Medicaid Care Management Programs by State

Medicaid care management programs represent a federally authorized but state-administered framework through which states deliver coordinated health services to enrolled beneficiaries, particularly those with complex medical, behavioral, or social needs. Each of the 50 states and the District of Columbia operates at least one care management initiative within its Medicaid program, with structural variations driven by waiver authority, state plan amendments, and managed care contracting. Understanding these programs requires distinguishing between federal funding mechanisms, delivery system models, and target population definitions — distinctions that carry significant consequences for beneficiary access and provider reimbursement.

• Definition and Scope
• Core Mechanics or Structure
• Causal Relationships or Drivers
• Classification Boundaries
• Tradeoffs and Tensions
• Common Misconceptions
• Checklist or Steps
• Reference Table or Matrix
• References

Definition and Scope

Medicaid care management programs are structured interventions within state Medicaid programs that assign care managers, coordinators, or interdisciplinary teams to beneficiaries identified as high-risk or high-need. The Centers for Medicare & Medicaid Services (CMS) defines care management in the Medicaid context through multiple regulatory pathways, including 42 CFR Part 438 for managed care organizations and 42 CFR Part 441 for home- and community-based services waivers.

The scope of these programs encompasses preventive, chronic disease, transitional, and behavioral health care management functions. As of the CMS Medicaid Managed Care final rule published in 2016 and subsequently amended, states operating managed care programs must contractually require health plans to maintain care management functions for high-risk populations (CMS, 81 FR 27498).

Across fee-for-service and managed care delivery systems, care management scope varies. Fee-for-service states may rely on Primary Care Case Management (PCCM) structures, while managed care states delegate care management responsibilities to contracted Managed Care Organizations (MCOs). The Kaiser Family Foundation's State Health Facts documents that all 50 states and D.C. have some form of Medicaid managed care enrollment, though the degree to which managed care covers specific populations differs substantially by state.

For a broader orientation to how care management models are classified nationally, the page on care management models and frameworks provides comparative context.

Core Mechanics or Structure

State Medicaid care management programs operate through three primary structural mechanisms: (1) Primary Care Case Management, (2) Managed Care Organization contracts, and (3) Section 1915(b) and Section 1115 waivers.

Primary Care Case Management (PCCM): Under PCCM, states pay a primary care provider a monthly management fee — typically between $2 and $5 per member per month (CMS, Medicaid PCCM Resource Guide) — to serve as the beneficiary's care coordinator. The provider authorizes referrals and manages utilization. Enhanced PCCM (PCCM-E) models allow states to add population health management activities, telephonic outreach, and risk stratification functions.

Managed Care Organization (MCO) Contracts: States contracting with MCOs under 42 CFR Part 438 must include contract provisions specifying care management standards. Federal regulations require that MCO contracts address identification of members with special health care needs, assessment protocols, and individualized care plans. CMS's 2020 Medicaid Managed Care rules clarified that states must ensure MCOs provide care management to members with complex conditions.

Waiver-Based Programs: Section 1115 Demonstration Waivers allow states to test alternative delivery models, including integrated care for dually eligible populations (individuals enrolled in both Medicare and Medicaid). Section 1915(c) waivers fund Home and Community-Based Services (HCBS) with embedded care coordination requirements. The Medicaid.gov waiver database lists all active demonstrations by state.

Risk stratification is integral to care management program mechanics. Beneficiaries are stratified into tiers — commonly low, medium, and high risk — based on claims data, diagnosis codes, pharmacy utilization, and social needs screening. Risk stratification in care management describes the algorithmic and clinical methodologies underlying this process.

Causal Relationships or Drivers

State variation in Medicaid care management program design is driven by three documented causal factors: federal waiver flexibility, state political economy, and Medicaid population demographics.

Federal Waiver Flexibility: CMS grants states discretion through Section 1115 and Section 1915 waivers to deviate from standard Medicaid rules. This flexibility allows states to impose enrollment requirements, test global payment models, or integrate behavioral and physical health services. The number of active Section 1115 waivers exceeded 50 as of data published by Medicaid.gov, with multiple states holding multiple simultaneous demonstrations.

