Implementation of Healthy DC Plan DC Health

Basic Health Plan (BHP): In DC called Healthy DC Plan Background: Medicaid eligibility is changing:
1) childless adults with incomes above 138% Federal Poverty Level (FPL), e.g., $21,597 for a household of 1 person; and
2) caregivers with incomes above 138% FPL.
Residents will have a new option for coverage.
ACA Section 1331 gives states an option to establish a BHP. A BHP is a health insurance program for moderate-income residents who are not Medicaid eligible and would otherwise be eligible to purchase coverage through an ACA Health Insurance Marketplace.
FEDERAL: We received federal approval (September 2025) to establish a BHP.
FUNDING: Federal funding pays for coverage. HBX’s implementation, operational, and administrative costs are not funded federally. HBX is a private-public partnership funded through an assessment.
HBX is leveraging its IT infrastructure for the BHP and working with DHCF and DISB to establish the BHP quickly. DOH is also providing support.<br>

FEDERAL ELIGIBILITY RULES A resident must be under age 65 and not offered affordable employer-sponsored coverage or have other coverage. 
US Citizens: DC residents with incomes over 138% Federal Poverty Level (over 133% FPL plus 5% income disregard) to 200% FPL are eligible.
Undocumented residents: Under federal law, undocumented residents are not eligible.<br>

Income Eligibility for Healthy DC Plan<br>

Federal funding for coverage for“lawfully present” residents “Lawfully present” individuals are non-citizens who have permission to live and/or work in the U.S.
H.R. 1 (a.k.a. One Big Beautiful Bill Act or Reconciliation Law) changed availability of federal funding to pay for coverage under Affordable Care Act programs. Individuals who are “lawfully present” will no longer qualify for APTC and federally funded BHP coverage (see exception below for certain categories).
Written federal guidance has not been issued. Informal guidance indicates the federal government will provide time for states to implement locally funded coverage programs if federally required.
Availability of federal funding:
For calendar year 2026 and beyond:
Below 100% FPL: no federal funding.
100% - 200% FPL: federal funding.
For calendar year 2027 and beyond:
100% to 200% FPL: Federal funding for Green Card holders, Cuban/Haitian refugees, or citizens of the Freely Associated (COFA) nations of the Marshall Islands, Micronesia and Palau living in the U.S.
0% to 200% FPL: all other “lawfully present” no federal funding.<br>

Healthy DC Plan: Affordable coverage and affordable health care for residents: Designed Healthy DC Plan to have no monthly premiums and no out-of-pocket cost for covered care from participating providers.
Hospitals participating in the Medicaid program also participate in Healthy DC Plan (adults)
Community Health Centers participating in the Medicaid program also are covered by Healthy DC Plan
Covered benefits: primary care, specialists, urgent care, emergency services, inpatient care, lab and imaging, Rx, mental health, and preventive care. All ACA benefits are covered.

Examples of services covered under Medicaid that are not covered by Healthy DC Plan: adult dental*, adult vision*, and non-emergency transportation to medical services (including bus, subway, and taxi vouchers, wheelchair vans, and ambulance).  Behavioral health is covered differently than under Medicaid.

Note: Pregnant residents and children remain covered under Medicaid. Reminder that Medicaid eligibility is changing for: 1) childless adults with incomes above 138% FPL; and 2) caregivers with incomes above 138% FPL.
* Will be covered if Enhanced Premium Tax Credit is extended<br>

Healthy DC Plan Required Providers Hospitals*
Children's National Medical Center
Howard University Hospital
Sibley Memorial Hospital
GW George Washington University Hospital
GW Cedar Hill Medical Center
Medstar Georgetown University Hospital
Medstar Washington Hospital Center
Medstar National Rehabilitation Hospital Health Centers
Bread for the City
Community of Hope, Inc
Elaine Ellis Center of Health
Family & Medical Counseling Services, Inc.
La Clinica Del Pueblo, Inc.
Mary's Center for Maternal and Child Care, Inc.
SOME (So Others Might Eat)
Unity Health Care, Inc
Whitman-Walker Clinic, Inc *Waiting for confirmation that amendments to participate were signed.<br>

Healthy DC Plan Open Enrollment: November 1, 2025 to January 31, 2026
Losing Medicaid due to Medicaid eligibility changes: automatic enrollment

AmeriHealth Caritas Medicaid MCO AmeriHealth Caritas District of Columbia Healthy DC Plan (coverage effective January 1, 2026)

MedStar Family Choice Medicaid MCO MedStar Family Choice Healthy DC Plan
(coverage effective January 1, 2026)

WellPoint DC Medicaid MCO   CareFirst BlueCross BlueShield Healthy DC Plan (coverage effective January 1, 2026)<br>

