Georgia Medicaid Case Management: TCM, HCBS, CMO ICM, DBHDD

A Georgia Medicaid card by itself does not connect your mother to a primary care provider, navigate her durable medical equipment authorization, schedule her transportation to dialysis, follow up when the behavioral health referral never produced an appointment, file the next reassessment for her SOURCE waiver, or chase down the pharmacy when the new prescription is held up at prior authorization. Someone has to do all of that, and across the Medicaid program, that someone is called a case manager or a care coordinator. In Georgia, depending on which waiver she is on, which managed care plan she belongs to, what her primary diagnosis is, and what age she is, that case manager may sit at a SOURCE provider agency, at the Georgia Department of Community Health, at one of the Georgia Families Care Management Organizations, at a Community Service Board, at a DBHDD-contracted support coordination agency, at a Georgia Pediatric Program (GAPP) nursing agency, or inside a foster care care coordination team at Georgia Families 360. The structures are layered, the federal authorities differ from one to the next, and most families never realize how many parallel case management systems are operating until something falls through a gap between them.

Case management is not a single Medicaid service. It is a federal benefit category at Section 1905(a)(19) of the Social Security Act, a Targeted Case Management option for specific populations at Section 1915(g), a required service inside every Section 1915(c) home and community-based services waiver, a Health Home option at Section 1945 (added by ACA Section 2703), and a contract requirement for every Section 1932 managed care plan. Georgia uses every one of these authorities except Health Homes. Add in foster care care coordination through Georgia Families 360, behavioral health care coordination through DBHDD's Community Service Boards and Assertive Community Treatment teams, EPSDT case management for children under twenty-one, and Olmstead-related intensive case management for individuals transitioning out of state hospitals, and Georgia ends up with multiple parallel care coordination structures. Each has its own caseload expectations, contact requirements, person-centered planning rules, and scope of what a case manager can and cannot do.

This guide translates Georgia's care coordination and case management infrastructure for the families who actually live inside it. It explains the federal authorities. It maps each Georgia program to the federal authority and the case management model. It describes who is eligible for what. It walks through how a case manager's responsibilities differ across SOURCE, CCSP, ICWP, NOW, COMP, GAPP, the CMOs' Intensive Care Management programs, DBHDD ACT teams, Community Service Boards, EPSDT, foster care, and the Olmstead-related intensive case management teams. It describes person-centered planning and the family's role in it. It covers the most common operational problems including case manager turnover, hand-offs between programs, gaps between physical and behavioral health, and the role family caregivers play as informal case managers. It ends with worked examples, a frequently asked questions section, and a list of phone numbers families need. Brevy publishes this guide because case management quietly determines whether a Georgia Medicaid card delivers on its promise.

By Brevy Care Team · Last verified May 12, 2026

Federal case management authorities

Medicaid case management is built on a stack of federal authorities. Understanding the stack matters because the rules, payments, and protections vary by authority.

Section 1905(a)(19) of the Social Security Act is the base authority for case management services. Case management is one of the optional Medicaid services listed in Section 1905(a). States that cover case management under the state plan must define the service, the population, the qualifications of case managers, and the methodology for payment. The federal definition is at 42 CFR 440.169 and describes services that assist beneficiaries in gaining access to needed medical, social, educational, and other services.

Section 1915(g) of the Social Security Act authorizes Targeted Case Management (TCM). TCM is an exception to two otherwise-binding Medicaid rules: statewideness (services must be offered statewide) and comparability (services must be comparable across eligibility groups). TCM lets a state target case management to specific defined populations including individuals with serious mental illness, individuals with serious emotional disturbance, individuals with intellectual or developmental disabilities, individuals with HIV/AIDS, pregnant women, children with special health care needs, individuals transitioning from institutions, individuals at risk of abuse or neglect, and other state-defined groups. The federal regulations are at 42 CFR 441.18.

Section 1915(c) of the Social Security Act authorizes HCBS waivers. Every approved 1915(c) waiver includes case management as a required service. Federal rules require that HCBS case management be conflict-free, meaning the case manager generally cannot also deliver direct services to the same individual and cannot be financially affiliated with providers of direct services, with limited exceptions documented in the waiver application. The case manager develops the person-centered service plan, authorizes services, monitors implementation, and reassesses needs at least annually.

Section 1945 of the Social Security Act, added by Section 2703 of the Affordable Care Act, authorizes Health Homes as an optional state plan service for Medicaid beneficiaries with multiple chronic conditions or a single serious and persistent mental health condition. Health Home services include comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support, and referral to community and social support services. States that adopt Health Homes receive enhanced federal matching funds for a limited initial period after CMS approves the State Plan Amendment, after which the federal match reverts to the regular state FMAP (consult current CMS Health Home guidance for the precise match level and duration). Georgia has not adopted a broad Health Home benefit.

