Virginia Medicaid

Quality Activities

The Office of Quality and Population Health is responsible for overseeing a broad range of quality improvement activities at DMAS. These activities include the Quality Strategy, annual Performance Improvement Projects (PIP) and Performance Measure Validation processes (PMV), and systematic Managed Care Organization Compliance Reviews. Other activities include the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicaid member satisfaction surveys for child and adult populations, as well as Foster Care and Birth Outcomes Focused Study reports.

Quality improvement activities developed through the Office of Quality and Population Health will be assessed and monitored through the soon to be launched Quality Improvement Committee (QIC). The purpose of the QIC will be to drive quality improvement by regularly monitoring progress, and recommending improvements to meet pre-determined performance metric and PIP quality targets, and will be comprised of disparate quality and clinical DMAS stakeholders.


Performance Improvement Projects (PIPs)

The Department of Medical Assistance Services requires contracted Managed Care Organizations to conduct annual Performance Improvement Projects. Through the annual PIP projects, MCOs strengthen the processes, quality and outcomes of their selected health projects, by implementing rapid quality improvement cycles. DMAS values the findings and information produced by PIPs toward improving 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 MCO’s 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


Performance Measure Validation (PMV)

According to federal mandates, a 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 MCO to its members. Performance measure validation (PMV) assesses the accuracy 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.

Commonwealth Coordinated Care Plus (CCC Plus) measures can be found in the current CCC Plus contract: CCC Plus Information

Medallion 4.0 measures can be found in the current Medallion 4.0 contract: Medallion 4.0 Information


Quality Strategy

In alignment with the CMS, DMAS develops a Quality Strategy to continually monitor, assess, and improve the timeliness and delivery of quality healthcare 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’ Quality Strategy provides the framework to accomplish DMAS’ overarching goal of designing and implementing a coordinated and comprehensive system to proactively drive quality throughout the Virginia Medicaid and CHIP system.

The DMAS recently completed an update to its three year (2020-2022) Quality Strategy document, which is organized around four broad based AIMS: 1) Enhance Member Care Experiences, 2) Promoting Effective Patient Care, 3) Achieving Smarter Spending, and 4) Improving Population Health. The DMAS Quality Strategy AIMS are in alignment with the National Quality Strategy and CMS’s Triple AIMS.

The 2020-2022 DMAS Quality Strategy can be found here: Medallion 4.0 Information


Annual Technical Report

CMS mandates require that the Annual Technical Report assess Managed Care Organization (MCO) strengths and weaknesses related to quality outcomes and timeliness of, and access to, items and services in its contract. The ATR also recommends improvements to the quality of health care services, provides for comparisons between MCOs, and an assessment of how well MCOs addressed prior year recommendations for improvement.

DMAS produces annual technical reports for the CCC Plus program, as well as the Medallion 4.0 program member populations. The Annual Technical Reports also function as one of the ways in which DMAS evaluates the three year Quality Strategy document. More information about the ATR reports can be accessed here:


Compliance Review

CMS requires each state with managed care programs to utilize an External Quality Review Organization (EQRO) to conduct a Compliance Review 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.

Compliance reviews assess

  • 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