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Y: INACTIVE: DVHA Performance Accountability Scorecard (retired embed code 04/23)

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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.

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Why Is This Important?
Enroll Members
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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

SFY23 priorities are:

  • PHE Unwind
  • Successfully implementing our new Data Reporting System
  • Recruitment/Retension, Succession Planning, and Professional Development
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May 2024
94.0%
75.0%
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May 2024
97.3%
100.0%
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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

SFY23 priorities are:

  • Continue to ensure eligible Vermonters can access LTC Medicaid as quickly as possible
  • Continued focus on improving business process efficiencies
  • Prepare for PHE Unwind
Pay for Care
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The Clinical Services Team (CST)

Please note that in the summer of 2020, the Clinical Integrity Unit, Clinical Operations Unit, and the Pharmacy Unit, merged and became the Clinical Services Team.  

The Clinical Integrity Unit (CIU) is responsible for the utilization management of mental health and detoxification 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, eating disorder treatment, and substance use detoxification services. The CIU 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.  The CIU also engages in Medical Record Reviews to support quality initiatives.

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

  • 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.

The 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 policies and procedures to support COVID testing and vaccinations by pharmacists during the Public Health Emergency.  

Who We Serve

The CIU serves Vermont Medicaid members who require mental health inpatient and detoxification services, eating disorder treatment, and ABA services.

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 members. The COU also serves the provider community, by providing education to support clinical review processes, so DVHA can better serve Vermont Medicaid members and the provider community.

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 CIU serves Vermont Medicaid members who require mental health inpatient and detoxification services, eating disorder treatment, and ABA services.

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 members. The COU also serves the provider community, by providing education to support clinical review processes, so DVHA can better serve Vermont Medicaid members and the provider community.

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.

Action Plan

CST SFY23 Priorities:

  • Development of Clinical Services Team (CST) Performance Scorecard Measure: Exceptions Requests
  • Develop and implement an integrated and coordinated prior authorization process between the DVHA Pharmacy Unit, DVHA Pharmacy vendor, Change Healthcare, and the Clinical Operations Unit to support medical necessity review and prior authorization requests for medications requiring inpatient, elective office visits, and/or out of network clinical review for medication administration
  • Development the clinical liaison work within the Clinical Services Team & include the advisory of the DVHA Chief Medical Officer to support DVHA’s clinical & payer requirements to improve care coordination & provide consultation and advisory direction to other units on a project basis to support shared objectives and align work
  • Utilize DVHA resources to support further unification of the Clinical Services Team

CIU SFY23 priorities:

  • Continue to expand VT Medicaid enrolled provider network for eating disorder treatment
  • Emergency department per diem rate for extended mental health stays
  • Monitor quality of care for inpatient psychiatric treatment for VT Medicaid members

COU SFY23 priorities:

  • Implement the Clinical Liaison work to support DVHA’s clinical & payer requirements
  • Develop and adopt a palliative care program
  • Continue the work of Clinical Audits and expand to include the Clinical Services Team
  • Engage in the work of increasing access to dental services as evidenced by; review of dental rates, increased dental provider network, & support of programmatic efforts targeted at specific populations (Adult Disabled population, Team Care) to support appropriate utilization & delivery of dental services.

Pharmacy SFY23 priorities:

  • Hep C Treatment in HUBS
  • NASPO Project: PBA/PBM RFP & acquisition of new contract
  • Drug Rebate and Coverage policies for High-Cost Drugs
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What We Do

The Casualty Recovery Team works to coordinate benefit and collection practices with providers, members, and other insurance companies to ensure that Medicaid is the payer of last resort. The team is responsible for Medicare Part D casework including claims processing assistance, coverage verification, and issue resolution.

The Provider Team 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 Third Party Liability Team (TPL) 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 team has been able to increase TPL cost avoidance dollars, a direct result of ensuring that correct TPL insurance information is in the payment systems and being used appropriately.

The Transportation Team ensures members have access to appropriate healthcare for their medical, dental, and mental health needs.  The Green Mountain Care Member Support Center contractor is the point of initial contact for members’ questions and concerns.  The team oversees the Non-Emergency Medical Transportation (NEMT) for members enrolled in Medicaid and Dr. Dynasaur programs.  The Transportation Team 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 these Teams (formerly known as the Coordination of Benefits (COB) Unit) and the Provider Member Relations (PMR) Unit merged and became the Member Provider Services (MPS) Unit.

Who We Serve

The Casualty Recovery and TPL Teams work 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 Tranportation and Provider Teams serves members enrolled in Medicaid and Dr. Dynasaur programs, as well as all providers enrolled with Vermont Medicaid.  The teams also serve internal stakeholders such as Gainwell Technologies, Division of Aging and Independent Living, as well as other departments within the Agency of Human Services.

How We Impact

The Casualty Recovery Team 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 team 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 TPL Team 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 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 Transportation and Provider Teams work with 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

SFY23 priorities are to:

  • Team alignment, team building, collaboration
  • Create implementation plan for Provider Management Module
  • Develop timeline for online third-party liability service
Payment Reform
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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

SFY23 priorities are:

  • Support the AHS Secretary’s office, the Director of Health Care Reform, and the Green Mountain Care Board with planning and design of the next iteration of Vermont’s All-Payer Model Agreement.
  • Continue to lead prioritization, planning, design, implementation, evaluation, and evolution of proposed, existing and new payment reform initiatives.
  • Continue to oversee the implementation, evaluation, and evolution of the VMNG ACO program.

