Transparency is essential to good public management. DVHA operates a public health plan that serves approximately a third of all Vermonters. This Scorecard is designed to let Vermonters know what strategic goals are important in operating our health plan and how DVHA is doing in striving for success. DVHA is committed to continually reviewing these priorities with our partners and stakeholders to ensure that we are delivering the best service possible for Vermonters.
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.
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.
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.
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:
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.
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.
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.
The top priorities/initiatives for the LTC Unit in SFY20 are:
The Clinical Operations Unit (COU) monitors the quality, appropriateness, and effectiveness of healthcare services requested by providers for members.
The COU ensures that:
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.
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.
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.
The top priorities/initiatives for the COU in SFY20 are:
Value Based Care: Clinical Scenarios, Clinical Audit
IT: OnBase, EQ Health
Performance Outcomes: COU Scorecard, PIP, Strategic Goals, Mission, Priorities
Value Based Care: Payer Collaboration, ACO Attribution & Clinical Intersection
IT: ADT Feeds, Work Bench
Performance Outcomes: Revision of COU Scorecard Measures, Clinical Project Results, & Clinical/Payment reform initiatives r/t ACO transition & attribution
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.
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.
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.
The top 2 priorities/initiatives for the COB Unit in SFY20 are:
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.
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.
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.
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.
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.
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.
THE TOP PRIORITIES/INITIATIVES IN SFY20 are:
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 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.
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.
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.
The Pharmacy Unit's top priorities/initiatives in SFY20 are:
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.
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.
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.
The top priorities/initiatives for the PMR Unit in SFY20 are:
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.
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.
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.
The top 2 priorities for the DRS in SFY2020 are:
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.
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.
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).
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.
The Vermont Blueprint for Health designs community-led strategies for improving health and well-being. The Blueprint’s design work responds to the emerging needs of Vermonters and the latest opportunities in health and human services reform by creating change in the delivery system. This work began with Patient-Centered Medical Homes, Community Health Teams, and Self-Management and Healthier Living Workshops. It subsequently expanded to include the Hub & Spoke system of opioid use disorder treatment, and the Women’s Health Initiative. In support of program implementation, full population data and analytics and learning collaboratives are available for policy makers, communities, and practices.
Services supported by the Blueprint for Health Program are available to all Vermonters.
The activities of the Blueprint serve as the foundation for strengthening primary care and expanding the ACO programs. This initiative is especially focused on building the links between community and medical services, so that patients have better coordinated care across the spectrum of services.
Together the following performance measures focus on whether Vermonters are better off as a result of this program. They do so by looking at the quality and efficiency of these programs and services.
The top 3 priorities/initiatives for the Blueprint in SFY20 are:
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.
The QICIU serves Vermonters enrolled in Medicaid who require behavioral health inpatient, residential, and ABA services.
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.
The top priorities/initiatives for the QICIU in SFY20 are:
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.
VCCI serves Medicaid members except members:
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.
THE TOP PRIORITIES/INITIATIVES FOR the VCCI unit IN SFY20 ARE:
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 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.
The Business Office's top 2 SFY20 priorities are:
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.
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.
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.
The top 2 priorities/initiatives for the Data Unit in SFY20 are:
The Health Information Exchange (HIE) Program is focused on the aggregation and exchange of health data. The vision for HIE in Vermont is represented in three overarching goals:
The Department of Vermont Health Access (DVHA) leverages federal funding under the HITECH Act and the State HIT-Fund to progress health information exchange activities on behalf of Vermont’s patients and providers.
Vermont’s Health Information Exchange (VHIE), operated by VITL, is a central system that aggregates data from electronic health records for use by providers and health care programs state-wide. DVHA contracts with VITL for operations and development of the VHIE system.
DVHA’s work on HIE is intended to serve the health care system and those who use it including patients, health care providers, the Department of Health, health care payers, care coordinators, community and system-wide delivery system programs, and population health programs and research.
DVHA partners with the HIE Steering Committee to develop and oversee an HIE strategic plan which articulates a vision for developing HIE infrastructure to benefit patients, providers, and population health and delivery system programs. The strategic plan guides public investments in HIE, which are managed at DVHA thanks to the federal governments’ commitment to ensuring that the health system has needed technologies to document care, exchange data, support care coordination, and more.
The top priorities for the HIE Unit in SFY19 are:
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.
The OMU serves DVHA Senior Leadership and all DVHA departments and units.
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.
The top priorities/initiatives for the OMU in SF20 are:
Primary Functions of the Medicaid Policy Unit
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.
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.
The priorities/initiatives for the Policy Unit in SFY20 include:
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.
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.
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.
The 2 top priorities/initiatives for the PIU in SFY20 are:
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.
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.
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.
The MCU's top priorities for SFY20 are:
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.
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.
The Legal Unit make an impact by facilitating the business objectives of the other units within DVHA.
The top 2 SFY20 priorities are:
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.
The Health Care Appeals Team (HCAT) serves all Medicaid members as well as Qualified Health Plan (QHP) members.
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.
The top two priorities/initiatives for the HCAT in SFY20 are:
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.
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.
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.
The two priorities/initiatives for OCM in SFY20 are:
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.
The Administrative Services & Operations Unit serves the entire department. We work directly and indirectly with staff at all levels.
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.
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.