Sihwa Jang
People say Medicaid like it is one thing. It is not. It is fifty programs running on fifty different sets of rules, with fifty different covered service lists, fifty different documentation requirements, and fifty different ideas about what counts as a reimbursable wellness intervention.
That complexity is exactly why most care agencies stay in their lane with Medicare billing and treat Medicaid as a supplemental payer at best. I talked to an agency director in Texas last year who had been operating under STAR+PLUS for six years and had no idea her health plan MCO could approve daily companion check-ins as a value-added service. She found out at a conference. Within four months, she had added it to twelve care plans. The Medicaid waiver programs — particularly HCBS waivers — are where the real AI reimbursement opportunity lives. For agencies serving low-income seniors, dual-eligible populations, or residents in states with robust Home and Community Based Services waivers, Medicaid is not supplemental. It is the primary revenue stream. And for AI-powered wellness call services specifically, the waiver landscape offers more reimbursement pathways than most agencies have ever explored.
Medicaid vs. Medicare: Why the Distinction Matters More Than You Think
Medicare is federal, uniform, and relatively predictable. The CPT codes your billing team knows for remote patient monitoring and care management apply the same way in California as they do in Ohio. The documentation requirements are standardized. The appeal process is the same everywhere.
Medicaid is a federal-state partnership, which means the federal government sets a floor and then largely gets out of the way. States can expand coverage, restrict it, waive requirements, design entirely new benefit categories, and contract with managed care organizations that have their own coverage rules layered on top of the state rules. It is genuinely complicated, and the agencies that master it have a significant competitive advantage over the ones that do not.
For AI-assisted wellness calls, the key insight is this: Medicare has a defined set of codes for remote patient monitoring that most billing teams already know. Medicaid, through its waiver authority, has the flexibility to cover services that Medicare does not, including daily companion check-ins, psychosocial support, and cognitive engagement activities, if the state has chosen to include them in its waiver design.
HCBS Waivers: The Architecture of Medicaid Home Care
The most important Medicaid vehicle for home and community-based services is the waiver system. Congress created these waivers to allow states to redirect Medicaid dollars away from nursing homes and toward home-based care. The theory is sound: keeping seniors at home is almost always cheaper than institutional care, and most seniors strongly prefer it.
1915(c): The Classic Home and Community Based Services Waiver
The 1915(c) waiver is the workhorse of home-based Medicaid funding. States use it to cover services that fall outside Medicaid's standard benefit package, including personal care, homemaker services, adult day care, and increasingly, technology-assisted monitoring and companionship services.
The critical feature of 1915(c) waivers is that they require nursing home level of care eligibility. The people your agency serves under this waiver are the ones who could be in a nursing home right now. The waiver is keeping them at home. Services that help maintain their safety, cognitive function, and emotional wellbeing are exactly what the waiver was designed to fund.
1915(i): State Plan Home and Community Based Services
Unlike 1915(c), the 1915(i) option does not require nursing home level of care. States can extend HCBS benefits to people with lower care needs, including seniors at risk of institutional placement who are not yet at that threshold. For agencies providing preventive wellness services, daily check-ins, and early detection of health changes, 1915(i) opens the door to a population that 1915(c) waivers leave out.
1915(k): Community First Choice
Community First Choice provides attendant care and related services with a six percent enhanced federal match, which gives states a strong financial incentive to expand it. Several states have used 1915(k) authority to include remote monitoring and technology-assisted care coordination. If your state has a CFC option, it is worth examining what services are included.
Section 1115 Demonstration Waivers
Section 1115 waivers give states the broadest flexibility of all, allowing them to test entirely new approaches to Medicaid service delivery. California's CalAIM initiative, for example, is an 1115 demonstration that has dramatically expanded the definition of covered services to include things that address the social determinants of health. Several states are using 1115 authority to pilot AI-assisted care monitoring programs explicitly.
Four States Worth Studying
Every state is different, and this is not a substitute for reviewing your specific state's waiver documents. But these four states represent a useful range of approaches.
California: CalAIM and Enhanced Care Management
California's CalAIM transformation is one of the most ambitious Medicaid redesigns in the country. It introduces Enhanced Care Management for high-need populations, including seniors at risk of institutional placement, and a Community Supports benefit that covers services traditionally outside Medicaid's scope. Care agencies in California should be actively investigating whether their AI wellness call programs qualify as supported services under their managed care plan contracts.
New York: Managed Long Term Care
New York's Managed Long Term Care program routes Medicaid funding through managed care plans that have significant flexibility in what services they cover. MLTC plans in New York have been early adopters of technology-assisted monitoring and are worth engaging directly to understand what they will reimburse for daily wellness calls and AI companion services.
Texas: STAR+PLUS
Texas runs its Medicaid long-term services through STAR+PLUS, a managed care model that includes a value-added services component. STAR+PLUS health plans have latitude to cover services beyond the standard benefit package, and several have included remote monitoring and telehealth-adjacent services. Agencies in Texas should review their MCO contracts carefully for this flexibility.
Florida: Statewide Medicaid Managed Care
Florida's SMMC program manages long-term services through a similar MCO structure. Florida has been relatively conservative in expanding covered services, but managed care plans in the program have discretion to add value-added services, and the state's large dual-eligible population makes it a significant market for agencies that successfully navigate the billing landscape.
How to Position AI Wellness Calls as a Covered HCBS Service
The framing that works across most state waiver programs is safety and preventive care. Daily wellness calls that detect early signs of health decline, medication non-adherence, fall risk, or cognitive changes are keeping seniors out of emergency rooms and nursing homes. That is the core value proposition of HCBS waivers, and it is also the core value proposition of a well-run AI companion call program.
The documentation challenge is demonstrating that connection explicitly. Your call summaries need to capture more than mood. They need to capture safety-relevant information: did the resident take their medications, did they mention pain or confusion, did their responses seem slower or more disoriented than usual? That kind of structured data creates a defensible record that the service is providing clinical value, not just social support.
Services like VoiceLegacy are designed to generate exactly this kind of structured output. The call happens, the summary is produced, patterns are flagged, and the data feeds back to the care team. That documentation chain is what turns a daily companion check-in into a Medicaid-billable service.
The Practical Playbook
If you are a care agency trying to figure out whether your state's Medicaid program will pay for your wellness call services, here is where to start.
- Download your state's current HCBS waiver documents from Medicaid.gov. Look specifically at the service definitions section and search for terms like remote monitoring, telephonic services, assistive technology, and psychosocial support.
- Contact your state's Medicaid managed care organizations directly if you operate in a managed care state. The MCO contracts often contain service flexibility that is not visible in the state plan documents.
- Engage a Medicaid billing consultant who specializes in LTSS, which stands for long-term services and supports. This is a narrow specialty and a generalist billing company may not have the knowledge you need.
- Document your current AI wellness call program as if it were already a billable service. Write service descriptions, care plan language, and outcome metrics. This preparation makes the conversation with your billing consultant and the state Medicaid office dramatically more productive.
The agencies that will win over the next decade are the ones that understand Medicaid not as a single program but as a system of state-level opportunities. Your state Medicaid office is not going to call you about this. The agencies that figure it out first will own those contracts for years. Start with your state's waiver documents. Find out which populations you serve are covered under HCBS. Then ask whether the daily wellness calls you are already making — or could be making — fit within that coverage framework. Most of the time, they do. We built VoiceLegacy to fit inside exactly this model.
Written by
Sihwa Jang