DVHA Performance Accountability Scorecard

Why Is This Important?

What We Do

The Health Access Eligibility and Enrollment Unit (HAEEU) consists of five teams that each fulfill a specific function in helping Vermonters down the path from learning about health programs to applying, enrolling, and understanding their rights and responsibilities.

Eligibility & Enrollment Team works directly with members and is responsible for managing documents sent in by applicants, determining eligibility, assisting in enrollment, providing customer support through the call center, and resolving escalated cases.

Maintenance & Operations Team ensures that the Unit’s systems are well maintained and tested. They monitor the integrity, accuracy, and timeliness of transactions and are accountable for the overall success and delivery of Open Enrollment. They document policies and procedures, streamline business processes, and provide member facing staff with the training and knowledge needed to be operationally ready. During Open Enrollment they manage outreach and education efforts, helping Vermonters understand health insurance terms, compare options, and get the most out of their health coverage by communicating with community partners, including hospitals, clinics, agricultural organizations, libraries, pharmacies, and other stakeholders.

Data Team reconciles file transactions between Vermont Health Connect’s case management system, billing system, health insurance issuers, and the State’s legacy ACCESS system. They maintain the Unit’s data and provide operational reports and dashboards.

Assistant Operations Team serves as the policy liaison for HAEEU. They provide guidance, direction, and interpretation of state health care eligibility and enrollment rules. They also direct the technical and operational implementation of those rules. Additionally, this team manages member notices, and application and form development.

Assister Team supports and manages the In Person Assister program which works to ensure that Vermonters have in person (or remote) assistance available to them to understand their benefits and responsibilities and help potential applicants understand health care programs and the application process. The program includes Assisters from 43 organizations throughout Vermont offering coverage of all 14 Vermont counties. Vermont In Person Assisters support thousands of households annually and each Assister organization has between 1 and 17 Assisters on staff. The Assister team also supports customers questions and concerns via the customer service email inbox and social media.

Who We Serve

HAEEU serves the more than 200,000 Vermonters who receive health benefits through Medicaid programs and/or the State's health insurance marketplace. Medicaid program members include those Vermonters who receive health coverage through Medicaid for Children and Adults (MCA), Dr. Dynasaur, Medicaid for the Aged, Blind and Disabled, VPharm, and the Medicare Savings Programs. The health insurance marketplace enrolls members in qualified health plans (QHP) and administers federal and state-based financial assistance, while also providing resources to Vermonters who buy unsubsidized health coverage on their own or through a small business.

How We Impact

Quality health coverage is a key ingredient of health and well-being. Vermont has one of the lowest uninsured rates in the nation and its health care system is consistently ranked one of the best, with one of the narrowest gaps in access between rich and poor residents. For many Vermonters, HAEEU is the doorway into this healthcare system.

Action Plan

The top priorities/initiatives for HAEEU in SFY21 are:

• Successfully unwind the programmatic changes and process the backlog of work associated with the Public Health Emergency
• Customer Facing Improvements (Premium Processing IE & E project and Customer Portal).  Most of the project work related to the Premium processing project will need to be completed in 2021 to meet the estimated go-live date of late summer 2022.
• Audit Compliance *
• MABD Compliance **
• Improve reporting load times.  Today data utilized in reports can be 4 – 5 days old.  The goal is to increase the load time resulting in more “real-time” data presented in reports. 
• Outreach/communication Strategy.  Review our current strategy and identify opportunities to develop/improve customer facing communication.

What We Do

Vermont's Long-Term Care (LTC) Medicaid Program is called Choices for Care. Vermont’s LTC staff assist eligible Vermonters with accessing services in their chosen setting. This could be in the client’s home, an approved residential care home, assisted living facility or an approved nursing home.

There are two parts to determining Vermont LTC eligibility:

1. Clinical eligibility which is performed by the Department of Disabilities, Aging and Independent Living (DAIL)
2. Financial eligibility performed by the Long Term Care Unit in the Department for Vermont Health Access (DVHA)

The LTC application is usually submitted to the DVHA Long Term Care Unit and a copy is forwarded to DAIL for the clinical assessment. In addition, upon receipt of the LTC application, DVHA workers begin the financial eligibility determination process. Many applicants have complex financial histories and have hired elder law attorneys to assist them with planning and sheltering their assets. The more complicated applications take a significant amount of staff time to analyze before making a final financial eligibility determination.

Who We Serve

LTC Medicaid serves eligible Vermonters who are over 65, blind or disabled and who are in need of access to long term supports and services at home, in an enhanced residential treatment center (ERC) or nursing facility.  When Vermont Medicaid covers services for these Vermonters, the families of those Vermonters experience relief from concerns about their family member’s long-term care needs.

How We Impact

Many Vermonters cannot afford to self-pay for their long-term care (LTC) supports and services and depend upon Vermont Medicaid to enable eligible Vermonters to access necessary LTC services.  Often when family members apply for Vermont LTC Medicaid for their relative, family caregivers are struggling to meet the needs of the applicant while maintaining all of their other work and family responsibilities.  LTC staff often hear from family members who are relieved when Vermont Medicaid begins providing LTC services for the applicant.

