Georgia Medicaid Targeted Case Management (TCM) Guide (2026)

Georgia Medicaid Targeted Case Management (TCM) is the case management benefit authorized under Section 1915(g) of the Social Security Act. It allows the Georgia Department of Community Health (DCH) to target case management to specific defined populations, including adults with serious mental illness (SMI), children with serious emotional disturbance (SED), individuals with intellectual or developmental disabilities (I/DD), individuals with HIV/AIDS, children with special health care needs (CSHCN), high-risk pregnant women in certain categories, and individuals transitioning out of institutional settings. This guide explains the federal framework, the Georgia target populations, the providers (Community Service Boards under the Department of Behavioral Health and Developmental Disabilities (DBHDD), the Georgia Department of Public Health (DPH), Ryan White Part B providers, and CMO care management), and how families qualify and use TCM.

By Brevy Care Team · Last verified May 12, 2026

TCM is one of the most useful but least understood Medicaid services. When a Georgia adult with schizophrenia is discharged from a Grady Hospital psychiatric admission and connected to the regional Community Service Board, the case manager assigned at the CSB is not simply a friendly outreach worker. She is delivering a specific Medicaid service called Targeted Case Management. When the parents of an eight-year-old with a complex congenital heart condition in Columbus call the Department of Public Health's Children with Special Health Care Needs program and get connected to a pediatric case manager, that case manager too is delivering TCM. When a Savannah man newly diagnosed with HIV connects with a Ryan White Part B agency and is paired with a case manager, that case manager is also delivering TCM (often dual-funded with Medicaid TCM and Ryan White Part B grant dollars).

Federal Medicaid law generally requires statewideness and comparability. TCM under Section 1915(g) is a deliberate exception: states can target case management to specific defined populations defined by diagnosis, condition, age, geography, or other criteria. This flexibility has allowed Georgia to build case management programs around the specific needs of people who would otherwise fall through gaps in coverage and coordination. The flexibility has also created billing complexity, which CMS and the HHS Office of Inspector General have policed for two decades through final rules, State Medicaid Director letters, and a long series of OIG audits.

This guide translates Georgia's TCM framework for families and providers. It explains the federal legal foundation, the Georgia target populations, the providers and operational patterns, and how families qualify, apply, and use TCM. It ends with worked examples drawn from Georgia's actual TCM populations, a frequently asked questions section, and a list of phone numbers families need. Brevy publishes this guide because TCM is the connective tissue for some of the most vulnerable populations in Georgia, and most families never realize the service exists until someone tells them.

The Federal Foundation

Medicaid case management as a service category dates from the 1970s, when states began experimenting with case management to support deinstitutionalization of individuals with mental illness and developmental disabilities. Section 1915(g) of the Social Security Act was added by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA 1985) to give states explicit authority to provide case management to specific target populations as an exception to statewideness and comparability. The statute has been amended several times since, most notably by the Deficit Reduction Act of 2005 to allow TCM during the days immediately preceding an institutional discharge, enabling effective transition planning. For the operative pre-discharge window and other specifics, consult the current CMS guidance on Section 1915(g).

The federal regulations governing TCM specify that TCM must include:

• A comprehensive assessment of the individual's needs. The assessment must consider medical, social, educational, vocational, and other relevant factors.
• Development of a specific care plan based on the assessment. The care plan documents goals, services, and responsible parties.
• Referral and related activities to help the individual obtain needed services. This includes scheduling, transportation coordination, and contact with providers, but does not include direct delivery of those services.
• Monitoring and follow-up activities. The case manager monitors the individual's progress and adjusts the care plan as needed.

The regulations also specify what TCM cannot be. TCM cannot duplicate other case management already covered (no double-billing for the same function). TCM cannot include the direct delivery of underlying medical services; for example, a case manager who is also a licensed therapist cannot bill TCM for time spent providing therapy. TCM must be voluntary. TCM cannot restrict the individual's free choice of qualified providers. These prohibitions matter because they have driven a substantial enforcement regime through HHS OIG audits and CMS guidance.

