Green Mountain Care Board staff detail Certificate of Need process, thresholds and pending bills

Laura Bellavoe, staff attorney for the Green Mountain Care Board, described the board’s Certificate of Need (CON) process, the legal thresholds that trigger review and ongoing legislative questions about exemptions and threshold levels.

CON review matters because it governs whether health-care projects—including facility construction, major equipment purchases and some service expansions—must undergo state review intended to limit duplication, control costs and protect access to care.

Bellavoe said a project may fall under CON jurisdiction in two ways: by exceeding capital-cost thresholds or by meeting non-cost criteria. As presented to the committee, a hospital capital cost that exceeds roughly $3,800,000 and a non-hospital capital cost that exceeds roughly $1,900,000 would trigger CON review; the board also looks at projected operating expenses for the first two fiscal years (the non-hospital operating threshold discussed was about $632,000 for a given year). Non-cost triggers include changes in licensed bed counts, offering home-health services (subject to a moratorium through 2030 with exceptions), transfer of ownership above 50 percent and establishment of ambulatory surgical centers.

Bellavoe described the review steps: a prospective applicant files a letter of intent; the board has 30 days to issue a jurisdictional determination; if the project is within jurisdiction an application follows and may proceed to hearing; after the application close date the board typically has 120 days to issue a statement of decision, though the statutory timelines can toll while applicants respond to requests for information and extensions may be granted for good cause. She said the CON effectively remains in force through project implementation and invoicing and can include conditions that survive to ensure compliance; if a holder does not complete a project within the allowed period the CON can lapse.

Bellavoe said CON activity in 2024 included 14 jurisdictional determinations, of which the board found four subject to review and 10 not subject to review, and the board received seven CON applications in 2024. She also summarized recent CON decisions that were approved (four projects with a combined value the board described as about $159.5 million), including UVM Medical Center purchases and equipment and other systems updates.

Committee members asked procedural and policy questions. One asked whether a youth mental-health facility funded through the Department of Mental Health and approved by the Legislature still needed CON review; Bellavoe said that under the statute the project remained subject to CON and that the project was moving to hearing next month. Sam Garvey from the Legislative Counsel’s office said exemptions or effective dates “really depend what’s in the bill.”

Bellavoe and board members discussed how Vermont’s thresholds compare with neighboring New England states: Vermont’s thresholds are lower than some peers, and the board has authority to adjust thresholds for inflation. The board’s rule sets a 10 percent material-change threshold (or any change that effectively creates a new project), and peer states use similar or varying standards.

Committee members raised staff and resource implications for the board: Bellavoe said CON reviews can demand significant staff time when large projects are filed and that the workload is shared among two to three staff plus the five board members. Board members indicated a general appetite to raise cost thresholds considerably; one member said there was consensus around a $10,000,000 threshold in prior internal discussions, though Bellavoe stressed the board would provide formal comment on specific legislation if requested.

The presentation closed with procedural clarifications: most legislation is prospective unless it specifies otherwise, CON timelines can toll while applicants respond, and some projects are explicitly exempted (for example, routine replacement of nonmedical equipment and certain programs administered by other state agencies). Bellavoe identified specific project types that have appeared in recent CON filings, including outpatient surgery centers, emergency department renovations, robotic surgical systems, linear accelerators, mental-health or substance-use facilities and electronic medical record replacements.

The board indicated it would be available to provide more specific testimony on bills under consideration and noted that increasing thresholds would reduce burdens on the board and regulated entities in years with large, complex submissions.