Vermont - Respite Care Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Vermont funds Respite Care Services through the Global Commitment to Health Section 1115 Demonstration, administered by the Department of Disabilities, Aging and Independent Living (DAIL). The service provides short-term relief for unpaid caregivers and is authorized under specific program budgets like Choices for Care (CFC), Developmental Disability Services (DDS), and the Traumatic Brain Injury (TBI) program.

Approval to bill Vermont Medicaid directly for this service requires first passing a programmatic review by the specific DAIL division overseeing the target population, such as the Adult Services Division (ASD) for CFC and TBI. Independent applicants targeting the developmental disabilities population face a closed-network model where they must typically subcontract under one of Vermont's regional Designated Agencies (DAs) or Specialized Service Agencies (SSAs) rather than enrolling as standalone direct-billers.

1. Service Definition and Scope

Respite care in Vermont offers temporary relief to unpaid primary caregivers, ensuring the waiver participant receives continuous supervision and support. The service is designed to maintain the primary caregiver's well-being and prevent institutionalization of the participant.

Under the TBI program, respite is explicitly defined in 24-hour increments, while DDS and CFC utilize hourly or daily models depending on the individual's person-centered care plan.

• TBI Respite Limit: Caregivers receive 2 days per month (24 days per year) of respite under the Traumatic Brain Injury program.
• TBI Increment: Billed and utilized in 24-hour increments.
• Prior Authorization: Required by the TBI Program Manager or designee prior to the utilization of respite services.
• DDS Respite: Authorized under the Developmental Disability Services budget for individuals with intellectual disabilities.
• CFC Respite: Included as a flexible support option under the Choices for Care program for older adults and persons with physical disabilities.

2. Regulatory and Oversight Agencies

Vermont consolidates HCBS oversight under the Agency of Human Services (AHS). DAIL manages the programmatic rules, clinical eligibility, and provider approvals.

The Department of Vermont Health Access (DVHA) serves as the state Medicaid agency, handling financial eligibility, Medicaid enrollment, and claims processing through its fiscal agent.

• Department of Disabilities, Aging and Independent Living (DAIL): https://dail.vermont.gov
• Adult Services Division (ASD): https://asd.vermont.gov
• Developmental Disabilities Services Division (DDSD): https://ddsd.vermont.gov
• Department of Vermont Health Access (DVHA): https://dvha.vermont.gov
• Vermont Medicaid Portal (Gainwell Technologies): https://vtmedicaid.com

3. Gatekeeping Prerequisites: Who Can Even Apply

Vermont heavily restricts direct Medicaid enrollment for HCBS providers, utilizing a programmatic pre-approval model and a designated agency system. A provider cannot simply submit a Medicaid enrollment application to DVHA; they must first secure division-level approval.

For the developmental disabilities population, the state relies on a closed network of regional agencies, making standalone enrollment exceedingly rare without a direct subcontract.

• ASD Pre-Approval: Required for CFC and TBI providers before DVHA will accept a Medicaid application.
• DDS Designated Agency Affiliation: Providers serving the DDS population typically must subcontract with a regional Designated Agency (DA) or Specialized Service Agency (SSA).
• DDSD Quality Review: Standalone agencies seeking direct DDS enrollment must pass a rigorous DDSD Quality Review evaluating financial stability and HCBS standards.
• Application Routing: ASD applications must be emailed directly to [email protected].

4. Licensure and Certification Requirements

Vermont does not issue a distinct "Respite Care License." Instead, agencies providing nursing-level respite must be licensed as Home Health Agencies, while non-medical respite providers operate under DAIL certification.

All providers must comply with federal and state standards for community integration and safety before being approved to deliver services.

• Home Health Agency License: Required from the Division of Licensing and Protection if the respite involves skilled nursing tasks.
• DAIL Certification: Non-medical respite providers must meet the certification standards outlined in the specific program's provider manual.
• HCBS Settings Rule: All providers must comply with the federal HCBS Settings Rule, ensuring community integration.
• Out-of-State Providers: Must complete the specific Out of State Provider Enrollment Application if located outside Vermont but serving VT residents.

5. Medicaid Provider Enrollment

Once DAIL approves the programmatic application, the provider is instructed to enroll with the State's Medicaid Fiscal Agent, Gainwell Technologies.

