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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyDC DHCF Medicaid Residency Policy Update | OpenPay…
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    CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

    Medicaid Residency Eligibility (Section 9502)

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    This rule governs how District Medicaid residency is determined, including temporary absences, institutional placements, and certain foster-care placements outside the District. It affects individuals applying for or receiving Medicaid and the District agencies and providers involved in eligibility and care arrangements.

    Policy Summary
    PayerDistrict of Columbia Department of Health Care Finance
    PolicyMedicaid Residency Eligibility (Section 9502)
    Policy CodePolicy N/A
    Change TypeRule amendment and clarification
    Effective DateN/A
    Next Review DateN/A
    Key ActionVerify that providers serving individuals in out-of-District foster-care placements are screened and enrolled in the District Medicaid program.
    SourceLink
    POLICY UPDATE CHANGES

    Temporary absences of less than ninety consecutive days may preserve District residency, and longer absences may qualify for good cause determined by DHCF.

    The rule permits certain District foster-care recipients living in out-of-District foster homes to remain District Medicaid residents when specified conditions are met.

    Geographic distance for foster-care best-interest determinations refers to distance from the location where services are provided.

    The school-attendance good-cause exception applies to individuals under age twenty-two and includes educational placements identified in District special-education rules.

    90 daysTemporary-absence period generally permitted for retaining District residency

    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.

    Under 22Age limit for the school-attendance good-cause example
    4 conditionsRequirements for certain out-of-District foster-care residents to retain District Medicaid residency
    3 examplesExamples of good cause for an absence exceeding 90 consecutive days
    NoneDistrict residency period required before Medicaid eligibility

    Medicaid Residency Eligibility Criteria

    Temporary Absence and Continued Residency

    An individual may retain District Medicaid residency during a temporary absence when ALL of the following conditions are met:

    ALL of the following

    • The individual considers the District of Columbia to be his or her fixed place of residence and intends to return to the District with the intent to reside after the temporary absence.

    • ONE of the following absence conditions applies:

      • The individual is absent from the District for less than ninety (90) consecutive days.< 90 consecutive days

      • The individual is absent for more than ninety (90) consecutive days for good cause determined by DHCF, and at least one recognized good-cause circumstance applies.

        • The absence is solely for school attendance: the individual is under age twenty-two (22) and is away from the District to attend a boarding school, other educational facility, or an educational placement under Title 5-E DCMR § 3013.6, and is otherwise eligible.
        • The individual is otherwise eligible, needs medical care, and temporarily resides outside the District; Medicaid eligibility may continue for as long as the need for medical care continues.
        • The individual has full-time employment in the U.S. military service and is away from the District because of a duty assignment, and is otherwise eligible.

    Out-of-District Foster-Care Residency

    The District may consider an individual under age twenty-one (21) who receives District Title IV-E foster-care assistance and lives in an out-of-District foster home to be a District resident when ALL of the following conditions are met:

    ALL of the following

    • The individual receives foster care as defined at 45 CFR § 1355.20.
    • The individual receives services from a provider screened and enrolled in the District Medicaid program pursuant to 29 DCMR §§ 9400 et seq.
    • The District's Child and Family Services Agency (CFSA) places the individual in an out-of-District foster home for reasons related to the safety, permanence, and well-being of abused and neglected children and their families.
    • The District evaluates all factors affecting the individual's best interests and determines that continued eligibility for and enrollment in the District Medicaid program is in the individual's best interest.

    Exceptions to Continued Foster-Care Enrollment

    For an individual described in Subsection 9502.24, the District may determine that continued eligibility for and enrollment in the District Medicaid program is not in the individual's best interest when ANY of the following applies:

    ANY of the following circumstances applies:

    • The individual cannot obtain services from a provider enrolled in the District Medicaid program because of the individual's geographic distance from the location where the services are provided.
    • The individual has special health needs that cannot be addressed by an available and accessible provider enrolled in the District Medicaid program.
    • The individual, or someone acting responsibly for the individual, requests that the individual be enrolled in the Medicaid program of the state where the individual is living.
    • The District evaluates all factors affecting the individual's best interests and determines that continued eligibility for and enrollment in the District Medicaid program is not in the individual's best interest.

    No Minimum Residency Period

    Medicaid eligibility may not be denied solely because the individual has not lived in the District for a specified period.

    ALL of the following

    • The Department shall not deny eligibility for Medicaid because an individual has not resided in the District for a specified period.
    • The Department shall not deny Medicaid eligibility to an institutionalized individual who satisfies the applicable residency rules solely because the individual did not establish residence in the District before entering the institution.

    Key Eligibility Thresholds

    Temporary absence
    Temporary-absence thresholdLess than 90 consecutive days
    District residenceThe District must remain the individual's fixed place of residence, with the individual intending to return and reside there.
    Longer absenceAn absence of more than 90 consecutive days may qualify for good cause as determined by DHCF.
    School-attendance good cause
    Age thresholdUnder age 22
    Purpose of absenceThe individual is away from the District for the sole purpose of attending school or another qualifying educational placement.
    Qualifying educational settings

    Operational Requirements for Providers and Agencies

    Documentation Required

    Verify District Medicaid provider enrollment

    For an out-of-District foster-care placement, services must be provided by a provider screened and enrolled in the District Medicaid program for the individual to potentially retain District residency.

    Documentation Required

    Support best-interest residency determination

    Support the District’s best-interest determination for foster-care cases by providing information on all factors affecting the individual’s best interests. Continued District Medicaid eligibility and enrollment must be in the individual’s best interest; the determination may consider whether services are accessible based on the distance from the location where services are provided and whether available providers can address special health needs.

    Key Residency and Foster-Care Definitions

    District resident age 21 or older
    DefinitionAn individual age 21 or older who does not live in an institution and is living in the District voluntarily and not for a temporary purpose.
    Intent to remainThe individual has no intention of presently leaving the District.
    Included circumstancesThe definition includes individuals without a fixed address and individuals who entered the District with a job commitment or seeking employment, whether or not currently employed.
    Residence for temporary-absence purposes
    Fixed residenceThe individual's fixed place of residence in the District.
    Intent to returnThe individual intends to return to the fixed place of residence after the temporary absence.
    Policy Summary
    PayerDistrict of Columbia Department of Health Care Finance
    PolicyMedicaid Residency Eligibility (Section 9502)
    Policy CodePolicy N/A
    Change TypeRule amendment and clarification
    Effective DateN/A
    Next Review DateN/A
    Key ActionVerify that providers serving individuals in out-of-District foster-care placements are screened and enrolled in the District Medicaid program.
    SourceLink
    On This Page
    Medicaid Residency Eligibility CriteriaKey Eligibility ThresholdsOperational Requirements for Providers and AgenciesKey Residency and Foster-Care Definitions
    A boarding school, other educational facility, or an educational placement identified in Title 5-E DCMR § 3013.6.
    Intent to resideThe individual intends to return and reside there following the temporary absence.
    Qualifying foster care
    Regulatory definitionFoster care as defined at 45 C.F.R. § 1355.20.
    Age requirementThe individual is under age 21.
    District assistanceThe individual receives foster-care assistance from the District under Title IV-E of the Social Security Act.