Vermont Medicaid Long-Term Care Application Packet (Choices for Care)

VERMONT MEDICAID LONG-TERM CARE APPLICATION PACKET — CHOICES FOR CARE (CFC)

TABLE OF CONTENTS

1. Applicant Identification
2. Program Overview and Routes to Coverage
3. Categorical and Clinical Eligibility
4. Financial Eligibility — Income
5. Financial Eligibility — Resources
6. Treatment of the Primary Residence
7. Spousal Impoverishment Protections
8. Sixty-Month Look-Back and Transfer Penalties
9. Medically Needy Spend-Down Pathway (MABD)
10. Required Documentation Checklist
11. Application, Notice, and Appeal Procedures
12. Estate Recovery
13. Authorizations and Signatures
14. Vermont Practice Notes
15. Sources and References

1. APPLICANT IDENTIFICATION

2. PROGRAM OVERVIEW AND ROUTES TO COVERAGE

2.1. Administering Agency. The Department of Vermont Health Access ("DVHA"), within the Agency of Human Services, administers Medicaid in Vermont under the umbrella brand "Green Mountain Care." Long-term services and supports for adults age 65 or older and adults with physical disabilities are delivered through the Choices for Care (CFC) program, operated under Vermont's Section 1115 Global Commitment to Health Demonstration Waiver.

2.2. Functional Screening. Functional and clinical screening is conducted by the Department of Disabilities, Aging and Independent Living ("DAIL") in cooperation with the local Area Agency on Aging or designated home health agency.

2.3. Service Settings. CFC funds three settings:

• ☐ Nursing Facility (skilled nursing home);
• ☐ Enhanced Residential Care (ERC) in a licensed residential care home or assisted living residence;
• ☐ Home and Community Based Services (HCBS) delivered in the participant's own home (personal care, adult day, respite, case management, assistive devices, home modifications).

2.4. Service Group. Applicant seeks placement in the:

• ☐ Highest Needs Group (entitlement; clinically eligible for nursing facility level of care);
• ☐ High Needs Group (subject to capacity / waitlist);
• ☐ Moderate Needs Group (limited services: adult day, case management, homemaker).

3. CATEGORICAL AND CLINICAL ELIGIBILITY

3.1. Categorical. Applicant must be:

• ☐ Age 65 or older; OR
• ☐ Determined disabled by SSA or by the State Medical Review Team (SMRT); OR
• ☐ Legally blind.

3.2. Citizenship / Immigration. Applicant is a:

• ☐ U.S. citizen;
• ☐ U.S. national;
• ☐ Qualified non-citizen (attach documentation).

3.3. Vermont Residence. Applicant is a Vermont resident with intent to remain (no minimum durational residency requirement).

3.4. Clinical Eligibility (CFC Highest Needs). Applicant requires extensive assistance or total dependence with at least one of the following Activities of Daily Living, OR has cognitive impairment with behavioral symptoms requiring 24-hour supervision: ☐ bathing ☐ dressing ☐ toileting ☐ transferring ☐ eating ☐ mobility.

4. FINANCIAL ELIGIBILITY — INCOME

4.1. Income Limit (Institutional / HCBS). Vermont applies the special income standard for institutionalized individuals at three times the SSI Federal Benefit Rate (300% of SSI), commonly approximately $2,901 per month (verify current figure on DVHA / Vermont Health Connect eligibility table). Applicants over the cap may still qualify through the Vermont MABD medically needy spend-down pathway (see Section 9).

4.2. Personal Needs Allowance (PNA). A nursing-facility resident retains a monthly Personal Needs Allowance (historically $77.25/month; verify current PNA). HCBS and ERC participants retain a higher protected amount based on the Maintenance Needs Allowance.

4.3. Cost of Care / Patient Share. Income above the protected allowances is applied toward the cost of care ("patient share"), after deducting:

• ☐ Personal Needs Allowance;
• ☐ Health insurance premiums (Medicare Part B/D, Medigap);
• ☐ Court-ordered support;
• ☐ Community spouse Monthly Maintenance Needs Allowance (if applicable).

4.4. Sources of Income (Applicant).

5. FINANCIAL ELIGIBILITY — RESOURCES

5.1. Resource Limit (CFC). Subject to verification on the current DVHA eligibility table:

• ☐ $2,000 — single applicant;
• ☐ $5,000 — single applicant who owns and continues to live in the homestead;
• ☐ $3,000 — two persons (couple, both applying through CFC);
• ☐ $4,000 — couple where both spouses are applicants in certain configurations.

