Virginia Medicaid
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Overview


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.


Medallion 4.0 Program Contract

Medallion 4.0 is a Medicaid program designed to provide access to acute primary care services, prescription drugs, and behavioral health services for the majority of Virginia’s Medicaid population. Populations covered by the Medallion 4.0 program include pregnant women, children, low-income parents and caretaker relatives living with children, FAMIS members, and current and former foster care and adoption assistance children. Some of the Medallion 4.0 priorities include engaging health systems and stakeholders, as well as providing holistic and integrated care to covered members.

For more information, please refer to the Additional Resources page.


Commonwealth Coordinated Care Plus (CCC Plus) Program Contract

DMAS provides integrated services and care covering community mental health and early intervention services, consumer-directed personal care, and Third Party Liability members via the CCC Plus program, which began in 2017. The CCC Plus program provides services and care to certain qualifying individuals, including those eligible for Medicare and Medicaid, and those needing long-term services and support (LTSS). Individuals receiving services through CCC Plus do so in a nursing care facility or through one of DMAS Home and Community Based Services 1915(c) Waivers.

For more information, please refer to the Additional Resources page.


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 or CCC Plus programs.

For more information, please refer to the Additional Resources page.