: (1) Prescription drugs; (2) Doctor or clinic visits; (3) Hospitalization expenses; (4) Durable medical equipment, prosthetics, orthotics, or other supplies (DMEPOS); or (5) Other services covered under the Medicaid State Plan, for which the beneficiary is eligible. (b) The beneficiary, family member of the beneficiary, or authorized representative of the beneficiary is currently paying an outstanding bill from a pharmacy, clinic, doctor’s office, hospital, or DMEPOS supplier; or (c) The beneficiary was improperly denied coverage of a Medicaid covered expense. This includes when: (1) The Department of Health Care Finance (the Department) incorrectly determined the beneficiary was no longer eligible for Medicaid at the time of renewal or recertification. (2) A healthcare provider or supplier is holding the beneficiary financially liable for a Medicaid covered expense because the beneficiary was incorrectly identified, by the Department, as ineligible for Medicaid. (3) A beneficiary is under age twenty-one (21) and was required to pay for any Early and Periodic Screening, Diagnostic, and Treatment service. (4) A beneficiary is dually eligible for Medicaid and a third-party insurer (including Medicare) and a healthcare provider or supplier is holding the beneficiary financially liable for any portion of the expenses for a Medicaid covered service not covered by the third-party insurer. 933.3 Request for reimbursement shall be submitted within twelve (12) months of the date the beneficiary incurred the Medicaid covered expense, or within twelve (12) months of the date the beneficiary was determined eligible for Medicaid, whichever is later. 933.4 To receive reimbursement, a beneficiary or their representative shall submit a Medicaid Reimbursement Form, available at https://dhcf.dc.gov/publication/medicaid-%E2%80%93-reimbursement-form, or the same information described in paragraphs (a) through (h), to the Department or the Medicaid Managed Care Plan (MCP) in which the beneficiary was enrolled on the date the service was provided. Each Medicaid Reimbursement submission should include: (a) The Medicaid beneficiary’s name, date of birth, social security number, mailing address, and Medicaid identification number; (b) The actual or estimated date of the service was provided; (c) The name and address of the provider; (d) The amount paid and owed, if applicable; (e) The amount paid by any other insurer, including Medicare; (f) The amount the beneficiary is requesting that Medicaid reimburse; and (g) A receipt(s) for the Medicaid covered service, showing payment to the provider; or (h) A signed and dated statement that the information provided is true and accurate, with an explanation of why a receipt from the provider cannot be presented. An inability to produce a receipt would be reasonable when: (1) The provider to whom the bill was paid has ceased operations; (2) The provision of services and payment is beyond the provider’s recordkeeping timeframe; (3) The provider no longer has access to the recordkeeping system associated with the service for the incurred expense; (4) The provider refuses to release payment receipt; or (5) The Department, on a case-by-case basis, determines that a reasonable circumstance exists. 933.5 If the Department receives a Medicaid Reimbursement Form, or the same information described in § 933.4, it shall identify whether the beneficiary was enrolled in Medicaid fee-for-service (FFS) or a Medicaid MCP on the date of service for which they are seeking reimbursement. (a) If the Department determines that the beneficiary was enrolled in Medicaid FFS on the date of service, the Department shall process the reimbursement claim. (b) If the Department determines that the beneficiary was enrolled in a Medicaid MCP on the date of service for which reimbursement is being requested, the Department shall, within thirty (30) calendar days after receiving the claim: (1) Provide written notice to the beneficiary that their claim will be processed by the Medicaid MCP. The notice shall also provide an explanation of the beneficiary’s right to appeal and request a fair hearing challenging an adverse determination by the Medicaid MCP; and (2) Forward the claim and notice to the Medicaid MCP. 933.6 Medicaid MCPs shall provide a final written determination to a beneficiary within sixty (60) calendar days of receiving the claim from the Department or the beneficiary. 933.7 In order for a written determination to be considered final, the MCP or the Department shall ensure: (a) The written determination includes: (1) A full payment of the claim; (2) A partial payment of the claim and an explanation of the partial denial; or (3) A denial of the claim and an explanation for the denial. (b) A denial of a reimbursement claim, in whole or in part, shall include a statement of the beneficiary’s due process appeal rights. (c) If payment is due in full or in part, the Department or the MCP, as applicable, shall make payment to the beneficiary by the required due date of the final written determination. 933.8 If a Medicaid MCP fails to issue a final written determination consistent with § 933.7 within sixty (60) calendar days, the MCP shall pay the full claim within five (5) business days after the expiration of the sixty (60) day deadline. 933.9 If the Department fails to submit a claim to an MCP within thirty (30) calendar days, resulting in the MCP not being able to issue a final written determination within ninety (90) calendar days of the claim’s initial submission to the Department, the Department shall pay the full claim within fifteen (15) calendar days after the expiration of the ninety (90) day deadline. 933.10 If the Department fails to issue a final written determination within ninety (90) calendar days from the date of the submission of the claim from a beneficiary enrolled in Medicaid FFS on the date of service for which reimbursement is requested, the Department shall pay the full claim within fifteen (15) business days after the expiration of the ninety (90) day deadline. 933.11 Medicaid FFS enrollees and Medicaid MCP enrollees may appeal the final determination on a claim for reimbursement, pursuant to § 9508 and MCP appeals processes, as applicable. 933.12 If a beneficiary is successful during a fair hearing challenging the denial of a claim for reimbursement by an MCP, the MCP cannot appeal that decision. SOURCE: Final Rulemaking published at 50 DCR 1182 (February 7, 2003); as amended by Final Rulemaking published at 52 DCR 11276 (December 30, 2005); as amended by Final Rulemaking published at 54 DCR 2519 (March 23, 2007); as amended by Final Rulemaking published at 54 DCR 9158 (September 21, 2007); as amended by Final Rulemaking published at 61 DCR 2615 (March 28, 2014); as amended by Final Rulemaking published at 73 DCR 005906 (April 10, 2026). District of Columbia Municipal Regulations Public Welfare 29 DCMR § 933