People enrolled in DC Medicaid generally receive services in one of two ways:
Fee-for-Service: In Fee-for-Service (FFS) Medicaid, you can go directly to any provider who accepts Medicaid. You do not need a referral from your primary care doctor. You will have to go to providers who accept DC Medicaid.
For more information, please review the Fee-for-Service Handbook.
Generally, people are in Fee-for-Service Medicaid if they are:
- Receiving Supplemental Security Income (SSI)
- Receiving Optional State Supplement Payment
- On Medicare and eligible for full Medicaid services (QMB Plus) - Qualified Medicaid Beneficiary (QMB)
- 65 years old or older
- In foster care with the Child and Family Services Agency (CFSA) - Children in Care
- Persons with disabilities
- Person receiving Long Tem Care Services
- Receiving coverage for an emergency medical condition - Emergency Medicaid
Note: For individuals enrolled in FFS Medicaid, there may be a $1.00 copay for prescriptions and $2.00 copay for eyeglasses.
Managed care: In Medicaid Managed Care, you must choose or be automatically assigned to a health plan through which you will receive services. You will then choose or be assigned a primary care doctor and may need referrals to see specialists. Managed care can also provide some extra help that isn’t available in Fee-for-Service Medicaid, such as help in coordinating your care or in getting services when you have special health problems. If you have questions about how to get health services, you can call the health plan directly. Most children, non-disabled parents/ caretaker relatives, pregnant women, and adults without dependent children (childless adults) are enrolled in Managed Care. There is no cost sharing for beneficiaries enrolled in Medicaid Managed Care. The managed care plans offered to Medicaid beneficiaries are:
a. AmeriHealth DC
b. MedStar Family Choice DC
c. Trusted Health Plan, Inc.
d. Health Services for Children with Special Needs (HSCSN) for
children and young adults with special health care needs
If you are not sure if you are in Fee-for-Service Medicaid or Managed Care, simply call the Office of the Health Care Ombudsman and Bill of Rights at 1-877-685-6391 and they will let you know.
Enrollment Broker – Managed Care Option
The District of Columbia’s Enrollment Broker provides each eligible managed care beneficiary information about the health plans provided under the Medicaid program and assist them in selecting a health plan that will meet their family and individual health needs. The Enrollment Broker will review and update contact information, assist in comparing health plans or with finding a doctor, and advise on meetings in your area to learn more about the health plans.
What you need to get started:
Once you receive your Welcome Packet from DC Healthy Families or DC HealthCare Alliance, you can enroll in a health plan.
Choosing a health plan and a doctor online is easy. It will only take about 10 minutes.
To get started, you should have the following:
- Member ID and PIN;
- You can find both of these on your letter from the DC Healthy Families or DC HealthCare Alliance program. If you don’t have them, call the Customer Service Center at (800) 620-7802.
- Your birth date, or;
- Your Medicaid ID number
You can enroll in managed care plan via online at DC Healthy Family Member Sign-In or via telephone on (202) 639-4030 or toll free 1-800-620-7802.
To enroll online, sign into the member account and follow the following four (4) steps:
Step 1: Click on “Select” next to the name of the person you want to enroll.
Step 2: Choose a health plan
Step 3: Choose a doctor
Step 4: Complete the health assessment form.
DC Healthy Families and DC HealthCare Alliance
6856 Eastern Avenue NW
Washington, DC 20012
Monday, Tuesday, Thursday, and Friday: 8 am – 7 pm
Wednesday: 8 am – 9 pm
Third Saturday of each month: 9 am – 1 pm
TTY/TDD Line: (866) 879-0065