The CMS Final Rule and OIG Audit History

In the 2000s, HHS OIG conducted a series of audits of state TCM programs and identified widespread billing problems. Common findings included:

• Billing for time that was actually direct service delivery. A case manager who provided counseling, transportation, or hands-on care during a contact billed the full contact time as TCM rather than separating out the non-TCM activities.
• Billing for activities that were not allowable TCM. Examples included billing for routine administrative work, supervisory time, or time spent on unrelated cases.
• Billing for individuals who did not meet the TCM target population criteria.
• Duplicate billing. The same case management function was billed under multiple authorities (TCM, HCBS waiver, EPSDT, managed care).
• Inadequate documentation. Time sheets, contact notes, and care plans were missing, incomplete, or did not support the billed time.
• Billing for services to individuals in institutional stays. With limited exceptions (the pre-discharge transitional period under the Deficit Reduction Act), TCM cannot be billed during an institutional stay because Medicaid generally does not pay for case management for institutionalized individuals.

OIG audit findings led to state recoupments across multiple states. CMS responded with a final rule tightening the definition of case management, restricting billing for activities overlapping with other Medicaid services, and requiring documentation standards. Congress and CMS subsequently softened certain restrictions while retaining the core framework. Consult the current CMS Medicaid case management guidance and the OIG's annual recommendations compendium for the operative requirements.

The practical implication for Georgia families and providers: TCM operations are documented carefully. Case managers track time in short units (or in some target populations, document monthly bundled work). Care plans are formal documents. Contact notes specify activities. The bureaucratic specificity reflects the compliance regime, not arbitrary paperwork.

Relationship to Other Case Management Authorities

A Georgia Medicaid beneficiary can receive case management under several distinct authorities. Understanding which authority applies matters for compliance and for knowing which agency to contact about problems.

Section 1915(c) HCBS waiver case management is provided as a required service in every Section 1915(c) home and community-based services waiver. Georgia's waivers are ICWP, CCSP, SOURCE, NOW, COMP, and GAPP. The HCBS case manager is paid through the waiver's case management billing code. HCBS case management and TCM are distinct: a waiver participant generally receives HCBS case management for waiver services rather than TCM for the same function, although some target populations (HIV/AIDS, CSHCN, SMI, SED) may receive supplementary TCM for needs not addressed in the waiver case management.

Section 1945 Health Homes (added by the Affordable Care Act) are an optional state plan service for individuals with multiple chronic conditions or a serious and persistent mental health condition. States that adopt Health Homes receive enhanced federal match for an initial period of approved Health Home operations; consult current CMS Health Home guidance for the operative match percentage and duration. Georgia has not adopted a broad Health Home benefit. Comparable functions in Georgia are delivered through HCBS waiver case management, CMO Intensive Care Management, and DBHDD-funded behavioral health case management.

Section 1932 managed care care management is required of every Medicaid managed care plan. The Georgia Care Management Organizations (CMOs) operate tiered care management with Standard Care Coordination, Care Management, and Intensive Care Management (ICM) tiers. CMO care management is funded through the CMO's capitation, not as separately billable case management.

EPSDT case management supports children under 21 with positive screening results who need diagnostic and treatment follow-up. EPSDT case management can be delivered through CMO care management, through TCM for qualifying populations, or through specialty programs.

Optional state plan case management is the broader case management benefit available to all Medicaid beneficiaries. Most states (including Georgia) limit broad state plan case management and instead use TCM for specific target populations.

The non-duplication rule means that a single case management function cannot be billed twice. Georgia's State Plan and CMO contracts specify the boundaries between these authorities. When the same individual is eligible under multiple authorities, the boundaries are typically managed by:

• Identifying a primary case manager for the overall plan.
• Specifying which case management functions each authority covers (HCBS waiver case manager owns waiver services; SMI TCM case manager owns psychiatric services and treatment adherence; HIV TCM case manager owns HIV-specific services and Ryan White coordination; CMO care management coordinates the medical care across the plan's network).
• Coordinating across case managers through shared care planning meetings or scheduled inter-team calls.
• Documenting the boundaries in the participant's record.

