1. Program Definition and Services

Case Management Services (Supports or Service Coordination) in Pennsylvania provide Medicaid-funded planning, advocacy, and monitoring for individuals with intellectual/developmental disabilities, autism, or physical care needs. Operating under strict conflict-free mandates to ensure care planning is independent of direct care delivery, services include:

• Assessment and Plan Development: Creating person-centered service plans (PCSP/ISP) and conducting needs and risk assessments within the individual’s home or community
• Monitoring and Linkage: Connecting participants with waiver programs, tracking service delivery, providing crisis intervention, and conducting ongoing health and safety checks

2. Regulations

The program is governed by 55 Pa. Code Chapter 6100 (Support for Individuals with an Intellectual Disability or Autism), 55 Pa. Code Chapter 52 (OLTL Home and Community-Based Services), and federal conflict-free case management mandates under 42 CFR § 441.301(c)(1).

3. Licensing or Certification

Case Management agencies do not hold a standard physical facility license. Instead, they must secure formal designation as an approved Supports Coordination Organization (SCO) through ODP or a Service Coordination Entity (SCE) through OLTL.

4. Responsible State Agency

The Department of Human Services (DHS) Office of Developmental Programs (ODP) and Office of Long-Term Living (OLTL) oversee provider approvals. Local Administrative Entities (AEs) manage regional ODP tracking, while Community HealthChoices (CHC) MCOs handle aging and physical disability contracts.

5. Application Process

The process is conducted through the HCSIS Portal and the PROMISe™ Medicaid Portal. Providers must clear conflict-of-interest screening, register under Provider Type 21 (Supports Coordination) or Provider Type 55 (Service Coordination Entity), and secure network panels with regional CHC MCOs or ODP AEs.

6. Required Documentation

While exact requirements vary by waiver target, providers typically need to submit:

• Pennsylvania Business Registration and Articles of Organization (PennFile)
• IRS EIN letter and active Type 2 Organizational NPI lookup profile
• Form DP 1059 (ODP Qualification Packet) or the unified OLTL Enrollment Framework
• Certificates of active Workers' Compensation, General Liability, and Professional Liability insurance
• Policy Manual detailing conflict firewalls, incident reporting timelines, and plan drafting parameters

7. Timeline for Approval

Navigating structural conflict verification, HCSIS onboarding, PROMISe™ setup, and regional panel contracting loops across county and state networks generally takes 3 to 5 months.

8. Pre-Application Process

Before applying, register your legal entity with the PA Department of State, obtain an IRS EIN, secure an organizational Type 2 NPI, and verify that your firm holds no equity or operational ties to any existing direct HCBS care provider.

9. Pre-Application Training

Waiver case managers must hold a minimum of a Bachelor's Degree in human services, social work, or a related field. Agency executives must fulfill mandatory ODP/OLTL orientation tracks via MyODP, and all frontline staff must clear PA State Police checks, Child Abuse clearances, and FBI fingerprinting.

10. Additional Notes

• Conflict Firewall: Under CMS rules, an agency cannot legally deliver direct, billable HCBS waiver care (such as personal care or day programs) to a participant for whom they also provide Case Management
• All coordination details, phone interactions, and face-to-face monitoring touchpoints must be entered into HCSIS or the MCO's portal within state-mandated documentation windows
• Funding pathways utilize Targeted Support Management (TSM) or specialized waiver-allocated monthly unit rates
• Case management records, plan adjustments, and choice justification logs must be securely archived for at least six years to ensure ongoing state Medicaid audit readiness

Why Choose Waiver Consulting Group?

Starting or expanding your Medicaid waiver-funded agency can feel overwhelming, but it doesn't have to be. At Waiver Consulting Group, we simplify the process by guiding you through licensing, compliance, provider enrollment, policies & procedures, and regulatory approvals in any state.

With proven expertise, a structured process, and ongoing support, we take the guesswork out of launching your healthcare business. Whether you're a first-time entrepreneur or an established provider looking to expand, our team ensures you stay compliant, competitive, and fully operational.

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