Vermont Medicaid (Green Mountain Care) Choices for Care (CFC) Program: Highest Needs Group

Last updated: March 08, 2024


Overview of Vermont Choices for Care: Highest Needs Group

Vermont’s Choices for Care Program, or CFC Program, provides Medicaid-funded long-term care for state residents who are elderly or physically disabled. CFC is broken into two groups based on care needs: the High / Highest Needs Group and the Moderate Needs Group. This page is focused on the Choices for Care High / Highest Needs Group.

While nursing home care is an available benefit via the CFC High / Highest Needs Group, the state also provides a variety of home and community based services (HCBS) to prevent and delay the need for such care. This includes in-home assistance with Activities of Daily Living (ADLs), such as bathing, dressing, personal hygiene, toiletry, eating, and mobility, and Instrumental Activities of Daily Living (IADLs), like preparing meals, housekeeping, money management, laundry, and shopping. Other available benefits may include home modifications for safety and accessibility, adult day care, assistive devices, and respite care.

Program participants can live at home, the home of a loved one, an enhanced residential care facility (a Level III residential care home, an assisted living residence, or home for the terminally ill), or an adult family care home (adult foster care home).

There is a consumer-directed option for program participants who reside in a home-based setting. Via Flexible Choices, the program participant or a “surrogate”, such as a friend or relative, becomes the “employer”. With the assistance of an advisor, a budget is created, and services are purchased with an approved cash allowance. This allows persons to hire, train, supervise, and even fire, the caregiver of their choosing. Friends and relatives, including one’s adult child or spouse, can be hired to provide care. A Fiscal Intermediary Service Organization handles the financial aspects of employment responsibilities such as background checks, tax withholding, and caregiver payments.

Medicaid in Vermont is called Green Mountain Care. Vermont’s entire Medicaid program operates under an 1115(a) Demonstration Waiver called Global Commitment to Health. The Choices for Care Long Term Care Medicaid Program through which nursing facility care and home and community based (HCBS) services are available is authorized under this Waiver. HCBS offered under the Vermont’s Choices for Care Program are not necessarily an entitlement; meeting the eligibility criteria does not mean one will immediately receive program benefits. Instead, the number of participant slots may be limited, and when these slots are full, a waiting list forms.

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Wait List Alternatives: Are you interested in connecting with a Medicaid Planning Professional to discuss alternatives to VT’s Choices for Care Program? Wait-lists can last from months to years, but there are other Medicaid programs that offer immediate care outside of nursing homes.
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 The Choices for Care Moderate Needs Group is for seniors and adults with physical disabilities who do not require a Nursing Facility Level of Care, but are at risk of requiring such care. Limited home and community based services, such as adult day care and homemaker services, are offered under this program.


Benefits of Choices for Care: Highest Needs Group

In addition to State Plan Medicaid benefits, such as physician visits, hospitalization, and nursing facility care, a variety of home and community based services are available. The exact HCBS benefits a program participant receives is based on an individualized service plan, but may include the following.

– Adult Day Care – daytime care and supervision in an adult day center
– Adult Family Care Home Services – around the clock care / supervision
– Assistive Devices
– Case Management
– Companion Care – non-medical care, supervision, and socialization
– Enhanced Residential Care Home Services – supervision, personal care assistance, social / recreational activities, on-site nurse
– Habilitation
– Home Modifications – i.e., ramps, grab bars, widening of doorways
– Homemaker Services – light housecleaning, laundry, meal preparation
– Non-Medical Transportation
– Personal Care Services – assistance with bathing, dressing, eating, toileting, laundry, preparing meals, shopping
– Personal Emergency Response Systems
– Respite Care – in-home and out-of-home care to relieve an unpaid primary caregiver

While services and supports can be provided in enhanced residential care facilities and adult family care homes, the cost of room and board is not covered by the CFC Program.


Eligibility Requirements for Vermont Medicaid’s Choices for Care Program

Choices for Care High / Highest Needs Group is for seniors (65+ years of age) and adults with physical disabilities (18+ years old) who are Vermont residents. Additional eligibility criteria follows and is relevant for those seeking home and community based services.

Financial Criteria: Income, Assets & Home Ownership

The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR). This figure increases each January, and in 2024, is $2,829 / month. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,829 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of their spouse. Only the applicant spouse’s income is considered, which is limited to $2,829 / month. Furthermore, the non-applicant spouse may be entitled to a Spousal Income Allowance, called a Monthly Maintenance Needs Allowance, from their applicant spouse.

