CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

EPD Waiver Person-Centered Service Planning and Case Management

Customize your policy alerts

Sign up for all District of Columbia Department of Health Care Finance policy alerts

Know when District of Columbia Department of Health Care Finance releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs person-centered service plans, case management responsibilities, reimbursement, care coordination, and transitional case management for beneficiaries receiving services under the District of Columbia EPD Waiver. Applies to beneficiaries, case managers, case management agencies, service providers, and DHCF or its designee.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyEPD Waiver Person-Centered Service Planning and Case Management

Policy CodePolicy N/A

Change TypeFinal rulemaking and operational update

Effective DateOctober 20, 2015

Next Review DateN/A

Key ActionDevelop and maintain a written Person-Centered Service Plan for each EPD Waiver beneficiary, obtain DHCF or designee approval, and update it at least annually or when health needs change.

SourceLink

POLICY UPDATE CHANGES

Replaces written individualized service plans with person-centered service plan requirements aligned with CMS standards.

Changes case management reimbursement to a per-member-per-month payment structure.

Adds transitional case management to case management and care coordination services.

30 daysPCSP completion deadline under an authorized exception

$245.96 PMPM

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

EPD Waiver Person-Centered Service Planning and Case Management

Customize your policy alerts

Sign up for all District of Columbia Department of Health Care Finance policy alerts

Know when District of Columbia Department of Health Care Finance releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyEPD Waiver Person-Centered Service Planning and Case Management

Policy CodePolicy N/A

Change TypeFinal rulemaking and operational update

Effective DateOctober 20, 2015

Next Review DateN/A

Key ActionDevelop and maintain a written Person-Centered Service Plan for each EPD Waiver beneficiary, obtain DHCF or designee approval, and update it at least annually or when health needs change.

SourceLink

POLICY UPDATE CHANGES

Replaces written individualized service plans with person-centered service plan requirements aligned with CMS standards.

Changes case management reimbursement to a per-member-per-month payment structure.

Adds transitional case management to case management and care coordination services.

30 daysPCSP completion deadline under an authorized exception

$245.96 PMPM

EPD Waiver Service Planning and Case Management Requirements

Rates, Limits, and Operational Timeframes

Case Management Reimbursement

Waiver Year 5 rate$245.96 per member per month

Reimbursement basisCase management services are reimbursed on a per member per month (PMPM) basis.

Payment conditionThe rate is contingent on performance of the required monthly and ongoing care coordination activities.

Case Manager Caseload and Availability

Maximum caseloadNo more than 45 beneficiaries may be assigned to each Case Manager at any point in time.

Required staffingEach Case Manager must perform case management duties on either a full-time or part-time basis.

AvailabilityCase management services must be available during regular business hours, with on-call coverage during weekends and evenings for emergencies.

Transitional Case Management Reimbursement

Maximum reimbursable periodTransitional case management reimbursement may not exceed 120 days during a hospital or nursing facility stay.

Payment timingReimbursement is made only after the beneficiary returns to the home or community setting, not during the institutional stay.

Reimbursement conditionThe Case Manager must perform activities during the institutional stay that facilitate the beneficiary's transition to the community.

PCSP Review

Review frequencyThe Case Manager must review the PCSP at least quarterly.

Implementation reviewThe implementation of the PCSP must be reviewed at least quarterly and as needed.

Monitoring connectionQuarterly review is part of ongoing care coordination and is supplemented by in-person monitoring visits at least monthly, or more frequently as needed.

PCSP Updates

Routine updateThe PCSP must be updated and revised at least annually.

Change in health needsThe PCSP must be updated whenever a change in the beneficiary's health needs warrants an update.

Requested update deadlineWhen required after monitoring activity or a beneficiary or representative request, necessary PCSP updates must be made within seven days.

Operational Response Timelines

Initial evaluationComplete an in-person initial evaluation within 48 hours of receiving notice of EPD Waiver enrollment.

PCSP submissionDevelop, complete, and submit the PCSP to DHCF or its designee within 10 business days after the initial evaluation.

Provider follow-upFollow up with selected service providers within five working days after service approval to ensure services are in place.

Inquiry responseAcknowledge and respond to beneficiary inquiries within 24 hours, unless a quicker response is needed for an emergency.

PCSP updateMake necessary PCSP updates within seven days of monitoring activity or a beneficiary's or representative's request to update the PCSP.

Required Case Management Activities

Documentation Required

Develop and Maintain the PCSP

The Case Manager must develop a written Person-Centered Service Plan (PCSP) for each EPD Waiver beneficiary, obtain DHCF or designee approval, and maintain it throughout service delivery. The plan must be person-centered, reflect the beneficiary’s needs, preferences, strengths, goals, risks, supports, and service choices, and be updated at least annually or whenever health needs change.