Section 1932 of the Social Security Act authorizes managed care under the state plan, and 42 CFR Part 438 governs managed care implementation. 42 CFR 438.208 specifically requires managed care plans to coordinate services across providers, coordinate with services outside the plan, identify members with special health care needs under 42 CFR 438.218, and provide care management for high-need members.

Section 1902(a)(43) and Section 1905(r) authorize the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children under twenty-one and require states to ensure that children with positive screening results receive necessary diagnostic and treatment services. EPSDT case management supports children with complex conditions in accessing the services they need.

Section 1115 of the Social Security Act authorizes demonstration waivers. Georgia's Pathways to Coverage demonstration is a Section 1115 program with limited care coordination for Pathways members.

These authorities overlap. A Georgia beneficiary may receive case management under more than one authority simultaneously (for example, HCBS waiver case management for personal care under SOURCE plus DBHDD CSB case management for serious mental illness). When authorities overlap, the rule is that the same case management function cannot be billed twice (no duplication of services).

Person-centered service planning

For every HCBS waiver participant in Georgia, the case manager facilitates a person-centered service planning process required by 42 CFR 441.301(c). The plan must:

Reflect the individual's own goals, preferences, strengths, and desired outcomes, not the agency's or family's preferences.

Be developed through a meeting that the individual chooses to attend, with people the individual chooses to include (which can include family caregivers, friends, advocates, or others).

Document the services to be delivered, the providers, the frequency, and the responsible parties.

Identify risks the individual faces and risk-mitigation strategies, written in a way that supports the individual's dignity and autonomy.

Specify back-up plans for critical supports (what happens if the personal support worker does not show up, what happens if the family caregiver is hospitalized).

Be reviewed at least annually and whenever the individual's circumstances change.

Be signed by the individual or the individual's authorized representative.

The case manager's role is to facilitate, document, and authorize, not to dictate. Families who feel that the case manager is steering the plan toward agency preferences rather than the individual's goals should raise the concern through the program, and ultimately can request a different case manager.

Person-centered planning is also required for managed care members with special health care needs under 42 CFR 438.208. The CMO care manager facilitates a comparable planning process.

SOURCE case management

SOURCE (Service Options Using Resources in a Community Environment) is Georgia's HCBS waiver for older adults and adults with physical disabilities who are at nursing facility level of care and need integrated primary care and HCBS supports. SOURCE is distinguished from other Georgia waivers by its integration of primary care with care coordination.

The SOURCE case manager is the central figure in the program. Responsibilities include:

Conducting the initial comprehensive needs assessment to establish nursing facility level of care, functional impairment, medical needs, behavioral health needs, social supports, and risks.

Facilitating the person-centered service planning meeting with the member, family caregivers (with member's permission), and the SOURCE primary care provider.

Developing the written service plan documenting authorized services: personal support services (PSS), adult day health (ADH), home-delivered meals, emergency response systems (ERS), respite, skilled nursing as needed, and others.

Coordinating with the SOURCE primary care provider. The case manager attends or contributes to primary care visits, ensures that medical needs identified in primary care translate into appropriate community supports, and links specialty care.

Conducting monthly contact with the member. Contacts may be phone, video, or in-home depending on case management plan and member needs.

Conducting quarterly or more frequent in-home visits to verify service delivery, observe living conditions, and reassess needs.

Authorizing services through DCH's authorization system. Service authorizations are issued for specified amounts and time periods.

Monitoring service delivery through provider documentation, member feedback, and observation.

Conducting annual reassessment of level of care and service needs. Annual reassessments are filed with DCH and trigger renewed authorizations.

Coordinating transitions when the member moves between settings (hospital, nursing facility short stay, back home) or when the member's needs change significantly.

Acting on critical incidents (falls, hospitalizations, abuse or neglect reports) and following up to support member safety.

SOURCE caseloads typically run large enough that each member receives a meaningful share of monthly attention but the case manager cannot be available for every minor question instantly. Families should ask the case manager what the typical response time is for non-emergencies (return calls within one to two business days is common) and what to do for urgent issues (contact provider directly, contact CMO nurse line, contact emergency services).

CCSP case management

CCSP (Community Care Services Program) is Georgia's longstanding HCBS waiver for older adults and adults with disabilities at nursing facility level of care. CCSP predates SOURCE and serves a broader population including individuals who do not need or want the SOURCE primary care integration.

The CCSP case manager performs the same core functions as the SOURCE case manager (assessment, planning, authorization, monitoring, reassessment) but without the integrated primary care model. CCSP case managers coordinate with whoever the member's primary care provider is (often a community physician separate from the case management agency).

CCSP caseloads run at a scale comparable to SOURCE, meaning monthly contact is the norm but the case manager is not available instantly for every question.

CCSP services include personal support services, adult day health, home-delivered meals, alternative living services (ALS), emergency response systems, skilled nursing, and others.

