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Virginia's Medicaid Program
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Overview


The Quality Improvement Unit works to evaluate, monitor, and provide recommendations to improve the quality of health care services for Virginia Medicaid members. The 2020-2022 DMAS Quality Strategy serves as a framework document for quality improvement (QI), and puts forward four broad Aims, consistent with the National Quality Strategy and CMS Triple Aim, which establish a complete and thorough QI system. The 2020-2022 Quality Strategy Aims include:

  • Improving Member Care Experiences
  • Helping Increase Effective Patient Care
  • Gaining Smarter Spending, and
  • Improving Population Health

The DMAS Quality Strategy lays out these structures of QI activities and proposed methods for measuring progress and outcomes, and improves the member’s experience of care. DMAS Quality Improvement activities drive improvements for members in the Commonwealth Coordinated Care Plus (CCC Plus) and Medallion 4.0 managed care programs, as well as for members in the Fee-for-Service program.

In alignment with CMS, DMAS develops a Quality Strategy to constantly monitor, test, and improve the timeliness and delivery of quality health care to all Medicaid and Children’s Health Insurance Program (CHIP) members served by the Virginia Medicaid managed care and Fee-for-Service (FFS) programs. DMAS’s Quality Strategy provides the structure to complete DMAS’s goal of designing and implementing a coordinated, complete and thorough system to proactively drive quality throughout the Virginia Medicaid and CHIP system.

DMAS is in the process of updating its three-year Quality Strategy document for 2023-2025, which will be available for public comment in the Fall/Winter of 2022.

Reference: Office of Quality and Population Health Studies and Reporting page

The Annual Technical Report evaluates the managed care organizations’ (MCOs) strengths and weaknesses related to quality outcomes, timeliness, access to care, items, and services in its contract. The ATR also recommends improvements to the quality of health care services, provides comparisons between MCOs, and provides an assessment of how well MCOs addressed prior-year recommendations for improvement. The report serves as an annual review of the MCOs' progress toward achieving the goals and objectives of the Quality Strategy.

Reference: Office of Quality and Population Health Studies and Reporting page

In accordance with federal mandates, DMAS’s qualified external quality review organization (EQRO) performs an annual external quality review (EQR) which includes validation of specific performance measures to assess the quality of care and services delivered by the managed care organization (MCO) to its members. Performance measure validation (PMV) assesses the validity of performance measures reported by MCOs and helps to determine the extent to which the selected performance measures follow state specifications and reporting requirements. The annual PMV process culminates in a report covering each program area, including recommendations for driving improvements.

CMS requires each state with managed care programs to use their contracted External Quality Review Organization (EQRO) to conduct a compliance review of each of the Medicaid managed care organizations that it contracts with (known as Operational and Systems Review (OSR) in Virginia) every three years. Compliance Reviews are conducted for both the Medallion 4.0 and CCC Plus programs at DMAS.

These compliance reviews assess, at a minimum, the following topic areas:

  • Enrollment and Disenrollment
  • Enrollee Rights and Protections
  • Emergency and Post-Stabilization Services
  • Availability of services
  • Assurances of adequate capacity and services
  • Coordination and continuity of care
  • Coverage and authorization of services
  • Provider selection
  • Confidentiality
  • Grievance and appeal systems
  • Sub-contractual relationships and delegation
  • Practice guidelines
  • Health information systems
  • Quality assessment and performance improvement

DMAS requires the contracted managed care organizations (MCOs) to conduct regular Performance Improvement Projects (PIPs) in alignment with CMS regulations and protocols. DMAS uses the findings and information produced by PIPs to improve the quality and services Virginia Medicaid members receive. Topics selected must focus on achieving significant improvement in clinical and non-clinical areas of care through measurement and intervention.

In 2020, Virginia MCOs implemented PIPs related to the following topics:

CCC Plus PIP Topics

Medallion 4.0 PIP Topics

Follow-Up After Hospital Discharge

Timeliness of Prenatal Care

Ambulatory Care - Emergency Department Visits

Tobacco Use Cessation in Pregnant Women

DMAS established the Performance Withhold Program (PWP) for the Medallion 4.0 and CCC Plus MCOs to reinforce Value Based Payment (VBP) principles by connecting financial incentives to the quality of care received by Virginia Medicaid managed care members. Annually, DMAS retains a quality withhold from each MCO and by successfully meeting or exceeding the performance standards and expectations developed by DMAS, MCOs are eligible to earn back all or a portion of their quality withhold. DMAS established the performance thresholds to foster MCOs’ high performance and continuous improvement.

Reference: Value-Based Purchasing and Performance Withhold (PWP) page