Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 010 - DIVISION OF RATE SETTING › Chapter 002 - METHODS, STANDARDS AND PRINCIPLES FOR ESTABLISHING PAYMENT RATES FOR PRIVATE NONMEDICAL INSTITUTIONS PROVIDING RESIDENTIAL CHILD CARE SERVICES › Section 13 010 002 - METHODS, STANDARDS AND PRINCIPLES FOR ESTABLISHING PAYMENT RATES FOR PRIVATE NONMEDICAL INSTITUTIONS PROVIDING RESIDENTIAL CHILD CARE SERVICES

Current through June, 2024
Part 1. GENERAL
				PROVISIONS
Section 1.1 Scope and Purpose.
These rules apply to all private nonmedical institutions that
				  are participating in the Vermont Medicaid program, providing services in
				  licensed residential treatment programs and that have a contract with at least
				  one of the placement authorizing departments (PAD) as defined in Section
				  13 of these rules. The purpose of
				  these regulations is to establish the methods, standards and principles used to
				  determine and calculate payment rates for these services consistent with
				  efficiency, economy and quality of care, in compliance with Title XIX of the
				  Social Security Act, and to ensure that no Medicaid reimbursement is made for
				  non-covered services. These rules identify those costs that are allowable as
				  the basis for setting rates.
Section
				1.2 Authority.
These rules are promulgated pursuant to
				  33 V.S.A.
				  §
												1901(a) to meet the
				  requirements of 33 V.S.A. Chapter 3,
				  42 U.S.C. §
												1396a(a)(30), and
				  42 C.F.R. Part 434, Subpart B
				  (relating to private nonmedical institutions.)
Section 1.3 General Description of the Rate
				Setting System.
Payment rates are established prospectively for each program
				  based on historic allowable costs of the program. A per diem rate is
				  established for each major category of service provided by these facilities:
				  medical treatment; room, board and supervision; and education. The approved
				  rate is based on a funding application and financial statements submitted to
				  the Division by the provider.
Section
				1.4 Requirements for Participation in Medicaid Program.
To be eligible to participate in the Medicaid program and
				  receive Medicaid reimbursement, a program must be licensed by the Department
				  for Children and Families' Residential Licensing and Special Investigations
				  Unit, have an approved Medicaid provider agreement with Department of Vermont
				  Health Access, and have an approved contract with at least one of the placement
				  authorizing departments (PAD) as defined in Section
				  13 of these rules.
Section 1.5 Prior Authorization of
				Placement.
Prior authorization by a PAD is required for all admissions
				  to residential treatment programs for which payment is anticipated from the
				  State or a political subdivision thereof.
Section 1.6 Responsibilities of Owners.
The owner of a residential treatment program shall prudently
				  manage and operate a program of adequate quality to meet its residents' needs
				  and comply with the rules and regulations or other requirements and standards
				  of the Agency of Human Services and the Agency of Education, including the
				  Department for Children and Families' Licensing Regulations for Residential
				  Treatment Programs. Neither the issuance of a per diem rate, nor final orders
				  made by the Director or a duly authorized representative of a PAD shall in any
				  way relieve the owner of such a program from full responsibility for such
				  compliance.
Section 1.7
				Duties of the Owner.
The owner of a residential treatment program participating in
				  the Medicaid program, or a duly authorized representative shall:
(a) Comply with the provisions of sub
				sections 1.4,
				1.5 and
				1.6 setting forth the requirements
				for participation in the Medicaid program.
(b) Submit master file documents, funding
				applications and supporting documentation in accordance with the provisions of
				sub sections
				3.1 and
				3.2 of these rules.
(c) Maintain adequate financial and
				statistical records and make them available at reasonable times for inspection
				by an authorized representative of the Division, the state or the federal
				government.
(d) Assure that an
				annual audit is performed by an independent public accountant in conformance
				with Generally Accepted Auditing Standards (GAAS), including a sub-schedule,
				when applicable, showing total PNMI revenues and costs, including allocated
				costs, and showing PNMI net program revenues.
(e) Report to the Division within 30 days
				when there has been a change of ownership or ownership structure of the
				program.
(f) Assure that the
				construction of buildings and the maintenance and operation of premises and
				programs comply with all applicable health and safety standards.
Section 1.8 Powers and Duties of
				the Division of Rate Setting and the Director.
(a) The Division shall establish and certify
				to the appropriate PADs per diem rates for payment to providers of residential
				child care services on behalf of residents eligible for assistance under the
				Social Security Act.
(b) The
				Division may require any residential treatment program or related party or
				organization to file such relevant and appropriate data, statistics, schedules
				or information as the Division finds necessary to enable it to carry out its
				rate setting function.
(c) The
				Division may examine books and accounts of any program and related parties or
				organizations.
(d) From time to
				time, the Director may issue notices of practices and procedures employed by
				the Division in carrying out its functions under these rules.
