For Your Benefit - District Leaders React to Supreme Court Ruling


Issue 3

July 2012

Table of Contents

District Leaders Welcome Supreme Court's ACA Decision

DC HBX Authority Board Update

ACA Medicaid Initiatives

Spotlight:  Insurance Subcommittee

DHCF Comments on Medicaid Primary Care Payments Proposal

IT RFP Update

Available Job Positions

July Calendar

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The Supreme Court’s ruling to uphold the 2010 Affordable Care Act (ACA) was welcome news to Mayor Vincent C. Gray and other District leaders.  In a statement released on the day of the Court’s decision, Mayor Gray acknowledged that the District already leads the nation in access to care and expressed his commitment to continue moving forward to ensure that every District resident has access to quality, affordable health care.

The Court ruled that the ACA, including the individual mandate that virtually all Americans buy health insurance, is constitutional.  The mandate dictated that nearly all Americans obtain health insurance or pay a fine.  That mandate was upheld under the federal government’s power to levy taxes rather than under the government’s power to regulate interstate commerce.  The Supreme Court did put some limits on the law’s plan to expand the Medicaid insurance program for the poor.  The Court ruled that the US government cannot threaten to withhold a state’s entire Medicaid allotment if the state refuses to participate in the expansion.

The District is not at risk of losing any Medicaid funding as a result of this ruling, because District officials have already begun implementation of the ACA’s Medicaid expansion provisions and will continue to implement the expansion.


...The District of Columbia is one of only 15 states in the nation that is moving ahead with establishing a State-based Health Benefit Exchange.  Although many states are still studying their options, DC is among a handful of states that have enacted legislation and are in the process of implementing their Exchanges.


Last month, Mayor Vincent C. Gray nominated seven prominent health care professionals to the newly-created Executive Board of the District Health Benefit Exchange Authority (DC HBX).  The board member nominations were referred to the DC Council Committee on Health and the Committee on Consumer Affairs.  Board members are expected to be sworn in on July 17.  Once confirmed, the Executive Board will begin holding regular meetings.  One of the first responsibilities of the new Executive Board will be the hiring of an Executive Director, who will organize, administer and manage the operations of the DC HBX Authority.  The Health Benefit Exchange Authority Establishment Act of 2011 calls for the Executive Board to hire an Executive Director within 60 days of a majority of the Executive Board members being confirmed.

After the Executive Board of the DC HBX is in place, the Health Reform Implementation Committee (HRIC) Subcommittees will continue to work on health reform activities, reporting to the DC HBX Authority on matters which are Exchange-related and to the appropriate Executive Agencies for non-Exchange matters.  However, the HRIC Executive Committee will no longer meet.

In addition, the law requires the DC HBX Authority to establish a standing nine-member Advisory Board, whose members must be DC residents.  Advisory Board members must be expert in at least one of the following areas:  health professionals; health insurance or exchange consumers; disease, demographic, or consumer interest advocacy groups; commercial or public sector health plans; insurance brokers; or health care foundations.  Recommendations for individuals to serve on the Advisory Board should be sent to Bonnie Norton, Acting Director, Health Care Reform and Innovation Administration, Department of Health Care Finance, at


The Affordable Care Act (ACA) included many provisions which expand Medicaid coverage and improve the delivery of health care services to Medicaid beneficiaries.  The District embraced these reforms and expanded Medicaid coverage to childless adults to age 65 with incomes up to 133 percent of the federal poverty level earlier than the ACA required.   Staff at the Department of Health Care Finance (DHCF) are working on implementing a number of ACA provisions related to Medicaid.  Several of these initiatives are described below.

Health Care Acquired Conditions – ACA, Section 2702
As of July 1, 2012, District of Columbia Medicaid providers will no longer be reimbursed for services relating to a specified list of health care acquired conditions(HCACs) when the condition is acquired during the hospital stay (that is, when the patient did not have the condition when admitted to the hospital).  In addition, no payment will be made for erroneous surgical or other invasive procedures and services directly related to the wrong surgery, when the practitioner erroneously performs a procedure.  DHCF has developed an FAQ  to answer provider questions about this new policy.

National Correct Coding Initiative (NCCI) – ACA Section 6507
The National Correct Coding Initiative was originally implemented by Medicare in 1996 to ensure accurate coding and reporting by physicians.  NCCI policies and edits identify procedures and services performed by the provider for the same beneficiary on the same date of service and flag those codes that should not be paid.  Under the ACA, DHCF is required to re-adjudicate all Medicaid claims for service dates on or after October 1, 2010.  If you have questions or would like more information about NCCI, please contact Provider Services at 202-698-2000.