5.2. Countable Resources. Cash; checking, savings, money-market accounts; CDs; stocks, bonds, mutual funds, brokerage accounts; non-homestead real property; cash-value life insurance above $1,500 face value; second vehicles.

5.3. Exempt / Non-Countable Resources.

• ☐ Homestead (subject to home-equity cap, see Section 6);
• ☐ One automobile (regardless of value when used for the applicant or community spouse);
• ☐ Personal effects, household goods, and furnishings;
• ☐ Irrevocable burial trust / pre-paid funeral contract;
• ☐ Burial fund up to $10,000 per person;
• ☐ Term life insurance and small face-value cash-value policies (face value ≤ $1,500);
• ☐ Independent living contract funds reserved for home modifications or additional care (verify current limit);
• ☐ Property essential to self-support.

5.4. Resource Inventory.

6. TREATMENT OF THE PRIMARY RESIDENCE

6.1. Homestead Exemption. The applicant's principal place of residence is non-countable while the applicant resides there or expresses an intent to return.

6.2. Home-Equity Cap. Federal law (42 U.S.C. § 1396p(f)) bars long-term care Medicaid eligibility if the applicant's equity in the home exceeds the annually indexed CMS cap (approximately $730,000-$752,000 for 2025/2026 — VERIFY current cap on DVHA published guidance). Exceptions exist where a spouse, minor, or disabled child resides in the home.

6.3. Intent to Return. Applicant declares: ☐ Intent to return to homestead at [________________________________]. ☐ No intent to return.

6.4. Lady Bird / Enhanced Life Estate Deeds. Vermont permits enhanced life estate ("Lady Bird") deed planning, which can avoid probate-only estate recovery; DVHA's expanded estate recovery posture should be confirmed before relying on this strategy.

7. SPOUSAL IMPOVERISHMENT PROTECTIONS

7.1. Community Spouse Resource Allowance (CSRA). Per 42 U.S.C. § 1396r-5, the community spouse may retain countable resources up to the CSRA (Vermont applies the maximum federal CSRA, historically near $154,140-$162,660 — VERIFY current cap).

7.2. Monthly Maintenance Needs Allowance (MMNA). The community spouse is entitled to a Minimum MMNA (historically near $2,555/month) up to a Maximum MMNA (historically near $3,948/month — VERIFY current floors and ceilings).

7.3. Snapshot Date. The "snapshot" of resources is taken on the first day of the first continuous period of institutionalization of at least 30 days. Snapshot date: [__/__/____].

7.4. Fair-Hearing Increase. A community spouse who cannot generate income up to the MMNA may petition for an expanded CSRA via DVHA fair hearing, supported by income/asset documentation.

8. SIXTY-MONTH LOOK-BACK AND TRANSFER PENALTIES

8.1. Look-Back Period. Sixty (60) months immediately preceding the date of Medicaid application. Look-back start date: [__/__/____].

8.2. Penalty Calculation. Penalty period (months) = uncompensated value transferred ÷ Vermont penalty divisor. Vermont's divisor is the statewide average private-pay nursing-facility rate published by DVHA (historically near $11,000-$11,500/month — VERIFY current divisor).

8.3. Penalty Start. Penalties begin on the later of (a) the date of transfer or (b) the date the applicant is otherwise eligible for Medicaid and would be receiving long-term care services but for the transfer.

8.4. Transfer Inventory. List ALL transfers (including gifts, sales for less than fair market value, property transferred to/from a trust) within the look-back:

8.5. Exempt Transfers (no penalty). Transfers to:

• ☐ A spouse, or to a third party for the sole benefit of the spouse;
• ☐ A blind or permanently disabled child;
• ☐ A trust for the sole benefit of a disabled person under age 65 (42 U.S.C. § 1396p(c)(2)(B)(iv));
• ☐ A "caregiver child" who resided in the homestead for at least two years immediately before institutionalization providing care that delayed institutionalization;
• ☐ A "sibling co-owner" with an equity interest who resided in the homestead at least one year before institutionalization;
• ☐ Transfer demonstrably made exclusively for a purpose other than to qualify for Medicaid.

9. MEDICALLY NEEDY SPEND-DOWN PATHWAY (MABD)

9.1. Vermont MABD Program. Vermont operates a Medicaid for the Aged, Blind, and Disabled (MABD) category with a medically needy spend-down. Applicants with countable income above the Protected Income Level (PIL) may become eligible by incurring medical expenses sufficient to reduce excess income to the PIL.

