How Medicaid Pays for Home Care in Vermont

Vermont does not run its home care through a waiver

Almost every explanation of Medicaid home care a Vermonter will read online is about a program Vermont does not have. States can cover home and community-based services through several different federal authorities — Section 1915(c) waivers, the 1915(i), (j) and (k) state plan options, or a Section 1115 demonstration 1Ref 1Centers for Medicare & Medicaid Services (2025).Home & Community Based Services Authorities.That states may cover home- and community-based services through several different Medicaid authorities — 1915(c) waivers, the 1915(i)/(j)/(k) state plan options, or Section 1115 demonstrations — which is the distinction between the waiver route most states use and the demonstration route behind Vermont's program.. Most states reach for waivers. Vermont chose the demonstration, and runs essentially its whole Medicaid program, long-term care included, under one statewide agreement with the federal government called Global Commitment to Health.

That choice has consequences a family feels immediately. There is no separate waiver to apply to and no slot to wait for. There is one long-term care program, Choices for Care, and one assessment that sorts people within it. Vermont also does not hand long-term care to commercial insurance plans the way many states do; the state itself acts as the managed care entity.

Advice built on how waivers work — slots, caps, interest lists — mostly does not describe Vermont. The background it comes from is real enough: Medicaid pays close to 70% of home care spending nationally, and in most states home care is an optional benefit delivered through capped waivers 2Ref 2KFF (Kaiser Family Foundation) (2025).Medicaid Home Care (HCBS) in 2025.That Medicaid pays for nearly 70% of U.S. home care spending, and that home care is generally an optional Medicaid benefit frequently delivered through capped waivers — the national pattern Vermont's entitlement departs from.. Vermont is that sentence's exception, not its example — which is also why Medicaid home care in Florida or Medicaid home care in Georgia answers the same question with an entirely different structure.

Choices for Care and the promise Vermont made in 2005

Choices for Care exists to remove a bias built into Medicaid everywhere else. For most of the program's history, nursing home care was an entitlement — qualify, and the state must pay — while care at home was optional, capped, and rationed. A family could be told, in effect, that Medicaid would pay for a bed in a facility today or a place on a list at home in three years. Vermont ended that asymmetry for its highest-need residents in 2005.

Under Choices for Care, a person in the Highest Needs group is entitled to services in the setting they choose: their own home, an enhanced residential care setting, or a nursing facility. The money follows the person rather than the building. Federal policy has pushed the same direction through the Money Follows the Person demonstration, which funds states to move Medicaid beneficiaries out of institutions and back into community settings 3Ref 3Centers for Medicare & Medicaid Services (2025).Money Follows the Person.That the Money Follows the Person demonstration funds states to transition Medicaid beneficiaries out of institutions such as nursing facilities and into community and home settings — the federal policy direction toward home-based rather than institutional long-term care. — Vermont simply arrived early and made it structural rather than a transition program bolted on afterwards.

The practical translation for a Vermont family: for a parent whose needs are high enough, nobody can tell you the only funded option is a facility. That is the question worth asking out loud during a hospital discharge, because it is not always the first thing offered.

The three needs groups decide almost everything

Everything in Choices for Care turns on which of three groups the clinical assessment places a person in, and families are rarely told this clearly. The assessment looks at what a person can and cannot do without help — bathing, dressing, transferring, toileting, eating, moving safely — along with cognition and the risks of being alone. The resulting group, not the diagnosis and not the family's account of it, determines whether services are guaranteed.

• Highest Needs — an entitlement. Services are guaranteed in the setting the person chooses, and there is no waiting list.
• High Needs — real services, but dependent on available funding, which means there can be a wait.
• Moderate Needs — a limited menu, funding-limited, and the group most people have never heard of.

This is where Vermont diverges most sharply from the country. 41 states reported HCBS waiting or interest lists in 2025, with roughly 0.7 million people on one and an average wait around 32 months 4Ref 4KFF (Kaiser Family Foundation) (2025).A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2025.That 41 states had HCBS waiting or interest lists in 2025, that roughly 0.7 million people were on such lists, and that the average wait for waiver services was about 32 months.. Vermont's Highest Needs group sits outside that arithmetic by design.

Which makes the assessment the event that matters. It is a snapshot, and a good morning can misrepresent a hard month. A person with dementia may perform a task correctly once, in a quiet room, with a professional watching, and be unable to initiate it unprompted on any ordinary day. Describing what happens at 5pm on the worst days is not exaggeration; it is the accurate answer to the question asked.

How the care is delivered, and who can be hired to give it

Choices for Care is not one service arriving one way. A person who qualifies picks how the care is delivered, and the options are genuinely different from one another rather than variations on a theme. This is the part of the Vermont program that most rewards a family reading closely before the care plan is written, because switching later is possible but slow.