Action Plan

The top priorities/initiatives for the LTC Unit in SFY21 are:

• Manage the unwinding from Public Health Emergency (PHE) to regular processing in a manner that preserves program integrity without causing additional burdens/barriers for customers.
• Once CMS provides guidance, develop plan for processing the backlog of applications that need to be readdressed after PHE ends. 
• Resume annual reviews and backlog of those not reviewed during PHE.
• Readdress backlog of applications approved under PHE guidance (self attestation of resources and income; no 60 month look back period).

What We Do

The Clinical Operations Unit (COU) monitors the quality, appropriateness, and effectiveness of healthcare services requested by providers for members.

The COU ensures that:

• requests for services are reviewed and processed efficiently and within the timeframes outlined in Medicaid Rule;
• over-and-under utilization of healthcare services is identified through the prior authorization (PA) review process and case tracking;
• clinical criteria for certain established clinical services, new technologies and medical treatments are developed and/or adopted;
• medical benefits are correctly coded;
• provider appeals are reviewed;
• provider education is offered related to specific Medicaid policies and procedures;
• quality improvement activities are performed to enhance medical benefits for members.

Please note that in the Summer of 2020, the Clinical Operations Unit, the Pharmacy Unit, and the Quality & Clinical Integrity Unit came together as the Clinical Services Team.  The Units are displayed separately in this scorecard due to their different lines of work.

Who We Serve

One of the main roles of the COU is reviewing prior authorization requests for medical necessity. These requests are for services or goods (examples: durable medical equipment, elective inpatient admissions, out of network office visits) for our beneficiaries.

The COU also serves our provider community, as we help support them by providing education around our processes, so we can better serve our beneficiaries.

How We Impact

The COU processed almost 16,000 prior authorization requests in calendar year 2019.  Decisions are based on Vermont Medicaid Rule 7102 – this in brief is medical necessity and least expensive, appropriate health service.  COU's priority is that our beneficiaries get what is medically appropriate while being fiscally responsible.

Action Plan

The top priorities/initiatives for the COU in SFY21 are:

• Evaluate and refine the internal data processes utilized to capture the federally mandated three-day PA turnaround timeframe, review PA process for efficiencies to support the reduction of provider administrative burden, and alignment of PA requirements, such as Imminent Harm and Out of Network requests for services, for ACO & Medicaid populations.
• Implementation and expansion of the Clinical Audit scope of work to support utilization management strategies specific to evaluating utilization and clinical outcomes for services no longer requiring prior authorization and to support policy, reimbursement, and clinical determinations within DVHA.

What We Do

The Coordination of Benefits (COB) Unit works to coordinate benefit and collection practices with providers, members, and other insurance companies to ensure that Medicaid is the payer of last resort. COB is responsible for Medicare Part D casework including claims processing assistance, coverage verification, and issue resolution. The unit also works diligently to recover funds from third parties where Medicaid should not have been solely responsible. Those efforts include estate recovery, absent parent medical support recovery, casualty recovery, patient liability recovery, Medicare recovery, Medicare prescription recovery, special needs recovery, and trust recovery. The unit has been able to increase Third Party Liability (TPL) cost avoidance dollars, a direct result of ensuring that correct TPL insurance information is in the payment systems and being used appropriately.

Please note that in the Fall of 2020 the Coordination of Benefits (COB) Unit and the Provider Member Relations (PMR) Unit merged and became the Member Provider Services (MPS) Unit.  They are displayed as separate units in this scorecard due to their different lines of work.

Who We Serve

The COB Unit works with providers, beneficiaries, probate courts, attorneys, estate executors, health insurers, liability insurance companies, employers, third party administrators (tpa) and Medicare A, B, C & D plans to ensure that Medicaid is the payer of last resort and that all possible types of recovery are pursued as required by federal law.   

How We Impact

The COB Unit recovers monies that Medicaid has paid as the primary insurer in error, that Medicaid has paid for the care of a beneficiary 55 years of age of older, who received long term care services or that Medicaid has paid for care for a beneficiary with another liable third party.  The collections from the recovery processes are utilized to offset program costs in the yearly Medicaid budget. 

The COB Unit assists Medicare beneficiaries with state health/pharmacy assistance obtain their prescription medications at the pharmacy, eligibility for pharmacy assistance, premium assistance, Low Income Subsidy (LIS), Medicare buy-in, and Medicare Open Enrollment.   The assistance given by this unit saves beneficiaries monies and allows them to access necessary pharmacy medications at a reasonable cost, while at the same time it saves the State of Vermont millions.  Ensuring that beneficiaries are receiving all of the federal programs (Medicare Buy-in, LIS PART D Coverage) for which they are eligible, means the State of Vermont will not be responsible for the costs of the services/items in the Medicaid budget. 

The updates done to systems to ensure correct claims processing properly, prevents Medicaid from being the primary payer in error, saving the program hundreds of millions of dollars annually.

