1. MEDICAID ELIGIBILITY QUALITY CONTROL (MEQC) PROGRAM
Wanda Williams
Quality Control Medicaid Consultant
Virginia Department of Social Services
February 15, 2019

2. MEQC Background Mandated by Centers for Medicare & Medicaid Services
Various versions date back to 1978
Significant changes due to the Affordable Care Act (ACA) due to MAGI
Five pilots to test system functions and eligibility determination within new eligibility system (VaCMS)

3. MEQC Background Final regulations restructure issued by CMS July 2017
CMS requires ongoing series of MEQC pilots
MEQC intention is to focus on potentially vulnerable or error prone errors
Devote part of MEQC pilots to negative actions

4. Overview of MEQC Requirements
States and District of Columbia divided in three cycles
Virginia is a cycle 1 state
One of 17 states to start new MEQC regulations
Virginia required to submit proposal to CMS and approval prior to start of review process
States have flexibility in designing first review

5. Overview of MEQC Requirements
MEQC review period January 1, 2019 – December 31, 2019
States required to review actions occurring in each month
States required to submit results to CMS
Corrective Action Plan and case narrative for identified error(s)
Active cases determined having an eligibility error
CMS requires evaluation of payment error

6. Overview of MEQC Requirements
Required to review total of 800 cases, both active and negative actions
Active Cases: 400 total
200 Medicaid & 200 Combination Medicaid/CHIP(FAMIS)
Negative Cases: 400 total
200 Medicaid & 200 CHIP(FAMIS)

7. Overview of MEQC Requirements
Random sample pulled from eligibility processing system
Each month random sample from VaCMS
Review of last action affecting eligibility for individual/case within the sample month
Approval, denials, terminations and/or changes
Applications, renewals, spenddowns, etc.

8. What Should Agency Expect
Broadcast
Quality Control (QC) will post a Broadcast prior to start of MEQC review explaining final process
Case Request
Via VaCMS as currently occurring for QC SNAP
Anticipates alert to worker/agency contact in VaCMS
Agency provide case within 5 business days (send if case in VaCMS)
Process will occur monthly until the end of yearly review

9. What Should Agency Expect
Comprehensive review of randomly sample individual
QC will complete full review of all eligibility elements to include:
Non-financial, Financial, Resources, as applicable, Income, Notices
Documentation/evaluation within VaCMS or depending on agency, paper evaluation/file
Review of SPIDer and MMIS
Separate household composition and income evaluation

10. Questions