ICWP case management

ICWP (Independent Care Waiver Program) is Georgia's HCBS waiver for adults age 21 to 64 with severe physical disabilities who would otherwise require hospital level of care but can live in the community with supports. ICWP emphasizes independent living and supports many participants in self-directed care arrangements where the participant directs the services and selects, hires, and supervises the personal support workers.

The ICWP case manager (sometimes called a support coordinator) is responsible for:

Verifying eligibility and hospital level of care.

Developing the person-centered plan with significant member direction.

Authorizing services: personal support services, skilled nursing, durable medical equipment, environmental modifications, and others.

Supporting self-direction. The case manager helps the member understand the participant-direction option, work with the financial management services agency (which handles payroll for the participant's chosen workers), and meet the responsibilities of being an employer of record (or co-employer) for the workers.

Monitoring service delivery and the member's safety.

Reassessing needs annually.

Coordinating with specialty medical care, durable medical equipment vendors, environmental modification contractors, and others.

ICWP caseloads vary. The program is smaller than SOURCE and CCSP, and case managers are concentrated in the case management agencies under DCH contract.

NOW and COMP case management (DBHDD support coordination)

NOW (New Options Waiver) and COMP (Comprehensive Supports Waiver) are Georgia's HCBS waivers for individuals with intellectual or developmental disabilities (I/DD). NOW serves individuals needing less intensive supports; COMP serves individuals needing more intensive supports including residential supports such as host home and group home placements.

NOW and COMP case management is called support coordination and is delivered through DBHDD-contracted support coordination agencies. The support coordinator:

Conducts the comprehensive assessment to establish intermediate care facility for individuals with intellectual disability (ICF/IID) level of care.

Facilitates the Individual Service Plan (ISP) meeting. The ISP is the I/DD version of the person-centered service plan.

Authorizes services: community living supports, supported employment, behavioral supports, therapies, host home or group home residential, family supports, respite, transportation, durable medical equipment, and others.

Coordinates with direct support professionals (DSPs) and their employing agencies.

Conducts regular monthly contact and quarterly in-home visits.

Conducts annual ISP review and updates.

Acts on critical incidents and supports safety.

NOW and COMP support coordination caseloads are typically smaller than those in the elderly/disabled waivers, reflecting the complexity of I/DD service planning and the multiple providers involved.

DBHDD operates the I/DD service system in close partnership with DCH. DBHDD sets clinical and policy standards; DCH operates the Medicaid administration. Families with I/DD members should understand both agencies' roles.

GAPP case management

GAPP (Georgia Pediatric Program) serves medically fragile children who require continuous nursing or skilled care to remain at home. GAPP case management is integrated with the pediatric nursing service. The nursing agency that provides the home nursing also typically employs the case manager who:

Conducts assessment and reassessment.

Develops the care plan with the child's parents or guardians.

Coordinates with the child's pediatrician, specialty providers, durable medical equipment vendors, school district (especially for the IEP and related services), and the family.

Monitors nursing service delivery.

Supports family caregivers who provide the bulk of day-to-day care between nursing shifts.

Coordinates transitions (hospital admissions, discharges).

GAPP case management caseloads vary by agency.

CMO Intensive Care Management

Each of the three Georgia Care Management Organizations (Amerigroup, CareSource, Peach State) provides care management as required by 42 CFR 438.208. Each CMO operates a tiered care management model:

Standard care coordination involves telephonic outreach for preventive care prompts (annual wellness visits, immunizations, screenings), condition-specific education (diabetes, asthma, hypertension), and gap-in-care follow-up. Most CMO members receive this level of attention as part of standard plan operations.

Care management involves more intensive engagement for members with chronic conditions. A registered nurse, licensed clinical social worker, or other licensed care manager conducts an assessment, develops a care plan, and conducts regular telephonic check-ins.

Intensive Care Management (ICM) is the highest tier and is offered for high-need members. ICM teams include nurses, social workers, behavioral health specialists, pharmacists, and community health workers. ICM members may include:

Members with multiple chronic conditions and high utilization patterns.

Members with recent hospitalizations or emergency department visits.

Members transitioning from institutional care (nursing facility, psychiatric hospital, jail).

Members with co-occurring physical and behavioral health needs.

Pregnant women with high-risk pregnancies.

Members eligible for HCBS services.

Members with serious mental illness or serious substance use disorder.

CMO ICM caseloads vary by intensity tier; ICM members receive face-to-face engagement (in homes, in clinics, in hospitals during admission, at community settings), frequent contact (weekly or more for high-acuity members), and intensive care coordination across multiple providers.

ICM is voluntary. Members can decline ICM enrollment. Members enrolled in HCBS waivers receive their primary case management from the waiver and may receive supplementary CMO care management for any non-HCBS care needs, with the two teams coordinating.

CMO ICM members can be referred by the primary care provider, by an emergency department or hospital, by a behavioral health provider, by the member or a family member, by DCH, or by the CMO's own data-driven outreach. The CMO outreach uses claims data, prescription data, and care gap data to identify members likely to benefit from ICM.

