Reimbursement Unit

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

SFY22 priorities are:

  • Continue efforts to work with stakeholders to professionalize payment methodologies. For SFY 2022, the unit will engage with DAIL in a major revamping of payment methodologies for the Enhanced Residential Care and Assistive Community Care Service programs.
  • With continued efforts to professionalize and update payment methodologies and the resulting need for funding to implement those changes, the unit will work towards having the funding amount needed for proposed updates available to AHS/DVHA BO for possible inclusion in the budget being submitted to the legislature for the following SFY.  
  • Continue work on the Orphan Code project.  Review and research on many of the remaining codes will require outreach to and working in a collaborative manner with other AHS departments.
Measures
Time
Period
Current Actual Value
Current Target Value
Current
Trend
Baseline
% Change
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy