NEMT referrals from case managers: what waiver, hospital, and health plan case managers can and cannot do

Case managers decide where a lot of NEMT work goes, but they are not all the same job and they do not play by the same rules. A waiver case manager plans a person’s long-term services and must leave the choice of provider to that person. A hospital discharge planner often needs a ride home the same day and uses the vendors the hospital has approved. A health plan care coordinator books through the plan’s own transportation network. Nothing of value can pass from you to any of them for a referral.

The kind of case manager decides where you apply, and the NEMT marketing guide covers outreach to every other referral source. For the rides these case managers arrange outside Medicaid, see our guide to getting private-pay clients. For booking steps from the case manager’s side, see scheduling a Medicaid ride for a patient.

Three kinds of case managers and the rules behind each

Each kind of case manager answers to a different federal rule, and that rule decides how a ride company gets picked.

Job titles vary by state and program, so ask what program the person works for. That tells you which row applies.

Waiver case managers: the participant picks the provider

In a Medicaid HCBS waiver, the case manager writes the service plan, but the participant chooses who delivers each service. Federal rules for 1915(c) waivers, at 42 CFR 441.301(c)(1)(vii), require the planning process to offer the person informed choices about the services they get and from whom. The written plan names who will provide each service, and the providers who deliver it sign it along with the person. Waiver rides cover trips to the community activities, jobs and day programs in the plan; our entry on waiver transportation explains how those rides are authorized.

Pennsylvania’s regulations for its long-term living waivers spell the steps out. Under 55 Pa. Code 52.26, the service coordinator must:

1. Give the participant a list of providers enrolled to deliver the service in the participant’s area.
2. Tell the participant they may choose any willing and qualified provider for a service on the plan.
3. Confirm with the provider the participant picks that it can deliver the service as written in the plan.
4. Give that provider the authorized type, scope, amount, duration and frequency of the service.
5. Check and document at least every quarter that the service is being delivered as the plan requires.

For a ride company, the list has three consequences. You only appear on the list if you are enrolled for that service in that area, so enroll in every county you can actually cover. The confirmation call in step 3 is your audition, so answer it the same day. And the quarterly check in step 5 means the case manager will hear about missed pickups, so the plan’s schedule is the contract you are judged on.

Why a waiver case manager cannot work for a waiver ride provider

Federal waiver rules keep case management and waiver services in separate hands, and waiver transportation is a waiver service. Under 42 CFR 441.301(c)(1)(vi), a provider of waiver services for a person, and anyone who has an interest in or works for that provider, may not provide that person’s case management or write their service plan. The only exception is when a state shows CMS that the sole willing and qualified case management entity in an area also provides services. The state must then set up conflict-of-interest protections, including separating the two functions inside the entity, and CMS must approve them.

States write the rule into their own codes, sometimes more tightly. Ohio’s rule for its nursing facility level of care waivers, OAC 5160-44-02 (effective July 1, 2024), adds provider oversight to the jobs a provider may not hold for its own clients. Pennsylvania’s 55 Pa. Code 52.28 says a service coordination entity and a provider of another service may not share any of these:

• a chief executive officer or equivalent
• an executive board
• a bank account
• supervisory staff
• a tax identification number
• a Medical Assistance provider agreement
• a master provider index number

So if you own a case management agency, keep your company’s waiver rides out of the plans of the people that agency serves, and expect the state to look for shared leadership, staff and bank accounts.

Hospital discharge planners: vendor lists, not choice lists

Hospital discharge planners book the ride companies the hospital has approved as vendors. The patient choice list in the federal discharge planning rule, 42 CFR 482.43(d), covers home health, nursing facilities, rehab hospitals and long-term care hospitals, not ride companies, so getting onto a planner’s list runs through purchasing and credentialing; our page on approved hospital vendors walks through it. When Medicaid pays for the ride home, the state’s broker or the patient’s health plan usually arranges it; see hospital discharge transportation. Rides for a homeless patient leaving the hospital have extra rules of their own.

Health plan care coordinators: the plan’s network decides

A Medicaid health plan’s care coordinator arranges rides inside the plan’s network. Under 42 CFR 438.208(b), each Medicaid managed care plan has to give every member a person or entity formally designated as primarily responsible for coordinating their services. That coordination covers moves between settings, including discharge planning after hospital and institutional stays, and services from community and social support providers. For members who need long-term services and supports, the plan’s service plans must follow the same person-centered process as a waiver plan, under 438.208(c)(3).

The provider choice is narrower than in a waiver. The federal free-choice rule, 42 CFR 431.51(b), lets members use any qualified provider except as allowed under the managed care rules in part 438, which let plans limit members to their networks. When the plan covers rides, the coordinator books them with the plan’s ride vendor or broker, and a network provider runs the trip. Getting these trips means joining that network; our guides on Medicaid health plan contracts and broker contracts cover the applications. For a trip no network provider can cover, plans sometimes sign a single case agreement.

What no case manager can accept

No case manager may take anything of value from you in return for sending you riders. Under 42 U.S.C. 1320a-7b(b), knowingly and willfully offering a person money, gifts or favors to get them to refer a patient whose care Medicaid or Medicare could pay for is a felony. That covers waiver, hospital and health plan referrals alike.

Case managers who are social workers are also bound by their profession’s code. Standard 1.16(c) of the NASW Code of Ethics (2021) prohibits social workers from giving or receiving payment for a referral when the referring social worker provides no professional service. Gift cards, lunches for the department and per-trip “finder’s fees” all fall on the wrong side. The kickback rules for NEMT page shows where the lines fall for gifts and for paying sales staff.

How to get on each case manager’s list

Each list has its own front door. Work the one that matches the trips you want:

1. Waiver case managers. Learn which of your state’s waivers include a transportation service and who administers it. Enroll for that service in every county you can serve. Then visit the agencies that employ the case managers there and ask how they show participants the provider list, so you know where your name will appear.
2. Hospital discharge planners. Meet the case management director, then complete the hospital’s supplier and credentialing steps so staff are allowed to book you. Offer the rides the hospital struggles with, such as same-day wheelchair or stretcher discharges.
3. Health plan care coordinators. Join the plan’s ride vendor or broker network for the counties and service levels you run. Once you are in, trips depend on how the broker assigns them; see how brokers hand out more trips for what they look at.

In every case, the first few rides are what the case manager remembers: on-time pickups, drivers who follow the plan, and a call back when something goes wrong.

Running case manager referrals in HealthRide

In HealthRide, riders and families follow their driver live from a text link, and facility staff track their rides from their own portal, so nobody has to call dispatch for an update. Trip records keep GPS-recorded miles, timestamps and signatures for each ride, which helps when a case manager checks that the plan was delivered. For plan trips, HealthRide connects with your brokers, like MTM, Alivi and Sentry, and their new trips show up on your board on their own. See broker connections.