Members who would like to request CMO care management or ICM should call the member services line printed on their plan ID card or listed on the plan's website.

DBHDD Community Service Boards

Georgia's Community Service Boards (CSBs) are the public mental health and developmental disability authorities for the state. CSBs are organized by region; each CSB serves a defined catchment area covering one or more counties. CSBs are funded through a combination of Medicaid, DBHDD state contracts, county funds, and other sources.

CSBs provide:

Case management for adults with serious mental illness (SMI). Case management is delivered by qualified mental health professionals (typically masters-level social workers, counselors, or psychologists) and supports access to medication, therapy, housing, and other supports.

Case management for adults with serious substance use disorders.

Support coordination for individuals with intellectual or developmental disabilities (separate from NOW/COMP waiver support coordination, where the I/DD support coordinator role differs).

Crisis services including mobile crisis response and crisis stabilization.

Outpatient mental health and substance use services.

Psychiatric medication management.

ACT services in many regions.

Some inpatient psychiatric services (in some CSB regions) or transition support to and from state psychiatric hospitals.

CSB case management for SMI is often delivered under TCM authority at Section 1915(g). The TCM target population for SMI is defined in the Georgia State Plan and covers adults with qualifying diagnoses and qualifying functional impairment.

CSB caseloads vary by region and population. SMI case management generally carries a smaller caseload than long-term-services case management, allowing for substantial face-to-face contact and home-based engagement.

Assertive Community Treatment (ACT) teams

ACT is the most intensive community-based behavioral health service model. ACT teams are multidisciplinary and include:

A team leader (often a master's-level clinician).

A psychiatrist or psychiatric nurse practitioner (typically part-time, integrated with the team).

Registered nurses.

Social workers.

Substance abuse counselors.

Peer specialists (individuals with lived experience of mental illness who provide peer support).

Vocational specialists for supported employment.

Other team members as needed (housing specialist, family liaison).

ACT teams operate with shared caseloads (any team member can engage any client) and a low staff-to-client ratio that supports frequent community contact. The team provides services in the community (in homes, at jobs, at coffee shops, anywhere the client is) including medication management, therapy, case management, substance use treatment, employment support, housing support, and crisis response, with around-the-clock availability per the national ACT fidelity model.

ACT serves individuals with the most severe and persistent mental illness, often those with multiple hospitalizations, justice system involvement, homelessness, or co-occurring substance use disorder. Georgia has been expanding ACT capacity as part of the federal Olmstead-related Settlement Agreement requirements between the U.S. Department of Justice and the State of Georgia.

Olmstead-related Intensive Case Management

The Olmstead-related Settlement Agreement between the United States Department of Justice and the State of Georgia required Georgia to expand community-based services for individuals with mental illness and individuals with developmental disabilities transitioning out of state psychiatric hospitals and other institutional settings. The settlement responded to findings about Georgia's compliance with the Americans with Disabilities Act and the Olmstead v. L.C. Supreme Court decision requiring states to serve individuals with disabilities in the most integrated setting appropriate.

Settlement-required services include:

Intensive Case Management (ICM) teams for individuals discharging from state psychiatric hospitals. ICM is structurally similar to ACT but is sometimes operated with somewhat different team composition or caseload structure.

Community supports for individuals with I/DD transitioning out of state-operated facilities or out of large private ICF/IID settings.

Expansion of housing supports including supportive housing.

Performance metrics with state reporting to a court-appointed independent reviewer.

The settlement has been periodically updated and remains in effect. The reviewer's annual reports document Georgia's progress. Families with members transitioning from state hospitals or out of large institutional settings should ask about ICM eligibility and availability.

Georgia Families 360 foster care care coordination

Georgia Families 360 is the specialized care coordination program for children and youth in DFCS foster care custody and certain juvenile justice involvement. The 360 program is operated by Amerigroup statewide as a single CMO assignment for the foster care population (rather than the three-CMO choice model that applies to most Georgia Families members). 360 provides:

Care coordination across physical health, behavioral health, dental, and pharmacy.

Trauma-informed approach reflecting the unique stresses of foster placement.

Coordination with DFCS caseworkers, the child's foster family, biological family (where appropriate), and the court.

Behavioral health coordination including therapy, psychiatric medication management, and crisis response.

Coordination with the school system.

Transition planning when the child achieves permanency (reunification, adoption, guardianship, aging out).

Families fostering children should ask about 360 care coordination and ensure they have the care coordinator's contact information.

EPSDT case management

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) is the Medicaid benefit for children under twenty-one that requires comprehensive screening, diagnosis, and treatment. EPSDT case management supports children who screen positive for conditions requiring follow-up by helping the family navigate the diagnostic and treatment process.