Georgia Targeted Case Management Target Populations

Georgia operates TCM for several distinct target populations defined in the State Plan. Each population has its own qualification criteria, provider type, and operational pattern.

Adults With Serious Mental Illness (SMI)

The SMI TCM target population includes adults age 18 and over with qualifying mental health diagnoses (schizophrenia, schizoaffective disorder, bipolar disorder, major depression with psychotic features, severe depression with functional impairment, severe anxiety disorders with functional impairment, severe PTSD, and certain other diagnoses) and qualifying functional impairment established through assessment.

The primary providers are Georgia's Community Service Boards (CSBs), the regional behavioral health entities that serve communities across Georgia. CSB SMI case managers are typically masters-level mental health clinicians (LCSW, LPC, LMFT, psychologists) or other qualified mental health professionals with appropriate licensure and training.

Caseloads vary by program and CSB; consult the agency for typical caseload ranges. The intensity of services varies based on individual need, ranging from monthly contact for stable individuals to weekly or more frequent contact for individuals in crisis or transition.

Activities include:

• Comprehensive psychosocial assessment and reassessment.
• Service plan development and updates.
• Coordination with the prescribing psychiatrist or psychiatric nurse practitioner.
• Coordination with therapy providers.
• Medication adherence support (without direct administration).
• Crisis coordination including with mobile crisis teams and crisis stabilization.
• Housing assistance coordination.
• Vocational rehabilitation and employment support coordination.
• Coordination with primary care.
• Substance use treatment coordination for co-occurring disorders.
• Coordination with social services (SSI/SSDI, food assistance, utility assistance).
• Family support and education with the individual's consent.
• Discharge planning if hospitalized.

SMI TCM is distinct from Assertive Community Treatment (ACT), which is a more intensive team-based service for individuals with the most severe and persistent mental illness. ACT teams provide all the SMI TCM functions plus direct psychiatric, nursing, and substance use services within the team. ACT and TCM are typically not billed simultaneously for the same individual.

Children With Serious Emotional Disturbance (SED)

The SED TCM target population includes children and adolescents under age 21 with qualifying mental health diagnoses and qualifying functional impairment. Qualifying diagnoses include disruptive mood dysregulation disorder, major depression, bipolar disorder, post-traumatic stress disorder, anxiety disorders with severe impairment, conduct disorder with severe impairment, autism spectrum disorder with severe behavioral health needs, and other severe child and adolescent mental disorders.

SED TCM is delivered by CSBs and other DBHDD-contracted providers. Services are integrated where appropriate with the wraparound service model, which is an evidence-based approach to coordinating care for children with complex needs across family, school, mental health, and community systems.

Activities include:

• Comprehensive child and family assessment.
• Service planning with family input.
• Coordination with the school district including IEP and Section 504 plans.
• Coordination with therapy and psychiatric medication providers.
• Coordination with juvenile justice or DFCS where applicable.
• Family support, education, and respite coordination.
• Crisis response coordination including with the Georgia Crisis and Access Line.
• Transition support across developmental milestones.
• Coordination with foster care care coordination (Georgia Families 360) for children in DFCS custody.

Individuals With Intellectual or Developmental Disabilities (I/DD)

The I/DD TCM target population includes individuals of any age with qualifying intellectual or developmental disabilities originating before age 22 and resulting in substantial functional limitations. Qualifying diagnoses include intellectual disability, autism spectrum disorder, cerebral palsy, epilepsy with significant functional impairment, and other developmental disabilities.

For individuals enrolled in the NOW or COMP HCBS waivers, the support coordinator's case management is funded as a Section 1915(c) waiver service, not as 1915(g) TCM. The functional services are largely the same, but the billing authority differs. For individuals not enrolled in a waiver who need case management, standalone I/DD TCM may apply.

