Case Management and Care Planning

Managed care organizations (MCOs) generally employ a service coordinator (or “care manager”) to direct the service planning process.  Often states require that service coordinators be nurses or social workers, or have a minimum level of experience in relevant work.  Some states require service coordinators to respect consumer’s culture and language and to promote self-direction.

Contents – To access the full text, please click each sub-topic.

  • Case manager must be social worker, licensed registered nurse, or have minimum of two years experience in providing case management services: Arizona a
  • Case manager must have bachelor’s degree in social services field, or be registered nurse, or may substitute experience for the educational requirements, to the point that with six years of experience no college degree is required: Florida b
  • Newly-hired case manager must receive training on person-centered approach: Florida c
  • Newly-hired case managers must receive training on enrollee rights and responsibilities: Florida d
  • Care coordinator must be nurse or have bachelor’s degree in health care profession (including social work): Tennessee e
  • Service coordinator must have undergraduate or graduate degree in social work or related field, or be nurse, advanced nurse practitioner, or physician assistant: Texas f
  • Geriatric Support Services Coordinator must be social worker, or have college decree with at least two years experience in assisting over-65 population: Massachusetts g
  • MCO must have supervisor of care management who is registered nurse with at least three years of experience in care management and additional two years in managed care and/or LTSS: Tennessee h

  • MCO must develop individualized plan of care within 5 or 7 business days, or as soon as possible, depending on circumstances: Florida i
  • Case manager must conduct face-to-face review within 5 days after consumer’s change of placement: Florida j
  • Case manager must meet face-to-face with consumer every 3 months: Florida k
  • MCO must complete care plan within 15 days after enrollment: Hawaii l
  • Care plans for consumers not needing nursing facility level of care must be reviewed and updated annually and when significant events occur: Hawaii m
  • Care plans for consumers needing nursing facility level of care must be reviewed every 90 days: Hawaii n
  • Service coordinator meets face-to-face with consumers in HCBS waiver program at least quarterly, and by telephone at least monthly: New Mexico o

  • Consumer decides how service gap will be filled if caregiver is unavailable: Arizona p
  • Case manager must assist consumer in developing personal emergency plan: Florida q
  • MCO must ensure case managers review with consumer the process for reporting unplanned gaps in service delivery: Florida r
  • Contingency plan must include information about actions that consumer should take to report gaps: Florida s
  • Informal support system must not be considered primary source of assistance in the event of gap, unless this is consumer’s and family’s choice: Florida t
  • Consumer has final say in how (informal versus paid service provider) and when back-up care will be delivered: Florida u
  • Contingency plan must be discussed with consumer at least quarterly: Florida v
  • Care plan for consumers needing nursing facility level of care must include back-up plan: Hawaii w
  • Back-up plan may involve use of informal and/or paid caregivers: Hawaii x
  • Consumer may not elect, as part of back-up plan, to go without services: Tennessee y
  • Consumer and representative have primary responsibility for development and implementation of back-up plan for consumer-directed services: Tennessee ``
  • MCO must assess the adequacy of back-up plan: Tennessee aa

  • Case manager must respect consumer’s culture, language, and belief system: Arizona bb
  • MCO must provide case managers with ongoing training, including topics such as cultural competency: Florida cc

  • Case manager must use holistic approach including community resources, not just MCO-covered services: Arizona dd, Florida ee
  • Care management system includes involvement of community organizations that are not providing covered services: New York ff
  • MCO must build on and not supplant a consumer’s existing support system: Tennessee gg
  • Service coordinator works with the primary care physician (PCP), even if PCP is out of network: Texas hh

  • MCO must ensure adequate staffing to meet case management requirements: Arizona ii
  • MCO must ensure adequate staffing to meet enrollee care planning needs: Florida jj, Hawaii kk
  • Recommended staffing ratio is at least one care coordinator for 125 consumers: Tennessee ll
  • Case manager caseload must not exceed specified maximum caseload standards: Arizona mm, Florida nn, Hawaii oo, Minnesota pp, Tennessee qq