Healthy DC Plan Automatic Enrollment (October Data File) *As of November 14, there are 15 residents that switched plans.<br>

New Customers: As of November 25th, there are 149 new customers who qualified and enrolled in Healthy DC Plan. Coverage begins January 1, 2026.
Plan selection by carrier: AmeriHealth Caritas District of Columbia 47, CareFirst BlueCross BlueShield 76, and MedStar Family Choice 26.<br>

Healthy DC Plan Outreach and Customer Communications Completed more than 50 outreach presentations
Coordinated with DHCF on a notice from DHCF introducing Healthy DC Plan to Medicaid enrollees who likely no longer qualify for Medicaid (September)
For the transitioning population:
Sent formal notices (two notices about their new eligibility for the Healthy DC Plan and their enrollment) – emailed, uploaded into their account, and sent U.S. Mail notice
Sent informal email communications (multiple rounds) – English and Spanish
Open rates: average 60%
Next round of communication is texting.<br>

Coordination and implementation with DHCF, DISB, DC Health, DHS, and DC Ombuds Office Examples of coordination (in addition to notices):

Call center talking points and scripts
Sharing of draft outreach material for review and input
Joint calls with federal regulators
DCAS data batch files – development, testing, retesting (since June 2025)
Pre-approved “forms” (Evidence of Coverage, Schedule of Benefits, Summary of Coverage) and transitional relief for network adequacy
Letter and newsletters to providers encouraging participation in Healthy DC Plan networks<br>

Additional automatic enrollment of residents later in December for coverage starting January 1, 2026. This enrollment batch file will be transferred from DHCF to HBX later in December.
To-date, HBX identified approximately 1,100 applications that need to be handled manually due to data issues. HBX staff are handling these individual cases. HBX staff have completed a third of these and enrolled eligible residents into a Healthy DC Plan.
In addition, HBX emailed and texted these residents encouraging them to complete a new application at www.healthydcplan.com. Completing a new application is the quickest way to get enrolled into either Healthy DC Plan or DC Health Link coverage. Call (833) 432-7526 / TTY: 711 for help enrolling.
Approximately 1,600 residents (with incomes above 200% FPL) don’t qualify for Healthy DC Plan. HBX staff are using outreach strategy and lessons from Medicaid “unwind” – emails, texts, and phone calls and DC Health Link Assisters. Healthy DC Plan Additional Enrollment<br>

Healthy DC Plan Carriers – Establishing and Operationalizing a New Book of Business Healthy DC Plan carriers quickly completed the legal, IT technical, and operational steps to be ready for open enrollment on November 1 for coverage to begin January 1, 2026.
Carriers successfully updated their systems and completed system testing for accepting Healthy DC Plan enrollments
Carriers created websites for Healthy DC Plan that include provider directories, prescription drug coverage information, and Healthy DC Plan coverage information
AmeriHealth Caritas: https://www.amerihealthcaritasdc.com/hdcp/enrollees.html
CareFirst: https://www.carefirst.com/healthydc/
MedStar Family Choice: https://www.medstarfamilychoicehealthydc.com/
Commitment from all three carriers:
By January 1 carriers will issue/issued electronic and/or paper Insurance ID Cards for the new Healthy DC Plan.
Carriers issuing/issued and sent a welcome letter, texts, and/or packets to enrollees.
Carriers have set up or will set up portals for network providers to check electronically patient’s coverage status.<br>

On behalf of the HBX Executive Board and HBX Staff: Thank you to Mayor Bowser for having the confidence in HBX to implement this critical health coverage program for DC residents.
Thank you to Deputy Mayor Turnage for your confidence and daily support, and especially, issue resolution.
Thank you to Chair Henderson and DC Councilmembers for your support of Healthy DC Plan.
Thank you to our Healthy DC Plan Advisory Council for their guidance, reviews, and commitment to help us establish the best possible coverage option for DC residents. Examples of activities:
Met weekly (initially); now bi-weekly
Reviewed and provided feedback on notices, email communications, and other consumer information
Informed community engagement and outreach strategy
Advised on operational approach, e.g., pregnancy transitions and staffing
Thank you to DCHA and DCPCA for their significant assistance on hospital and community health center participation in provider networks for Healthy DC Plan.
Thank you to our incredible sister agencies (especially DHCF and DISB) for their work to help get Healthy DC Plan implemented.
And thank you to our amazing HBX team for your unwavering commitment and 24-7 work to get Healthy DC Plan designed and operationalized by November 1. And now, DC residents have continuity of coverage and continuity of care.<br>

www.HealthyDCPlan.com<br>