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Ohio - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Ohio Medicaid restricts the delivery of HCBS case management and care coordination to statutorily designated entities or agencies awarded specific managed care contracts, such as Care Management Entities (CMEs) under the OhioRISE program. Independent agencies cannot simply submit a standard Medicaid provider application to offer standalone waiver case management.

Agencies seeking to provide this service must first secure a contract with Aetna Better Health of Ohio for youth behavioral health populations, operate as a designated Area Agency on Aging (AAA) for the PASSPORT waiver, or function as a County Board of Developmental Disabilities for DODD waivers. Only after securing one of these structural designations can an entity add the corresponding case management specialty to their Ohio Medicaid Provider Network Management (PNM) profile.

1. Service Definition and Scope

In Ohio, case management encompasses assessment, person-centered service planning, referral, and continuous monitoring across a Medicaid participant's full service package. The state divides this service by population, utilizing distinct terminology such as Care Coordination (OhioRISE), Service and Support Administration (DODD), and Waiver Case Management (ODA/ODM).

The core function remains consistent: ensuring individuals receive necessary medical, behavioral, and social services while maintaining compliance with HCBS settings rules and waiver requirements.

2. Regulatory and Oversight Agencies

Multiple state departments and managed care entities oversee case management depending on the target population. The Ohio Department of Medicaid (ODM) holds the ultimate federal authority and manages the centralized provider enrollment system.

Day-to-day oversight, credentialing, and quality reviews are delegated to specific operating agencies and contracted managed care plans.

3. Gatekeeping Prerequisites: Who Can Even Apply

HCBS case management in Ohio is a closed-network, designation-only service. There is no open enrollment pathway for a standard home care or behavioral health agency to become a waiver case manager without a prior structural designation or procurement award.

An applicant must meet one of the specific statutory or contractual preconditions listed below before the state will accept an application for a case management specialty code.

4. Licensure and Certification Requirements

Ohio does not issue a generic "Case Management License." Instead, agencies must hold the underlying certification appropriate for their provider type before adding the case management specialty.

For behavioral health and youth populations, this typically requires certification from the Ohio Department of Mental Health and Addiction Services (OhioMHAS).

5. Medicaid Provider Enrollment

All provider enrollment is processed through Ohio Medicaid's Provider Network Management (PNM) module. Agencies must first enroll as a base provider type and then request the specific case management specialty.

During the specialty addition process, providers must upload proof of their managed care contract or statutory designation.

6. Staffing, Training and Background Checks

Staffing qualifications are dictated by the specific case management program. OhioRISE requires specific supervisor-to-staff ratios and specialized assessment certifications.

All personnel must clear state and federal background checks routed directly to ODM.

7. Documentation, Policies and Records

Agencies must maintain comprehensive records of assessments, person-centered service plans, and continuous monitoring notes in accordance with HCBS settings rules.

Documentation must prove that the individual led the planning process and that all waiver services are actively monitored for effectiveness.

8. Billing, Rates and Claims

Billing procedures depend on the program structure. OhioRISE claims are submitted directly to the managed care plan, while other populations may utilize fee-for-service billing.

Both the billing agency and the rendering practitioner must be properly enrolled and linked in the PNM system.

9. Approval Sequence and Timeline

Because this is a closed-network service, the timeline is dictated by procurement cycles or managed care contracting windows rather than a standard application processing timeframe.

Agencies must wait for Aetna Better Health of Ohio to open network contracting for CMEs before initiating the Medicaid specialty enrollment.

10. Common Denials and Survey Findings

Applications for case management specialties are immediately rejected if the agency lacks the required managed care contract or statutory designation.

Post-enrollment, survey findings frequently center on lapsed staff certifications or failure to update care plans within required timeframes.

11. Key Contacts and Resources

Providers must utilize the PNM module for all enrollment actions and refer to the specific managed care plan or state agency for program rules and billing manuals.

For OhioRISE, Aetna Better Health of Ohio serves as the primary contact for network contracting.

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