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Contracts and Regulations


The work of the Office of Quality and Population Health is guided the CMS 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, services, and reduce and streamline spending. Updates to DMAS programs are made as needed, and based on stakeholder interests, managed care organization (MCO) performance, achievement of goals, and or when significant changes are made to the DMAS structure. Finally, the DMAS contracts with Medicaid Managed Care Organizations to provide care and services to approximately 1,780,000 Virginia residents as of February 1, 2021.

 


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 to implement Medicaid benefits must utilize an External Quality Review Organization (EQRO) and must maintain a three year Quality Strategy document, among other requirements.

Additional information about the current CMS External Quality Review protocols can be found at: https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol4/pdf/CFR-2011-title42-vol4.pdf

 


Medallion 4.0 Program Contract

Medallion 4.0 is a Medicaid program designed to provide access to acute primary care services and prescription drugs, and behavioral health services for a 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.


More information about the Medallion 4.0 program can be found here.

 


Commonwealth Coordinated Care Plus Program Contract

The 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 Commonwealth Coordinated Care 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. The CCC Plus program provides services and care to approximately 267,700 lives as of January 15, 2021.


More information on the CCC Plus contract can be accessed here.

 


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 Commonwealth Coordinated Care Plus programs.

More information related to Virginia Medicaid Expansion can be found here.

 


Managed Care Organization NCQA Accreditation

The National Committee for Quality Assurance (NCQA) accredits Managed Care Organizations 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 Managed Care Organizations to maintain accreditation with NCQA.

For more information on Virginia MCO accreditation status, please visit https://reportcards.ncqa.org/#/health-plans/list?state=Virginia&insurance=Medicaid