 

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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

SFY23 priorities are:

  • Complete annual nursing home and PNMI desk reviews and set rates in a timely manner.
  • Nursing Home and PNMI rule making, including implementing a lower minimum occupancy for the nursing homes and inflation for the PNMIs.
  • Plan and prepare for a transition away from the current RUG-IV acuity measure used to set nursing home rates.
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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

SFY23 priorities are:

  • Continue Cross agency collaboration with DAIL and HMA Burns & Associates to complete legislatively mandated rate studies.
  • Staff development and succession planning, professional development.
  • Participate in updates to the GME program. Work on access to care issues.
Support
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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

SFY23 priorities are to:

  • Revise 52 points of light report
  • MDWAS project
  • Contribute to stabilization of health system
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Feb 2023
$696.16Mil
$700.79Mil
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Mar 2023
$99.57Mil
$125.87Mil
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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

SFY23 priorities are:

  • Build an inventory, schedule, and incorporate AHS measures into the current workplan
  • Provide data and reports to stakeholders to meet 100% of Federal reporting requirements per IGAs and CMS
  • Assess Data Team’s capacity and role for continued support of MMIS Projects (MDWAS, TMSIS)
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What We Do

The Risk and Quality Management Team  is comprised of the Medicaid Compliance Unit (MCU), the Oversight & Monitoring Unit (OMU), & Quality Improvement Unit (QIU).  Like many organizations, compliance functions at DVHA often lead to quality improvement activities. The purpose of bringing these groups together under one larger team is to gain efficiencies regarding our comprehensive regulatory environment and realize greater success in our work.

The over-arching goals of that team include:

  • create a culture of pro-active regulatory compliance and continuous quality improvement;
  • identify, analyze, prioritize and correct compliance risks across all departments and programs responsible for Medicaid service delivery;
  • take advantage of opportunities to move beyond compliance and identify ways to improve the services we deliver to Vermonters;
  • coordinate the production and/or analysis of standard performance measures pertaining to all Medicaid enrollees, including the special health care needs populations (service provision delegated to IGA partners).

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 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 Quality Improvement Unit (QIU) 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.

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.

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

The QIU serves Vermonters enrolled in Medicaid.

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.

The OMU Audit & Internal Control Team 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 OMU Health Care Quality Control Team 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 QIU supports the Department in creating a culture of quality improvement; supporting units to strive for and demonstrate improvement.

Action Plan

MCU SFY23 Priorities:  

  1. Continue work with the Medicaid Risk Assessment Project by reviewing additional compliance standards with Medicaid programs across AHS
  2. Ensure that our subject-matter experts are prepared for the 2023 EQRO audit topics and that corrective actions from prior audits are completed or on schedule for completion
  3. Once our AHS-DVHA IGA is completed, update department IGAs to include a schedule of monitoring deliverables that match the recommendations from the Risk Assessment Project
  4. Update the Utilization Management Plan to match any changes that arise from the new AHS IGA
  5. Continue to serve as a compliance consultation resource for Medicaid programs across AHS

OMU SFY23 Priorities:

  1. PHE Unwind
  2. Successfully implementing our new Data Reporting System
  3. Recruitment/Retention, Succession Planning, and Professional Development

QIU SFY23 Priorities:

  1. Quality Improvement Projects – PIP and Foster Care Learning Collaborative
  2. Continue to coordinate DVHA’s Risk Assessment work group
  3. Re-envision the DVHA Performance Accountability Scorecard
Policy
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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

SFY23 priorities are:

  • Implementation of 1115 waiver initiatives
  • Katie Beckett process improvement
  • Procure new 1115 evaluator and begin developing a comprehensive plan for Medicaid 1115 program and investment evaluation
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What We Do

The Special Investigations Unit (SIU) 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 SIU 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

SFY23 priorities are:

  • Work with Pharmacy Unit – Controlled Substances monitoring and analysis
  • Continue micro audits
  • Proactive Analytics
Appeals
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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

SFY23 priorities are:

  • Continue to resolve 50% appeals prior to hearing
  • PHE Unwind
  • Meet established SLA timelines
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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.

Through collaborative partnerships with project teams and organizational leaders, the Organizational Change Management (OCM) Team 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

The Administrative Services & Operations Teams serve the entire department. They work directly and indirectly with staff at all levels.

The OCM Team 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. They serve all end users impacted by change, from DVHA staff to Vermonters and everyone in between.

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.

The OCM Team 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

SFY23 priorities are:

  • Recruitment, retention, reward & recognition
  • New DVHA intranet
  • Accessibility
PM
SFY 2022
14.6%
1
PM
Mar 2023
100%
80%
42

Clear Impact Suite is an easy-to-use, web-based software platform that helps your staff collaborate with external stakeholders and community partners by utilizing the combination of data collection, performance reporting, and program planning.

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