Action Plan

The top 2 priorities/initiatives for the COB Unit in SFY20 are: 

• Create a sustainable process to establish a data-matching relationship with insurers and onboard two insurers.
• Cross-train all COB staff in all the applicable processes done by each of the respective units.

What We Do

The MMIS Maintenance & Operations (M&O) Unit supports DVHA’s priority to effectively manage IT projects by establishing consistent practices and standards to monitor MMIS modules once they are operational. The unit also supports DVHA’s priority to improve operational performance by providing compliance oversight of IT vendors, a consistent DVHA-wide approach to IT change management, and by promoting adherence to national correct coding standards.

Who We Serve

The MMIS M&O Unit supports DVHA leadership, other DVHA units whose work is supported by MMIS modules, other AHS departments that interact with the MMIS, and providers and beneficiaries who rely on the MMIS to process claims for Medicaid services.

How We Impact

The MMIS M&O Unit supports business units in managing MMIS operations, applies consistent methods and standards to IT vendor performance management, and ensures DVHA follows a consistent and transparent approach to IT change management that is aligned with state policies.

Action Plan

What We Do

The Payment Reform Unit seeks to transition Vermont Medicaid’s health care revenue model from Fee-for-Service payments to value-based payments with the goal of providing better, more efficient, coordinated care for Vermonters. In support of this goal, the Payment Reform Unit partners with internal and external stakeholders in taking incremental steps toward the integrated healthcare system envisioned by the Vermont All-Payer Accountable Care Organization Model agreement with the Centers for Medicare and Medicaid Services. The Payment Reform Unit also works with providers and provider organizations in testing models, and ensures the models encourage higher quality of care and are supported by robust monitoring and evaluation plans.

Who We Serve

The Payment Reform Unit is available as a resource to DVHA and to other departments within the Agency of Human Services in the consideration of potential payment reform options. The unit is also responsible for the implementation and oversight of the Vermont Medicaid Next Generation (VMNG) Accountable Care Organization (ACO) program, a financial model designed to support and empower the clinical and operational capabilities of the ACO provider network in support of the Triple Aim of better care, better health and lower costs.

How We Impact

By designing and testing new payment models both for DVHA and other departments within the Agency of Human Services, the Payment Reform unit plays a crucial role in support of DVHA’s goal of transitioning to more value-based payment structures which in turn supports Vermont’s overall health reform efforts. All models being developed ultimately support the Triple Aim in healthcare, which will ensure better care, better health, and lower costs for Vermonters.

Action Plan

THE TOP PRIORITIES/INITIATIVES IN SFY20 are:

• To continue to oversee the implementation, evaluation, and evolution of the Vermont Medicaid Next Generation (VMNG) program, as well as the Mental Health, Residential Substance Use Disorder, and Applied Behavior Analysis payment reform initiatives.
• To provide support to Departmental and Agency leadership in considering and planning for any additional value-based payment reform models to support continued advancement toward an integrated healthcare system in Vermont.
• To understand and engage in the unique internal and external stakeholder landscape for each Payment Reform initiative, emphasizing respectful, transparent, and collaborative interactions.

What We Do

The DVHA Pharmacy Unit is responsible for managing all aspects of Vermont’s publicly funded pharmacy benefits programs. The pharmacy unit oversees the contract with DVHA’s pharmacy benefits manager (PBM) Change Healthcare. Together with its PBM, the Pharmacy Unit is responsible for: working with pharmacies, prescribers and members and resolving all drug-related issues; processing over 2 million pharmacy claims annually, facilitating appeals related to prescription drug coverage within the pharmacy benefit; making drug coverage determinations for pharmacy claims and physician-administered drugs; assisting with drug appeals and exception requests; overseeing federal, state, and supplemental drug rebate programs ; overseeing and managing the Drug Utilization Review Board; managing DVHA’s preferred drug list (PDL); and conducting pharmacy utilization management programs and drug utilization review activities focused on promoting rational prescribing practices and alignment with evidence-based clinical guidelines. The Pharmacy Unit enforces coverage rules in compliance with federal and state laws and implements legislative and operational changes to the pharmacy benefit programs as needed.  The Pharmacy unit also implements new programs and policies that support value-based payments and pharmacist clinical services. For example, the Unit implemented a payment structure for pharmacists performing Medication Therapy Management (MTM) activities, and also policies and procedures to support COVID testing and vaccinations by pharmacists during the Public Health Emergency.  

Please note that in the Summer of 2020, the Pharmacy Unit, the Clinical Operations Unit, and the Quality & Clinical Integrity Unit came together as the Clinical Services Team.  The Units are displayed separately in this scorecard due to their different lines of work.

Who We Serve

The Pharmacy Unit's primary stakeholders are Vermont Medicaid enrolled members, prescribers, and pharmacies. The unit also interacts with many other internal and external stakeholders such as other units within DVHA, other departments within the Agency of Human Services, various legislative committees, pharmaceutical manufacturers, and others.