Obtain final approval and signatures from the Case Manager, beneficiary, and/or representative and provide completed-plan copies or requested components to contributors and others included in development.
Document goals and how they relate to the amount, duration, and scope of services; Medicaid and non-Medicaid supports; providers; risks and mitigation; health and safety assurances; applicable restrictions and consent; end-of-life planning, as appropriate; and self-direction components when Services My Way is selected.
Use accessible, culturally and linguistically appropriate planning, including interpreters or translated written materials for beneficiaries or representatives with low literacy or Limited English Proficiency.
Review the PCSP at least quarterly and revise it when needs, goals, risks, services, or supports change.

Key Terms

Person-Centered Service Plan (PCSP)

DefinitionA written plan developed for each EPD Waiver beneficiary and approved by DHCF or its designee.

Person-centered contentThe PCSP reflects the beneficiary's needs, preferences, strengths, and goals.

Required planning elementsThe plan addresses or documents goals, selected contributors, services and supports, risks, safety assurances, and applicable self-direction components.

Transitional Case Management

DefinitionCase management provided during a hospital or nursing facility stay to facilitate the beneficiary's transition back to the home or community setting.

During the institutional stayThe Case Manager maintains contact with the beneficiary or representative and keeps the beneficiary connected to community resources or helps establish those connections.

Prior Authorization

Meet Evaluation and Authorization Timelines

Complete the initial evaluation and PCSP submission within the required timeframes, and coordinate prompt authorization and implementation of approved services. DHCF or its designee must prior authorize PCSP-recommended services within seven business days of receipt, except for services approved to be delivered sooner.

Conduct an in-person initial evaluation within 48 hours after notice of the beneficiary’s EPD Waiver enrollment.
Develop, complete, and submit the PCSP to DHCF or its designee within 10 business days after the initial evaluation.
Within 5 working days after service approval, follow up with selected providers to confirm services are in place at sufficient quantity and quality, unless an earlier need or health jeopardy requires faster action.
Use person-centered planning that accounts for preferences, convenient meeting arrangements, interdisciplinary-team feedback, strengths, housing and employment goals, guardianship-related concerns, and meaningful access needs.

Documentation Required

Coordinate, Monitor, and Document Ongoing Care

Perform the monthly and ongoing care-coordination activities required for reimbursement and safe, effective delivery of EPD Waiver services. Monitor the beneficiary and service implementation, resolve issues promptly, maintain complete records, and document required information in DHCF’s electronic case management system.

Conduct at least monthly, or more frequently as needed, in-person monitoring visits in the beneficiary’s home and supplement them with telephone contact based on individual needs.
Review PCSP implementation at least quarterly; review risks, goals, outcomes, services, supports, utilization, and provider progress; revise the PCSP when needed; and document the review and service-status summary electronically.
Respond to monitoring requests within 48 hours and make necessary PCSP updates within 7 days of the monitoring activity or the beneficiary’s/representative’s request, using required in-person planning processes.
Coordinate waiver and non-waiver services, help select eligible providers, provide referrals and benefits information, monitor supplies and equipment, assess continued waiver participation, and ensure services are utilized and maintain the beneficiary in the community.
Acknowledge beneficiary inquiries within 24 hours, or sooner for emergencies; promptly communicate major updates, issues, or problems to DHCF or its designee.
Maintain legible records of services, contacts, assessments, and quarterly reviews and upload all required information to DHCF’s electronic case management system.
For annual recertification, coordinate reassessments and documentation, upload information at least 60 days before the certification period expires, update the PCSP, and follow up with providers within five working days after authorization.
For Services My Way, complete required training; explain the program at initial evaluation, reassessment, PCSP updates, and upon request; assist with enrollment and PCSP goals; submit forms; communicate with support brokers about health and safety; and facilitate transition to agency-based personal care aide services when participation ends.

Note

Coordinate Transitions from Institutional Care

Provide transitional case management during an institutional stay for no more than 120 days to facilitate a safe transition back to the community. Transitional activities must preserve existing supports, establish needed resources, and ensure services are ready when the beneficiary is discharged.

Maintain contact with the beneficiary and/or representative throughout the institutional stay.
Keep the beneficiary connected to community resources, such as housing, and assist with reconnecting to existing resources or connecting to new resources after discharge.
Participate in person in discharge-planning meetings at the institutional provider’s site.
Secure required service prior authorizations so services are in place on the first day of discharge.
For Medicaid reimbursement, perform and document the required transitional case-management activities during the institutional stay.

Denial Risk

Prevent Duplication and Improper Substitution

Coordinate service-specific safeguards so waiver services supplement rather than replace or duplicate services available through EPSDT, residential contracts, or other applicable programs and responsibilities. Apply these checks before incorporating or authorizing the relevant service in the PCSP.

For beneficiaries ages 18 through 21, ensure occupational and physical therapy available under EPSDT is fully utilized and that waiver services do not replace or duplicate EPSDT services.
Before ordering chore aide services for a beneficiary living in a rental property or residential facility, examine the landlord’s or homeowner’s responsibilities under the lease, residential contract, applicable law, and regulations.
For beneficiaries requiring Environmental Accessibility Adaptations (EAA), assist with required home-adaptation assessments, evaluations, or bids in accordance with the chapter.
Document coordination decisions and use the utilization-review process to achieve appropriate delivery and prevent duplicative, unnecessary, or inappropriate services.