Division of Rate Setting

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.

SFY22 priorities are:

• Incorporating the implications of COVID into the nursing home rate setting process for both PNMIs and Nursing Homes.
• Nursing Home and PNMI rule making, including implementing a lower minimum occupancy for the nursing homes and inflation for the PNMIs.  These changes require support and budget from our AHS partners (DAIL/DCF/DMH).
• Plan and prepare for a transition away from the current acuity measure used quarterly to adjust the nursing component of the Medicaid nursing facility rate to a new measure of acuity based on data that will be available in the future.  This requires reestablishment of the Data User Agreement with CMS that was unexpectedly cancelled a few years ago.
• Participate in the development of the new transfer of ownership financial review while continuing to participate in the interim review process.
• Develop and implement a staffing / hiring / training plan for retirement of all four of the nursing home auditors expected to occur in the next 1-2 years.  These are technical positions requiring a high level of accounting and auditing expertise.