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Council asks DHCF how MCO, network and prior-authorization changes affect access
Summary
Committee members pressed DHCF on network adequacy, prior-authorization turnaround, provider directories, dental access and whether managed-care shifts could change quality and emergency usage. DHCF said rates and standard metrics are available and pledged follow-up on urgent prior-authorizations and network verification processes.
Council members sought details on how the recent Alliance transition to fee-for-service and MCO changes affect access and quality. DHCF staff said provider directories are available via plan websites and provided capitation numbers: Medicaid managed-care capitation averaged $663.42/month (FY24) and $689.04 (FY25); Alliance capitation was $452.55 (FY24) and $500.49 (FY25). DHCF staff acknowledged differences in benefit packages across plan types and said they will provide additional data on wait times and urgent prior-authorization response-time trends.
Members raised concerns about network adequacy versus true access: a provider listed in a network may not practically offer the advertised service. DHCF said network adequacy standards include dental providers and that metrics are often numeric (providers per enrollees and time/distance), and that they will follow up with more detailed measures such as appointment wait times and any feedback loops between DC Health licensure actions and DHCF provider lists.