EPSDT case management can be delivered through the CMO's care management or ICM programs, through TCM target populations (for children with specific qualifying conditions), or through specialty programs (CSHCN, GAPP, behavioral health). Georgia's approach uses CMO ICM as the primary vehicle for complex pediatric care coordination, with specialty TCM or program-specific case management layered for children with qualifying conditions.

Families with children who have complex conditions should ask the CMO for ICM enrollment and should ask the primary care pediatrician for help identifying any specialty case management programs the child may qualify for (CSHCN, GAPP, behavioral health TCM, others).

Other state and community case coordination resources

Beyond Medicaid-funded case management, Georgia families have access to additional care coordination resources:

The Aging and Disability Resource Connection (ADRC) at 1-866-552-4464 provides information and referral, options counseling, and benefits screening for older adults and adults with disabilities. ADRC counselors help families understand their options and apply for the right programs.

The Georgia Long-Term Care Ombudsman advocates for residents of nursing facilities, assisted living communities, and personal care homes; locate the current statewide intake line on the Georgia Division of Aging Services website. Ombudsmen help residents and families resolve complaints and navigate placement decisions.

GeorgiaCares SHIP provides free Medicare counseling, including for dual eligibles whose Medicare-Medicaid coordination requires careful attention.

211 Georgia connects families with community resources including utility assistance, food assistance, transportation, and other supports that often appear in case management plans.

Disability Rights Georgia provides legal advocacy for individuals with disabilities, including those facing service denials, abuse, or institutional placement disputes.

Faith-based and community organizations frequently provide informal case management support, particularly in rural areas or for immigrant communities. Case managers should be aware of these informal supports and incorporate them into the service plan where appropriate.

Family caregivers as informal case managers

Family caregivers across Georgia perform de facto case management functions every day:

Tracking appointments and following up when appointments are missed.

Managing medications including prescriptions, dosing, refill timing, and side effects.

Coordinating between primary care, specialty care, behavioral health, dental, vision, and others.

Advocating for services when authorizations are denied.

Navigating durable medical equipment ordering, fitting, and repair.

Coordinating transportation including non-emergency medical transportation (NEMT) for Medicaid trips.

Managing in-home caregivers, scheduling, and back-up plans.

Maintaining records of services received and benefits claimed.

Federal Medicaid generally does not pay family caregivers for case management functions. The exceptions are limited and apply mostly under self-direction at Section 1915(j) where the participant (or the participant's authorized representative) directs the services and selects, hires, and supervises the workers. Even in self-direction, the family member acting as employer or co-employer is performing functions analogous to case management but is paid for the direct care work, not for case management as a separately billable service.

The practical implication: family caregivers should be treated as essential partners with formal case managers. Person-centered service plans should document the family caregiver's role, the family caregiver's capacity (how many hours, what days, what tasks), and back-up plans for when the family caregiver is unavailable. Formal case managers should provide family caregivers with training, support, and respite resources.

Families and case managers who work well together produce better outcomes. Families and case managers who do not work well together produce gaps that ultimately harm the member.

Worked examples

Eleanor, 78, Macon, SOURCE waiver. Eleanor is widowed, lives alone, has type 2 diabetes, hypertension, mild cognitive impairment, and mobility limitations after a hip fracture two years ago. Her son Robert lives in Atlanta and visits on weekends. Eleanor is enrolled in SOURCE. Her SOURCE case manager, Patricia, is at a SOURCE provider agency in Bibb County. Patricia conducted Eleanor's initial assessment, facilitated the person-centered planning meeting (Robert attended by phone), and authorized twenty-five hours per week of personal support services plus three days per week of adult day health plus emergency response system plus skilled nursing one visit weekly for diabetes management. Patricia conducts monthly phone contact with Eleanor and quarterly home visits. Patricia coordinates with Eleanor's SOURCE primary care provider, who is a geriatrician affiliated with the SOURCE agency. When Eleanor fell last spring and was hospitalized, Patricia coordinated the hospital discharge plan, arranged for short-term increased PSS hours, and conducted a special in-home visit two weeks post-discharge to assess for ongoing risk. When Eleanor's cognitive impairment progressed and she was missing medications, Patricia worked with the primary care provider to add a medication management home health visit and worked with Robert to set up a weekly pill organizer. Patricia is also the person Robert calls when something goes wrong (the PSS worker did not show up, the adult day health bus was an hour late, the new medication is causing dizziness). Eleanor's SOURCE case management is not perfect (Patricia carries a full caseload and Robert sometimes has to leave two voicemails before getting a callback), but it is the connective tissue holding Eleanor's care together and keeping her at home rather than in a nursing facility.