• Agency-directed — a home health or home care organization employs the workers, schedules them, and covers the shifts. Least work for the family, least control.
• Consumer-directed — the participant is the employer. They recruit, hire, train, schedule, and can dismiss their own workers, with a fiscal intermediary handling payroll and taxes.
• Surrogate-directed — the same, when the participant cannot manage it themselves and a family member or friend acts as surrogate employer.
• Flexible Choices — a monthly allowance the participant budgets themselves, trading some services for the freedom to solve the problem their own way.
• Adult Family Care — the person lives in an approved caregiver's home, sometimes a relative's, and that household is paid to provide the care.

The consumer-directed and surrogate-directed options are how a Vermont family member gets paid. Medicaid's self-directed model is built for it: the beneficiary manages a budget and selects, hires, trains, and manages their own caregivers, and in some states may pay a family member 5Ref 5Centers for Medicare & Medicaid Services (2025).Self-Directed Services.That Medicaid self-directed service delivery lets a beneficiary manage a budget and select, hire, train, and manage their own caregivers, and that some states permit paying a family member — the federal model behind Vermont's consumer-directed and surrogate-directed options.. Which relatives can be hired is narrower for a spouse than for an adult child, and it is the rule to confirm before anyone quits a job. Vermont also runs an Attendant Services Program through its disability and aging department, including a state-funded track for some adults who do not qualify for Medicaid at all.

The Moderate Needs group is the door before the crisis

Moderate Needs is the part of Choices for Care that goes most underused, and it is aimed at exactly the person most families are worried about first. Not the parent who cannot transfer out of bed — the parent who is managing, mostly, but has stopped cooking properly, is not safe to leave for a full day, and whose daughter is quietly burning through her own leave to cover the gaps.

The Moderate Needs menu is smaller by design: homemaker help, adult day services, and case management, rather than a full attendant care plan. It is funding-limited, so it is not guaranteed the way Highest Needs is, and it can carry a wait. But it is the only group that is available before things have fully come apart, and adult day services in particular buy a working caregiver the one thing no amount of advice does, which is hours.

A parent who does not need hands-on help yet is not too early to ask about Choices for Care. The assessment is the same conversation either way, and being told a person is Moderate Needs today is not a rejection. It is a baseline, and it means the program already knows who they are when the day comes that the answer changes.

The oldest, most rural state, and the workers who are not there

An entitlement is a promise about money, not a promise about a person in the doorway. Vermont has one of the oldest populations in the country and one of the most rural, and both facts land on the same problem. Its largest city has fewer than fifty thousand people. There is no metro labor pool for home care to draw on, and a February drive up an unplowed dirt road in the Northeast Kingdom is a real constraint on whether an aide can reach a house at all.

So in Vermont the binding limit is frequently the workforce rather than the eligibility rules. A family can hold a fully authorized Highest Needs plan and still be unable to staff the overnight hours. This is not a paperwork failure and appealing it does not help, because there is nothing to appeal.

What does help is the choice of delivery option. In a town where no agency has spare staff, consumer-directed hiring lets a family employ someone who is already there — a neighbor, a cousin, someone known at the store — and pay them through Medicaid at a rate the state sets. Rural Vermont is where self-direction stops being a philosophical preference about autonomy and starts being the only arrangement that produces an actual caregiver on an actual Tuesday.

Where to start in Vermont, and what to have ready

Two determinations run in parallel and both have to land before Choices for Care begins. The clinical one is the in-home assessment that sorts a person into Highest, High, or Moderate Needs. The financial one tests income and countable resources against Vermont's long-term care Medicaid limits, and it is a different test from the one used for regular Medicaid coverage — a person can be on Vermont Medicaid already and still have to qualify separately for long-term care.

Before either, it is worth being clear about why this program is the whole conversation. Medicare does not pay for ongoing custodial care. Help with bathing, dressing, meals, and supervision is generally paid out of pocket, by Medicaid for those who qualify, or by a long-term care insurance policy 6Ref 6Administration for Community Living (2025).Costs of Care.That Medicare does not pay for ongoing custodial or personal care, and that home care is generally paid out of pocket, by Medicaid for those who qualify, or by long-term care insurance.. Vermont's five Area Agencies on Aging will walk a family through all of it, at no cost, and they are not selling anything.

What makes the assessment go well:

• Write down two weeks before it happens. Falls, nights, missed medications, what the person could not do without help and who did it instead.
• Have the person there and let them answer. Then fill in what a good morning conceals, rather than correcting them in front of the assessor.
• Ask which group the assessment landed in and why. It is the fact that decides whether services are guaranteed, and a family is entitled to understand the reasoning.
• Ask about the delivery options by name, before the plan is drafted, if a relative might become the paid caregiver.