(e) The Director shall prescribe the forms
				required by these rules and instructions for their completion.
(f) Copies of each notice of practice and
				procedure, form, or set of instructions shall be sent to the general
				representative of each residential treatment program participating in the
				Medicaid program at the time it is issued. A compilation of all such documents
				currently in force shall be maintained at the Division, pursuant to
				3 V.S.A.
				§
												835, and shall be available to the
				public.
(g) The Division shall
				prescribe procedures and forms to be used in the completion of time
				studies.
(h) The Division, in
				consultation with the PADs, shall establish and certify the occupancy standards
				to be used in the rate setting process.
(i) Neither the issuance of final per diem
				rates nor final orders of the Division which fail, in any one or more
				instances, to enforce the requirements of these rules shall be construed as a
				waiver of such requirements in the future. The obligations of the provider with
				respect to performance shall continue, and the Division shall not be estopped
				from requiring such future performance.
(j) Neither the Division nor the PADs shall
				be bound in determining the allowability of reported costs, in ruling on
				applications for rate adjustments, or in making any other decision relating to
				the establishment of rates, by any prior decision. Such decisions shall have no
				precedential value. Principles and decisions of general applicability shall be
				issued as a Division practice or procedure, pursuant to Section
				1.8(d).
(k) Notwithstanding any other provisions of
				these rules, the Division may, at the discretion of the Director, establish and
				certify per diem rates pursuant to these rules for licensed Vermont residential
				treatment programs for the use of other states placing children in the program
				when the program is not currently contracting with a Vermont PAD to place
				children.
Section 1.9
				Powers and Duties of the Department for Children and Families, Department of
				Mental Health, Department of Disabilities, Aging and Independent Living,
				Department of Health's Division of Alcohol and Drug Abuse Programs and Agency
				of Education and other PADs relating to Rate Setting.
(a) The PADs shall establish and enforce
				billing and payment procedures.
(b)
				The PADs reserve the right to review, modify, accept or reject any adjustment
				requests made in accordance with Sections
				8 and
				9 of these rules.
(c) The Department for Children and Families
				is responsible for licensing standards and enforcement. The PADs are
				responsible for program standards, placement procedures, and contract
				enforcement.
Section 1.10
				Computation of and Enlargement of Time; Filing and Service of Documents.
(a) In computing any period of time
				prescribed or allowed by these rules, the day of the act or event from which
				the designated period of time begins to run shall not be included. The last day
				of the period so computed shall be included, unless it is a Saturday, a Sunday,
				or a state or federal legal holiday, in which event the period runs until the
				end of the next day which is not a Saturday, a Sunday, or a state or federal
				legal holiday.
(b) For the purposes
				of any provision of these rules in which time is computed from the receipt of a
				notice or other document issued by the Division or other relevant
				administrative officer, the addressee of the notice shall be rebuttably
				presumed to have received the notice or other document three days after the
				date on the document.
(c) When by
				these rules or by a notice given thereunder, an act is required or allowed to
				be done at or within a specified time, the relevant administrative officer, for
				just cause shown, may at any time in her or his discretion, with or without
				motion or notice, order the period enlarged.
(d) Filing shall be deemed to have occurred
				when a document is received and date-stamped as received at the office of the
				Division of Rate Setting or in the case of a document directed to be filed
				under this rule other than at the office of the Division, when it is received
				and stamped as received at the appropriate office. Filings with the Division
				may be made by telefacsimile (FAX), but the sender bears the risk of a
				communications failure from any cause. Filings may also be made electronically,
				but the sender bears the risk of a communications failure from any cause,
				including, but not limited to, filings blocked due to size.
(e) Service of any document required to be
				served by this rule shall be made by delivering a copy of the document to the
				person or entity required to be served or to his or her representative or by
				sending a copy by prepaid first class mail to the official service address.
				Service by mail is complete upon mailing.
Section 1.11 Representation in All Matters
				before the Division of Rate Setting.
(a) A
				provider may be represented in any matter under this rule by the owner (in the
				case of a corporation, partnership, trust, or other entity created by law,
				through a duly authorized agent), the executive officer of the PNMI, or by a
				licensed attorney or an independent public accountant.
(b) The provider shall file written
				notification of the name and address of its representative for each matter
				before the Division. Thereafter, on that matter, all correspondence from the
				Division will be addressed to that representative. The representative of a
				provider failing to so file shall not be entitled to notice or service of any
				document in connection with such matter, whether required to be made by the
				Division or any other person, but instead service shall be made directly on the
				provider.
Section 1.12
				Severability.
If any part of these rules or their application is held
				  invalid, the invalidity does not affect other provisions or applications which
				  can be given effect without the invalid provision or application, and to this
				  end the provisions of these rules are severable.
Section 1.13 Effective Date.
These rules are effective from July 25, 1995 (as amended
				  August 1, 1999, August 1, 2003, August 5, 2008, February 24, 2014, September 8,
				  2015, and July 1, 2023).