Marcus, 45, Albany, ICWP plus CMO ICM. Marcus has multiple sclerosis (MS) with progressive disability. He uses a power wheelchair, has bowel and bladder dysfunction, has had recurrent urinary tract infections requiring hospitalization, and has periods of severe spasticity. Marcus lives with his sister, who serves as his self-directed personal support worker for the personal care he needs. Marcus is enrolled in ICWP and is also enrolled with Peach State for his other Medicaid services. His ICWP case manager, Diane, is at an ICWP case management agency. Diane helped Marcus set up the self-directed services arrangement and works with the financial management services agency that handles his sister's payroll. Diane authorizes the personal support hours, the durable medical equipment (chair maintenance, lift, hospital bed), and the home modifications (ramp). When Marcus had a severe MS exacerbation last fall and was hospitalized for ten days, the hospital discharge planner referred Marcus to Peach State ICM. The Peach State ICM nurse, Andrea, conducted a face-to-face assessment, developed a complementary CMO care plan addressing his medical complexity (neurology follow-up, infectious disease consult for the recurrent UTIs, physical therapy, medication review), and coordinated with Diane. Diane and Andrea now operate as a team: Diane owns the HCBS waiver and the self-direction; Andrea owns the medical and specialty coordination. They have a standing biweekly call. When Marcus is doing well, the team is in maintenance mode. When Marcus has a flare, both case managers escalate.

Aisha, 32, Savannah, CMO ICM during pregnancy. Aisha is pregnant with her second child. She has lupus, chronic kidney disease (stage 3), and a history of preterm delivery with her first child. She is enrolled in Amerigroup for pregnancy Medicaid. The Amerigroup care management team identified Aisha as high-risk based on her diagnoses and prenatal claims, and enrolled her in ICM. Her ICM nurse, Latasha, conducted a face-to-face assessment, coordinated with her maternal-fetal medicine specialist, her nephrologist, and her rheumatologist. Latasha helped Aisha schedule and keep appointments (NEMT through Modivcare for the longer-distance maternal-fetal medicine appointments in Macon), supported her medication adherence, coordinated her dental care during pregnancy (Amerigroup's dental subcontractor), and arranged a high-risk delivery plan with the hospital. Aisha had complications late in the third trimester and required a preterm cesarean. Latasha coordinated her hospital stay, the NICU coordination for her baby, and her postpartum care. Postpartum, Latasha continues ICM through Aisha's continuous postpartum coverage window under Georgia's postpartum extension. Aisha credits Latasha with helping her keep her health stable enough to deliver a healthy baby.

Diana, 84, rural Bulloch County, CCSP. Diana lives alone in a small home outside Statesboro. She has congestive heart failure, COPD, mild dementia, and severe arthritis. Her closest family is her granddaughter who lives in Savannah and visits twice a month. Diana is enrolled in CCSP. Her CCSP case manager, Karen, serves the rural Southeast Georgia region with a full multi-county caseload. Karen drives to Diana's home quarterly and conducts monthly phone contact. Diana's CCSP plan authorizes 18 hours per week of personal support services, adult day health is not available locally (the nearest center is 40 minutes away), home-delivered meals five days per week, and emergency response system. Karen has been working with Diana on a fall prevention plan after Diana fell in February. The challenge in rural areas is finding personal support workers willing to drive to Diana's home. Karen has had to switch home care agencies twice in the last year because the first agency lost staff and the second agency had reliability problems. Karen's relationship with the third agency is more stable but the family worries about coverage when the regular worker is off. Diana's granddaughter and Karen coordinate by text message, which has been the practical solution given the granddaughter's work schedule.

Jamil, 8, Columbus, EPSDT plus CSHCN TCM. Jamil has a complex congenital condition with multiple specialty needs (cardiology, pulmonology, gastroenterology, neurology) and behavioral health needs related to anxiety. Jamil is enrolled with CareSource. His mother, Karina, was struggling to coordinate his care across the specialists, the school system, and the durable medical equipment vendor. Karina called CareSource and requested care management. She was enrolled in CareSource ICM and assigned a pediatric care manager. The ICM nurse conducted an assessment and identified that Jamil qualified for the state's Children with Special Health Care Needs (CSHCN) program through the Department of Public Health, which provides TCM-billable case management for qualifying children. Jamil's TCM case manager at the CSHCN program coordinates his specialty care, while the CareSource ICM nurse provides supplementary support and handles the CMO-side authorizations and the medical home pediatrician relationship. Together, the two-person care team has reduced the burden on Karina substantially. Karina still does much of the day-to-day case management work (appointment scheduling, school communication, medication tracking), but she now has two professional partners. Jamil's school IEP team also includes the CSHCN case manager.