This process links the DAIL approval to the Medicaid Management Information System (MMIS) for claims processing and requires standard federal disclosures.

• Fiscal Agent: Gainwell Technologies operates the Vermont Medicaid Provider Enrollment Portal.
• Prerequisite: The official DAIL approval letter must be attached to the MMIS enrollment application.
• Screening Risk Level: HCBS providers are typically subject to moderate or high-risk screening, requiring site visits.
• Application Fee: Subject to the federal Medicaid application fee unless waived or paid to Medicare.

6. Staffing, Training and Background Checks

Direct support professionals providing respite must meet baseline qualifications established by DAIL and pass comprehensive background screenings.

Training requirements vary by the waiver program, with specialized populations requiring specific competency demonstrations.

• Age Requirement: Direct care workers must typically be at least 18 years old.
• Background Checks: Mandatory screening through the Vermont Adult Abuse Registry, Child Abuse Registry, and criminal history databases.
• TBI Specific Training: Staff must be trained on the specific brain injury recovery protocols outlined in the participant's TBI Service Plan.
• Direct Care Worker Registry: Vermont is implementing a registry platform to track qualifications and background clearances for direct care workers.

7. Documentation, Policies and Records

Providers must maintain detailed records demonstrating that respite was delivered as authorized in the person-centered care plan.

Documentation must prove the primary caregiver was relieved and the participant remained safe during the service delivery.

• Service Plan Alignment: Respite delivery must strictly match the authorized hours and increments in the DAIL-approved care plan.
• Timesheets: Must include exact start and stop times, date of service, and the signature of the participant or surrogate.
• Incident Reporting: Critical incidents during respite must be reported to the DAIL program manager within 24 hours.
• Record Retention: Medicaid records must be retained for a minimum of six years from the date of service or claim payment.

8. Billing, Rates and Claims

Respite claims are processed through the Vermont MMIS operated by Gainwell Technologies. Rates are established by the Agency of Human Services.

Reimbursement depends on the specific program budget and whether the care is self-directed or agency-provided.

• TBI Billing Increment: Billed in 24-hour units as authorized by the TBI Program Manager.
• CFC Surrogate Rates: Historically set around $10.00/hr for personal care/respite when participant-directed, though agency rates differ.
• Prior Authorization Requirement: Claims will deny if the specific respite units were not prior-authorized in the MMIS.
• Billing Portal: Claims are submitted electronically via the Provider Electronic Solutions (PES) software or the Vermont Medicaid portal.

9. Approval Sequence and Timeline

The pathway to becoming a billing provider is sequential and cannot be expedited by applying to Medicaid first.

The entire process from DAIL submission to MMIS activation requires coordination between multiple state divisions.

• Step 1: Submit the fillable provider enrollment application to ASD or DDSD.
• Step 2: Undergo DAIL programmatic review and quality assessment.
• Step 3: Receive official DAIL approval and instructions to apply to Medicaid.
• Step 4: Submit the MMIS application via Gainwell Technologies.
• Step 5: Complete federal background screenings and site visits if applicable.

10. Common Denials and Survey Findings

Applications and claims are frequently delayed or denied due to procedural missteps, particularly bypassing the DAIL pre-approval requirement.

During audits, documentation failures are the leading cause of recoupment for respite services.

• Premature Medicaid Application: Denied immediately if submitted to Gainwell without the DAIL ASD/DDSD approval letter.
• Missing Prior Authorization: Claims denied because the provider billed for respite before the TBI Program Manager approved the care plan.
• Incomplete Timesheets: Recoupments issued when timesheets lack the participant's signature or exact start/stop times.
• Unapproved Settings: Funds recouped if respite is provided in a setting that does not comply with the HCBS Final Settings Rule.

11. Key Contacts and Resources

Prospective providers should utilize the official state portals and division contacts for the most current forms and manuals.

The Adult Services Division is the primary starting point for CFC and TBI programs.

• Adult Services Division (ASD) Provider Enrollment: http://asd.vermont.gov/resources/provider-enrollment
• ASD Enrollment Email: [email protected]
• Vermont Medicaid Portal: https://vtmedicaid.com
• Developmental Disabilities Services Division (DDSD): https://ddsd.vermont.gov
• Department of Vermont Health Access (DVHA): https://dvha.vermont.gov

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