Vermont - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Vermont Department of Disabilities, Aging and Independent Living (DAIL) requires prospective Case Management Organizations (CMOs) for the Developmental Services (DS) and Brain Injury Program (BIP) waivers to obtain state certification before applying for Medicaid enrollment. Under recent Conflict-Free Case Management standards, a CMO must formally attest that it will not provide any other Medicaid-funded Home and Community-Based Services (HCBS) in Vermont.

Because Vermont does not issue a standard facility license for case management, approval is a sequential process starting with programmatic authorization from DAIL's Adult Services Division (ASD) or Developmental Disabilities Services Division (DDSD). Only after DAIL issues an approval letter or CMO Certification can an agency submit a Medicaid provider enrollment application to the Department of Vermont Health Access (DVHA) through the Provider Management Module.

1. Service Definition and Scope

In Vermont, Case Management is an administrative and coordination-focused service designed to help individuals access necessary waiver and community supports. It is not a direct care service, but rather the mechanism for developing and overseeing the participant's Individual Support Plan (ISP).

The scope of case management spans across multiple Vermont waivers, including Choices for Care (CFC), Traumatic Brain Injury (TBI), and Developmental Services (DS). Case managers are responsible for functional assessments, service coordination, referral generation, and ongoing monitoring of service delivery and participant satisfaction.

• Core Function: Conducting comprehensive functional and needs-based assessments for waiver participants.
• Service Planning: Developing, reviewing, and updating the Individual Support Plan (ISP) with the participant and their support team.
• Coordination: Linking individuals to authorized waiver services such as personal care, respite, and supported employment.
• Monitoring: Overseeing service delivery to ensure it aligns with the ISP and meets the participant's health and safety needs.
• Transition Support: Facilitating safe transitions from hospitals, institutions, or schools into community-based settings.
• Advocacy: Ensuring participant rights are upheld and empowering individuals to direct their own care when possible.

2. Regulatory and Oversight Agencies

Programmatic oversight and certification of case management providers are managed by the Vermont Department of Disabilities, Aging and Independent Living (DAIL). DAIL operates distinct divisions for different waiver populations, which dictate where a provider submits their initial application.

The Department of Vermont Health Access (DVHA) serves as the state Medicaid agency, handling the financial and enrollment aspects. DVHA contracts with Gainwell Technologies to operate the Vermont Medicaid Portal and Provider Management Module.

• Program Oversight: Vermont Department of Disabilities, Aging and Independent Living (DAIL) (https://dail.vermont.gov)
• Adult Waivers: DAIL Adult Services Division (ASD) (https://asd.vermont.gov)
• Developmental Waivers: DAIL Developmental Disabilities Services Division (DDSD) (https://ddsd.vermont.gov)
• Medicaid Authority: Department of Vermont Health Access (DVHA) (https://dvha.vermont.gov)
• Medicaid Enrollment System: Vermont Medicaid Portal (https://www.vtmedicaid.com)
• Local Coordination: Designated Agencies (DAs) (https://mentalhealth.vermont.gov/services/designated-agencies)

3. Gatekeeping Prerequisites: Who Can Even Apply

Vermont enforces strict structural preconditions for case management providers to comply with federal Conflict-Free Case Management (CFCM) rules and ensure adequate network capacity. An entity cannot simply enroll as a Medicaid provider without first clearing DAIL's programmatic gates.

For the Developmental Services (DS) and Brain Injury Program (BIP) waivers, the state imposes specific mandates on organizational scope and service delivery that block applicants unable to operate on a statewide basis.

• Conflict-Free Mandate: CMOs must attest they will not provide any other Medicaid-funded HCBS in Vermont to avoid conflicts of interest.
• Statewide Requirement: DS and BIP Case Management providers must possess the infrastructure to offer services statewide.
• Zero-Reject Policy: Certified CMOs must serve every eligible individual referred by the State or the State's designee.
• Prior State Approval: DAIL programmatic approval (ASD approval or DDSD CMO Certification) is required before a DVHA Medicaid application is accepted.
• Designated Agency Affiliation: Historically, and for certain local populations, providers must establish an affiliation or contract with a local Designated Agency (DA).

4. Licensure and Certification Requirements

Vermont does not utilize a traditional Department of Health facility license for HCBS case management. Instead, providers must achieve certification directly through DAIL by demonstrating compliance with specific program standards.

For adult programs like Choices for Care (CFC) and TBI, providers submit a fillable enrollment application directly to the Adult Services Division. For DS and BIP, entities must meet the comprehensive Case Management Certification Standards.

• Certification Standard: Must meet DAIL's Case Management Certification Standards for the applicable waiver.
• Business Registration: Active registration with the Vermont Secretary of State.
• Code of Ethics: Must establish an organizational Code of Ethics aligning with the State of Vermont Executive Code of Ethics.
• ASD Application: CFC and TBI applicants must submit the ASD fillable application to [email protected].
• Policy Manual: Must develop and submit a comprehensive Case Management Services Policy & Procedure Manual for state review.

5. Medicaid Provider Enrollment

Once DAIL issues programmatic approval, the agency must enroll as a billing provider with the Department of Vermont Health Access (DVHA). This is completed electronically through the Provider Management Module (PMM).

Because case management involves directing Medicaid funds and services, providers are subject to federal ACA screening requirements during the enrollment process.

