Virginia MedicaidOverview
The work of the Office of Quality and Population Health is guided by external quality review (EQR) mandated protocols and federal agencies such as the Centers for Medicare and Medicaid Services (CMS). Additionally, DMAS programs are guided by interests and directives from the Virginia General Assembly, the state legislative body, and other state oversight authorities to improve care and services, and reduce and streamline spending. Updates to DMAS programs are made as needed, and are based on stakeholder interests, managed care organization (MCO) performance, achievement of goals, and/or when significant changes are made to the DMAS structure. DMAS contracts with MCOs to provide care and services.
Cardinal Care
As of January 1, 2023, Virginia Medicaid members are part of Cardinal Care - a single system of care for all of our 2 million members. Cardinal Care connects members to the care that they need when they need it and reduces transitions between programs as their health care needs evolve. All managed care and fee-for-service Medicaid members are part of the Cardinal Care program.
Cardinal Care Managed Care
On October 1, 2023, Virginia Medicaid consolidated the two managed care programs of Medallion 4.0 (Acute) and Commonwealth Coordinated Care Plus (MLTSS) into Cardinal Care Managed Care (CCMC).
Managed Care Organization NCQA Accreditation
The National Committee for Quality Assurance (NCQA) accredits managed care organizations (MCOs) through a process of evaluating against a set number of measures of performance, quality, and outcomes. The NCQA certifies compliance with the criteria, assures quality and integrity, and offers purchasers and members a standard of comparison in evaluating health care organizations. Virginia requires contracted MCOs to maintain accreditation with NCQA.
For more information, please refer to the Additional Resources page.
Code of Federal Regulations
The work of DMAS’s Office of Quality and Population Health is guided by mandated Centers for Medicare and Medicaid Services (CMS) external quality review (EQR) protocols. States that contract with managed care organizations (MCOs) to implement Medicaid benefits must utilize an External Quality Review Organization (EQRO) and must maintain a three-year Quality Strategy document, among other requirements.
For more information, please refer to the Additional Resources page.
Medicaid Expansion
Beginning January 1, 2019, more adults aged 19-64 in Virginia with incomes up to 138% of the Federal Poverty Guidelines were eligible to receive high-quality Medicaid services and care through Medicaid Expansion. Individuals qualifying for Medicaid Expansion may receive services and care under the existing Medicaid Medallion 4.0 (Acute) or CCC Plus (MLTSS) programs.
For more information, please refer to the Additional Resources page.