DBHDD-contracted support coordination agencies deliver both NOW/COMP waiver support coordination and standalone I/DD TCM. The support coordinator may be the same person regardless of which authority is paying.

Activities include:

• Comprehensive assessment of intellectual and adaptive functioning.
• Individual Service Plan (ISP) development or comparable care plan.
• Coordination with direct support professionals and their employing agencies.
• Coordination with day programs and supported employment.
• Coordination with residential supports (host home, group home, family setting).
• Behavioral support coordination.
• Therapy coordination.
• Family support and respite coordination.
• Transition planning.

Individuals With HIV/AIDS

The HIV/AIDS TCM target population includes individuals diagnosed with HIV infection or AIDS who need case management to support treatment, medication adherence, and access to ancillary services. The HIV/AIDS case management role is particularly critical because of the medical complexity of HIV treatment, the importance of antiretroviral medication adherence to viral suppression and prevention of transmission, and the substantial social and behavioral health comorbidities that often accompany HIV.

HIV/AIDS TCM in Georgia is closely integrated with the federal Ryan White HIV/AIDS Program. The Georgia Department of Public Health administers Ryan White Part B. Many HIV/AIDS case managers are funded through a combination of Medicaid TCM (for individuals with Medicaid coverage) and Ryan White Part B grant dollars (for individuals without Medicaid or for activities not covered by Medicaid). The Ryan White program is the payer of last resort by federal law, meaning Medicaid bills first for Medicaid-eligible individuals and Ryan White covers the gaps. Case managers track time and activities carefully to ensure proper funder attribution.

Activities include:

• Comprehensive assessment of medical, social, and behavioral health needs.
• Antiretroviral medication adherence support.
• Coordination with the HIV care provider.
• Coordination with pharmacy and the AIDS Drug Assistance Program (ADAP) for medication access.
• Coordination with primary care for non-HIV health needs.
• Behavioral health coordination including for depression, anxiety, and other psychiatric comorbidities.
• Substance use treatment coordination.
• Housing assistance including coordination with HOPWA (Housing Opportunities for Persons With AIDS) where applicable.
• Food assistance coordination including SNAP and HIV-specific food programs.
• Dental care coordination (HIV-specific dental services may be available through Ryan White).
• Peer support linkage.
• Disclosure support.
• End-of-life planning where applicable.

Children With Special Health Care Needs (CSHCN)

The CSHCN TCM target population includes children under age 21 with qualifying chronic medical conditions, complex care needs, or significant functional limitations. The CSHCN program is operated by the Georgia Department of Public Health and is funded through a combination of Maternal and Child Health Bureau Title V block grant funds and Medicaid TCM for Medicaid-eligible children.

CSHCN program qualifying conditions include congenital conditions, complex chronic conditions, severe developmental disabilities, conditions requiring multi-specialty coordination, conditions requiring durable medical equipment, and others defined by the program. CSHCN TCM case managers are typically registered nurses, licensed clinical social workers, or other qualified pediatric clinicians.

Activities include:

• Comprehensive assessment of medical, developmental, social, and educational needs.
• Coordination across the child's multiple medical specialists.
• Coordination with the medical home pediatrician.
• Coordination with durable medical equipment vendors.
• Coordination with the school district including IEP, Section 504, and school nursing.
• Coordination with Babies Can't Wait early intervention for children 0-3.
• Family support and education.
• Insurance coordination especially for families with Medicaid plus private insurance.
• Transition planning to adult care.
• Crisis coordination for medical emergencies.
• Coordination with subspecialty residential programs where applicable.

High-Risk Pregnant Women

Georgia covers TCM for some categories of high-risk pregnant women under State Plan provisions. The target population includes pregnant women with high-risk conditions: gestational diabetes, hypertensive disorders of pregnancy, multiple gestation, history of preterm delivery, substance use during pregnancy, severe mental illness during pregnancy, severe chronic medical conditions, and others.

For Medicaid members enrolled in a CMO (most pregnant Medicaid members in Georgia), high-risk pregnancy case management is typically delivered through CMO care management or ICM, funded through the CMO's capitation rather than as separately billed TCM. Standalone TCM for high-risk pregnancy applies more often in fee-for-service Medicaid contexts.

