Looking for help for a family member? Start with the guides instead — this section is written for referring professionals.
For professionals
EDWP case management for hospital discharge planners
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Every page needs a named approver before it goes live — DCH General Services §605.1.28 makes
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A Georgia EDWP waiver referral will not usually produce services by a discharge date. Enrollment commonly takes two to six months and there is often a waiting list. It solves the ongoing support need after the Medicare-covered episode ends, which is where most readmission risk sits. Refer in parallel with a short-term bridge, not instead of one.
What a waiver referral will not do for you
It will not put a helper in the house by Friday. EDWP enrollment commonly runs two to six months from first contact to services starting, and there is often a waiting list because the waiver has a limited number of funded slots. No case management agency changes that, and any that implies otherwise is describing something it does not control.
Treat a waiver referral the way you would treat an application for anything with an eligibility determination in front of it: start it early, in parallel, and plan the discharge around what is actually available this week.
What it does do
It solves the part of the problem that the Medicare-covered episode does not: ongoing, non-medical help at home once skilled services end. That is where the readmission sits – the eighth week, not the second, when home health has discharged, the family caregiver has run out of leave, and nothing has replaced either.
A referral made from the unit puts the clock in motion while the member is still somewhere with staff, records and a working phone number, all of which are harder to assemble once the person is home and the family is coping alone.
The bridge, and where the waiver sits behind it
Discharge planning still runs on the tools you already use:
- Medicare home health after a qualifying stay, for the skilled episode.
- A short skilled nursing stay, where rehabilitation potential supports it.
- Private-pay home care, which is what most families end up buying for the gap, and which they should be told is a gap measure rather than a permanent arrangement.
- Non-waiver services administered through the Area Agency on Aging, which are a separate track from the waiver with their own eligibility and their own front door.
- Family and community supports, honestly assessed rather than assumed.
The waiver referral runs underneath all of that. Nothing about referring for case management conflicts with any of it, and the family does not have to choose between them.
The one structurally useful fact
Georgia General Services §602.11 provides that the plan of care may be approved, and the nursing-home level of care attested to, by the member’s own physician or by the case management agency’s medical director. ACHS has a medical director on staff.
That is program mechanics, not a speed promise. What it means in practice is that this particular step does not have to sit in a queue behind a community physician’s office returning a form – which is a step discharge planners are used to chasing. It removes one dependency. It does not compress the waiting list, the financial determination or the scheduling of the assessment, and it should not be presented to a family as making the process fast.
Provider choice – §1894
Medicaid members have the right to choose their providers, including their case management agency, and to change that choice later. What that asks of you at discharge is presentation, not suppression: give the member or their representative the agencies serving the region as a set of options, note that they may switch afterward if it is not working, and let them pick. Naming one agency as the route is steering, and it is the thing an auditor looks for.
If a member is already served by another case management agency, that relationship stands. Answer questions honestly if they ask about changing; do not open the subject.
What to hand the family
Three things, in this order:
- The Medicare-versus-Medicaid distinction, because they will otherwise assume the home health nurse currently visiting is permanent. The guide on that difference is written for a family reading it in a hospital corridor.
- The realistic timeline, so nobody hears “we applied” and expects services in a fortnight. What happens after a hospital discharge covers the gap and the bridge options in family language.
- The front door. The Area Agency on Aging / ADRC – in metro Atlanta the Atlanta Regional Commission, whose public service is Empowerline – screens people into the waiver and into other programs. It is independent of any provider, which is exactly why it is the right first call for a family that has not been screened.
No statement made at referral is an eligibility determination. Only the assessment and Medicaid’s own review decide that, and families should hear that from you before they hear it from anyone else.
Questions people ask about this
Can a waiver referral solve a discharge happening this week?
No. EDWP enrollment commonly runs two to six months from first contact to services starting, and there is often a waiting list. What a referral made from the unit does is start that clock early, so that ongoing support is in place before the short-term Medicare-covered services end.
Does the member's own physician have to sign the level-of-care attestation?
Not necessarily. Under Georgia General Services 602.11 the plan of care may be approved and the nursing-home level of care attested to by the member's own physician or by the case management agency's medical director. An agency with a medical director on staff is not dependent on the member's physician for that step.
What do I tell a family who has been told Medicare will cover home care?
That Medicare covers short, skilled care after a qualifying stay and ends when skilled care is no longer needed, while the Medicaid waiver covers ongoing non-medical help at home for as long as the person stays eligible. They are different programs. This is the most common and most costly misunderstanding families arrive with.
Can I refer to a specific case management agency, or do I have to give a list?
Medicaid members have the right to choose their providers, including their case management agency, and to change later. Present the agencies serving the region as options and let the member or their representative choose. Naming one agency as the only route is steering.
Should I refer a member who is going to a skilled nursing facility rather than home?
Yes, if returning home is a realistic goal. A referral made at SNF admission uses the rehabilitation stay as lead time on the waiver process rather than starting from zero at the point the facility Medicare days run out.
Related questions
- What we need from you The documentation checklist for an EDWP case management referral in Georgia: identifiers, clinical picture, level-of-care forms, transition context and consent.
- When a parent is being discharged What to do this week when a parent is leaving the hospital and cannot manage alone: who to call, what to ask, and what can bridge the gap.
- Choosing your provider Georgia waiver rules give a member the right to choose their EDWP provider, oblige the case manager to tell them what is available, and forbid bundling all services with one company.