State Political Economy: States that opted into Medicaid expansion under the Affordable Care Act (ACA) gained 13.8 million additional enrollees as of 2022 (KFF Health Insurance Coverage of the Total Population), creating pressure to develop scalable care management infrastructure. Non-expansion states face a different population mix, with higher proportions of individuals qualifying through disability or long-term care pathways — populations with higher per-capita care management intensity.

Population Demographics: Medicaid serves a disproportionately high share of individuals with behavioral health needs. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that Medicaid finances approximately 26% of all mental health spending in the United States (SAMHSA, Behavioral Health Spending and Use Accounts). This concentration drives states to develop specialized behavioral health care management tracks within broader Medicaid programs.

Classification Boundaries

Medicaid care management programs divide along four principal classification axes:

By Delivery System: Fee-for-service (FFS) programs assign care managers at the state agency or PCCM level. Managed care programs delegate care management to contracted MCOs. Dual-eligible programs operate under Financial Alignment Initiative (FAI) demonstrations or Medicare-Medicaid Plans (MMPs) with shared care management responsibilities. The Social Security Fairness Act of 2023 (enacted January 5, 2025) repealed the Windfall Elimination Provision (WEP) and Government Pension Offset (GPO), which may affect the benefit calculations and financial circumstances of some dually eligible beneficiaries — particularly retired public employees — who participate in integrated Medicare-Medicaid care management programs. Restored Social Security income for affected individuals may trigger Medicaid eligibility redeterminations or changes in cost-sharing obligations.

By Target Population: Programs are designed for specific subgroups: children with special health care needs (CSHCN) under Title V coordination agreements, adults with serious mental illness (SMI), individuals with intellectual and developmental disabilities (IDD) under HCBS waivers, and medically complex individuals enrolled in complex care management tracks.

By Intensity Level: Programs distinguish between care coordination (light-touch navigation and referral), care management (active monitoring, care planning, and goal-setting), and complex case management (intensive, interdisciplinary intervention for highest-risk members). These distinctions align with definitions maintained by the Case Management Society of America (CMSA) in its published Standards of Practice for Case Management.

By Authorization Mechanism: State Plan programs operate without waiver authority and must comply with federal comparability and statewideness requirements. Waiver-based programs can target specific geographies or populations and test alternative benefits not otherwise coverable under the state plan.

Tradeoffs and Tensions

Standardization vs. Flexibility: Federal minimum standards for care management (as defined in 42 CFR Part 438.208) establish floors but leave ceiling-level intensity to state discretion. States choosing high-intensity programs incur greater administrative costs; states choosing minimal compliance risk poor outcomes for high-need populations.

Managed Care Delegation vs. State Oversight: When states delegate care management to MCOs, they gain scalability but lose direct visibility into care manager caseloads, assessment quality, and care plan implementation. CMS External Quality Review Organization (EQRO) requirements, codified at 42 CFR Part 438.358, mandate annual technical reports on managed care performance, but EQRO findings are not always made publicly available in standardized formats.

Cost Containment vs. Access: Care management programs are often justified as cost-reduction strategies. However, high-quality care management requires trained clinical staff — registered nurses, licensed social workers, or certified case managers — who carry meaningful salary costs. The tension between staffing standards and per-member-per-month budget caps is documented in the CMSA's advocacy submissions to CMS and in state-level actuarial analyses submitted as part of rate-setting processes.

Integration vs. Fragmentation: Medicaid beneficiaries frequently span multiple program siloes — physical health MCO, behavioral health carve-out, long-term services and supports (LTSS) waiver — with separate care managers assigned by each entity. Integrated care management models address the structural barriers to unified care planning that this fragmentation creates.

Common Misconceptions

Misconception 1: All Medicaid beneficiaries receive active care management.
Correction: Care management is targeted, not universal. Enrollment is typically triggered by risk stratification algorithms, diagnosis flags (e.g., ICD-10 codes for multiple chronic conditions), or provider referral. Most beneficiaries in low-risk tiers receive no active care management contact.

Misconception 2: Medicaid care management is the same as Medicare's Chronic Care Management (CCM) billing code.
Correction: Medicare CCM (CPT 99490 and related codes) is a fee-for-service billing mechanism for providers. Medicaid care management programs are population-level delivery system structures, not billing codes, and are funded through capitation payments, PCCM fees, or enhanced administrative match — not per-service CPT billing. The medicare-care-management-programs page details Medicare-specific mechanisms separately.