Activities include prenatal care coordination, coordination with maternal-fetal medicine specialists, behavioral health coordination, substance use treatment coordination, nutrition counseling coordination including WIC, non-emergency medical transportation (NEMT) coordination for prenatal appointments, postpartum care coordination, linkage to home visiting programs, and linkage to family planning postpartum. Georgia adopted the twelve-month postpartum continuous coverage extension in 2022, so high-risk pregnancy case management can continue across the full twelve-month postpartum period for many participants.

Individuals Transitioning From Institutions

Section 6052 of the Deficit Reduction Act of 2005 amended Section 1915(g) to allow TCM during the days immediately preceding an institutional discharge. This pre-discharge case management is critical for successful transitions to community settings; the operative day-window is in the current CMS guidance.

Georgia's Olmstead Settlement Agreement with the U.S. Department of Justice required Georgia to expand intensive community-based case management for individuals transitioning out of state psychiatric hospitals and out of large I/DD institutional settings. The settlement is part of Georgia's compliance with the Americans with Disabilities Act and the Olmstead v. L.C. decision, which requires states to serve individuals with disabilities in the most integrated setting appropriate.

The settlement-related Intensive Case Management (ICM) teams operate with structural similarities to ACT but are sometimes funded and structured differently, with specific performance metrics and reporting to a court-appointed independent reviewer.

Activities include:

• Pre-discharge assessment and planning beginning during the allowed pre-discharge window.
• Coordination with the institutional discharge planner.
• Identification of community-based providers (mental health, substance use, primary care, residential supports).
• Housing assistance coordination.
• Initial post-discharge stabilization including frequent contact in the first weeks.
• Crisis support.
• Linkage to ongoing community-based case management or ACT for individuals with severe and persistent mental illness who need long-term intensive support.

Provider Qualifications and Operations

TCM providers must meet qualifications specified in the Georgia State Plan and DCH/DBHDD provider manuals. The qualifications vary by target population but generally require:

• A bachelor's or master's degree in a relevant field (social work, psychology, education, nursing, public health).
• Appropriate licensure where applicable (LCSW, LPC, LMFT, RN).
• Training specific to the target population (for example, HIV/AIDS case management training, pediatric complex care training, behavioral health crisis training).

The employing agency must be enrolled as a Medicaid TCM provider with DCH. Provider enrollment requires documentation of organizational capability, quality assurance programs, compliance with applicable accreditation requirements, compliance with documentation standards, and compliance with reporting requirements.

TCM is typically billed in short units, although some target populations use monthly bundled rates. Documentation requirements include:

• Date and time of each contact.
• Duration of contact.
• Nature of contact (phone, in-person, video).
• Activities performed (assessment, care planning, referral, monitoring).
• Outcomes and next steps.
• Signature or electronic authentication by the case manager.

The documentation must support the billed time. Time spent on direct service delivery, agency administrative work, or supervision cannot be billed as TCM.

How Families Qualify for and Access Targeted Case Management

The pathway depends on the target population.

For SMI or SED TCM, contact the regional Community Service Board. Each CSB serves a defined geographic catchment area covering one or more counties. The DBHDD provider directory lists each CSB and its service area. Call DBHDD Intake at 1-888-273-1414 for help identifying the correct CSB. An initial assessment by a qualified mental health professional establishes diagnosis and functional impairment.

For I/DD TCM (or NOW/COMP waiver support coordination), contact DBHDD Intake at 1-888-273-1414 to begin the process. The intake assessment establishes eligibility. For waiver enrollment, eligibility decisions and planning list management are handled through DBHDD.

For HIV/AIDS TCM, contact the regional Ryan White Part B provider or call DPH for referral. Provider availability varies by region.

For CSHCN TCM, call the DPH CSHCN program at 1-855-707-8277. The program will conduct an intake assessment to determine eligibility.

