In the District of Columbia:
  • There were a total of 201,777 beneficiaries enrolled in District Medicaid as of July 2011. Of these, 136,003 were enrolled into managed care organizations (MCOs). Children and adults who qualify for Medicaid because they belong to an income-eligible family, as well as poverty level pregnant women and CHIP enrollees, are required to enroll into an MCO. Children enrolled in these MCOs receive physical, behavioral, and oral health services from their MCO.
  • The District has developed a managed care product specifically for children with special health care needs who meet SSI eligibility requirements. Enrollees in the voluntary Health Services for Children with Special Needs (HSCSN) plan receive all EPSDT services from their well-child visit screenings to treatment services for chronic conditions and special needs. As of July 2011 there were 4,626 children enrolled in the plan.
  • All managed care organizations offer transportation services and the District also operates a capitated non-emergency transportation broker program that serves children who are on fee-for-service. As of July 2011, 51,617 beneficiaries received non-emergency transportation services from that contractor.
As of 2013, 96,445 individuals (aged 0 – 20) were eligible for HealthCheck, the District’s Medicaid benefit for children and adolescents (also know as the Early and Periodic Screening, Diagnostic, and Treatment benefit, or EPSDT). According to CMS data from 2013, HealthCheck achieved a screening ratio of 95% and a participation ratio of 63%. 48,006 children received dental services, with 43,919 receiving preventive dental services.
Last updated July 2014.
Medical Necessity The District’s EPSDT manual currently defines medical necessity for EPSDT services as “medical, surgical or other services required for the prevention, diagnosis, cure, or treatment of a health related illness, condition or disability including services necessary to prevent a detrimental change in either medical, behavioral, mental or dental health status.” 
Initiatives to Improve Access
District MCO contracts include child/EPSDT network adequacy requirements such as:
  • Include medical subspecialists and pediatric specialists and subspecialists;
  • Demonstrate a hospital network in the District capable of furnishing a full range of tertiary services to enrollees, including at least one hospital that specializes in pediatric care; and
  • Maintain a sufficient number of dental providers, including dentists, pediatric dentists, orthodontists and oral surgeons to meet the need of enrollees.
Reporting & Data Collection
The District requires its managed care organizations (MCOs) to compile and submit quarterly reports for HealthCheck utilization and outreach efforts. These reports are generated by MCOs using encounter data, and supplemented by other data sources.
Behavioral Health
The Department of Health Care Finance (DHCF) contracts with managed care organizations (MCOs) to provide most behavioral health care. Children with significant behavioral health needs may voluntarily enroll into a specialized MCO that serves only children with special health care needs and provides an integrated behavioral and physical health care benefit. The Health Services for Children with Special Needs (HSCSN) Plan is a managed care organization that focuses on the SSI/SSDI child population. Enrollment in the plan is voluntary; children who do not choose to enroll in the plan remain in fee-for-service Medicaid.
Integrating primary care with developmental, behavioral and oral health care Physicians are expected to screen for developmental and behavioral health issues within the standard well-child visit; the HealthCheck Manual and a collection of screening guidelines, tools, and recommendations provided for District physicians offer guidance on performing these and other screens as part of the well-child visit. In 2013, the DHCF partnered with Georgetown University and The National Alliance to Advance Adolescent Health to develop new training modules on transition issues for pediatricians on its HealthCheck website, including modules on mental health, autism spectrum disorders, and substance use and abuse.
Supporting to Providers and Families
Support to Providers:
The HealthCheck website portal provides education, resources, and online training on EPSDT to the provider community. The District has also adopted a version of the Bright Futures curriculum as the foundation for its EPSDT benefit. This guidance has been incorporated into HealthCheck information and provider materials.  The website is not only intended for providers, but also for government agencies serving children and families as well.
Support to Families:
Since its creation, the HealthCheck portal has been expanded to include educational and training resources for families and District government agencies.
All MCOs (including the Health Services for Children with Special Needs MCO) also provide outreach and information to families on the EPSDT benefit.   
Care Coordination
The Health Services for Children with Special Needs (HSCSN) managed care plan provides comprehensive services to children, most of whom have an SSI-level of disability. In addition to a broad set of benefits available, the plan is required to coordinate with other services and systems, including Individuals with Disabilities Act (IDEA) services, mental health and substance abuse services, child protective services, and other systems that can involve transitions for children with special health care needs, such as Title V.
Contract and plan provisions for HSCSN managed care plan require that the MCO provides all enrollees with a Care Coordinator, whose responsibilities include:
  • At minimum 4 face-to-face visits per year to understand the needs of enrollees and their families;
  • Development and coordination of a treatment plan for enrollees
  • Arranging transportation for the enrollee and the enrollee’s family; and
  • Assisting with planning and arranging services, transitions between care settings, and aging out of the HSCSN plan. 
Oral Health
In 2004, the District developed a dental periodicity schedule and a plan to improve provider participation, training, coordination of dental services and outreach. The schedule follows the American Academy of Pediatric Dentistry’s Periodicity Schedule oral health recommendations in consultation with the local dental community.
The Department of Health Care Finance works closely with the District’s Pediatric Oral Health Coalition to improve pediatric dental services for children in Medicaid. As of FY 2014, the District implemented payment for fluoride varnish services by primary care providers  in an effort to increase the number of young children receiving oral health services. The District’s HealthCheck provider training portal began offering a training on fluoride varnish as well.