Medicaid Managed Care Plans (MCPs)

The District contracts with 2 MCPs to provide access to services for the DC Healthy Families Program (DCHFP). Those MCPs are AmeriHealth Caritas DC and MedStar Family Choice DC. Health Services for Children with Special Needs (HSCSN) is the MCP contracted to provide access to services for the Child and Adolescent Supplemental Security Income Program (CASSIP).

Under these contracts, managed care plans (MCPs) are generally paid a fixed monthly amount for each enrollee and assume financial responsibility for providing covered services, a model known as risk-based managed care. More than 90% of the approximately 100,000 DC Medicaid beneficiaries under 21 receive services through managed care arrangements, while 10% remain in traditional fee-for-service Medicaid. However, the District’s managed care contracts do not place unlimited financial risk on the plans. The contracts include risk corridors, which function as a financial safety net. In simple terms, if a plan’s costs are significantly higher or lower than expected, DHCF and the plan share a portion of the gains or losses. This limits the amount of financial risk borne by the plan while still creating incentives to manage costs and provide care efficiently. MCPs remain responsible for maintaining provider networks, authorizing and paying for covered services, coordinating care, and administering grievances and appeals. Children under age 21 are entitled to the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services benefit, which requires coverage of all medically necessary services available under federal Medicaid law. Although managed care plans administer benefits on a day-to-day basis, DHCF remains legally responsible, as the District’s single state Medicaid agency, for ensuring compliance with federal Medicaid requirements and District law.

The current Managed Care Contract for DCHFP as of April 1, 2023.