For high-risk pregnancy case management, ask the obstetrician for referral. For CMO-enrolled members, call the CMO care management line: Amerigroup 1-800-600-4441, CareSource 1-855-202-0729, Peach State 1-800-704-1484.

For transitional TCM, the institutional discharge planner should initiate referrals to community providers as part of discharge planning. Families and individuals can also contact community providers directly during the allowed pre-discharge window.

In all cases, the individual or family can self-refer; provider referral is not required.

What to Expect From Targeted Case Management

After eligibility is established and the participant agrees to receive TCM (TCM is voluntary), the case manager will conduct an initial comprehensive assessment. The assessment typically takes one to two visits and covers medical, behavioral health, social, family, housing, financial, and other relevant areas.

The case manager will then develop a written care plan documenting goals, services, providers, frequency of contact, and crisis plan elements. The care plan is reviewed with the participant and (with the participant's consent) family members or other supports.

Ongoing contact frequency varies. SMI TCM at a CSB might involve weekly or more frequent contact for newly engaged individuals and monthly contact for stable individuals. CSHCN TCM might involve monthly contact for stable conditions and more frequent contact during care transitions. ACT-like intensive case management for institutional transitions involves daily or near-daily contact in the initial weeks.

Reassessments occur at regular intervals (typically annually, sometimes more frequently for higher-intensity services). Crisis response is part of TCM. The case manager should be available to respond to crises within the agency's stated response window or to coordinate with crisis services (Georgia Crisis and Access Line at 1-800-715-4225, mobile crisis teams, or 988).

Worked Examples

Aisha, 34, Atlanta, SMI TCM at View Point Health (Gwinnett CSB). Aisha has schizophrenia diagnosed in her early twenties. She has had multiple psychiatric hospitalizations and one prolonged state hospital stay. After her most recent discharge, she was connected to View Point Health for outpatient psychiatric care and TCM. Her case manager, Tonya, is a Licensed Clinical Social Worker. Tonya conducted the initial assessment over two visits and developed a service plan addressing medication adherence, housing, peer support, primary care, and family relationships. Aisha attends monthly psychiatric medication appointments with the prescriber at View Point Health, attends weekly individual therapy, and attends a peer support group. Tonya has helped her apply for SSDI (still pending), apply for HUD subsidized housing (still on waitlist), and connect with a primary care provider for her co-occurring hypertension. Tonya meets with Aisha twice monthly, alternating between View Point Health and Aisha's apartment. When Aisha began experiencing increased auditory hallucinations last spring, Tonya worked with the prescriber to adjust her medication and increased contact frequency for six weeks. Aisha credits Tonya with helping her avoid another hospitalization.

Marcus, 12, Augusta, SED TCM at Serenity Behavioral Health Systems (Augusta CSB). Marcus has bipolar disorder and severe anxiety. He has been hospitalized twice in the past two years. His mother, Karen, works full time and has two younger children. Marcus's SED TCM case manager, Andrea, is a Licensed Professional Counselor. Andrea facilitates a wraparound team that includes Karen, Marcus, Marcus's school counselor, Marcus's psychiatric prescriber, Marcus's individual therapist, and a peer specialist parent partner who provides peer support to Karen. The team meets monthly to review Marcus's IEP, his medication response, his school attendance, his behavioral plan at home, and Karen's well-being. Andrea coordinates respite for Karen through DBHDD-funded respite resources, helps Marcus access summer therapeutic camp, and has been working with the school district on Marcus's transition from middle school to high school. Andrea also handles crisis response coordination, which has been needed three times in the past year. The wraparound approach has stabilized Marcus enough that the family has avoided hospitalization for over a year.