Vermont has set a minimum income allowance of $2,555 / month. This allows an applicant spouse to supplement their non-applicant spouse’s monthly income, bringing their income up to this amount. The state also sets a maximum income allowance of $3,853.50 / month. While this potentially allows a non-applicant spouse a higher income allowance, any additional amount above the minimum income allowance is dependent on one’s shelter and utility costs. A Spousal Income Allowance, however, can never push a non-applicant’s total monthly income over $3,853.50.

In 2024, the asset limit is $2,000 for a single applicant. An exception does, however, exist for single applicants who own a home and continue to live in it; these applicants can have up to $5,000 in assets. For married couples, with both spouses as applicants, the asset limit is $4,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are still limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can retain up to $2,000, while the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA) to prevent spousal impoverishment. The CSRA allows the non-applicant spouse to keep up to $154,140 in assets.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a Look-Back Rule and violating it results in a Penalty Period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our Medicaid Spend-down Calculator.


Home Ownership
The home is often the highest valued asset a Vermont Medicaid applicant owns, and many persons worry that Medicaid will take it. For eligibility purposes, the home is considered exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has Intent to Return, and in 2024, their home equity interest is no greater than $713,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– The applicant has a spouse living in the home.
– The applicant has a minor child living in the home.
– The applicant has a permanently disabled or blind adult child living in the home.

While the home is likely exempt while one is receiving Medicaid benefits, it may not be safe from Medicaid’s Estate Recovery Program. Learn more about the potential of Medicaid taking the home here.


Medical Criteria: Functional Need

An applicant must require a Nursing Facility Level of Care (NFLOC). A need for significant assistance with Activities of Daily Living (i.e., transferring, eating, toileting, bed mobility) is generally indicative that one requires this level of care. A need for skilled nursing, such as wound care, open lesions, tube feedings, and dialysis, are also taken into account. Cognitive deficits, such as impaired decision making skills and / or impaired judgement, and specific behaviors, such as wandering, which are common in persons with Alzheimer’s Disease or a related dementia, are also considered. However, a diagnosis of dementia, in and of itself, does not mean one will automatically meet the level of care need. An in-person assessment is completed by a registered nurse in order to determine if one requires a NFLOC.

 Learn more about long-term care Medicaid in Vermont.


Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for VT Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

Persons who have income over the limit, but have high medical bills, can become income eligible via Vermont’s Spend-Down Program. This program permits applicants to spend their “excess” income on medical expenses in order to meet the Medically Needy income limit. The amount that must be paid each month can be thought of as a deductible. Once one’s “deductible” has been met for the month, Choices for Care will pay for services and supports. More about the Medically Needy pathway to eligibility.

When persons have assets over the limits, one option is to “spend down” assets. Examples include paying off debt, making home modifications, and purchasing pre-paid funeral and burial expense trusts called Irrevocable Funeral Trusts. Another option, but one that must be implemented well in advance of the need for care, is placing assets in a Medicaid Asset Protection Trust. There are many other strategies when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in Vermont to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional Medicaid planning strategies that not only help one meet Medicaid’s financial criteria but can also protect assets from Medicaid’s Estate Recovery Program. These strategies often violate Medicaid’s 60-month Look-Back Rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.


How to Apply for Vermont Choices for Care: Highest Needs Group

Before You Apply

Prior to applying for the CFC Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.

Since home and community based services are not an entitlement, there may be a waiting list to receive these benefits. In the case of a waiting list, applicants with a higher need for care are given priority. This means persons who submitted an application at a later date than other applicants may be awarded a participant slot first if their needs are greater.


Application Process

Persons can apply for the Choices for Care Program by completing and submitting an Application for Long-Term Care Medicaid. Persons can also call the ESD Benefits Service Center at 800-479-6151 to request a mailed application and / or to ask program related questions.

More information about the CFC Program can be found here and here. Persons can also call the Area Agency on Aging (AAA) Helpline at 800-642-5119 to be connected to their local agency, or click here, for links to the 5 local agencies.

The Department of Disabilities, Aging & Independent Living (DAIL) within the Vermont Agency of Human Services (AHS) administers the Choices for Care Program and determines functional eligibility. The Economic Services Division (ESD) within the Department of Vermont Health Access (DHVA) determines financial eligibility.


Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even longer. Furthermore, as a waiting list for home and community based services may exist, approved applicants may spend many months waiting to receive benefits.

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