Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

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Products and Devices

Transportation Services

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Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: District of Columbia (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes			Limited to procedures safely performed in ambulatory setting, as approved by CMS	Negotiated rate	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes			Mental health clinics must be state-approved	Fee for service	CN & MN
Federally Qualified Health Center Services
Yes				Prospective cost based rate/visit with ancillaries paid fee for service	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes			Cosmetic and oral surgery limited to emergency repair due to injury or trauma, pre-surgical days limited to 1 unless medically justified, weekend admissions must be medically justified	Prospective payment/discharge using DRG and peer group adjustment or percentage of charge for specific hospitals and services	CN & MN
Outpatient Hospital Services
Yes			Cosmetic and oral surgery limited to emergency repair due to injury or trauma	Cost based payment	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes		Yes	Rehab centers must be state-approved	Fee for service	CN & MN
Rural Health Clinic Services
No
Practitioner Services
Certified Registered Nurse Anesthetist Services
No
Chiropractor Services
No
Dental Services
Yes				Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes			Limited to trauma care	Fee for service	CN & MN
Nurse Midwife Services
Yes				Fee for service	CN & MN
Nurse Practitioner Services
Yes				Fee for service	CN & MN
Optometrist Services
Yes				Fee for service	CN & MN
Physician Services
Yes		Specified surgical procedures		Fee for service	CN & MN
Podiatrist Services
Yes		Specified services		Fee for service using Medicare upper limits	CN & MN
Psychologist Services
No
Prescription Drugs
Prescription Drugs
Yes	$1/Rx	Specified drugs and injectables including Percodan and Dalmane		AWP-10%, plus $4.50 dispensing fee	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
Yes		Treatment plan		Fee for service	CN & MN
Services for Speech, Hearing and Language Disorders
No
Products and Devices
Dentures
Yes
Eyeglasses
Yes	$2/service		1 pair eyeglasses/2 years, minimum diopter correction required	Fee for service	CN & MN
Hearing Aids
No
Medical Equipment and Supplies
Yes		Specified med equipment and med supply items, depending on cost		Fee for service	CN & MN
Prosthetic and Orthotic Devices
Yes				Fee for service using Medicare payment ceilings	CN & MN
Transportation Services
Ambulance Services
Yes				Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes		Medi-van transport		See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes		Yes	Limited to diagnostic and preventive services only	Dependent upon service and billing provider	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes				Fee for service	CN & MN
Targeted Case Management
Yes			Quantity limits vary by type of service	Fee for service	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Services for the following populations: 2, 4, 5 & 8 - See service-specific FN	Dependent upon the services provided	CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes		Plan of care required, 36 visits/year, 8 hours/home health aide visit, PT and OT must be in plan, SP not covered, only specified med equipment and supplies covered	Fee for service using Medicare cost ceilings	CN & MN
Hospice Care
Yes		Two 90-day periods and one 30-day period with additional 30-day periods as necessary	Prospective rates based on Medicare methodology	CN & MN
Personal Care Services
Yes		8 hours/day up to 1,040 hours/year, care must cost less than in nursing facility	Fee for service using hourly rates, adjusted for multiple beneficiaries same address	CN & MN
Private Duty Nursing Services
Yes	Yes		Fee for service using Medicare limits	CN & MN
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes		18 days hosp or therapeutic leave/year	Prospective cost based per diem	CN & MN
Inpatient Psychiatric Services, under age 21
Yes			Prospective cost based per diem	CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes		60 hosp or therapeutic leave days/year	Prospective cost based per diem with limits	CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes		18 days hosp or therapeutic leave/year	Prospective per diem based on cost, with efficiency incentives, up to Medicare limits	CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: The District has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to additional low-income, non-disabled adults age 50 through 64 with income at or below 50 percent of the federal poverty level (FPL), who are not custodial parents or caretakers of children under age 19. The District has also extended Medicaid eligibility to working disabled adults with HIV/AIDS, permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA); qualified beneficiaries must have income at or below 300 percent of the FPL. The benefit package, managed care delivery system and cost sharing requirements for these beneficiaries are the same as for the traditional Medicaid population. No premium is required.