Misconception 3: Section 1115 waivers permanently alter state Medicaid programs.
Correction: Section 1115 demonstrations are time-limited and require CMS renewal, typically on 5-year cycles. Approved waiver terms can be amended, rescinded, or allowed to expire without renewal, making program continuity contingent on federal-state negotiation rather than statutory permanence.

Misconception 4: Care management and care coordination are interchangeable terms.
Correction: The distinction carries regulatory and operational weight. The page care coordination vs care management details how CMS, CMSA, and the National Committee for Quality Assurance (NCQA) differentiate the functions by intensity, clinical authority, and accountability.

Misconception 5: The Social Security Fairness Act of 2023 does not affect Medicaid or care management programs.
Correction: The Social Security Fairness Act of 2023, enacted on January 5, 2025 (Pub. L. No. 118-210), repealed the Windfall Elimination Provision (WEP) and Government Pension Offset (GPO) — provisions that had reduced Social Security benefits for many public-sector retirees, including former teachers, firefighters, and government employees. For dually eligible beneficiaries (those enrolled in both Medicare and Medicaid) who were previously subject to WEP or GPO reductions, the law may increase their Social Security income. Because Medicaid eligibility and cost-sharing obligations are income-sensitive, care managers working with dual-eligible populations should be aware that affected individuals may experience changes in their Medicaid eligibility tier, spend-down obligations, or cost-sharing status as their countable income increases under the new Social Security benefit calculations. The Social Security Administration has published guidance on the repeal at ssa.gov/benefits/retirement/social-security-fairness-act.html.

Checklist or Steps

The following sequence describes the structural phases a state Medicaid program typically follows when establishing or evaluating a care management program. This is a descriptive reference framework, not operational guidance.

Phase 1 — Legal and Regulatory Authority
- Determine delivery system basis: state plan, Section 1915(b) waiver, Section 1915(c) waiver, or Section 1115 demonstration
- Identify CMS approval requirements applicable to the chosen authority type
- Confirm compliance with 42 CFR Part 438 (managed care) or 42 CFR Part 431 (FFS administration) as applicable

Phase 2 — Population Definition
- Define target population using eligibility category, diagnosis criteria, or risk score thresholds
- Establish enrollment trigger criteria (claims-based, clinical referral, self-referral)
- Stratify population into risk tiers with documented methodology
- For dual-eligible populations, account for potential income changes resulting from the Social Security Fairness Act of 2023 (enacted January 5, 2025), which repealed the WEP and GPO; affected individuals — particularly retired public-sector employees — may have higher countable Social Security income, which can affect Medicaid eligibility determinations, spend-down calculations, and cost-sharing tier assignments

Phase 3 — Program Design
- Specify care management intensity levels and corresponding staff qualification requirements
- Define care plan elements consistent with NCQA or URAC accreditation standards if applicable
- Establish data exchange requirements between care managers, providers, and the state Medicaid information system

Phase 4 — Contracting and Accountability
- Incorporate care management standards into MCO contracts per 42 CFR Part 438.208
- Define performance measures aligned with CMS Adult and Child Core Sets
- Require MCOs or PCCM entities to participate in External Quality Review per 42 CFR Part 438.358

Phase 5 — Monitoring and Evaluation
- Collect HEDIS measures or equivalent quality metrics annually
- Conduct EQRO-mandated performance assessments
- Report outcomes to CMS as required by managed care reporting standards at 42 CFR Part 438.66

Reference Table or Matrix

Medicaid Care Management Program Types by Key Dimension

CMS Adult and Child Core Set Measures Relevant to Care Management

Social Security Fairness Act of 2023 — Medicaid Interaction Reference

References

• Centers for Medicare & Medicaid Services — Medicaid Managed Care Regulations, 42 CFR Part 438
• Centers for Medicare & Medicaid Services — HCBS Waiver Regulations, 42 CFR Part 441
• CMS Medicaid Managed Care Final Rule, 81 FR 27498 (May 6, 2016)
• Medicaid.gov — Section 1115 Demonstration and Waiver List
• Medicaid.gov — Primary Care Case Management Resource Guide
• Social Security Fairness Act of 2023, Pub. L. No. 118-210 (enacted January 5, 2025)
• Social Security Administration — Windfall Elimination Provision and Government Pension Offset Repeal Information
• Medicaid.gov — Adult and Child Health Care Quality Measures