Vermont - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Vermont Medicaid covers in-home skilled nursing under two distinct models: agency-directed Home Health Services governed by Health Care Administrative Rule (HCAR) 4.231, and High-Technology Nursing (HTN) for medically complex care under HCAR 4.232. To operate as an agency-directed provider, an entity must first secure a Certificate of Need (CON) from the Green Mountain Care Board before applying for a Home Health Agency license through the Division of Licensing and Protection.

Alternatively, individual Registered Nurses and Licensed Practical Nurses may bypass the agency CON process by enrolling directly with Vermont Medicaid to provide family-managed HTN services. Both pathways require enrollment through the Provider Management Module administered by Gainwell Technologies, with service authorizations managed jointly by the Department of Vermont Health Access (DVHA), the Department of Health (VDH), and the Department of Disabilities, Aging and Independent Living (DAIL).

1. Service Definition and Scope

Skilled nursing in Vermont is delivered either as intermittent home health visits or as continuous High-Technology Nursing (HTN) for medically complex individuals. HTN services exceed what can be provided through part-time home health agency services and are often referred to in other settings as private duty nursing.

Services must be delivered under the direction of a treating physician. The state allows these services to be delivered concurrently with Choices for Care or pediatric waiver services, provided there is no duplication of the exact nursing tasks.

• Service Name: High-Technology Nursing (HTN) or Medically Complex Nursing Services.
• Rule Citation: Health Care Administrative Rule (HCAR) 4.232 for HTN and 4.231 for Home Health Services.
• Delivery Models: Agency-directed (via a Medicaid-enrolled Home Health Agency) and Family-managed (via independent nurses directly enrolled with Vermont Medicaid).
• Scope of Practice: RN and LPN services delivered under a physician's Plan of Care (Form 485).
• Concurrent Care Restriction: HTN cannot be billed concurrently with standard home health nursing visits, as there cannot be two plans of care for the same nursing service.

2. Regulatory and Oversight Agencies

Oversight of skilled nursing services is divided among several Vermont state departments depending on the age of the member and the delivery model. Licensing is handled by the Division of Licensing and Protection, while Medicaid enrollment is processed by Gainwell Technologies.

Clinical authorizations for HTN are managed by the Department of Health for pediatric members and the Department of Disabilities, Aging and Independent Living for adult members.

• Department of Vermont Health Access (DVHA): Manages Medicaid enrollment, policy, and claims processing (https://dvha.vermont.gov/).
• Division of Licensing and Protection (DLP): Regulates and surveys Home Health Agencies (https://dlp.vermont.gov/).
• Department of Disabilities, Aging & Independent Living (DAIL): Manages adult HTN and Choices for Care waivers (https://dail.vermont.gov/).
• Vermont Department of Health (VDH): Manages pediatric HTN referrals and authorizations (https://www.healthvermont.gov/).
• Provider Management Module (Gainwell): The online portal for all Medicaid provider enrollment applications (https://vermont.hppcloud.com/ProviderEnrollment/EnrollmentCreate).

3. Gatekeeping Prerequisites: Who Can Even Apply

Vermont strictly limits the establishment of new Home Health Agencies through a Certificate of Need process. Entities cannot simply apply for a license; they must first prove a state need for their agency.

However, individual nurses wishing to provide HTN services under the family-managed model are exempt from the CON requirement and may enroll directly as independent providers.

• Agency Prerequisite: A Certificate of Need (CON) from the State is required for all new Home Health Agencies under 33 V.S.A. § 1951(6).
• Independent Nurse Exemption: Individual RNs and LPNs enrolling specifically for family-managed HTN do not require a CON.
• Medicare Certification: Agency-directed providers must typically be certified to provide services pursuant to 42 U.S.C. § 1395x(o).
• Needs Assessment: Members must have a state-authorized clinical needs assessment completed before any provider can be authorized to bill for services.

4. Licensure and Certification Requirements

Agencies must maintain active licensure through the Division of Licensing and Protection. Independent nurses must maintain their professional nursing licenses in good standing with the Vermont Board of Nursing.

Agencies are also subject to specific state mandates regarding patient rights, including the handling of advance directives.

• Licensing Authority: Division of Licensing and Protection (DLP) Survey and Certification unit issues Home Health Agency licenses.
• Professional Licensure: All direct care staff must hold active Vermont RN or LPN licenses.
• Advance Directives: HHAs must maintain written policies on advance directives and document in patients' files whether a directive is in effect.
• Ethics Forms: Providers must obtain Advance Directive forms from the Vermont Ethics Network to provide to patients.

5. Medicaid Provider Enrollment

All enrollment is conducted electronically through the Provider Management Module. Paper applications are no longer accepted by DVHA.

Providers must complete federal screening requirements based on their risk category as mandated by the Affordable Care Act.

