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Glossary

Medicaid waiver case management agency

The organization a state's Medicaid waiver authorizes to take applications, coordinate the level-of-care determination, write the person-centered service plan and arrange services. States call it case management, support coordination or service coordination; under federal rule it may not also be the member's provider.

Also HCBS case management agency, case management agency, support coordination agency, service coordination agency, CMA

The agency goes by a different name in nearly every state. Georgia’s waiver case managers work through CCSP and SOURCE; Colorado calls its entities case management agencies and reorganized them in 2024; Louisiana and Florida’s developmental disabilities program say support coordination; Texas managed care organizations and New York’s nursing home transition waiver say service coordination; Indiana’s PathWays program says care management. West Virginia, Wyoming and Utah credential them on state pages. Underneath the names the job is the same, and it is the job the Medicaid waiver cannot run without.

Three things the agency owns:

  • The application. It takes the referral, confirms the person wants services at home, and starts both determinations: financial eligibility with the Medicaid office, and the nursing facility level of care through the level-of-care form and the state’s assessor.
  • The documentation. The physician signs the instrument; the agency gets the instrument to the physician with the records that let it be signed, and answers the state reviewer’s request for information when something is missing. This is where the time goes.
  • The plan. Once the person is eligible the agency writes the person-centered service plan under 42 CFR 441.301(c), arranges the providers, and monitors. In structured family caregiving states it is the agency that hands the provider agency its plan and assessment.

The one thing it may not be is the provider. Under 42 CFR 441.301(c)(1)(vi), providers of waiver services to a person, and anyone employed by or with an interest in one, may not provide that person’s case management or develop their service plan, unless the state shows no other willing and qualified entity exists. That is conflict-free case management, and it is why the agency assembling the records is never the agency delivering the care.

For an agency the records question is concrete. It needs the hospital’s discharge summaries, the specialists’ notes, the primary care record and the medication list, for the form and later for the plan, from organizations it has no relationship with, on the state’s clock. Records for the Medicaid waiver case management agency is the page for that work.

Where it is defined

Vivlio for case managementThe physician's documentation behind the level-of-care form, retrieved before the state's clock runs out.

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