How We Impact

The Pharmacy Unit established and actively manages a pharmacy best practice and cost control program designed to ensure that members receive high-quality, clinically appropriate, evidence-based medications in the most efficient and cost-effective manner possible.

Action Plan

The Pharmacy Unit's top priorities/initiatives in SFY20 are:

• Coordinating management of drugs available through both medical benefit and pharmacy benefit
• Developing new strategies for “extremely high cost” drugs (in excess of $500,000 per treatment)
• Promoting value-based pharmacist clinical services to reduce adverse medication-related events and improve health outcomes.

What We Do

The Provider and Member Relations Unit (PMR) ensures members have access to appropriate healthcare for their medical, dental, and mental health needs. The unit monitors the adequacy of the Green Mountain Care (GMC) network of providers and ensures that members are served in accordance with managed care requirements. The Green Mountain Care Member Support Center contractor is the point of initial contact for members’ questions and concerns.  PMR oversees the Non-Emergency Medical Transportation (NEMT) for covered service for members enrolled in Medicaid and Dr. Dynasaur programs. PMR oversees and monitors NEMT, issuing policies and procedures to coincide with changing circumstances and federal and state directives.  NEMT is a statewide service for providing transportation for eligible members to and from necessary, non-emergency medical services. It is provided through a contract between the State of Vermont, Department of Vermont Health Access (DVHA) and the Vermont Public Transportation Association (VPTA).

Please note that in the Fall of 2020 the Coordination of Benefits (COB) Unit and the Provider Member Relations (PMR) Unit merged and became the Member Provider Services (MPS) Unit.  They are displayed as separate units in this scorecard due to their different lines of work.

Who We Serve

The Provider and Member Relations Unit (PMR) serves members enrolled in Medicaid and Dr. Dynasaur programs as well as all Providers enrolled with Vermont Medicaid.  The PMR Unit also serves internal stakeholders such as DXC, Division of Aging and Independent Living, as well as other departments within the Agency of Human Services.

How We Impact

The Provider and Member Relations Unit (PMR) works with all members of Vermont Medicaid to ensure that they have access to covered services as well as ensuring that the provider community is actively engaged with DVHA.

Action Plan

The top priorities/initiatives for the PMR Unit in SFY21 are:

• Ensuring members are receiving all federal programs they are eligible for, including pharmaceutical assistance, and that Medicaid members understand the Medicaid program (and their benefits).
• Engaging with providers to improve participation with the Medicaid program, and increase access for Medicaid members.
• Assuring that Medicaid is the payer of last resort by maintaining correct TPL insurance information in the payment systems and appropriate use of that information.

What We Do

The Division of Rate Setting (DRS) calculates and certifies Medicaid rates for residential services provided to Vermonters by 34 Vermont nursing homes, out-of-state nursing homes, 14 residential facilities for youth called Private Non-Medical Institutions (PNMIs), the Intermediate Care Facility for the Developmentally Disabled (ICF/DD), and hospital swing bed rates.  The Division’s rules govern the processes for setting the Medicaid rates of each different type of facility.

Who We Serve

The Division of Rate Setting serves the providers for which it sets rates as well as the approximately 1,700 nursing home and ICF/DD Medicaid residents and 140 PNMI residents.  DRS is also a resource to DVHA and other departments within the Agency of Human Services, State of Vermont, and external stakeholders, providing census and financial data as well as analysis used to formulate budgets, establish policy and examine trends within the industry.

How We Impact

The Division plays a crucial role in supporting a stable system of long-term care in Vermont by setting cost-based rates, pursuant to the Division’s rules, that allow for a high degree of predictability to providers while ensuring the resources necessary to supply high quality care Vermonters.  The Division’s work removing unallowable cost reimbursements from Medicaid rates has saved the State millions of dollars over the years.  The Division also works with the Attorney General’s Office to recoup fraudulent payments.

Strategy

The top 2 priorities for the DRS in SFY2020 are:

• To update the nursing home and PNMI rules, policies and procedures to ensure that they reflect current CMS regulations and align with current priorities.
• To work towards transitioning nursing facilities from a prospective case mix reimbursement system known as RUG-IV to the recently adopted CMS patient-driven payment model (PDPM).   

What We Do

The DVHA Medicaid Reimbursement Unit oversees rate setting, pricing, participate in quarterly code changes, provider payments, and reimbursement methodologies for a large array of services provided under Vermont Medicaid. The Reimbursement Unit is primarily responsible for implementing and managing prospective payment reimbursement methodologies developed to align with CMS Medicare methodologies for outpatient and inpatient services.

In addition, the Reimbursement Unit oversees a complementary set of specialty fee schedules including, but not limited to:  RBRVS (professional services), durable medical equipment, ambulance and transportation, clinical laboratory, physician administered drugs, dental, and home health. The unit also manages the FQHC and RHC payment process as well as supplemental payment administration such as the DSH and GME programs.

Who We Serve

Through our work with Medicaid providers and their stakeholders in implementing payment pricing and policy DVHA Reimbursement has an impact on and serve all Vermont Medicaid recipients.  