Eleanor, 67, Macon, HIV/AIDS TCM at the Medical Center Ryan White program. Eleanor was diagnosed with HIV three years ago. She is dual eligible (Medicare and Medicaid) and her HIV treatment is partly paid through Medicare Part D, the AIDS Drug Assistance Program (for medications Medicare does not cover), and Medicaid (as the secondary payer). Her HIV case manager, Renee, is funded through a combination of Medicaid TCM and Ryan White Part B grant dollars. Renee tracks her time carefully to ensure proper funder attribution. Renee coordinates Eleanor's HIV care with the infectious disease specialist, her primary care with a separate community physician, her diabetes care, her behavioral health (Eleanor receives outpatient depression treatment), and her dental care (through the Ryan White-funded dental program). Renee also helped Eleanor enroll in HOPWA-funded supportive housing and helps her navigate the complexity of Medicare-Medicaid coordination of benefits. Renee meets with Eleanor monthly, with additional contact during transitions or problems. Eleanor's HIV is well-controlled and her overall health has improved substantially since she began receiving coordinated care.

Jamil, 6, Columbus, CSHCN TCM at the DPH District 7 office. Jamil was born with a complex congenital heart defect and has had multiple cardiac surgeries. He also has feeding difficulties requiring a gastrostomy tube, and developmental delays. His mother, Karina, was overwhelmed by the complexity of his care across pediatric cardiology at the Atlanta Children's Hospital, pediatric pulmonology and gastroenterology at a closer Columbus practice, the durable medical equipment vendor for his feeding pump, the special education preschool, and his medical home pediatrician. Karina enrolled Jamil in the CSHCN program when she heard about it from a hospital social worker. Jamil's CSHCN case manager, Vanessa, is a registered nurse with pediatric specialty training. Vanessa coordinates Jamil's appointments across the specialists, ensures that consult notes and lab results are shared among the providers, attends his IEP meetings at school, coordinates with the durable medical equipment vendor for supply replenishment and equipment troubleshooting, and helps Karina navigate the dual coverage. Vanessa is also helping Karina prepare for Jamil's transition to elementary school. Karina says Vanessa has given her back hours each week that she previously spent on phone calls and faxes between providers.

Lorraine, 58, Savannah, I/DD TCM. Lorraine has Down syndrome with mild intellectual disability. She has lived with her daughter Tasha and Tasha's family since her own mother died ten years ago. Lorraine is not currently enrolled in the NOW or COMP waiver (she remains on the planning list). She receives I/DD TCM through a DBHDD-contracted support coordination agency in Chatham County. Her case manager, James, is a Qualified Developmental Disability Professional. James helped Lorraine enroll in the Senior Companion day program three days per week, coordinates her primary care, her dental care, her annual gynecological care, and her behavioral health (Lorraine has anxiety that occasionally needs medication adjustment). James also helped Tasha plan for Lorraine's longer-term future given Tasha's own aging concerns. James meets with Lorraine and Tasha quarterly. He also serves as Lorraine's advocate in the ongoing planning list situation, encouraging DBHDD to prioritize waiver enrollment.

Diana, 28, rural Bulloch County, high-risk pregnancy TCM. Diana is in her second pregnancy. Her first pregnancy ended in preterm delivery at 32 weeks. She has gestational diabetes and lupus. Her obstetrician referred her to Amerigroup care management when she enrolled in pregnancy Medicaid. Amerigroup's ICM team identified her as high-risk based on history, diagnoses, and rural residence (the maternal-fetal medicine specialist is in Savannah, sixty miles away). Her ICM nurse, Patricia, is technically delivering CMO care management funded through capitation, with elements that would be billable as TCM in fee-for-service contexts. Patricia coordinates Diana's prenatal care with both the obstetrician and the maternal-fetal medicine specialist, arranges NEMT for the longer trips to Savannah, supports her medication adherence (insulin for the gestational diabetes plus continued lupus medications during pregnancy), and conducts weekly check-in calls during the third trimester. Patricia is preparing the postpartum plan including continued lupus management, family planning counseling, and behavioral health screening for postpartum depression. Patricia will continue ICM through Diana's twelve-month postpartum continuous coverage period.

Common Questions and Problems

Can I have Targeted Case Management and HCBS waiver case management at the same time? Generally not for the same function. If you are enrolled in an HCBS waiver, the waiver case management covers your waiver services and is paid through the waiver. TCM may supplement for needs not addressed in the waiver case management, such as TCM-specific population services (SMI TCM, HIV/AIDS TCM). The boundary is documented in the care plan to avoid duplication.

