Vermont - Home Health Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Vermont Department of Disabilities, Aging, and Independent Living (DAIL), through its Division of Licensing and Protection (DLP), licenses Home Health Agencies providing intermittent skilled nursing and therapy under 33 V.S.A. § 1951.

Applicants must secure a Certificate of Need (CON) from the Green Mountain Care Board and achieve Medicare certification before the state will issue a full license or approve Medicaid enrollment. The Department of Vermont Health Access (DVHA) reimburses these services for eligible beneficiaries under the Global Commitment to Health Section 1115 demonstration and standard Medicaid state plan.

1. Service Definition and Scope

Vermont defines home health services in statute as medically necessary, intermittent, skilled home health services provided by Medicare-certified home health agencies. These services are delivered in the patient's residence under a physician-ordered plan of care.

The scope includes skilled nursing, physical therapy, occupational therapy, speech-language pathology, and home health aide services. It explicitly excludes primary care services, occupational health clinics, and nursing home room and board.

• Statutory Definition: 33 V.S.A. § 1951(2)(A)(i) defines the service as medically necessary, intermittent, skilled home health services provided by Medicare-certified agencies.
• Included Services: Skilled nursing, physical therapy, occupational therapy, speech therapy, and home health aide services.
• Excluded Services: Primary care services, occupational health clinics, and travel/flu clinics.
• Plan of Care: Requires a physician-ordered plan of care that is reviewed and updated at least every 60 days.

2. Regulatory and Oversight Agencies

The Division of Licensing and Protection (DLP) within DAIL is the primary regulatory body responsible for licensing and conducting survey and certification activities for home health agencies in Vermont.

The Green Mountain Care Board (GMCB) regulates market entry through the Certificate of Need process, while the Department of Vermont Health Access (DVHA) manages Medicaid provider enrollment and reimbursement.

• Division of Licensing and Protection (DLP): Conducts surveys and issues state licenses (https://dlp.vermont.gov).
• Department of Vermont Health Access (DVHA): Manages the Medicaid State Plan and provider reimbursement (https://dvha.vermont.gov).
• Green Mountain Care Board (GMCB): Reviews and approves Certificate of Need applications for new agencies (https://gmcboard.vermont.gov).
• Adult Services Division (ASD): Approves providers for specific waiver programs like Choices for Care (https://asd.vermont.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Vermont heavily restricts the establishment of new home health agencies. A Certificate of Need (CON) is a mandatory structural precondition that blocks any applicant from proceeding to licensure if community need cannot be proven.

Additionally, state administrative rules require federal Medicare certification as a strict prerequisite for an agency to become a designated home health agency in Vermont.

• Certificate of Need (CON): Required from the Green Mountain Care Board before establishing a new home health agency or expanding into new geographic territories.
• Federal Certification: VT ADC 12-4-205:3 requires agencies to obtain and maintain federal Medicare certification to become a designated home health agency.
• Geographic Service Area: CON approval dictates the specific counties or regions the agency is legally permitted to serve.
• Financial Feasibility: CON applicants must prove financial stability and unmet community need to the GMCB before approval is granted.

4. Licensure and Certification Requirements

Once a CON is obtained, the agency must apply for a state license through the Division of Licensing and Protection. The agency must comply with the Rules for the Designation and Operation of Home Health Agencies.

Licensure is closely tied to federal certification; the state conducts the initial Medicare survey (or accepts accreditation from an approved body like CHAP) to validate compliance with federal Conditions of Participation.

• Application Form: Submitted to DAIL DLP with the required licensing fee and proof of CON approval.
• Medicare Tie-In: State licensure is contingent upon successful Medicare survey and certification (CMS-1572).
• Administrator Qualifications: Must employ a qualified administrator with documented health care management experience.
• Clinical Director: Must employ a registered nurse (RN) as the supervising clinical director to oversee all patient care.

5. Medicaid Provider Enrollment

Medicaid enrollment is processed through the Vermont Medicaid Provider Management Module (PMM) operated by Gainwell Technologies. Providers must hold an active DLP license and Medicare certification before applying.

Agencies enroll as Provider Type 38 (Home Health Agency) and must complete the standard institutional enrollment application, including ownership disclosures.