How We Impact

The unit works with Medicaid providers and other stakeholders to support equitable, transparent, and predictable payment policy to ensure efficient and appropriate use of Medicaid resources. The unit is involved with addressing the individual and special circumstantial needs of members by working closely with clinical staff from within DVHA and partner agencies to ensure that needed services are provided in an efficient and timely manner. We work closely and collaboratively on reimbursement policies for specialized programs with AHS sister departments, including Disabilities, Aging and Independent Living (DAIL), the Vermont Department of Health (VDH), the Vermont Department of Mental Health (DMH), and the Department for Children and Families (DCF). 

Action Plan

The top priorities/initiatives for the Reimbursement Unit in SFY20 are:

• Continue working with suppliers and stakeholders on the update to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies fee schedule.  

• Continue efforts to work with stakeholders to support equitable, transparent, and predictable payment policy to ensure efficient and appropriate use of Medicaid resources.

• Continued focus on resolution of timely filing requests.

What We Do

The Quality Improvement & Clinical Integrity Unit (QICIU) includes the Quality Team and the Clinical Utilization Review Team. The Quality Team collaborates with AHS partners to develop a culture of continuous quality improvement, maintains the Vermont Medicaid Quality Plan and Work Plan, coordinates quality initiatives including formal performance improvement projects, coordinates the production of standard performance measures, and is the DVHA lead unit for the Results Based Accountability (RBA) methodology & produces the DVHA RBA Scorecards.

The Clinical Utilization Review Team (UR) is responsible for the utilization management of mental health and substance use disorder services. The team works toward the integration and coordination of services provided to Vermont Medicaid members with substance use disorders and mental health needs. The team performs utilization management activities including concurrent review and authorization of mental health and substance use disorder services. The UR Team also administers the Team Care program, which locks a member to a single prescriber and a single pharmacy. In addition, the Autism Specialist authorizes applied behavior analysis (ABA) services for children.  

Please note that in the Summer of 2020, the Quality & Clinical Integrity Unit, the Clinical Operations Unit, and the Pharmacy Unit came together as the Clinical Services Team.  The Units are displayed separately in this scorecard due to their different lines of work.

Who We Serve

The QICIU serves Vermonters enrolled in Medicaid who require behavioral health inpatient, residential, and ABA services.

How We Impact

The Quality Team supports the Department in creating a culture of quality improvement; supporting units to strive for and demonstrate improvement.

The Clinical Utilization Review Team ensures that our members get the services needed for the appropriate length of time.

Action Plan

The top priorities/initiatives for the QICIU in SFY21 are:

• Identify a new formal DVHA PIP topic, partners and initial evidence-based intervention(s).
• Identify pathways for change – data analysis through scorecard monitoring is one pathway to move towards operational performance improvement, but other opportunities exist and should be explored. 
• Stay involved and engaged in new opportunities/innovations to ensure access to quality care for our members – e.g. telemedicine policy moving forward and connectivity care packages for our most vulnerable populations.

What We Do

The Vermont Chronic Care Initiative (VCCI) provides holistic, intensive, and short-term case management services to Vermont residents enrolled in Medicaid, including dually eligible members. VCCI works with members referred for complex case management by healthcare and human services providers, state colleagues and partners, as well as through our care management predictive modeling methodology. VCCI case managers and outreach coordinators are also welcoming members new to Medicaid (NTM), and screening members to identify and prioritize needs. Our screening tool asks members questions about access to care (including primary and dental) , the presence and status of health conditions, and inquiry about other needs that would assist them in maintaining +/or improving their health such as housing, food and safety. The VCCI team works to connect members with medical homes, community-based self-management programs, local care management teams and assist in navigating the system of health and health related care.

Who We Serve

VCCI serves Medicaid members except members:

• receiving CMS funded case management
• receiving services through Department of Aging & Independent Living (DAIL) or Department of Mental Health (DMH) 

How We Impact

The VCCI case managers are community based; and are stationed within the communities they live in. They work closely with their community health care and social service providers; collaboratively working with each other and the member on the member identified priorities. The case managers are closely linked with their AHS Field Directors – which has proven vital when working with members that may be involved with DCF, DOC, DMH, DAIL, and VDH. VCCI case managers meet with members in varied locations- homes, PCP offices, homeless camps, hospitals, shelters- successfully engaging members that have been historically hard to find and difficult to engage.

Action Plan

THE TOP PRIORITIES/INITIATIVES FOR the VCCI unit IN SFY20 ARE:

• Align with health care reform efforts and formal adoption of complex care model and team-based care; utilization of common tools.
• Facilitate connection to appropriate level of care within the ACO model either at primary care or with a care team.
• New to Medicaid or those members with gaps in PCP care – outreach/screen – orient to system of care; provide brief intervention to facilitate PCP and dental access.  Connect to appropriate level of care.
• High/Very High Risk – short term case management to connect to appropriate level of care. 

What We Do

The Business Office (BO) supports, monitors, manages, and reports on all aspects of fiscal planning and responsibility. The unit includes Accounts Payable/Accounts Receivable (AP/AR) & Fiscal Analytics.