Tasha's mother, 65, Atlanta, COMP waiver. Tasha's mother, Joanne, has intellectual disability and lives in a host home managed by an I/DD provider agency in DeKalb County. Joanne is enrolled in COMP. Her support coordinator, Andre, is at a DBHDD-contracted support coordination agency carrying a typical I/DD support-coordination caseload. Andre conducts monthly contact with Joanne, quarterly in-home visits to the host home, and an annual ISP review meeting. Joanne's ISP authorizes the host home placement, day program supports four days per week, behavioral supports, therapy, transportation, and respite for the host home provider. Andre coordinates with the direct support professionals at the host home, the day program staff, Joanne's primary care provider, her behavioral health prescriber, and Tasha (her sister-daughter who is her authorized representative). When the host home had a staffing change last year, Andre attended the transition meeting, helped onboard the new host home family on Joanne's care needs, and conducted extra contact in the first sixty days to verify the transition was going well. Andre also helped Tasha understand the EVV requirements that now apply to the day program's transportation worker. The I/DD service system has many moving parts, and Andre is the connector.

Common operational problems

Case manager turnover. Case managers move on (to other agencies, out of case management, out of the workforce) frequently. When a case manager leaves, the new case manager inherits a caseload that may be unfamiliar. Families experiencing case manager turnover should:

Get the new case manager's name, phone, and email promptly.

Schedule an introductory meeting (phone, video, or in person) within the first 2 to 4 weeks.

Prepare a brief overview of the member's needs, preferences, and history.

Confirm that the existing service authorizations remain in place.

Document any unresolved issues that the prior case manager was working on.

Caseload pressure. Even when a case manager is excellent, a large caseload limits responsiveness. Families should be realistic about response times (24 to 48 hours for non-urgent calls is common) and should use the provider directly for service-specific questions (call the home care agency about a missed shift, call the durable medical equipment vendor about an equipment problem, call the pharmacy about a prescription).

Hand-offs between programs. Members transition between programs (aging into different services, transitioning between waivers, transitioning between managed care plans, moving from foster care to adult Medicaid). Hand-offs require coordination. Families should request joint meetings between the outgoing and incoming case manager and should keep a copy of the existing service plan to provide to the new team.

Gaps between physical and behavioral health. Coordination between physical health (CMO) and behavioral health (DBHDD, CSB, ACT) providers is a chronic challenge. The federal MHPAEA and 42 CFR 438.208 require coordination, but in practice the systems often run in parallel. Families bridging the gap can request that the physical health and behavioral health care teams have a joint phone call to align on the member's care.

Authorization denials and gaps in coverage. When a case manager authorizes services but the service does not get delivered (provider does not have capacity, scheduled hours fail to be covered, equipment does not arrive), the case manager owes follow-up. Families should document the gap and contact the case manager. If the case manager cannot resolve, escalate to the case management agency supervisor, then to DCH Member Services.

Disagreement with the service plan. If the family disagrees with the case manager's assessment or the authorized services, the family has the right to request reconsideration, request a different case manager, and ultimately to request a fair hearing under DCH appeal procedures. See Brevy's guide on appeals and fair hearings for the detailed process.

How families engage productively with case managers

Some practical tactics that produce better case management outcomes:

Designate one family contact. Decide which family member will be the primary contact with the case manager. Multiple family members calling about the same issue creates confusion. The primary family contact should be authorized in writing by the member (or be the member's legal representative) to communicate with the case manager.

Communicate goals, not just symptoms. The person-centered planning process is supposed to start from the member's goals (what does she want her life to look like, where does she want to be, what activities matter to her). Lead with goals, then describe how current symptoms or limitations get in the way.

Keep records. A simple spreadsheet of authorized services, providers, contact information, and dates of major events helps everyone. Bring the records to the annual reassessment meeting.

Use the annual reassessment meeting fully. The annual meeting is the formal opportunity to update the plan. Prepare for it. Bring questions. Identify what is working, what is not, and what should change in the coming year.

Document critical events. Falls, hospitalizations, medication changes, equipment problems, missed shifts, and other significant events should be documented and shared with the case manager. The documentation helps the case manager adjust the plan.

Involve the medical team. The case manager should know who the member's physicians and other providers are and should coordinate with them. Ensure your case manager has current contact information for the medical team.

Ask about caseload and response times. Understand what to expect. If the case manager's response times are consistently too slow for your needs, ask whether a higher-intensity case management option is available (CMO ICM, ACT if appropriate, supplementary programs).

Escalate respectfully when needed. If something is not working, raise it through the case management agency supervisor, then through DCH Member Services or DBHDD as appropriate. Most case management agencies want to resolve problems and would rather know than not know.

DCH and DBHDD oversight of case management

The Georgia Department of Community Health (DCH) operates the Medicaid program and contracts with the case management agencies and the CMOs that deliver case management. DCH monitors case management through:

Required quarterly and annual reports from case management agencies and CMOs.

Random and targeted audits of case management documentation.

Member complaints reported through Member Services or other channels.

Critical incident reporting and investigation.

Quality metrics specified in CMO and case management agency contracts.

The Department of Behavioral Health and Developmental Disabilities (DBHDD) operates the I/DD and behavioral health service system and oversees support coordination, CSBs, ACT, and other behavioral health case management functions. DBHDD has its own quality assurance and incident management framework. Concerns about DBHDD-operated case management can be reported through the DBHDD intake and quality channels listed on the agency website.

