To get a Medicaid case manager, call the member services number on your managed care plan card and ask for a case management referral, or contact your state Medicaid agency directly if you’re on fee-for-service Medicaid. Case management is an optional Medicaid benefit under federal law, so availability varies by state, but most states offer it in some form.1Medicaid.gov. Mandatory and Optional Medicaid Benefits Once you request one, the provider runs an assessment to decide whether case management is appropriate and at what level.
How to Request a Case Manager
Most Medicaid beneficiaries today are enrolled in managed care, and the request path depends on which side of that line you’re on.
If You’re in a Managed Care Plan
Call the member services number on the back of your plan card and ask specifically about case management. Many managed care organizations assign case managers automatically to members with certain diagnoses or high service use, but you can also request one before the plan flags you. The plan may run a phone assessment to gauge your level of need. If your medical situation is complex, describe it clearly on that first call rather than waiting for the plan to piece it together from claims data.
If You’re in Fee-for-Service Medicaid
Contact your state Medicaid agency directly. Medicaid.gov keeps a directory of every state agency’s phone number and website on its “Where Can People Get Help” page.2Medicaid.gov. Where Can People Get Help With Medicaid and CHIP Ask whether your state covers case management and how to request a referral. You can also ask your primary care provider to initiate the referral, which sometimes moves faster because the clinical need gets documented upfront.
What Happens After You Ask
Expect an assessment. The case management provider reviews your medical records, current conditions, and support needs to decide whether case management fits and what intensity of service you need. Processing generally runs 30 to 90 days, though it varies by state and by how backed up the agency is. If you’ve been waiting more than a few weeks without hearing anything, follow up. Requests that sit quietly in a queue are the ones that take the longest.
Who Qualifies
You first have to be enrolled in Medicaid. Eligibility is based on income (measured using Modified Adjusted Gross Income for most groups), family size, residency, and non-financial factors like citizenship or immigration status.3Medicaid.gov. Eligibility Policy If you already have Medicaid, that hurdle is cleared.
Beyond enrollment, qualifying depends on which type of case management your state offers. Federal law recognizes two.
General case management is available to any Medicaid-eligible person who lives in the community or is transitioning into one, wherever the state offers the benefit.4eCFR. 42 CFR 440.169 – Case Management Services States that include general case management in their Medicaid plan must offer it statewide on equal terms. There’s no additional clinical threshold beyond Medicaid enrollment.
Targeted case management is aimed at defined groups: people with intellectual disabilities, chronic mental illness, brain injuries, children with special healthcare needs, older adults needing long-term services, and other complex populations.5Centers for Medicare & Medicaid Services. Medicaid Definition of Covered Case Management Services Clarified States can limit targeted case management to specific populations or specific regions, which is why availability differs so much by ZIP code.
Many states also provide case management through Home and Community-Based Services (HCBS) waivers for people who would otherwise need institutional care. Waivers have their own eligibility criteria and enrollment caps, and those caps produce waitlists in most states.
What Your Case Manager Actually Does
Federal regulations describe four core activities: assessing your medical, social, and educational needs; building a written care plan with you; making referrals and coordinating appointments, transportation, and community programs; and monitoring the plan, including at least one formal reassessment each year.4eCFR. 42 CFR 440.169 – Case Management Services
The practical value is coordination. Instead of you calling five offices to arrange a ride to a specialist, chase down a prior authorization, and follow up on a referral, the case manager runs that traffic. For people juggling chronic conditions, disabilities, or complex care, that’s where most of the benefit lives.
The care plan is collaborative. Federal rules require your active participation in setting goals, identifying services, and choosing who else takes part in planning.4eCFR. 42 CFR 440.169 – Case Management Services You’re not just signing off on someone else’s document. If a proposed goal doesn’t match your priorities, push back. Between annual reassessments, call your case manager when things change: a new diagnosis, a provider who isn’t working out, a housing shift. The most effective case managers hear from their clients regularly.
Your Right to Choose or Switch Case Managers
Federal law gives Medicaid beneficiaries the right to receive services from any qualified, willing provider, and that includes case management.6eCFR. 42 CFR 431.51 – Free Choice of Providers If more than one qualified case management agency operates in your area, you get to pick.7Centers for Medicare & Medicaid Services. Questions and Answers – Technical Assistance Tool Your state cannot force you to use a specific case manager because it’s more convenient for the agency.