• The AP/AR Unit is tasked with processing vendor payments, reimbursement of employee travel expenses, billing and receipt of provider assessments, collection of pharmacy assessments, drug rebate receipts, and other miscellaneous receivables. This unit is also responsible for reconciliations, financial reporting, tracking of department assets, and assisting with audits.
• The Fiscal Analytics Team formulates and performs analysis of the programmatic budget, periodic financial reporting, and ad-hoc research requests providing analytic support for DVHA leadership. This team monitors program changes to determine financial impact, assists with programmatic budget preparation, and ensures financial reporting alignment with federal and state regulations.  Maintaining expertise in federal rules and regulations related to the provision of Medicaid Services under existing and future waivers.  Ensuring close collaboration with project staff to promote compliant cost allocation strategies while maximizing federal revenue. 

Who We Serve

• Department of Finance & Management
• State of Vermont Treasurers Office
• DVHA Vendors
• DVHA Contractors
• DVHA Grantees
• Agency of Human Services
• Agency of Digital Services
• Office of the Attorney General
• AHS CO
• State of Vermont Legislature – Joint Fiscal Committee

How We Impact

The Business Office is responsible for estimating, implementing and tracking Medicaid budget while projecting and presenting caseload as well as expenditure estimates.  This unit deals with the Legislative budget requests, the fiscal analysis for all Medicaid changes, and production of all departmental expenditure reporting using Generally Accepted Accounting Principles (GAAP) and statutory basis of accounting principles.  In the last year, we have implemented improvements to the method for Incurred but Not Reported (IBNR) calculations and per member per month calculations. The team is responsible for communicating changes to the required reporting to the fiscal agent and ensuring that those changes are implemented in accordance with AHS’ needs. 

Within the accounts payable responsibilities, the Business Office is engaged in an improvement project to move to electronic document storage and process routing.

Action Plan

The Business Office's top 2 SFY20 priorities are:

• Continuing to develop in-depth work instructions for all areas of the Business Office responsibility and fully train back-ups in those tasks. This will ensure that service and reporting are delivered consistently. This will further allow us to develop target ranges for our KPIs and make assessments of individual and team performance. DVHA will also continue to strive to be an active participating partner in projects with a fiscal impact allowing all areas of DVHA business to contribute to the goal. 
• To improve integration with IT project staff and operations teams in order to provide more accurate and timely support.

What We Do

The Data Management and Integrity Unit provides data analysis, distribution of Medicaid data extracts to contractors, reporting to regulatory agencies, the legislature, and other stakeholders. We deliver: mandatory federal reporting to the Centers for Medicare and Medicaid Services (CMS); routine Vermont Healthcare Claims Uniform Reporting and Evaluations System (VHCURES) data feeds; the annual Healthcare Effectiveness Data and Information Sets (HEDIS) data extracts for performance measurement reporting; weekly medical and pharmacy claims files and monthly eligibility records to support Care Coordination for the Vermont Chronic Care Initiative (VCCI) and the Vermont Medicaid Next Generation Pilot Project - a risk-based program between the DVHA and OneCare Vermont an accountable care organization. In addition, we provide ad hoc data analysis for internal DVHA divisions and other AHS departments and state agencies. These requests include Public Record Requests (PRR) which are managed by the Legal Unit and are forwarded to the Data Unit as deemed necessary.

Who We Serve

We serve a variety of internal DVHA units, partnering AHS departments, additional state agencies, and external contractors/vendors working on behalf of DVHA with access to and an understanding of information regarding the implementation of Medicaid policies and programs.

How We Impact

We serve as experts on researching and mining data, statistical analysis, and reporting on mandated state and federal requirements. We are accountable for producing and understandable display of quantitative information to colleagues and decision makers using modern databases and sophisticated statistical, mapping and reporting software. We are responsible for recording, preserving, validating and updating the methodologies, syntax, queries and directives for each analysis, extract and final product.

Action Plan

The top 2 priorities/initiatives for the Data Unit in SFY20 are:

• Continue to provide Burns and Associates and OneCare Vermont regular data extracts, as well as routine reporting to the Payment Reform team to support the continued implementation of the Vermont Medicaid Next Generation (VMNG) Accountable Care Organization (ACO) program.
•  Supporting the Agency of Human Services Central Office with required reporting to support the Global Commitment to Health Section 1115 Medicaid Demonstration Evaluation, and the 1115 Substance Use Disorder (SUD) Demonstration Monitoring Protocol.

What We Do

The Oversight & Monitoring Unit (OMU) consists of two teams; Audit & Internal Control and Healthcare Quality Control. The OMU is responsible for ensuring the effectiveness and efficiency of departmental control environments, operational processes, regulatory compliance, and financial and performance reporting in line with applicable laws and regulations.

Who We Serve

The OMU serves DVHA Senior Leadership and all DVHA departments and units.

How We Impact

The OMU facilitates and consults on numerous exams, reviews and audits to establish professional working relationships between the DVHA units, examiners, regulators and auditors resulting in a better understanding of what is truly an issue versus a miscommunication, which results in reduced of findings.

