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

Last reviewed: 2026-09-10

Washington delegates Medicaid HCBS case management exclusively to state employees, county governments, and designated Area Agencies on Aging (AAAs) under the Department of Social and Health Services (DSHS). Private, independent agencies cannot enroll as open-market case management providers for waivers such as COPES, Community First Choice (CFC), or the Basic Plus waiver.

Because the state treats HCBS case management as a delegated administrative function rather than a standard fee-for-service provider type, approval requires statutory designation as an AAA or a direct county subcontract with the Aging and Long-Term Support Administration (ALTSA) or the Developmental Disabilities Administration (DDA). Entities outside of this closed governmental and AAA network are structurally blocked from applying.

1. Service Definition and Scope

In Washington, case management encompasses the comprehensive assessment of client needs using the Comprehensive Assessment Reporting Evaluation (CARE) tool, the development of a person-centered service plan, and ongoing monitoring of the client's health and welfare. Case managers authorize waiver services, coordinate with medical and social service providers, and ensure clients meet the nursing facility level of care criteria.

The scope of work is strictly defined by DSHS manuals and waiver appendices. Case managers act as the gatekeepers for waiver expenditures, managing service limits and conducting annual reassessments to adjust care plans as client conditions change.

• Assessment Tool: Comprehensive Assessment Reporting Evaluation (CARE) system used for all HCBS level of care determinations.
• Service Planning: Development and annual updating of the Person-Centered Service Plan (PCSP).
• Authorization: Prior authorization of waiver services and generation of service authorizations for direct care providers.
• Monitoring: Minimum required face-to-face visits and collateral contacts to verify service delivery and client health.
• Referral: Connecting clients to non-Medicaid community resources and housing supports.

2. Regulatory and Oversight Agencies

The Department of Social and Health Services (DSHS) is the primary operating agency for Washington's HCBS waivers, managing the programs through two main administrations: ALTSA for older adults and individuals with physical disabilities, and DDA for individuals with intellectual and developmental disabilities. These administrations oversee the contracted AAAs and county offices that perform case management.

The Washington State Health Care Authority (HCA) serves as the single state Medicaid agency, maintaining the ProviderOne MMIS system and overseeing the overarching Medicaid State Plan and waiver authorities.

• DSHS Aging and Long-Term Support Administration (ALTSA): Oversees COPES and CFC waivers (https://www.dshs.wa.gov/altsa).
• DSHS Developmental Disabilities Administration (DDA): Oversees Basic Plus, Core, and Community Protection waivers (https://www.dshs.wa.gov/dda).
• Washington State Health Care Authority (HCA): Single state Medicaid agency managing provider enrollment (https://www.hca.wa.gov).
• ProviderOne: The state's Medicaid Management Information System (MMIS) portal (https://www.waproviderone.org).

3. Gatekeeping Prerequisites: Who Can Even Apply

Washington operates a closed network for HCBS case management. The state does not accept applications from private businesses to become independent case management agencies. Instead, case management is performed by state DSHS employees, county government staff, or designated Area Agencies on Aging (AAAs).

To provide this service, an entity must already hold a statutory designation as an AAA under the Older Americans Act or possess a specific county government contract with DSHS. There is no open enrollment window, RFP, or application process for private entities to bypass this structural precondition.

• Statutory Designation: Must be a designated Area Agency on Aging (AAA) recognized by the state.
• Governmental Affiliation: Alternatively, must be a county government entity contracting directly with DDA or ALTSA.
• Closed Network: No open enrollment for private, independent case management agencies.
• Delegated Administrative Function: Case management is classified as an administrative function in Washington's 1915(c) waiver appendices, restricting it to state or local non-state governmental entities.

4. Licensure and Certification Requirements

Because case management is restricted to state, county, and AAA entities, the Washington State Department of Health (DOH) does not issue a specific "Case Management Agency" license. Oversight and certification are handled entirely through contractual compliance with DSHS.

Contracted AAAs and counties must adhere to the operational standards outlined in their DSHS contracts, the Washington Administrative Code (WAC), and the Revised Code of Washington (RCW 74.39A.095), which dictate case management ratios, assessment timelines, and consumer notification requirements.

• Facility Licensure: No DOH facility or agency license exists for HCBS case management.
• Contractual Certification: Authority to operate is granted via the DSHS/ALTSA or DSHS/DDA contract.
• Statutory Authority: Operations governed by RCW 74.39A.095 regarding case management contractual requirements.
• Business Registration: AAAs and counties must maintain standard Washington Secretary of State and Department of Revenue registrations.

5. Medicaid Provider Enrollment

Entities performing case management must be enrolled in the ProviderOne system, managed by the Health Care Authority (HCA). Enrollment requires completing a Core Provider Agreement and submitting the application through the ProviderOne portal.

Because case management is largely an administrative function, the enrollment process for AAAs and counties is coordinated directly with DSHS and HCA to ensure the entity is properly linked in the MMIS to authorize services and receive administrative claiming payments.

• System: ProviderOne is the mandatory MMIS for all Washington Medicaid enrollment and billing.
• Agreement: Must sign the HCA Core Provider Agreement.
• Provider Type: Enrolled under specific governmental or AAA taxonomy codes as directed by DSHS.
• NPI Requirement: Must obtain and register a National Provider Identifier (NPI).
• Coordination: Enrollment is facilitated by DSHS contract managers rather than standard open-market application.