9.2. Spend-Down Period. A six-month budget period applies; the applicant satisfies the spend-down by submitting bills, premiums, and qualifying medical expenses.

9.3. Allowable Spend-Down Expenses. Health insurance premiums (including Medicare and Medigap), out-of-pocket medical/dental/vision/hearing bills, prescription costs, transportation to medical appointments, and remedial care.

9.4. Note on CFC vs. MABD. CFC long-term care services use a higher special income standard (≈ 300% SSI) without the MABD spend-down. Applicants over the CFC income cap may use a Qualified Income Trust ("Miller Trust") strategy if available; verify current Vermont policy with DVHA before establishing.

10. REQUIRED DOCUMENTATION CHECKLIST

☐ DVHA application form (Form 202LTC or current successor)
☐ Birth certificate or other proof of date of birth
☐ Proof of U.S. citizenship or qualified non-citizen status
☐ Social Security card
☐ Medicare card and proof of Part B/D enrollment
☐ Proof of Vermont residence (utility bill, lease, deed)
☐ Marriage certificate (if applicable)
☐ Death certificate of deceased spouse (if applicable)
☐ Divorce decree / separation agreement (if applicable)
☐ Sixty (60) months of bank, brokerage, retirement, and investment statements for ALL accounts (applicant and spouse)
☐ Sixty (60) months of life-insurance statements (face value, cash value)
☐ Real-property deeds, current tax assessment, mortgage statements
☐ Vehicle titles and current valuation
☐ Pre-paid funeral / burial trust contracts
☐ Trust instruments (revocable and irrevocable)
☐ Annuity contracts (with payout schedule)
☐ Pension and annuity benefit verification
☐ Two most recent federal income-tax returns
☐ Current health-insurance cards and premium statements
☐ Durable Power of Attorney / Authorized Representative designation
☐ Guardianship order (if applicable)
☐ Functional / clinical assessment results from DAIL
☐ Documentation supporting any exempt transfer claimed in Section 8

11. APPLICATION, NOTICE, AND APPEAL PROCEDURES

11.1. Filing. File the completed Form 202LTC, supporting documentation, and clinical screening request:

• DVHA, Application & Document Processing Center, 280 State Drive, Waterbury, VT 05671;
• Phone: 1-800-250-8427; or
• Online via the Vermont Health Connect / Green Mountain Care portal.

11.2. Effective Date. Medicaid coverage may be retroactive for up to three (3) calendar months prior to the month of application if the applicant was otherwise eligible.

11.3. Notice of Decision. DVHA must issue a written eligibility determination (45 days for non-disability cases; 90 days where disability determination is required).

11.4. Fair Hearing. Adverse decisions may be appealed to the Human Services Board pursuant to 3 V.S.A. Chapter 25 within ninety (90) days of notice. Aid pending appeal is available in certain circumstances.

11.5. Reconsideration / SMRT. Disability denials may be reviewed by the State Medical Review Team prior to or in addition to a fair hearing.

12. ESTATE RECOVERY

12.1. Federal Mandate. Pursuant to 42 U.S.C. § 1396p(b), Vermont must seek recovery from the estates of deceased Medicaid recipients age 55 and older for long-term care services received.

12.2. Vermont Estate Recovery Scope. Vermont historically recovers from probate estates and may recover from non-probate transfers in some circumstances; DVHA's current estate recovery policy and Vermont Department for Children and Families administrative guidance should be reviewed.

12.3. Hardship Waiver. A surviving heir may petition DVHA for an undue-hardship waiver, particularly where the estate is the sole income-producing asset of the heir or is the heir's primary residence.

12.4. Disclosure to Applicant. The applicant acknowledges receipt of written notice of the estate-recovery program: ☐ Yes ☐ No.

13. AUTHORIZATIONS AND SIGNATURES

I, [APPLICANT NAME], declare under penalty of perjury under the laws of the State of Vermont that the foregoing information is true and correct to the best of my knowledge. I authorize DVHA, DAIL, and their agents to verify all information disclosed, including the obtaining of financial records under the Right to Financial Privacy Act and 33 V.S.A. § 1901 et seq. I understand that a knowingly false statement may subject me to criminal prosecution and disqualification.