The Health Care Quality Control Unit reviews beneficiary enrollment and eligibility determinations consistent with guidelines set forth in the Federal Payment Error Rate Measurement (PERM) regulations. This process requires a separate and distinct business area to conduct quality control reviews of eligibility determinations, based on CMS defined scopes, quantities and time frames. 

Action Plan

The top priorities/initiatives for the OMU in SF20 are:

• Establish control environment testing based on existing SOPs
• Complete an inventory of other controls existing in DVHA areas to assess need for further SOPs
• Close the current open CAPs for prior audits
• Assist with ACO contract and control environment
• The goal of the O&M group is to facilitate open communication, through a single voice, to ensure all expectations of auditors and regulators are met, and that there are no repeat findings.  Collectively, this transparency will promote further success of the program.

What We Do

Primary Functions of the Medicaid Policy Unit

• Oversight and Coordination of Vermont's Global Commitment to Health 1115 Demonstration Waiver
• Policy Development and Implementation
• Medicaid Administrative Rulemaking
• Policy Research and Analysis
• Administration of:
  • 1115 Global Commitment to Health Waiver
  • Medicaid State Plan
  • Global Commitment Register
  • PBR (Policy, Budget, Reimbursment) Process

Who We Serve

The Medicaid Policy unit serves all of AHS in the policy development and implementation of the Vermont Medicaid program. Additionally, the Unit serves broader external stakeholders including the Vermont Legislature, Vermont Legal Aid, Vermont’s Congressional Delegation, the Medicaid and Exchange Advisory Board, Vermont’s Medical Society, and the Vermont Hospitals Association to both navigate and improve on Medicaid policy statewide.

How We Impact

The Medicaid Policy Unit works to ensure that DVHA and other AHS departments administer the Medicaid program in compliance with federal and state regulations. Additionally, the Policy Unit works with AHS staff and other public and private partners to develop and implement effective Medicaid policy aimed at advancing the agency’s goals of improving access and quality while reducing overall costs.

Action Plan

The priorities/initiatives for the Policy Unit in SFY20 include:

1. Psychiatric IMD 1115 Waiver Amendment
   1. Summit application by Sept. 2019
   2. Negotiation with CMS
   3. Finalize terms
   4. Begin drawing down FFP
2.  1115 Waiver Administration and Planning
   1. Administration of existing waiver.
   2. Planning/preparation for new waiver in 2022
3. Administrative Rulemaking
   1. The Medicaid Policy Unit is currently undergoing a 5-7-year project to rewrite all of Vermont’s Medicaid administrative rules under one centralized framework. Rule work of significant importance underway in SFY2020 include:
      1. Gender Affirmation Surgery
      2. Medical Necessity
      3. EPSDT
   2. Updated and consolidated Medicaid rules promotes transparency, reduces provider/beneficiary confusion.
4. Medicaid Policy Development and implementation at AHS, including:
   1. Payment reform initiatives for Developmental Services, Residential Treatment for Substance Use Disorder, and Children’s Integrated Services
   2. Federal and/or state legislation
5. Home and Community Based Services (HCBS)
   1. Continue systems work to comply with federal HCBS conflict of interest rules
   2. Begin work to move HCBS from 1115 Waiver to State Plan authority (required by 2022)
6. Improved Early, Periodic, Screening, Diagnostic, and Treatment (EPSDT) process
   1. Operational process improvements to ensure EPSDT services that are not listed as covered services under Vermont Medicaid are reviewed for medical necessity and, if appropriate, covered on an individual basis. 
   2. As a result of this operational improvement, Medicaid-enrolled children under 21 and their providers will be able to receive a decision on EPSDT coverage faster, as requests will be reviewed as part of the normal prior authorization process, rather than going through a separate, prolonged, and administratively arduous exception request process. 

What We Do

The Program Integrity Unit (PIU) works to establish and maintain integrity within the Medicaid Program and engages in activities to prevent, detect and investigate Medicaid provider and beneficiary fraud, waste and abuse. 

Who We Serve

The PIU serves the Medicaid recipients and taxpayers of Vermont.  We protect the integrity of Medicaid payments to providers and the enrollment of Medicaid-eligible Vermont citizens to ensure taxpayer dollars are spent on the health and welfare of the recipients that need it.

How We Impact

By identifying and preventing fraud, waste and abuse from providers and beneficiaries which diverts dollars that could otherwise be spent to safeguard the health and welfare of Medicaid recipients. The fraud, waste and abuse we prevent and detect means there are more funds available for the recipients that really need it. We ensure services were provided as billed, were medically necessary, and at the proper cost.

Action Plan

The 2 top priorities/initiatives for the PIU in SFY20 are:

• To monitor all PI initiatives defined in the ACO contract with the ACO that will establish a strong compliance program.
• To identify audit projects and measure cost avoidance from PI involvement.

What We Do

The Medicaid Compliance Unit (MCU) collaborates with programs responsible for delivering Medicaid services to ensure that programs are run in compliance with state and federal laws, rules and policies, as well as the terms and conditions of our Global Commitment waiver.

