Changes to Medicaid programs, services, and policies require a coordinated review to ensure alignment with federal and state regulations as well as Vermont Medicaid policies and practices. The Policy, Budget and Reimbursement (PBR) form provides a tool to support the systematic coordination of AHS departments and units and provides essential documentation regarding the change. The routine use of the PBR form creates a process that serves as an internal safeguard against any unintended consequences of proposed changes.
Policy, Budget & Reimbursement (PBR) forms require review and approval from the lead department business office, DVHA Reimbursement Unit, DVHA Program Integrity Unit, Medicaid Policy Unit, AHS Finance, and the DXC Contract Lead. The goal is to have approval from all before the change is effective and to issue public notice, if required.
The Medicaid Policy Unit manages the PBR process for changes to Medicaid. Having a PBR signed by all reviewers prior to effective date indicates the health and proper utilization of the PBR process. It strengthens the change to have had fiscal, policy, reimbursement, and program integrity review it and allows time for public notice (if required).
If we are not finalizing PBRs prior to their effective dates, we are at risk for the following:
- Poor budgeting: Adding new coverage for services or making other Medicaid changes without understanding the fiscal impact ahead of time inhibits DVHA’s and the Agency’s ability to manage the Medicaid budget.
- Loss of, or inability to, receive federal match: Changes to the Medicaid program can require federal approval, or at a minimum, federally required public notice. Without a system that ensures we check for these needs prior to implementation, the chance that we miss a federal approval or public notice requirement increases.
- Non-compliance with state and federal policies: We cannot ensure accuracy of Medicaid changes without a coordinated review by subject matter, financial, coding, reimbursement, and policy experts.
- Public engagement: Public notice and other public engagement has the most value when conducted prior implementation. By ensuring have internally engaged each other prior to a Medicaid change, we can increase our ability to also engage externally as well.
- Cost of mistakes: It can be costly to implement a Medicaid change (in MMIS or otherwise) that then needs to revised after implementation because certain considerations or connections were not made. By maximizing accuracy via the PBR Process, we increase the likelihood that it is done correctly the first time.
Quarter 3 and 4 have a decrease due to staffing resources and COVID-19 response.
Last updated: 10/15/2020