ECM Eligibility Criteria
Medi-Cal managed care members are eligible for the Enhanced Care Management (ECM) benefit if they meet the following eligibility criteria as members of the ECM Populations of Focus. Members may qualify for multiple Populations of Focus. The ECM Populations of Focus seek to improve the health outcomes of a group by monitoring and identifying members within that group. ECM providers can serve one or more Populations of Focus.
ECM Populations of Focus and Eligibility Criteria
Individuals Experiencing Homelessness
A. Adults without dependent children/youth living with them experiencing homelessness who:
- Are experiencing homelessness, defined as meeting one or more of the following conditions:[1]
- Lacking a fixed, regular and adequate nighttime residence;
- Having a primary residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground;
- Living in a supervised publicly or privately operated shelter, designed to provide temporary living arrangements (including hotels and motels paid for by federal, state, or local government programs for low-income individuals or by charitable organizations, congregate shelters, and transitional housing);
- Exiting an institution into homelessness (regardless of length of stay in the institution);
- Will imminently lose housing in next 30 days;
- Fleeing domestic violence, dating violence, sexual assault, stalking, and other dangerous, traumatic, or life-threatening conditions relating to such violence; and
- Have at least one complex physical, behavioral or developmental need, with inability to successfully self-manage, for whom coordination of services would likely result in improved health outcomes and/or decreased utilization of high-cost services. [2]
B. Homeless families or unaccompanied children/youth and youth
Children, youth and families with members under age 21 who are:
- Experiencing homelessness as defined under the modified HHS 42 CFR Section 11302 homeless definition; or
- Sharing the house of other persons (i.e., couch surfing) due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; or are abandoned in hospitals (in hospital without a safe place to be discharged to), as modified from the 45 CFR 11434a McKinney-Vento Homeless Assistance Act definition of “at risk of homelessness.” [3]
Individuals at Risk for Avoidable Hospital or Emergency Department Utilization
A. Adults who meet one or more of the following conditions:
- Five or more emergency room visits in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.[4]
- Three or more unplanned hospital and/or short-term skilled nursing facility (SNF) stays in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.
B. Children and youth who meet one or more of the following conditions:
- Three or more emergency department visits in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.[5]
- Two or more unplanned hospital and/or short-term SNF stays in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.
Individuals with Serious Mental Health and/or Substance Use Disorder (SUD) Needs
A. Adults who:
- Meet the eligibility criteria for participation in or obtaining services through specialty mental health services (SMHS) delivered by Mental Health Plans (MHPs); the Drug Medi-Cal Organization Delivery System (DMC-ODS) or the Drug Medi-Cal (DMC) program;[6] and
- Are experiencing at least one complex social factor influencing their health (e.g., lack of access to food, lack of access to stable housing, inability to work or engage in the community, high measure (four or more) of adverse childhood experiences (ACEs) based on screening, former foster youth, history of recent contacts with law enforcement related to mental health and/or substance use symptoms); and
- Meet one or more of the following criteria:
- Are at high risk for institutionalism,[7] overdose and/or suicide.
- Use crisis services, emergency departments, urgent care or inpatient stays as the primary[8] source of care.
- Experience two or more emergency department visits or two or more hospitalizations due to serious mental health or SUD in the past 12 months.
- Are pregnant and postpartum (12 months from delivery).
B. Children and youth who meet the eligibility criteria for participation in or obtaining services through one or more of:
- SMHS delivered by MHPs.
- The DMC-ODS or the DMC program.
Individuals Transitioning from Incarceration
A. Adults who:
- Are transitioning from incarceration or have transitioned within the last 12 months; and
- Have at least one of the following conditions: mental illness, substance use disorder (SUD), chronic condition/significant non-chronic clinical condition, intellectual or developmental disability (I/DD), traumatic brain injury (TBI), HIV/AIDS, pregnant or postpartum.
B. Children and youth who are transitioning from a youth correctional facility or transitioned from being in a youth correctional facility within the past 12 months. No further criteria are required to be met for children and youth to qualify for this ECM population of focus.
