Case management in the carve-in era: What changes, what doesn't

Community Long Term Care (CLTC) case managers and waiver case management staff sit at the center of South Carolina's managed care carve-in — they're the ones fielding questions from members and families, coordinating across a now more complex payer landscape, and absorbing new administrative steps without necessarily gaining new resources to do it.

What's genuinely new for case managers

• A second point of contact per member. For members affected by the carve-in, case managers now need to track both the member's MCO (for medical services) and the existing FFS waiver services process — two systems to coordinate instead of one.
• Prior authorization complexity. Authorizations that previously ran through a single, familiar FFS process may now require coordination with an MCO's separate prior-authorization process for medical services, even while waiver services stay on the old process.
• Continuity-of-care questions during transition. Members moved into managed care mid-treatment or mid-authorization generate real questions case managers need clear, current answers for — not assumptions carried over from before the transition.

What hasn't changed — and is worth reinforcing with staff

The waiver eligibility determination process, waiver service authorization, and the core case management function itself remain in the fee-for-service model for the waivers affected by this carve-in. It's worth explicitly communicating this to case management staff, because uncertainty during a transition tends to make people assume everything changed when often a meaningful portion of the process is stable.

Practical steps for case management teams

1. Build a simple, current one-page reference listing each MCO operating in South Carolina with correct prior-authorization contacts, updated whenever SCDHHS or the MCOs change their guidance — not a static document created once and left untouched.
2. Flag affected members clearly in your internal systems so case managers immediately know which members require MCO coordination versus which remain fully in the FFS pathway.
3. Create an escalation path for authorization gaps. During any managed care transition, some authorizations fall through structural cracks. Case managers need a known escalation contact — both within your organization and at SCDHHS — rather than guessing who to call.
4. Revisit this quarterly, not just at go-live. Managed care carve-ins tend to have a second wave of adjustments months after the initial effective date, as edge cases surface. Build a recurring check-in rather than treating the transition as a one-time event.

Case management leaders should also monitor SCDHHS's waiver amendment and renewal notices directly — several HCBS waivers have amendments or renewals with 2026 effective dates that will affect eligibility, service definitions, and reserved capacity categories.