6. Staffing, Training and Background Checks

Individual case managers employed by AAAs or counties must meet strict educational and background requirements. DSHS requires case managers to hold a minimum of a bachelor's degree in social services, human services, or a closely related field, often with required years of relevant experience.

All staff must pass a fingerprint-based background check through the DSHS Background Check Central Unit (BCCU) prior to client contact, with renewals required every two years. Case managers must also complete extensive state-mandated training on the CARE assessment tool.

• Background Checks: Fingerprint-based checks processed by the DSHS Background Check Central Unit (BCCU) required initially and every two years.
• Education Minimum: Bachelor's degree in social work, psychology, or a related human services field.
• Experience: Typically requires 2-4 years of paid social service experience depending on the specific degree.
• System Training: Mandatory certification in the Comprehensive Assessment Reporting Evaluation (CARE) tool.
• Continuing Education: Ongoing annual training requirements as specified in the AAA/county DSHS contract.

7. Documentation, Policies and Records

Case management documentation in Washington is heavily centralized within the state's CARE system. Case managers must enter all assessment data, service plans, and case notes directly into CARE, which serves as the official record for level of care and service authorization.

Agencies must maintain internal policies regarding HIPAA compliance, incident reporting, and grievance procedures. Records must be retained for a minimum of six years following the termination of services or contract.

• Primary System: All assessments and care plans must be documented in the state's CARE system.
• Timeliness: Assessments and service plans must be completed and signed within strict timeframes (e.g., annual reassessments prior to the expiration of the current plan).
• Incident Reporting: Mandatory reporting of abuse, neglect, or exploitation to Adult Protective Services (APS) or Residential Care Services (RCS).
• Record Retention: Client and administrative records must be kept for at least six years.
• Signatures: Service plans require documented signatures from the client or legal representative.

8. Billing, Rates and Claims

Unlike direct care services, HCBS case management in Washington is generally not billed as a fee-for-service claim by private providers. Instead, AAAs and counties receive funding through administrative claiming or specific contracted allocations from DSHS.

Funding is distributed based on caseload formulas and legislative appropriations. The ProviderOne system is used by case managers to generate service authorizations for direct care providers (like home care agencies), rather than to submit 15-minute increment claims for their own time.

• Payment Model: Administrative claiming and contracted allocations, not fee-for-service.
• System: ProviderOne is used to authorize services for other providers.
• Rate Setting: Funding levels are determined by the state legislature and DSHS based on caseload forecasting.
• Cost Reporting: AAAs and counties must submit periodic expenditure reports to DSHS.
• No Private Billing: Private agencies cannot bill Medicaid for HCBS case management.

9. Approval Sequence and Timeline

Because the network is closed, there is no standard approval sequence for new private applicants. The network only expands or changes if the state designates a new AAA or establishes a new county contract, which is exceedingly rare.

For a newly established county program or AAA, the timeline involves legislative or statutory designation, followed by months of contract negotiation with DSHS, ProviderOne enrollment, and mandatory CARE system training for all hired staff.

• Step 1: Statutory designation as an AAA or county government entity.
• Step 2: Contract negotiation and execution with DSHS ALTSA or DDA.
• Step 3: Submission of the Core Provider Agreement to HCA for ProviderOne enrollment.
• Step 4: BCCU background checks for all hired case management staff.
• Step 5: Mandatory CARE system training and certification for staff before caseload assignment.

10. Common Denials and Survey Findings

Oversight of AAAs and county case management entities is conducted by DSHS through regular contract compliance reviews. Findings typically center on documentation timeliness and accuracy within the CARE system.

Common issues include failing to complete annual reassessments before the previous plan expires, inadequate documentation of required face-to-face monitoring visits, and missing client signatures on the Person-Centered Service Plan.

• Late Assessments: Failure to complete the CARE reassessment prior to the expiration of the current service plan.
• Monitoring Deficiencies: Missing documentation of required quarterly or semi-annual face-to-face client visits.
• Signature Gaps: Missing client or guardian signatures on the finalized service plan.
• Background Checks: Allowing staff to conduct client visits before the BCCU background check is fully cleared.
• Service Authorization Errors: Discrepancies between the CARE service plan and the authorizations entered into ProviderOne.

11. Key Contacts and Resources

Prospective entities and current contractors must coordinate directly with their respective DSHS administration and the Health Care Authority. The primary portals for policy and system access are managed by these state agencies.

The ProviderOne portal and the DSHS Background Check Central Unit are critical operational systems for all contracted case management entities.

• DSHS ALTSA: Oversees aging and physical disability waivers (https://www.dshs.wa.gov/altsa).
• DSHS DDA: Oversees developmental disability waivers (https://www.dshs.wa.gov/dda).
• Washington State Health Care Authority (HCA): Medicaid agency and ProviderOne administrator (https://www.hca.wa.gov).
• ProviderOne Portal: MMIS for enrollment and authorizations (https://www.waproviderone.org).
• DSHS BCCU: Background Check Central Unit for staff clearances (https://www.dshs.wa.gov/ffa/background-check-central-unit).

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