• Enrollment Portal: Provider Management Module (PMM) administered by Gainwell Technologies.
• Application Structure: Only one service location and one provider type can be enrolled per PMM application.
• Federal Screening: All newly enrolling providers are subject to ACA Section 6401 federal screening requirements.
• Retroactive Enrollment: DVHA may consider a 90-day retroactive effective date if requested with supporting rationale, though it does not guarantee payment.

6. Staffing, Training and Background Checks

Staffing models differ significantly between agency-directed and family-managed care. In the family-managed model, the member or their family acts as the primary coordinator.

All providers must adhere to standard Medicaid non-discrimination and professional practice standards.

• Staff Qualifications: Services must be delivered by a licensed RN or LPN.
• Physician Orders: All nursing care must be directed by a treating physician.
• Primary Coordinator Role: In family-managed models, a designated coordinator is responsible for distributing the Plan of Care to independently enrolled nurses.
• Blended Models: In cases where both agency and independent nurses provide care, nursing assessment duties are shared and coordinated by the Primary Coordinator.
• Background Checks: Standard Agency of Human Services background check requirements apply to all enrolled providers.

7. Documentation, Policies and Records

Vermont Medicaid requires strict adherence to documentation standards, particularly regarding physician orders and face-to-face encounters.

Authorizations for HTN are not indefinite; they require annual redetermination based on updated clinical assessments.

• Plan of Care: All procedures must be documented in a Plan of Care (Form 485) maintained by the HHA or Primary Coordinator.
• Face-to-Face Encounter: The Agency of Human Services requires documentation that a face-to-face encounter occurred for the initial ordering of home health services.
• Nursing Assessments: Limited to one (1) unit per day for billing purposes.
• Redeterminations: The need for medically necessary HTN services is redetermined annually, with notices sent 90 days prior to the end of the authorization period.
• Referral Forms: Physicians must use the specific Pediatric High-Tech Nursing Referral Form or Adult High-Tech Nursing Referral Form.

8. Billing, Rates and Claims

Reimbursement structures vary by delivery model. Agency-directed HTN utilizes a unique monthly payment model based on authorized hours, rather than strict fee-for-service billing for every hour worked.

Providers must ensure all claims meet timely filing limits and cannot bill members for missed appointments.

• Payment Model (Agency): The HTN monthly payment is 33.3% of the equivalent FFS payment for providing the total authorized hours of service.
• Minimum Threshold: A Home Health Agency retains the full monthly payment if the recipient receives at least 50% of their authorized hours during the month.
• Timely Filing: All claims, including those during approved retroactive enrollment periods, must meet Vermont Medicaid's timely filing standards.
• Missed Appointments: Providers may not bill Vermont Medicaid or the member any fee for missing a scheduled appointment.
• Pharmacy Tax: If the provider operates a retail pharmacy, a $0.10 monthly assessment is due for each prescription filled.

9. Approval Sequence and Timeline

The timeline for approval depends heavily on whether the applicant is an agency requiring a CON or an independent nurse enrolling directly.

Medicaid enrollment cannot begin until all prerequisite licensure and certifications are secured.

• Step 1: Obtain a Certificate of Need from the Green Mountain Care Board (Agencies only).
• Step 2: Secure a Home Health Agency license from the Division of Licensing and Protection (Agencies only).
• Step 3: Submit the online application through the Provider Management Module with active nursing licenses.
• Step 4: Pass ACA-mandated federal screening and background checks.
• Step 5: Receive a Vermont Medicaid provider ID number and confirmation of enrollment letter from DVHA.

10. Common Denials and Survey Findings

Enrollment and claims are frequently delayed or denied due to administrative errors in the PMM portal or failure to follow specific Vermont billing rules.

Surveyors closely monitor compliance with face-to-face documentation and advance directive policies.

• Missing Face-to-Face: Failure to document the initial physician face-to-face encounter for home health services.
• Concurrent Billing: Attempting to bill HTN concurrently with standard home health nursing visits.
• Threshold Failures: Failing to meet the 50% authorized hours threshold required to retain the agency-directed monthly HTN payment.
• Incomplete PMM Application: Attempting to enroll multiple service locations or provider types on a single PMM application.
• Advance Directive Non-Compliance: Failing to document in patients' files whether an advance directive is in effect.

11. Key Contacts and Resources

Providers should utilize the official state portals and department websites for the most current forms, manuals, and contact information.

The Provider Management Module is the primary interface for all enrollment actions.

• Provider Management Module (Gainwell): https://vermont.hppcloud.com/ProviderEnrollment/EnrollmentCreate
• Division of Licensing and Protection (DLP): https://dlp.vermont.gov/
• Department of Vermont Health Access (DVHA): https://dvha.vermont.gov/
• Vermont Department of Health (VDH): https://www.healthvermont.gov/
• Department of Disabilities, Aging & Independent Living (DAIL): https://dail.vermont.gov/

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