DVHA Performance Accountability Scorecard

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

SFY24 priorities are:

• PHE Unwind
• Focusing on QA and productivity for efficiencies.
• Finalizing RFP’s for Optum and Maximus
• Project alignment and coordination with TMSIS, Global Commitment and IEE
• Open enrollment and COLA

What We Do

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 SFY24 priorities:

• Develop and formalize a CST Data Reporting Book.
• Utilize DVHA resources to support continued unification of CST.
• Review and monitor procurement activities.
• Continue to monitor and refine current CST exceptions request performance measure.
• Engage in weight loss/ healthy lifestyle project.

CIU SFY24 priorities:

• Continue to monitor and assess Emergency Department Per Diem for Extended Mental Health Stays.
• Monitor and support the ABA Value Based payment project.
• Continue to monitor quality of care for inpatient psychiatric treatment for VT Medicaid members.                           
• Explore provider network to enhance and stabilize ABA services.

COU SFY24 priorities:

• Eliminating “I” status associated with PA process with real time PA processing systems
• Refining DVHA Fee Schedule
• Comprehensive Pain Pilot
• Identification of storage & delivery modality of expensive and or complex DME
• Advance Palliative Care Program

Pharmacy SFY24 priorities:

• Focus on Value based agreements
• Improve/Upgrade 340 B process
• Mandatory 90 Day PA form
• Continue NASPO Project Work

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

SFY24 priorities are to:

• Promoting, monitoring, and reporting on dental access
• COB On-Demand
• Improving communications for customer service and operational efficiency
• Planning for a new online Third-Party Liability service
• Orienting a new MPS Director

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

SFY24 priorities are:

• Continue to oversee the implementation, evaluation, and evolution of the Vermont Medicaid Next Generation (VMNG) program, including successful negotiation of 2024 VMNG contract amendment (including the Global Payment Program, (pending federal approval) and planning for the next stage of the program, and future alignment with the next iteration of the All-Payer Model Agreement.
• We anticipate engaging in a new payment reform project with the Division of Substance Use with a target implementation date of 1/1/2026.
• Finalize VBP design for DS payment reform by the end of SF2024.
• Incorporate best practices for payment reform design, implementation, and evaluation into new and existing payment reform projects.

What We Do

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.

The QIU also partners with the Compliance and Oversight & Monitoring units as part of the larger Risk & Quality Management Team. 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).

Who We Serve

The QIU serves Vermonters enrolled in Medicaid.

How We Impact

The QIU supports the Department in creating a culture of quality improvement; supporting units to strive for and demonstrate improvement.

Action Plan

SFY24 priorities:

• Continue formal PIP
• Participate in planning, monitoring, and evaluation of the BR APM
• Risk Management:  finish internal review of Standards, making recommendations and implementing interventions to reduce risk.
• Risk Management:  prepare for and complete 2024 audit with minimal repeat findings
• Quality Measure Planning & Reporting