Vermont - Skilled Respite Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Vermont does not license or enroll Skilled Respite as a distinct, standalone provider category within its Medicaid program. Agencies seeking to deliver respite care requiring licensed nursing staff must instead be licensed as a Home Health Agency (HHA) by the Division of Licensing and Protection, or be formally designated as a Designated Agency (DA) or Specialized Service Agency (SSA) under the Developmental Disabilities Services Division.

Entities seeking to provide skilled nursing respite must first secure a Certificate of Need (CON) from the Green Mountain Care Board if operating as a home health agency, or obtain official designation from the Department of Disabilities, Aging and Independent Living (DAIL) before submitting a Medicaid enrollment application to Gainwell Technologies.

1. Service Definition and Scope

In Vermont, skilled respite is authorized under the Global Commitment to Health 1115 Waiver for populations with complex medical needs, such as those in the Choices for Care or Traumatic Brain Injury (TBI) programs. It provides temporary relief to primary unpaid caregivers of individuals whose medical acuity requires an RN or LPN.

Because Vermont integrates skilled respite into broader home health or specialized waiver services, providers must operate under the scope of their overarching agency license or designation, delivering care according to a physician-ordered plan of care.

• Service Category: Home Health Agency services or Specialized Service Agency waiver services
• Target Population: Individuals in the Choices for Care, TBI, or Developmental Disabilities waivers requiring nursing-level care
• Delivery Setting: The participant's primary residence or an approved specialized community setting
• Covered Tasks: Medication administration, wound care, tube feeding, and continuous medical observation
• Excluded Services: Respite provided by unlicensed personal care attendants or companions
• Authorization Limit: TBI respite requires prior authorization by the TBI Program Manager and is typically used in 24-hour increments

2. Regulatory and Oversight Agencies

Multiple divisions within the Vermont Agency of Human Services oversee the delivery of skilled waiver services. The Department of Disabilities, Aging and Independent Living (DAIL) manages the specific waiver programs and provider enrollment approvals.

Licensure for agencies providing skilled nursing is handled by the Division of Licensing and Protection, while the Green Mountain Care Board controls market entry for home health agencies.

• Department of Disabilities, Aging and Independent Living (DAIL): Approves waiver providers and manages HCBS programs (https://dail.vermont.gov)
• Division of Licensing and Protection (DLP): Licenses Home Health Agencies and conducts regulatory surveys (https://dlp.vermont.gov)
• Developmental Disabilities Services Division (DDSD): Oversees Designated Agencies and Family Managed Respite (https://ddsd.vermont.gov)
• Green Mountain Care Board (GMCB): Administers the Certificate of Need program for healthcare facilities (https://gmcb.vermont.gov)
• Department of Vermont Health Access (DVHA): Serves as the state Medicaid agency managing the Global Commitment waiver (https://dvha.vermont.gov)
• Gainwell Technologies: Operates the Vermont Medicaid provider enrollment portal and MMIS (http://www.vtmedicaid.com)

3. Gatekeeping Prerequisites: Who Can Even Apply

Vermont strictly controls the entry of new agencies capable of providing skilled nursing services. A standalone business cannot simply apply to be a skilled respite provider; they must pass through structural market-control gates.

For home health agencies, this requires a Certificate of Need. For developmental disability providers, it requires a formal designation process that is rarely opened to new applicants unless a specific geographic or service gap is identified.

• Certificate of Need (CON): Required from the Green Mountain Care Board before establishing a new Home Health Agency
• DA/SSA Designation: Required from DAIL to operate as a Designated Agency or Specialized Service Agency for DD/TBI waivers
• Geographic Need Review: The GMCB and DAIL evaluate whether existing agencies in a county already meet the population's needs
• Medicare Certification: Home Health Agencies must meet Medicare Conditions of Participation (CoPs) to be licensed in Vermont
• DAIL Pre-Approval: Providers must submit a fillable application to [email protected] and receive approval before applying to Medicaid

4. Licensure and Certification Requirements

Agencies delivering skilled respite must hold a Home Health Agency license from the Division of Licensing and Protection. This licensure mandates adherence to both state regulations and federal Medicare standards.

Agencies operating under the DDSD framework must maintain their Specialized Service Agency certification, which involves rigorous quality management and case management standards.

• License Type: Vermont Home Health Agency License
• Regulatory Standard: Compliance with Medicare Conditions of Participation (CoPs) for home health
• Inspection Frequency: DLP conducts unannounced surveys typically every 36 months or upon complaint
• Administrator Qualifications: Must employ a qualified agency administrator and a clinical director (usually an RN)
• Insurance Requirements: Must maintain comprehensive general liability and professional liability insurance
• Physical Office: Must maintain a physical business office within the state of Vermont or an approved border catchment area

5. Medicaid Provider Enrollment

After securing DAIL approval and the appropriate license or designation, the agency must enroll with Vermont Medicaid through the fiscal agent, Gainwell Technologies.

The enrollment process requires submitting the DAIL approval letter alongside standard Medicaid agreements, ownership disclosures, and EFT authorization forms.

• Fiscal Agent: Gainwell Technologies manages the Provider Management Module (PMM)
• Prerequisite Document: Must include the official approval letter from the Adult Services Division or DDSD
• Provider Type: Enrolled under the specific HCBS waiver provider type authorized by DAIL (e.g., Home Health Agency)
• Application Portal: Vermont Medicaid Provider Enrollment Portal (http://www.vtmedicaid.com/#/provEnrollInstructions)
• Screening Risk Level: Home Health Agencies are typically subject to high-risk screening, including fingerprint-based background checks
• Revalidation: Providers must revalidate their Medicaid enrollment every five years

6. Staffing, Training and Background Checks

Because this service involves skilled nursing, all direct care must be provided by nurses licensed by the Vermont Board of Nursing. Unlicensed assistive personnel cannot perform skilled respite.