Applicant Signature: [________________________________]

Print Name: [APPLICANT NAME]

Date: [__/__/____]

Authorized Representative Signature (if applicable): [________________________________]

Print Name and Capacity: [________________________________]

Date: [__/__/____]

Attorney Signature: [________________________________]

[ATTORNEY NAME], Vermont Bar No. [####]

Counsel for Applicant

[STREET ADDRESS] | [CITY, VT ZIP] | Tel: [__________] | Email: [__________]

14. VERMONT PRACTICE NOTES

• Single-state plan / 1115 waiver. Choices for Care is authorized through Vermont's Section 1115 Global Commitment to Health Demonstration. The waiver is renewed periodically; service array, screening criteria, and resource/income standards may change at renewal — confirm against the most recent CMS-approved Special Terms and Conditions.
• Entitlement vs. capacity. Highest Needs Group services are an entitlement once clinical criteria are met. Moderate Needs services are subject to appropriated capacity and waitlists.
• Annuities. A spousal annuity is a permissible spend-down strategy only if it meets all DRA-2005 conditions: irrevocable, non-assignable, actuarially sound, with the State of Vermont named as remainder beneficiary in the first position to the extent of any Medicaid paid (or second position behind a community spouse / minor or disabled child).
• Pooled and special-needs trusts. First-party (d)(4)(A) and pooled (d)(4)(C) trusts (42 U.S.C. § 1396p(d)(4)) are honored. Vermont participates with national pooled trust providers; verify Medicaid payback provisions.
• Caregiver-child exemption. The two-year care threshold is strictly construed. Document daily caregiving, physician corroboration that institutionalization was avoided, and exclusive residence.
• Lady Bird deeds. Vermont practitioners use enhanced life estate deeds to bypass probate-only estate recovery; coordinate with title insurance and confirm DVHA's current expanded recovery posture.
• Treatment of IRAs. Vermont generally counts the non-applicant spouse's qualified retirement accounts in pay status differently from those of the applicant. Confirm under current DVHA HBEE rules.
• Coordination with VA Aid & Attendance. Applicants receiving VA Aid & Attendance pension must report the benefit; portions may be excluded from countable income depending on classification (UME vs. pension).
• Pre-eligibility planning. All transfers, trust funding, annuity purchases, and asset reconfigurations should be completed under the supervision of a Vermont elder-law attorney with current knowledge of DVHA HBEE rules and the live 1115 waiver Special Terms and Conditions.

15. SOURCES AND REFERENCES

• Department of Vermont Health Access (DVHA) — Long-Term Care Medicaid: https://dvha.vermont.gov/providers/long-term-care-medicaid
• DVHA — Green Mountain Care: https://dvha.vermont.gov/
• Department of Disabilities, Aging and Independent Living (DAIL) — Choices for Care: https://dail.vermont.gov/
• Vermont Health Connect — 2025 / 2026 Eligibility Tables: https://info.healthconnect.vermont.gov/compare-plans/eligibility-tables
• Vermont Health Connect — Medicaid Spenddowns: https://info.healthconnect.vermont.gov/compare-plans/medicaid-and-dr-dynasaur/medicaid-spenddowns
• Vermont Legal Aid — Choices for Care Resource Limits: https://vtlawhelp.org/choices-care-resource-limits
• Vermont Legislature — Title 33, Chapter 19 (Health Care for Vermonters): https://legislature.vermont.gov/statutes/title/33
• Code of Vermont Rules — Health Benefits Eligibility & Enrollment (HBEE): https://regulations.justia.com/states/vermont/agency-13/
• Centers for Medicare & Medicaid Services — Vermont 1115 Global Commitment to Health: https://www.medicaid.gov/medicaid/section-1115-demonstrations/
• 42 U.S.C. § 1396p (Liens, Adjustments and Recoveries; Transfers): https://www.law.cornell.edu/uscode/text/42/1396p
• 42 U.S.C. § 1396r-5 (Spousal Impoverishment): https://www.law.cornell.edu/uscode/text/42/1396r-5
• 3 V.S.A. Chapter 25 (Administrative Procedure Act / Human Services Board fair hearings)

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Vermont-licensed attorney must review and customize this document before filing or relying on any planning strategy. Medicaid figures (asset limits, income limits, penalty divisor, home-equity cap, spousal allowances, PNA/MMNA) are revised annually and may have changed since the last_updated date above; verify all dollar amounts on the official DVHA and Vermont Health Connect eligibility tables before submission.