Can my CMO care manager and my CSB case manager work together? Yes. CMO care management coordinates your physical health and the plan-network services. CSB SMI TCM coordinates your psychiatric care and TCM-specific functions. The two should communicate with you and (with your consent) with each other. Ask both to coordinate by phone or video.

Why does my case manager document everything in such detail? Federal billing compliance requires the documentation. Case managers track activities, time, and outcomes because federal auditors (HHS OIG, CMS) review documentation to verify proper billing. The detailed documentation also creates a record that helps with continuity if your case manager changes.

My case manager says she cannot transport me to appointments. Why? TCM cannot include direct service delivery. Non-emergency medical transportation (NEMT) is a separate Medicaid service. Your case manager can coordinate transportation through an NEMT provider but cannot personally drive you (and cannot bill TCM for time spent driving).

My family member is in a nursing facility. Can he get Targeted Case Management? Generally TCM is not billable during an institutional stay because the institution's per diem rate is supposed to cover comparable functions. The exception is the pre-discharge window under Section 6052 of the Deficit Reduction Act of 2005, when transitional TCM is allowed to support successful return to the community.

Can I refuse TCM? Yes. TCM is voluntary. Refusing TCM does not affect your eligibility for other Medicaid services.

What if I am unhappy with my case manager? Request a different case manager at the same agency, or transfer to a different agency that operates in your area. Your provider's quality assurance staff or DBHDD/DPH program staff can help.

Can my family caregiver be paid as my case manager? No. Federal Medicaid rules do not allow family caregivers to be paid as case managers for their family members. Family caregivers can be paid as personal support workers under some self-directed arrangements (with limits), but the case manager role is distinct.

Frequently Asked Questions

A few more common questions families ask:

What target populations does Georgia cover under TCM? Adults with serious mental illness, children with serious emotional disturbance, individuals with intellectual or developmental disabilities, individuals with HIV/AIDS, children with special health care needs, certain high-risk pregnant women, and individuals transitioning from institutions.

Is TCM the same as HCBS waiver case management? No. HCBS waiver case management is authorized at Section 1915(c) and is funded through the waiver. TCM is authorized at Section 1915(g) and is funded separately. The activities can be similar but the billing authorities differ and the rules about who can be served differ.

My family member was just discharged from a state psychiatric hospital. What case management is available? Individuals transitioning from state psychiatric hospitals may qualify for Intensive Case Management (ICM) under Georgia's Olmstead settlement, ACT teams (for those with the most severe and persistent mental illness), or standard SMI TCM at a Community Service Board. Discharge planning from the state hospital should initiate the community connection. If it did not, contact DBHDD at 1-888-273-1414.

Can I have TCM if I am enrolled in a CMO? Yes. CMO care management and TCM serve different functions. CMO care management is coordinated through the plan's capitation. TCM is for target populations needing specialty case management.

What is the difference between TCM and Health Homes? TCM is authorized at Section 1915(g); Health Homes are authorized at Section 1945. States that adopt Health Homes receive enhanced federal match for an initial period of operations. Georgia has not adopted a broad Health Home benefit, so most Georgia case management for the conditions Health Homes would cover is delivered through TCM, HCBS waivers, or CMO care management.

How is TCM billed? TCM is typically billed in short units. Some target populations use monthly bundled rates. The case manager documents the date, time, duration, nature, and activities of each contact. The Medicaid program (or the CMO for managed care members) pays the provider directly.

Key Contacts

This guide is for general informational purposes only and does not constitute legal, medical, or financial advice. Federal and state Medicaid rules change frequently. Verify current rules with your case management provider, your CMO, the Department of Community Health, the Department of Behavioral Health and Developmental Disabilities, the Department of Public Health, and other authoritative sources before making decisions about care.

Find personalized help navigating Georgia at brevy.com.