Agencies must conduct comprehensive background checks on all staff before they have direct contact with vulnerable adults or children.

• Clinical Staffing: Must be delivered by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensed in Vermont
• Registry Checks: Mandatory checks against the Vermont Adult Abuse Registry and Child Protection Registry
• Criminal Background: Fingerprint-based state and FBI criminal history checks required for all direct care staff
• OIG Exclusion: Monthly screening against the federal LEIE and SAM.gov databases
• Orientation: Staff must complete agency-specific orientation on waiver rules, incident reporting, and patient rights
• Supervision: LPNs must be supervised by an RN in accordance with Vermont Board of Nursing regulations

7. Documentation, Policies and Records

Skilled respite requires rigorous clinical documentation to justify the medical necessity of nursing-level care during the caregiver's absence.

Providers must maintain detailed care plans, physician orders, and shift notes that align with the participant's overarching waiver service plan.

• Physician Orders: Skilled nursing tasks must be ordered by a physician or advanced practice registered nurse
• Care Plan: Must have a person-centered care plan approved by the TBI Program staff or waiver case manager prior to implementation
• Shift Documentation: Nurses must document vital signs, interventions, and patient response for every respite shift
• Incident Reporting: Critical incidents must be reported to DAIL within 24 hours of discovery
• Record Retention: Clinical and billing records must be retained for a minimum of seven years
• Live-in Agreements: Not applicable for temporary skilled respite, but required if transitioning to Adult Family Care

8. Billing, Rates and Claims

Skilled respite is billed to Vermont Medicaid using specific HCPCS codes authorized on the participant's waiver service plan. Claims are processed through the Gainwell MMIS.

Rates for skilled nursing services are established prospectively by the Department of Vermont Health Access (DVHA) and are published in the official fee schedules.

• Billing System: Claims submitted via the Gainwell Provider Electronic Solutions (PES) software or web portal
• Prior Authorization: Mandatory prior authorization from the waiver program manager before delivering services
• HCPCS Codes: Billed using standard nursing codes (e.g., T1002 for RN, T1003 for LPN) with appropriate waiver modifiers
• Rate Setting: Rates are determined by DVHA and published on the Vermont Medicaid Fee Schedule page
• Unit Measurement: Billed in 15-minute increments or per diem depending on the specific waiver authorization
• Third-Party Liability: Medicaid is the payer of last resort; providers must bill primary insurance if applicable

9. Approval Sequence and Timeline

The pathway to providing skilled respite is lengthy due to the Certificate of Need and licensure requirements. Prospective agencies should plan for a multi-year process.

Only after the CON is granted and the HHA license is issued can the agency apply to DAIL for waiver provider status and subsequently enroll in Medicaid.

• Step 1: Submit Letter of Intent and CON application to the Green Mountain Care Board (6-12 months)
• Step 2: Apply for Home Health Agency licensure with the Division of Licensing and Protection (3-6 months)
• Step 3: Submit the fillable Provider Enrollment Application to DAIL Adult Services Division (30-60 days)
• Step 4: Complete the Medicaid Provider Enrollment application via Gainwell Technologies (30-45 days)
• Step 5: Receive Medicaid Welcome Letter and Provider ID
• Step 6: Obtain prior authorizations for specific waiver participants before initiating care

10. Common Denials and Survey Findings

Applications are most frequently halted at the Certificate of Need stage, as Vermont heavily restricts the proliferation of new home health agencies to protect existing market stability.

During regulatory surveys, agencies are commonly cited for documentation failures, particularly regarding the timely updating of physician orders and care plans.

• CON Denial: Failure to prove a definitive unmet need for skilled nursing services in the proposed geographic area
• Application Rejection: Submitting a Medicaid enrollment application to Gainwell without the required DAIL approval letter
• Survey Citation: Incomplete or missing background checks in personnel files prior to patient contact
• Survey Citation: Failure to document RN supervision of LPNs according to state nursing board rules
• Claim Denial: Billing for skilled respite without an active prior authorization on file in the MMIS
• Claim Denial: Exceeding the authorized number of respite hours or days per the participant's service plan

11. Key Contacts and Resources

Prospective providers must coordinate with multiple state entities. The DAIL Adult Services Division is the primary contact for waiver-specific enrollment questions.

For licensure and market entry, agencies must consult the Division of Licensing and Protection and the Green Mountain Care Board.

• DAIL Adult Services Division: [email protected] (https://asd.vermont.gov/resources/provider-enrollment)
• Division of Licensing and Protection: Oversees HHA licensure (https://dlp.vermont.gov)
• Green Mountain Care Board: Manages the Certificate of Need process (https://gmcb.vermont.gov)
• Vermont Medicaid Provider Enrollment: Gainwell Technologies portal (http://www.vtmedicaid.com/#/provEnrollInstructions)
• Developmental Disabilities Services Division: Manages DA/SSA designations (https://ddsd.vermont.gov)
• Vermont Board of Nursing: Regulates RN and LPN scope of practice (https://sos.vermont.gov/nursing/)

See all Vermont services · Vermont Medicaid consulting · book a consultation.