One exception. When targeted case management serves only people with developmental disabilities or chronic mental illness, the state can narrow the provider pool by requiring specialized qualifications. You still choose among the providers who meet those stricter standards.6eCFR. 42 CFR 431.51 – Free Choice of Providers
If the assigned case manager isn’t working out, you can switch. Contact your plan or state agency and request reassignment. You don’t need to file a formal complaint, but documenting specific problems (missed appointments, failure to follow up on referrals) helps if the agency resists.
Conflict-Free Case Management on Waivers
If your case management comes through an HCBS waiver, federal rules prohibit the same agency from both providing your direct care services and serving as your case manager.8Medicaid.gov. Mitigating Conflict of Interest in Case Management – Outcomes to Date A case manager is supposed to advocate for you and connect you with the best available services. That advocacy is compromised when the case manager’s employer is also billing Medicaid for your personal care or therapy.
If you find that the same organization is doing both, raise it with your state Medicaid agency. When only one provider exists in a given geographic area, the state must put specific conflict-of-interest protections in place and offer an alternative dispute resolution process.
Waitlists for Waiver-Based Case Management
Case management delivered through HCBS waivers is capped, and when demand exceeds slots, states maintain waiting lists. As of 2025, 41 states kept such lists, with more than 600,000 people waiting for waiver services nationally. The average wait was 32 months, and some individuals waited longer.
A few things to know while you’re on a list:
- You may still qualify for other services while waiting. Most people on HCBS waiver waitlists remain eligible for other home care through the Medicaid state plan, such as personal care services. What you lose access to until a waiver slot opens are the specialized waiver services like supported employment or adult day programs.
- Some states screen for waiver eligibility before adding you to the list; others add everyone and screen later. If your state screens upfront, your list position carries more weight.
- Many states fill slots in the order people applied. Families sometimes add children with developmental disabilities to the list years before services will be needed.
Starting in July 2027, a new federal rule will require states to publicly report how many people are on waiver waiting lists, whether they’ve been screened, and how long recently enrolled individuals waited.
If You’re Denied: How to Appeal
If your request is denied, or if your plan reduces or terminates case management you’re already receiving, you have appeal rights. Timing matters, and missing a deadline can cost you protections.
The Denial Notice
Your managed care plan must send a written notice explaining the decision, the reasons, your right to appeal, how to request an expedited appeal if your health is at risk, and your right to keep receiving services while the appeal is pending.9eCFR. 42 CFR 438.404 – Timely and Adequate Notice of Adverse Benefit Determination You can also ask for free copies of the documents, records, and medical necessity criteria the plan relied on. Missing information in the notice is worth flagging in your appeal.
Keeping Services While You Appeal
When a plan tries to terminate or reduce case management you’ve been receiving, you can request that those services continue at the previously authorized level during the appeal. To preserve that right, file for continuation of benefits within 10 calendar days of the notice date, or before the termination takes effect, whichever gives you more time.10eCFR. 42 CFR 438.420 – Continuation of Benefits While the MCO Appeal and State Fair Hearing Are Pending That window is tight, and it’s where many people lose their rights.
One risk to weigh: if the appeal goes against you, the plan may be allowed to recover the cost of services provided during the appeal period, depending on your state’s recoupment policy.10eCFR. 42 CFR 438.420 – Continuation of Benefits While the MCO Appeal and State Fair Hearing Are Pending Recoupment from beneficiaries is uncommon in practice, but ask about your state’s policy before requesting continuation.
State Fair Hearing
If the plan denies your internal appeal, you can request a state fair hearing, an independent review run by the state rather than the plan.11eCFR. 42 CFR 431.220 – When a Hearing Is Required You generally have up to 90 days from the date on the denial notice to request one.12eCFR. 42 CFR Part 431, Subpart E – Fair Hearings for Applicants and Beneficiaries If you want services to continue through the fair hearing, you must request continuation within 10 days of the plan’s appeal decision.
What It Costs
Most Medicaid beneficiaries pay nothing out of pocket for case management. Federal law lets states impose nominal copayments for some services, but several groups are exempt entirely, including children, pregnant women, and terminally ill individuals.13Medicaid.gov. Cost Sharing Out of Pocket Costs Where copayments apply at all, they’re capped at small amounts for beneficiaries below the poverty line. If you get a bill for case management and it looks wrong, call your managed care plan or state Medicaid agency before paying.