Medical Management Program Overview

Our Medical Management Program is highly integrated - addressing the medical, behavioral, pharmacy, educational, and social service needs of our enrollees.

We operate across all the organizational units within CareFirst CHPDC to optimize the alignment of resources throughout our system of care. Our goal is to empower our enrollees in decision making, using a person-centered model that addresses both their complex medical needs but includes social determinants, i.e., homelessness, food insecurity, abuse and other social factors. We have created a program that is high-touch, targeted and cost-effective to assure that our enrollees receive high quality, accessible and equitable health care services.

Compliance

Our program is compliant with the District's HMO Act, the District requirements in C.5.22 and related sections, 42 C.F.R. * 438.210(b), and NCQA 'Standards for Accreditation of a Managed Care Organization.' The purpose of our Medical Management Program is to ensure the appropriate allocation of resources by providing quality care and service in the most cost- effective manner to CareFirst CHPDC enrollees. Our program is designed to ensure that enrollees receive appropriate, timely, evidence-based care. We facilitate our enrollees' receipt of all appropriate health care services in a fair, impartial and consistent manner.