Medicaid for nursing home and home care in Vermont

Who qualifies

You must meet four tests:

1. You live in Vermont.
2. Age or disability. You are 65 or older, or 18 or older with a physical disability.
3. Care needs. The state finds that you need nursing-home-level care. In Choices for Care this is called the "High" or "Highest" need group.
4. Money rules. Your income and assets meet the limits below.

Two different offices decide. The Department of Vermont Health Access (DVHA) checks your money. The Department of Disabilities, Aging and Independent Living (DAIL) checks your care needs.

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Money rules

If your income is over the standard

You are not shut out. Vermont lets you "spend down." If your income is above the limit for your group, you must spend down to the protected income level ($1,375 a month outside Chittenden County, $1,483 inside it) in the month you apply or the next month.

Your home

Your main home is not counted as long as it stays your principal place of residence. If your equity in the home is more than $752,000, you may not qualify for long-term care.

Gifts and transfers: the 60-month look-back

When you apply, DVHA looks at money or property you gave away or sold for less than it was worth in the 60 months before you asked for coverage. A transfer for fair value has no penalty. For gifts, Vermont adds up the value and divides by the average private cost of a nursing home ($12,535.13 a month). The result is the length of time Medicaid will not pay for your long-term care. There are hardship rules, and some transfers of a home to certain family members are allowed.

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If you are married: what your spouse keeps

The spouse who stays at home is called the "community spouse."

• Assets: Your spouse can keep up to $162,660 of the couple's countable assets.
• Income: Your spouse keeps their own income. If it is low, part of your income can go to them. The standard allocation is $2,707 a month, and the most it can be is $4,066.50 a month.
• Other family: A dependent family member with no income can get an allocation of up to $902.33 a month.

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The patient share: what you pay each month

Once you qualify, most of your income goes toward your care. This is your "patient share." Medicaid pays the rest. Before your share is figured, Vermont lets you keep:

• In a nursing home: A personal needs allowance of $79.93 a month ($159.85 for a couple).
• At home on Choices for Care: A community maintenance allowance of $1,483 a month for rent, food and bills.
• Home upkeep: A home upkeep deduction of up to $787.26 a month can be allowed for six months, to help keep up your home.
• Spouse and family allocations, as above.

You never pay more than the cost of your care.

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Choices for Care: where you can get care

Choices for Care is Vermont's long-term care program for people who need nursing-home-level care. You can choose:

• Home-based care. Traditional services, Flexible Choices, or Adult Family Care. This can be in your own home or a family member's home.
• Enhanced Residential Care. Care in an approved residential care home or assisted living.
• Nursing facility. Care in an approved nursing home.

Moderate Needs Group

If you need some help but not nursing-home-level care, the Moderate Needs Group may pay for homemaker help, adult day, case management or flexible funds. You do not have to be eligible for Medicaid, but funding is limited. Ask your Area Agency on Aging or home health agency.

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How to apply, step by step

1. Get form 202LTC. Download it from the DVHA long-term care page, or call the LTC Customer Support Unit at 802-476-0100 or toll-free 1-833-840-0061 and ask for one by mail.
2. Fill it out and sign it. List all income and assets for you and your spouse.
3. Mail it to Green Mountain Care Application and Document Processing Center, 280 State Drive, Waterbury, VT 05671-1500. You can also fax the application to 802-241-0865.
4. Send proof when asked. Mail it to the same Waterbury address, upload it with a secure AHS Uploader account at my.vermont.gov, drop it off at a DCF district office, or fax it to 802-241-0514. The DVHA office in Waterbury does not take walk-ins.
5. Have the care needs assessment. For Choices for Care, a DAIL Long-Term Care Clinical Coordinator decides if you meet the High or Highest level. Your local home health agency or Area Agency on Aging can help start this.
6. Get your notice. It will say whether you qualify and how much your patient share is.

DVHA will tell you which proof of income and assets it needs. Send only the documents it asks for.

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After you are approved

• Yearly review. DVHA reviews your eligibility at least once a year. Send back renewal forms on time.
• Report changes in income, assets or address. Call 1-855-899-9600, Monday to Friday, 7:45 a.m. to 4:30 p.m.
• If you are denied. You have 90 days from the date on the notice to appeal an eligibility decision. Call 1-855-899-9600, email [email protected] with "Appeal" in the subject line, appeal in your online account, or write to the Human Services Board, 6 Baldwin Street, Suite 305, Montpelier, VT 05633-4302.

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Common mistakes

• Gifts in the past 60 months. Gifts to children or others can delay coverage. Tell DVHA about them up front.
• Thinking you earn too much. Income over the standard does not automatically mean no.
• Forgetting the care-needs part. DVHA approval alone is not enough for Choices for Care. DAIL must also find you need that level of care.

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Free help

• Senior HelpLine: 1-800-642-5119. It connects you to your local Area Agency on Aging, which also runs SHIP (free Medicare counseling).
• LTC Customer Support Unit (money questions): 802-476-0100 or 1-833-840-0061.
• DAIL Adult Services Division: 802-241-0294.
• Legal help: Vermont Legal Aid at 1-800-889-2047.

Read more about paying for a nursing home, and see all benefits in Vermont. If you have Medicare, see how Medicare Part A covers short nursing home stays.

Phone numbers: Free help lines for Vermont agencies

Check what you may qualify for