Who We Serve

The MCU coordinates with departments across AHS to ensure that Vermont Medicaid members benefit from a healthcare system that follows all required rules and policies.  Much of this work is designed ensure that the services we deliver are medically necessary and that our processes serve the medical needs of our members in accordance with statutes and rules.

How We Impact

The MCU provides consultation and assistance to Vermont Medicaid programs on compliance issues and assists these programs with compliance corrective actions as necessary.  This impacts our programs and members by ensuring the effectiveness and efficiency of our Medicaid service delivery system and limits the number of adverse findings we have during external audits.

Action Plan

The MCU's top priorities for SFY20 are:

• Ensure that our Electronic Visit Verification system is fully implemented by the end of CY 2020.
• Work with AHS to reconfigure our compliance program to improve coordination across the Agency.
• To prepare for the annual EQRO audit by reviewing the audit standards with responsible program managers
• To review programs involved with the audit to ensure that our procedures follow federal, state and agency requirements and that our adherence to the standards can be demonstrated through data and documentation

What We Do

The Legal Unit provides legal advice and services as needed to all other DVHA units and the Commissioner’s Office.  The Contracts and Grants team within the Legal Unit assists with all departmental procurement needs from requests to contract through contract execution, manages vendor and subrecipient invoice processing, and conducts subrecipient monitoring.

Who We Serve

The Legal Unit serves directly all other units within the department and, indirectly, all Vermonters receiving or benefitting from the services, programs and projects DVHA funds and supports.

How We Impact

The Legal Unit make an impact by facilitating the business objectives of the other units within DVHA.

Action Plan

The top 2 SFY20 priorities are:

• Continue to improve DVHA contracting and procurement processes to shorten the duration and increase the efficiency those processes.
• Focus on high-quality, efficient and responsive service to improve client satisfaction.

What We Do

The Health Care Appeals Team (HCAT) is responsible for both covered services and eligibility appeals and fair hearing processes.  It coordinates the internal covered services appeal process on standard and expedited timeframes.  It also processes and, where possible, resolves requests for fair hearings on eligibility determinations.

Who We Serve

The Health Care Appeals Team (HCAT) serves all Medicaid members as well as Qualified Health Plan (QHP) members.

How We Impact

The Health Care Appeals Team (HCAT) facilitates the process for members to address issues with their coverage or eligibility.  This not only benefits individual members, but it enables system-wide improvements by identifying patterns and working with other units to prevent issues from arising again.

Action Plan

The top two priorities/initiatives for the HCAT in SFY20 are:

• Meeting established SLA timelines
• Continuing to resolve as many appeals informally as possible

What We Do

Through collaborative partnerships with project teams and organizational leaders, Organizational Change Management (OCM) ensures that end users are ready, willing, and able to adopt major changes to processes and technology in order to improve outcomes for Vermonters.

Who We Serve

OCM works primarily on programs and projects within the DVHA IT Portfolio, collaborating with program management, project management, and leaders from business units impacted by the program and project work. We serve all end users impacted by change, from DVHA staff to Vermonters and everyone in between.

How We Impact

OCM works as a partner with impacted leaders and other business representatives to manage the communication, training effectiveness, organizational readiness, coaching, and sustainability efforts that will result in a successful implementation and adoption of the proposed change.

Action Plan

The two priorities/initiatives for OCM in SFY20 are:

• Get new team members trained and up-to-speed on OCM best practices so that all applicable projects across the DVHA IT portfolio have the same high level of OCM support.
• Create a consistent, repeatable process for all OCM team members to use in supporting projects. This includes checklists to identify required activities and associated deliverables, templates and tools to facilitate the work, and resources to support the execution of required tasks. 

What We Do

The Administrative team works to help achieve consistency in our department through our processes, procedures, and overall workforce development. We provide administrative support to the Commissioner’s office, manage positions and recruitment as well as payroll.

The Operations team manages the day to day operational items for DVHA, this includes addressing building related issues such as moves, space planning and floor plans, VOIP phones, and IT equipment. This also includes the department’s Continuity of Operations Plan (COOP), Records Retention and building safety.

Who We Serve

The Administrative Services & Operations Unit serves the entire department. We work directly and indirectly with staff at all levels.

How We Impact

The Admin team has a strong focus on exceptional customer service. We also work to strengthen and improve the development and wellbeing of DVHA employees, and by doing so, we have a direct impact on employee engagement thus improving the output of their performance and work they do for the department.

The Operations team impacts the department by addressing daily issues that come up within the buildings for staff. We educate and support staff. We offer consistent guidelines and procedures for the daily operational items needed in order to perform their job, as well as ensuring any discomforts or workplace safety concerns are addressed.

Action Plan

The Operations team has recently reorganized and merged with the Administrative Services Team. With this change, some of the work and responsibilities have also changed. The priority for this fiscal year is to review all processes and procedures, ensure standard operating procedures are documented and updated. Identify areas and opportunities for improvement and efficiencies.