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Medicaid Reports

Managed Care Organization External Quality Review Annual Technical Reports (page link)
The Code of Federal Regulations (42 CFR §438.350) requires states contracting with Managed Care Organizations (MCOs) to conduct annual, independent reviews of the Medicaid managed care program. To meet these requirements, DHCF contracts with Qlarant, an independent External Quality Review Organization (EQRO), which evaluates the quality, accessibility, and timeliness of healthcare services furnished by the MCOs through a variety of mandatory and optional activities in accordance with the Centers for Medicare and Medicaid Services (CMS)-developed EQRO Protocols.

The Annual Technical Report (ATR) describes EQR methodologies for completing activities; provides MCO performance measure results; summarizes compliance results; and includes an overview of the quality, access, and timeliness of healthcare services provided to the District’s Medicaid managed care beneficiaries. Recommendations for improvement are made, and if acted upon, may positively impact beneficiary outcomes. For ATRs published before 2019, please visit this page.

The Code of Federal Regulations (42 CFR §438.350) requires states contracting with Managed Care Organizations (MCOs) to conduct annual, independent reviews of the Medicaid managed care program. To meet these requirements, DHCF contracts with Qlarant, an independent External Quality Review Organization (EQRO), which evaluates the quality, accessibility, and timeliness of healthcare services furnished by the MCOs through a variety of mandatory and optional activities in accordance with the Centers for Medicare and Medicaid Services (CMS)-developed EQRO Protocols. Qlarant completed the following External Quality Review (EQR) activities in the current measurement year:

  • Compliance Review, known as the Operational Systems Review (OSR)
  • Performance Improvement Project (PIP) Review
  • Performance Measure Validation (PMV)
  • Network Adequacy Validation (NAV)
  • Encounter Data Validation (EDV)

In addition to completing federally mandated EQR activities, 42 CFR §438.364(a) requires the EQRO to produce a detailed technical report that describes the manner in which data from all activities conducted were aggregated and analyzed, and conclusions drawn as to the quality, accessibility, and timeliness of the care furnished by the MCOs. This document is Qlarant’s report to DHCF on the assessment of MCO performance as evaluated during the measurement year (MY), January 1 through December 31. Notations will be added in the respective reports to reflect any EQR activities completed outside of the normal 12 month review cycle.

The Managed Care Program encompasses DC Healthy Families Program, Child and Adolescent Supplemental Security Income Program and District Dual Choice Program. The associated health plans participating in the respective programs are noted in the attached table.

The Annual Technical Report (ATR) describes EQR methodologies for completing activities; provides MCO performance measure results; summarizes compliance results; and includes an overview of the quality, access, and timeliness of healthcare services provided to the District’s Medicaid managed care beneficiaries. Recommendations for improvement are made, and if acted upon, may positively impact beneficiary outcomes.

MCO External Quality Review Annual Technical Reports

Medicaid Managed Care Performance Reports

The Medicaid Managed Care Performance Reports illustrate the financial condition of the District’s MCOs over the duration of a calendar year. Administrative functions of the MCOs – such as timely claims processing, enrollee encounter systems, and appropriate claims denial procedures – are also detailed in the report.

CMS Form 416 (sending these files by separate email)

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health and specialty services.

Early: Assessing and identifying problems early

Periodic: Checking children's health at periodic and inter-periodic, age-appropriate intervals

Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems

Diagnostic: Performing diagnostic tests to follow up when a risk is identified, and

Treatment: Control, correct or reduce health problems found.

The CMS-416 is used by CMS to collect basic information on State Medicaid programs to assess the effectiveness of EPSDT services. The District requires its participating Medicaid managed care plans to complete a MCP 416 for their enrollees.

Annually, states must provide CMS with the following information: Enrollment figures, Number of children provided child health screening service and well-child visits; Number of children referred for corrective treatment; and  Number of children receiving dental services  and lead screens;  National 416 data prior to 2019 can be accessed here.

CMS 416 FY24

CMS 416 FY23

CMS 416 FY22

CMS 416 FY21

CMS 416 FY20

CMS 416 FY19

Medicaid and Alliance Enrollment Reports

Medicaid and Alliance Enrollment Reports capture beneficiary enrollment data from a window in time across the District’s Managed Care Organizations, fee-for-service program and D-SNP.

Enrollment Reports 2025

Enrollment Reports 2024

Enrollment Reports 2023

Enrollment Reports 2022

Enrollment Reports 2021

Enrollment Reports 2020

Enrollment Reports 2019

For enrollment information prior to 2019, please visit this page

DC Medicaid MCO Report Cards

DHCF annually publishes an MPC report card that compares how the MCPs compare to one another in key areas of performance, like access to care, child services, and care for adults with chronic illnesses. Enrollees are encouraged to use the report cards as tools in selecting an MCO for their care.

  • DC Medicaid MCO 2024 Report Card
  • DC Medicaid MCO 2023 Report Card – Unreported due to Public Health Emergency
  • DC Medicaid MCO 2022 Report Card – Unreported due to Public Health Emergency
  • DC Medicaid MCO 2021 Report Card – Unreported due to Public Health Emergency
  • DC Medicaid MCO 2020 Report Card – Unreported due to Public Health Emergency
  • DC Medicaid MCO 2019 Report Card

 Miscellaneous Data and Reports

These items are published on an as-needed basis, generally in support of specific or time-limited projects at DHCF. They reflect point-in-time data on various health and District Medicaid-related issues. This list also includes a current copy of the District’s Medicaid Managed Care Quality Strategy, 2024-2027.

 

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