  • MCO must provide case managers with ongoing training, including topics such as participant direction: Florida rr, Tennessee ss
  • MCO must ensure that agreement is reached on consumer’s desired level of direct management: New Mexico tt
  • Care coordinator must verify consumer’s interest in participating in consumer direction: Tennessee uu
  • Care coordinator must obtain written confirmation of consumer’s decision to participate in consumer direction: Tennessee vv, Wisconsin ww
  • Consumer’s service plan should promote consumer direction and self-determination: Texas xx

  • Case manager must verify that medically necessary services are available in consumer’s community: Florida yy
  • MCO must provide service coordinator to all consumers who request one, or based on assessment: Texas ```
  1. Ariz. Contract, p. 39.  (back)
  2. Fla. Contract, Atch. II, Exh. 5, p. 30.  (back)
  3. Fla. Contract, Atch. II, Exh. 5, p. 31.  (back)
  4. Fla. Contract, Atch. II, Exh. 5, p. 31.  (back)
  5. Tenn. Contract, p. 151.  (back)
  6. Tex. Contract, pp. 18, 8-131.  (back)
  7. Mass. Contract, p. 33.  (back)
  8. Tenn. Contract, p. 368.  (back)
  9. Fla. Contract, Atch. II, Exh. 5, p. 33.  (back)
  10. Fla. Contract, Atch. II, Exh. 5, p. 41.  (back)
  11. Fla. Contract, Atch. II, Exh. 5, p. 41.  (back)
  12. Haw. RFP, p. 163.  (back)
  13. Haw. RFP, p. 163.  (back)
  14. Haw. RFP, p. 163.  (back)
  15. N.M. Contract, pp. 49-50.  (back)
  16. Ariz. Contract, p. 41.  (back)
  17. Fla. Contract, Atch. II, Exh. 5, p. 35.  (back)
  18. Fla. Contract, Atch. II, Exh. 5, p. 46.  (back)
  19. Fla. Contract, Atch. II, Exh. 5, p. 47.  (back)
  20. Fla. Contract, Atch. II, Exh. 5, p. 47.  (back)
  21. Fla. Contract, Atch. II, Exh. 5, p. 47.  (back)
  22. Fla. Contract, Atch. II, Exh. 5, p. 47.  (back)
  23. Haw. RFP, p. 162.  (back)
  24. Haw. RFP, p. 162.  (back)
  25. Tenn. Contract, pp. 4, 170.  (back)
  26. Tenn. Contract, p. 4.  (back)
  27. Tenn. Contract, p. 129.  (back)
  28. Ariz. Contract, p. 40.  (back)
  29. Fla. Contract, Atch. II, Exh. 5, p. 32.  (back)
  30. Ariz. Contract, p. 40.  (back)
  31. Fla. Contract, Atch. II, Exh. 5, p. 35.  (back)
  32. N.Y. Medicaid Advantage Plus Contract, Sect. 10, p. 10.  (back)
  33. Tenn. Contract, pp. 109, 119, 279.  (back)
  34. Tex. Contract, p. 8-131.  (back)
  35. Ariz. Contract, p. 41.  (back)
  36. Fla. Contract, Atch. II, Exh. 5, p. 33.  (back)
  37. Haw. RFP, p. 156.  (back)
  38. Tenn. Contract, p. 152.  (back)
  39. Ariz. Contract, pp. 41-42.  (back)
  40. Fla. Contract, Atch. II, Exh. 5, p. 33.  (back)
  41. Haw. RFP, pp. 156-57.  (back)
  42. Minn. Contract, p. 112  (back)
  43. Tenn. Contract, p. 152.  (back)
  44. Fla. Contract, Atch. II, Exh. 5, p. 32.  (back)
  45. Tenn. Contract, p. 155.  (back)
  46. N.M. Contract, p. 44.  (back)
  47. Tenn. Contract, p. 116  (back)
  48. Tenn. Contract, p. 116.  (back)
  49. Wis. Contract, pp. 51-52.  (back)
  50. Tex. Contract, p. 19.  (back)
  51. Fla. Contract, Atch. II, Exh. 5, p. 39.  (back)
  52. Tex. Contract, p. 8-130.  (back)

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