Medicaid Emergency Psychiatric Demonstration – ACA, Section 2702
The District of Columbia is one of 13 states participating in the Medicaid Emergency Psychiatric Demonstration (MEPD).  The Demonstration provides Medicaid payments to private Institutions for Mental Diseases (IMDs) for individuals 21 to 64 years of age, in fee for service Medicaid, who require treatment to stabilize psychiatric emergency medical conditions (i.e., individuals who express suicidal or homicidal thoughts or gestures, and who are determined to be dangerous to themselves or others).  The District’s Demonstration is being jointly administered by the Department of Health Care Finance and the Department of Mental Health.

Psychiatric Institute of Washington (PIW) is the only privately-operated IMD in the District.  As an IMD, it has not been able to accept Medicaid patients 21 to 64 years of age.  The MEPD will both allow PIW to accept those Medicaid patients who qualify and ensure that they receive a coherent stabilization plan, discharge planning, post-discharge services and post-discharge monitoring. This Demonstration is expected to:
  • Expand the care options for Medicaid-eligible individuals in need of emergency psychiatric treatment for the stabilization of suicidal or homicidal ideations or gestures;
  • Reduce emergency room overcrowding and hospital readmission rates and total hospital days for the target population;
  • Improve continuity of care; and
  • Extend community tenure post-discharge.
Beginning July 2, 2012, referrals of individuals for the MEPD project will come from the Department of Mental Health’s Comprehensive Psychiatric Emergency Program (CPEP) and from community hospitals.  For more information about the Demonstration, contact Claudia Schlosberg, J.D., Director, Health Care Policy and Research Administration, Department of Health Care Finance at, or Suzanne Fenzel, J.D., Assistant Attorney General, Department of Mental Health at


Check out the Frequently Asked Questions on the health reform website.  If you don't see your question, send it to  We will try to address it in future newsletters.



The Health Reform Implementation Committee (HRIC) was created to keep the Mayor advised on the implementation of the Affordable Care Act (ACA) and make sure that health reform implementation activities in the District are carried out successfully.  One of the six standing subcommittees of the HRIC is the Insurance Subcommittee.

The DC Department of Insurance, Securities and Banking (DISB) has led the Insurance Subcommittee since May 2010.  Its primary responsibilities are the establishment of the DC Health Benefits Exchange (DC HBX) insurance marketplace and all ACA-related insurance market regulations.  DISB and the Insurance Subcommittee focus on the Exchange core functions of Plan Management, including the small group (SHOP) Exchange, and Financial Management.

One of the first tasks of the Insurance Subcommittee was to develop the recommendations for legislation that would authorize the establishment of a District-based Exchange.  The Subcommittee obtained input on the Exchange’s governance, administration, and conflict of interest provisions from committee members, stakeholders, and public information forums in all wards of the District.  The Subcommittee also used research and findings from Mercer, the District’s Exchange planning grant contractor.  The recommendations, which were approved by the full HRIC, Deputy Mayor for Health and Human Services, and Mayor, were largely adopted in the final version of the Exchange legislation (Health Benefit Exchange Authority Establishment Act of 2011), which was signed into law on January 17, 2012.

The Subcommittee’s next focus was the development of health insurance market rules for both the DC HBX insurance marketplace and market on the whole.  The Subcommittee’s recommendations have been transmitted to the Mayor and are awaiting consultation with the newly appointed DC HBX Authority Executive Board for implementation.

The Insurance Subcommittee has identified current priorities to ensure the District both successfully applies for a Level 2 establishment grant by August 15, 2012 and meets the federal Exchange certification criteria by November 16, 2012.  Some of the most pressing issues for the Insurance Subcommittee’s focus will be to:
  • Finalize Qualified Health Plan (QHP) requirements for both the DC HBX insurance marketplace plans and carriers;
  • Finalize selection of the District’s Essential Health Benefit benchmark package;
  • Establish the framework and regulations for inclusion of stand-alone dental plans in the DC HBX insurance marketplace;
  • Begin beta testing and integration of the National Association of Insurance Commissioner’s SERFF (System for Electronic Rate and Form Filing) plan management module for QHP filings;
  • Establish framework and guidelines for employer plan selection options on the SHOP; and
  • Determine how best to integrate brokers and agents into the DC HBX insurance marketplace.