Disability Rights Georgia provides external legal advocacy for individuals with disabilities, including those experiencing problems with case management.

A few more common questions:

Can my family member sit in on my case management meetings? Yes, if you want them there. Person-centered planning is led by the participant, and you choose who attends. You can authorize a family member or other representative to communicate with the case manager between meetings as well.

Will my case manager bill me for services? No. Medicaid pays the case manager. You do not pay anything out of pocket for Medicaid case management services.

What is the difference between a case manager and a care manager? The terms are often used interchangeably. In Georgia practice, case manager typically refers to HCBS waiver case managers, support coordinators, and TCM case managers. Care manager typically refers to CMO care management staff (often RNs or LCSWs). The functions overlap substantially. The distinction matters mostly for billing authority and for knowing which agency to contact.

What is the difference between SOURCE case management and CCSP case management? The main difference is the SOURCE program integrates the case manager with the member's primary care provider in a single program design, whereas CCSP case management coordinates with whatever primary care provider the member already has. SOURCE was designed specifically to integrate primary care with HCBS for older adults and adults with disabilities at NF level of care. CCSP predates SOURCE and serves a broader population.

What is the difference between an Assertive Community Treatment (ACT) team and a CSB case manager? ACT is the most intensive community-based behavioral health service model and is reserved for individuals with the most severe and persistent mental illness. ACT teams are multidisciplinary, share caseloads under a low staff-to-client ratio, and provide around-the-clock availability. A CSB case manager works in a more conventional case management role, provides scheduled contact, and coordinates with separately employed prescribers, therapists, and others.

What is the role of the Community Service Board? The CSB is the public behavioral health and developmental disabilities authority for a defined geographic region. CSBs provide case management, outpatient mental health and substance use services, crisis services, support coordination for some I/DD members, and other services. CSBs serve communities across Georgia and are funded through a combination of Medicaid, DBHDD state contracts, county funds, and other sources.

What is Targeted Case Management (TCM) and how do I qualify? TCM is case management for specific defined populations under Section 1915(g) of the Social Security Act. Allowable target populations in Georgia include individuals with serious mental illness, individuals with HIV/AIDS, children with special health care needs, individuals with intellectual or developmental disabilities, pregnant women, and others. Qualification depends on meeting the diagnostic and functional criteria for the specific target population. Your primary care provider, behavioral health prescriber, or community organization can help determine whether you qualify and where to apply.

My family member is being discharged from a state psychiatric hospital. What case management is available? Individuals transitioning out of state psychiatric hospitals may qualify for Intensive Case Management (ICM) under the Olmstead-related Settlement Agreement requirements. ICM teams are operated by community providers under DBHDD contract. Discharge planning from the state hospital should include connection to ICM (or to ACT if appropriate). If discharge planning has not addressed community-based services, contact DBHDD intake or Disability Rights Georgia.

My child is in foster care. Who is the case manager? For DFCS foster care, two parallel case managers exist. The DFCS caseworker manages the foster care case (custody, placement, family reunification, court proceedings). The Georgia Families 360 care coordinator manages the health care coordination across physical health, behavioral health, dental, and pharmacy. The DFCS caseworker and the 360 care coordinator should communicate with each other. Foster parents should have contact information for both.

How are case management services paid for? For HCBS waivers, case management is a covered waiver service paid under fee-for-service Medicaid or by the CMO depending on the member's coverage. For CMO care management, the case management is included in the CMO's capitation payment. For TCM, case management is billed by the qualified case management provider on a fee-for-service basis. The member does not pay out of pocket for any of these.

Can I appeal a service authorization decision my case manager made? Yes. If your case manager (or the program) reduces, denies, or terminates a service you receive or want, you have the right to a fair hearing. Notice of the decision must be sent to you with information about how to appeal. The deadline to request a hearing is typically thirty days for fair hearings and shorter for plan-level appeals. See Brevy's guide on appeals and fair hearings for the detailed process.

Key contacts

Aging and Disability Resource Connection (ADRC): 1-866-552-4464. The statewide front door for older adults and adults with disabilities seeking information, referral, and benefits screening.

211 Georgia: dial 211. Community resources including utility assistance, food assistance, transportation, and other supports.

988 Suicide & Crisis Lifeline. Round-the-clock mental health crisis support.

For other agency contacts (DCH Member Services, the DBHDD intake and quality lines, the Georgia Crisis and Access Line, the Long-Term Care Ombudsman, the three Georgia Families CMOs' member services lines, and Disability Rights Georgia), pull the current numbers from each agency's official website (medicaid.georgia.gov, dbhdd.georgia.gov, aging.georgia.gov, and thedlcga.org) or the member services number printed on your plan ID card. Phone numbers change as agencies and CMO contracts shift; the official websites carry the current routing.

Find personalized help navigating Georgia Medicaid care coordination at brevy.com.