• Enrollment Portal: Vermont Medicaid Provider Enrollment Portal via Gainwell Technologies.
• Provider Type: Enrolled under Provider Type 38 (Home Health Agency).
• Application Fee: Subject to the CMS institutional provider application fee, unless already paid to Medicare during federal enrollment.
• Revalidation: Required every 5 years through the PMM portal to maintain active billing status.

6. Staffing, Training and Background Checks

Vermont requires strict background checks for all patient-facing staff, utilizing both the Adult Protective Services (APS) registry and the Vermont Crime Information Center (VCIC).

Clinical staff must hold active Vermont licenses, and home health aides must complete state-approved training and competency evaluations.

• Background Checks: Mandatory VCIC criminal history and APS registry checks for all staff providing direct patient care.
• RN Licensing: Nurses must hold an active, unencumbered license from the Vermont Board of Nursing or a recognized compact state.
• Aide Training: Home health aides must complete a state-approved training program and pass a competency evaluation.
• In-Service Training: Home health aides require a minimum of 12 hours of annual in-service education.

7. Documentation, Policies and Records

Agencies must maintain comprehensive clinical records and administrative policies. Records must accurately reflect the physician-ordered plan of care and all interventions provided.

Agencies are also required to collect and transmit Outcome and Assessment Information Set (OASIS) data for adult patients as part of federal and state quality reporting.

• Clinical Records: Must include the physician-ordered plan of care, clinical notes, medication profiles, and discharge summaries.
• OASIS Data: Mandatory collection and transmission of OASIS data for adult skilled care patients.
• Emergency Preparedness: Must maintain an emergency preparedness plan compliant with CMS Appendix Z requirements.
• Record Retention: Patient records must be retained for at least 7 years post-discharge.

8. Billing, Rates and Claims

DVHA reimburses home health services using a fee schedule based on visit types, or through specific waiver rates for programs like Choices for Care.

Medicaid is the payer of last resort; agencies must bill Medicare or commercial insurance before submitting claims to Vermont Medicaid.

• Claim Format: Billed on the UB-04 institutional claim form or the electronic 837I equivalent.
• Prior Authorization: Required for services exceeding the initial evaluation and standard visit limits established by DVHA.
• Fee Schedule: Rates are published on the DVHA website under the Home Health Fee Schedule.
• Third-Party Liability: Providers must exhaust Medicare and commercial insurance benefits before billing Medicaid.

9. Approval Sequence and Timeline

The approval process is lengthy due to the Certificate of Need requirement and the wait for a Medicare certification survey. The entire process typically takes 12 to 24 months.

Medicaid enrollment cannot begin until the CON is approved, the state license is issued, and the Medicare tie-in notice is received.

• CON Approval: 6-12 months for Green Mountain Care Board review, public comment, and hearings.
• State Licensure Application: 30-60 days for DLP review of the initial application packet.
• Medicare Survey: 3-6 months waiting period for the initial certification survey by DLP or an approved accrediting organization.
• Medicaid Enrollment: 45-60 days for processing through the Vermont Medicaid PMM after license issuance.

10. Common Denials and Survey Findings

DLP conducts unannounced surveys to ensure compliance. Deficiencies often stem from care plan deviations or incomplete background checks.

At the application stage, the most common reason for denial is the failure to prove unmet community need during the Certificate of Need process.

• CON Denial: Failure to prove unmet community need or financial viability to the Green Mountain Care Board.
• Care Plan Deviations: Providing services or visit frequencies not explicitly authorized in the physician's plan of care.
• Background Check Lapses: Allowing staff to provide direct care before VCIC and APS clearances are fully returned and reviewed.
• OASIS Errors: Incomplete, inaccurate, or late transmission of required OASIS assessment data.

11. Key Contacts and Resources

Prospective providers must coordinate with multiple state entities, primarily the Green Mountain Care Board for market entry and the Division of Licensing and Protection for licensure.

Medicaid enrollment and billing inquiries are handled by the Department of Vermont Health Access and its fiscal agent.

• Division of Licensing and Protection: https://dlp.vermont.gov
• Green Mountain Care Board: https://gmcboard.vermont.gov
• Department of Vermont Health Access: https://dvha.vermont.gov
• Vermont Medicaid Provider Portal: https://vtmedicaid.com

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