    See the Calendar below for details on the Insurance Subcommittee and HBX Insurance Market Working Group meetings in July.


On June 11, 2012, DHCF filed comments in response to the Centers for Medicare and Medicaid Services (CMS) proposed rule implementing ACA Section 1202 requiring states to increase Medicaid payments for certain primary care services to 100 percent of the Medicare fee schedule.  The new rates are effective January 1, 2013 through December 31, 2014 and apply to physicians under contract to MCOs as well.

Although the statute names only three specialty designations that would be eligible for the increased payment rates, the proposed rule would require states to pay the increased “minimum payment” to a much broader group of practitioners.  Specifically, CMS proposes to expand the list of eligible providers to an additional 44 subspecialists related to the primary care specialists designated in the statute as recognized by the American Board of Medical Specialties (ABMS).  While the District agrees that many primary care subspecialists render primary care services to Medicaid beneficiaries and that many are important in the provision of primary care, DHCF raised concern that the ABMS list was both overly expansive and under-inclusive.  Specifically, included among eligible providers are physicians who practice sports medicine and sleep medicine.  However, notably absent from the ABMS listings are OB/GYNs and psychiatrists, both of which are important providers of primary care services to Medicaid beneficiaries.  DHCF also raised concerns about the additional, significant administrative burden that the proposed rule imposes on state agency staff, particularly at a time when so much of our time and resources are being devoted to establishing the DC Health Benefit Exchange and implementing new Medicaid eligibility standards to align the Medicaid program with the Exchange rules.  For a copy of DHCF’s comments, please contact Claudia Schlosberg, J.D., Director, Health Care Policy and Research Administration at


The issuance of the Health Benefit Exchange Systems Integration RFP has been delayed.  All dates related to the procurement, including the pre-bidder’s conference, are TBD pending the release of the RFP.  Once the RFP is released, the District will post an updated timeline outlining the schedule for important activities and dates associated with this solicitation to the health reform website, where the draft Statement of Work is currently available.


The District of Columbia’s Health and Human Services agencies are still seeking candidates to work on health care reform and the District’s new health care and human services eligibility and enrollment solution.

If you are interested in the following positions in the Department of Health Care Finance, please visit the DC Jobs website for more information.
·         Medicaid Program Manager (Job ID: 20032)
·         Medicaid Policy Project Manager (Job ID 20033)
·         Ombudsman Consumer Assistance Project Manager (Job ID 20034)
·         Exchange Consumer Assistance Project Manager (Job ID 20024)
·         Exchange Information and Privacy Officer (Job ID: 20028)

If you are interested in the following positions in the Department of Human Services, please send your cover letter and resume to  These positions will also be posted on the Department of Human Resources website ( in the coming weeks.
·         Program Analyst
·         Management Analyst
·         IT Project Manager
·         IT Specialist (Mainframe)
·         IT Specialist (Application Software)
·         IT Specialist (Database Manager)


Monday, July 9, 3:00 PM
Insurance Subcommittee Plan HBX Market Working Group Meeting
Department of Insurance, Securities and Banking, 810 First Street NE, 7th Floor

Tuesday, July 10, 11:00 AM
Insurance Subcommittee Meeting
Department of Insurance, Securities and Banking, 810 First Street NE, 7th Floor

Tuesday, July 10, 2:00 PM
Exchange Operations Subcommittee Meeting
Department of Health Care Finance, 899 North Capitol Street NE, Room 6130

Wednesday, July 11, 2:00 PM
Communications Subcommittee Meeting
John A. Wilson Building, 1350 Pennsylvania Avenue NW, Room 306

Wednesday, July 11, 3:00 PM
Information Technology Subcommittee Meeting
Department of Human Services, 64 New York Avenue NE, 6th Floor Large Conference Room

Thursday, July 12, 2:00 PM
Health Services Delivery Subcommittee Meeting
Department of Health, 899 North Capitol Street NE, Room 535

Thursday, July 12, 2:00 PM
Medicaid Expansion and Eligibility Subcommittee Meeting
Department of Human Services, 64 New York Avenue NE, 5th Floor Conference Room

Monday, July 23, 2:00 PM
Insurance Subcommittee Plan HBX Market Working Group Meeting
Department of Insurance, Securities and Banking, 810 First Street NE, 7th Floor

Wednesday, August 1, 2:00 PM
Communications Subcommittee Meeting
John A. Wilson Building, 1350 Pennsylvania Avenue NW, Room 306

Produced by The Crider Group