• Please note in the above chart the solid trend line represents the total % and the dotted trend line represents DVHA's %
• The target for all departments for this measure is 80%

• Contact for Change (varies)
• Business Office of the lead department
• AHS Finance
• Gainwell Technologies
• DVHA/MMIS Liaison and Clinical, Provider Member Relations, Reimbursement, and Program Integrity Units are notified at onset of routing for all PBRs

This measure is important because it captures adherence to the Policy, Budget and Reimbursement (PBR) process prior to implementing significant Medicaid changes.

The PBR form provides a tool to support the systematic coordination of AHS departments and units and provides essential documentation regarding the change. The routine use of the PBR form creates a process that serves as an internal safeguard against any unintended consequences of proposed changes.

Changes to Medicaid programs, services, and policies require a coordinated review to ensure alignment with federal and state regulations, as well as Vermont Medicaid policies and practices.  The goal is to have approval from all before the change is effective and to issue public notice, if required.

If we are not finalizing PBRs prior to their effective dates, we are at risk for the following:

• Poor budgeting
• Loss of, or inability to, receive federal match
• Non-compliance with state and federal policies 
• Public engagement
• Cost of mistakes (e.g. MMIS programming)

SFY20 Quarters 3 and 4 show a significant decrease of finalized PBRs prior to implementation, which is a direct result of staffing resources shifting to COVID-19 response across the Agency. During these two quarters, 32 COVID PBRs were finalized using an expedited process in order rapidly respond to the public health emergency. SFY21 Q1 shows a rebound - late July 2020 and after much of the initial COVID policy response had been addressed, the Policy Unit reinstated the full PBR process, requiring completion in advance of implementation.

Narrative last updated:  01/21/2021

1. In response to the COVID-19 emergency, an abbreviated PBR process was temporarily put in place to allow for expedited review and approval of COVID-related changes.
2. In the summer of 2020, Gainwell established the Claims and Policy Support team. This team is devoted to researching claims-related requests for State staff, including reviewing any necessary MMIS work related to PBRs. Use of this team as opposed to the more generic “Agency Requests” mailbox has proven to be a value gain for the PBR process in that the MMIS piece of Medicaid changes is better coordinated and takes pressure off other State staff responsible for approving the recommended MMIS change.