§ 4–651.11. Reimbursement for home visiting services.

(a) By July 1, 2025, health insurance coverage through Medicaid or the DC HealthCare Alliance and the Immigrant Children's Program shall cover and reimburse eligible home visiting services provided by an eligible home visiting program; except, that no Medicaid payment shall be made until such time that CMS approves the Medicaid state plan amendment described in subsection (b) of this section.

(b)(1) By March 31, 2025, DHCF shall submit for approval from CMS an amendment to the Medicaid state plan to authorize the Medicaid payments described in this section.

(2) While preparing the Medicaid state plan amendment application, DHCF shall:

(A) In consultation with organizations providing home visiting services and other relevant entities, establish criteria and processes for billing and reimbursement of eligible home visiting services, including:

(i) Establishing coverage and eligibility criteria to include at least the covered population;

(ii) Establishing a payment methodology based on monthly payments per individual or family receiving eligible home visiting services so that the payment results in adequate reimbursement;

(iii) Developing program support and training for home visitors to facilitate billing; and

(iv) Assessing the viability of incentive payments to home visitors whose clients attend postpartum appointments with a medical provider; and

(B) In consultation with DOH and other relevant entities, issue rules to determine eligibility for reimbursement by Medicaid, the DC HealthCare Alliance, and the Immigrant Children's Program.

(c) For purposes of this section, the term:

(1) "CMS" means the Centers for Medicare & Medicaid Services.

(2) "Covered population" means:

(A) First-time expectant parents; and

(B) Families, and expectant parents, who have children under the age of 5 and meet 3 or more medical, behavioral, or social risk factors, as determined by DHCF.

(3) "Eligible home visiting program" means a home visiting program that conforms to a home visitation model that has been in existence for at least 3 years and:

(A) Is research-based and grounded in relevant empirically based knowledge;

(B) Has demonstrated program-determined outcomes;

(C) Is associated with a national organization, institution of higher education, or other organization that has comprehensive home visitation program standards to ensure high quality service delivery and continuous program quality improvement;

(D) Meets the U.S. Department of Health and Human Services' criteria for evidence of effectiveness as determined by a Home Visiting Evidence of Effectiveness review or meets substantially equivalent criteria for evidence of effectiveness as determined by a credible, independent academic or research organization; and

(E) Employs registered nurses as home visitors.