• Enrollment Portal: Provider Management Module (PMM) accessed via the Vermont Medicaid Portal (https://www.vtmedicaid.com).
• Required Attachment: The DAIL approval letter or CMO Certification must be uploaded with the PMM application.
• Identifiers: Must supply a Type 2 National Provider Identifier (NPI) and the legal entity's Federal Tax Identification Number (TIN).
• Screening Level: Subject to ACA provider screening and revalidation per Title 42 CFR 455.410 and 455.450.
• Fiscal Agent: Applications and subsequent claims are processed by Gainwell Technologies on behalf of DVHA.

6. Staffing, Training and Background Checks

Case managers in Vermont must possess the educational background necessary to navigate complex medical and social support systems. Agencies are responsible for verifying these credentials before assigning staff to participants.

All patient-facing staff must clear state and federal background checks and complete mandatory orientation training prescribed by DAIL or the affiliated Designated Agency.

• Qualifications: Case managers typically must hold a degree in human services, social work, or possess equivalent documented experience.
• Background Checks: Mandatory criminal history and abuse registry clearances for all staff interacting with waiver participants.
• Initial Training: Must attend and complete case management training required by DAIL or the local Designated Agency prior to billing.
• Conflict Prohibition: Individual case managers cannot be involved in the direct delivery of other HCBS to the participant they manage.
• Ongoing Education: Staff must complete annual continuing education on incident reporting, participant rights, and HCBS Settings Rules.

7. Documentation, Policies and Records

DAIL requires prospective case management agencies to submit a robust Policy & Procedure Manual during the certification phase. This manual must dictate how the agency will handle intake, assessment, and continuous monitoring.

Recordkeeping must be meticulous, as DVHA and DAIL conduct routine audits to ensure that billed case management units correspond to actual, documented coordination activities.

• Intake Procedures: Documented workflows for receiving referrals and initiating functional assessments.
• ISP Timelines: Policies detailing the required timeframes for ISP development, periodic review, and annual revision.
• Participant Rights: Written protocols for informed consent, grievance handling, and upholding dignity.
• Service Logs: Maintenance of detailed contact notes and monitoring documentation to substantiate Medicaid claims.
• Transition Planning: Procedures for facilitating and documenting safe transitions between care settings.

8. Billing, Rates and Claims

Case management is billed directly to Vermont Medicaid (DVHA) using specific procedure codes tied to the participant's authorized waiver. It is reimbursed as an administrative or coordination service.

Rates are established by DVHA fee schedules and vary depending on whether the service is provided under Choices for Care, the Brain Injury Program, or Developmental Services.

• Payer: Department of Vermont Health Access (DVHA).
• Billing System: Claims are submitted electronically through the Vermont Medicaid Portal.
• Rate Setting: Reimbursement rates are published on the DVHA fee schedules for each specific waiver program.
• Claim Substantiation: Every billed unit must be backed by a corresponding service log or ISP monitoring note in the participant's file.
• Billing Prohibition: Cannot bill for case management if the agency is also billing for direct care services for the same individual.

9. Approval Sequence and Timeline

Becoming a case management provider in Vermont is a multi-phase process that cannot be expedited by skipping the programmatic review. Entity formation and policy drafting must occur before any state contact.

The timeline is heavily dependent on the provider's ability to produce compliant policy manuals and DAIL's current application queue.

• Phase 1: Business registration, NPI acquisition, and Policy Manual development (typically 2-3 weeks).
• Phase 2: Submission of the programmatic application to DAIL ASD or DDSD for CMO Certification.
• Phase 3: Upon DAIL approval, submission of the Medicaid enrollment application via the PMM (typically 1-2 months for processing).
• Phase 4: Staff credentialing, completion of mandatory DAIL/DA training, and receipt of initial ISP assignments.

10. Common Denials and Survey Findings

Applications are frequently rejected at the DAIL stage if the agency fails to demonstrate how it will meet the strict conflict-free or statewide service mandates. DVHA will automatically deny Medicaid enrollments that lack the prerequisite DAIL approval.

During post-enrollment audits, the most common survey citations involve inadequate documentation of ongoing service monitoring or failure to update the ISP when a participant's needs change.

• Conflict Violations: Denials for agencies attempting to provide both case management and direct HCBS.
• Capacity Failures: Rejection of DS/BIP applications that cannot prove the ability to serve individuals statewide.
• Missing Prerequisites: DVHA enrollment denials due to missing the DAIL ASD approval letter or CMO Certification.
• Documentation Gaps: Audit findings for missing service logs, late ISP revisions, or inadequate transition planning notes.

11. Key Contacts and Resources

Prospective providers must interact with multiple divisions within the Vermont Agency of Human Services. The specific division depends on the target waiver population.

All Medicaid enrollment and billing inquiries are handled through the DVHA portal and its fiscal agent.

• DAIL Adult Services Division (ASD): Oversees Choices for Care and TBI (https://asd.vermont.gov)
• DAIL Developmental Disabilities Services Division (DDSD): Oversees DS and BIP (https://ddsd.vermont.gov)
• Department of Vermont Health Access (DVHA): Medicaid authority (https://dvha.vermont.gov)
• Vermont Medicaid Portal: Enrollment and billing system (https://www.vtmedicaid.com)
• Designated Agencies Directory: Local coordination partners (https://mentalhealth.vermont.gov/services/designated-agencies)

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