Waiver Documentation Requirements

Medicaid waiver programs require specific documentation to support service delivery and ensure compliance during audits. Whether you manage HCBS, SCL, RISE, or other state waiver programs, understanding what to document—and when—is essential for case managers.

Core Documentation Elements

Every waiver program requires these foundational documents:

• Level of Care Assessment: Documentation proving the participant meets institutional level of care criteria
• Person-Centered Service Plan: The plan developed with the participant outlining services, goals, and preferences
• Freedom of Choice Form: Signed documentation showing the participant chose community-based services
• Contact Notes: Records of all interactions with the participant and their support network
• Incident Reports: Documentation of any critical incidents affecting participant health or safety

Service Plan Requirements

The person-centered service plan is the cornerstone of waiver documentation. It must include:

• Participant strengths, preferences, and goals
• Identified needs based on assessment
• Services authorized with specific units or hours
• Provider information for each service
• Risk mitigation strategies
• Backup plans for critical services
• Signatures from participant (or legal representative) and case manager

Contact Note Standards

Contact notes must document every interaction with purpose and outcome. Each note should include:

• Date, time, and duration of contact
• Type of contact (face-to-face, phone, email)
• Purpose of the contact
• What was discussed or observed
• Any follow-up actions needed
• How this contact supports service plan goals

Monitoring Requirements

Most waiver programs require regular monitoring visits. Document these elements:

• Participant health and safety status
• Service delivery verification (are services being provided as planned?)
• Progress toward service plan goals
• Participant satisfaction with services
• Any changes in condition or circumstances
• Updated contact information for participant and providers

Audit-Ready Documentation

To pass audits, your documentation should:

• Be legible and clearly dated
• Show logical connection between assessment, plan, and services
• Include required signatures within timeframes
• Demonstrate medical necessity for each service
• Reflect the participant's voice and choices

State-Specific Variations

While federal requirements provide the framework, each state adds specific requirements. Common variations include:

• Monitoring visit frequency (monthly, quarterly, annually)
• Service plan update timelines
• Required assessment tools
• Signature and dating requirements
• Electronic vs. paper documentation standards

Always verify your state's specific requirements through your state Medicaid agency or case management manual.