Adults Living in the Community and at Risk for Long-Term Care (LTC) Institutionalization
Adults who are:
- Living in the community who meet the SNF level of care criteria;[9] OR who require lower-acuity skilled nursing, such as time-limited and/or intermittent medical and nursing services, support, and/or equipment for prevention, diagnosis, or treatment of acute illness or injury;[10] and
- Actively experiencing at least one complex social or environmental factor influencing their health (including, but not limited to, needing assistance with activities of daily living (ADLs), communication difficulties, access to food, access to stable housing, living alone, the need for conservatorship or guided decision-making, poor or inadequate caregiving which may appear as a lack of safety monitoring); [11] and
- Able to reside continuously in the community with wraparound supports (i.e., some individuals may not be eligible because they have high-acuity needs or conditions that are not suitable for home-based care due to safety or other concerns).
Adult Nursing Facility Residents Transitioning to the Community
Adult nursing facility residents who are:
- Interested in moving out of the institution; and
- Likely candidates to do so successfully; and
- Able to reside continuously in the community.
Children or Youth Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS Condition
Children and youth who are:
- Enrolled in CCS or CCS WCM; and
- Experiencing at least one complex social factor influencing their health. Examples include (but are not limited to) lack of access to food; lack of access to stable housing; difficulty accessing transportation; high measure (four or more) of ACEs screening; history of recent contacts with law enforcement; or crisis intervention services related to mental health and/or substance use symptoms.
Children or Youth Involved in Child Welfare
Children and youth who meet one or more of the following conditions:
- Under age 21 and currently receiving foster care in California.
- Under age 21 and previously received foster care in California or another state within the last 12 months.
- Aged out of foster care up to age 26 (having been in foster care on their 18th birthday or later) in California or another state.
- Under age 18 and are eligible for and/or in California’s Adoption Assistance Program.
- Under age 18 and are currently receiving or have received services from California’s Family Maintenance program within the last 12 months.
Birth Equity Population of Focus
- Adults and youth who are pregnant or postpartum (through 12 months period); and
- Are subject to racial and ethnic disparities as defined by California public health data on maternal morbidity and mortality (effective January 1, 2024).
Department of Health Care Services (DHCS) defines homelessness as one of the following:[12]
- An individual or family who lacks a fixed, regular and adequate nighttime residence.
- An individual or family having a primary residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground.
- An individual or family living in a supervised publicly or privately operated shelter, designed to provide temporary living arrangements (including hotels and motels paid for by federal, state, or local government programs for low-income individuals.
- An individual or family living in a shelter.
- An individual exiting an institution to homelessness.
- An individual or family who will imminently lose housing in next 30 days.
- Unaccompanied youth and homeless families and children and youth defined as homeless under other federal statutes.
- Victims fleeing domestic violence, dating violence, sexual assault, stalking, and other dangerous, traumatic, or life-threatening conditions relating to such violence.
In addition, and as of January 1, 2022, the Plan supported the transition of members to ECM and enrollment in ECM for:
- All members enrolled in a Whole Person Care (WPC) pilot as of December 31, 2021, who are identified by the WPC Lead Entity as belonging to a Population of Focus (includes children and youth currently served by WPC).
- All members of ECM Populations of Focus who are enrolled in or are in the process of being enrolled in the Health Homes Program (HHP) as of December 31, 2021 (includes children and youth currently served by HHP).
[1]This definition of homelessness is based on the U.S. Department of Health and Human Services (HHS)42 CFR § 11302 - General definition of homeless individual with the modification to Clause (v) timeframe for an individual who will imminently lose housing has been extended from 14 days (HHS definition) to 30 days. The wording of this definition has also been slightly modified for clarity, relative to the originally released definition.
[2]Pregnant and postpartum individuals who are homeless are considered to have met this definition.
[3]See McKinney-Vento Homeless Assistance Act.
[4]Including appropriate timing, interventions within outpatient care settings, care plan development, communication with the Member, interdisciplinary care team, or referrals.
[5]Including appropriate timing, interventions within outpatient care settings, care plan development, communication with the Member, interdisciplinary care team, or referrals.
[6]Further information on access criteria for the SMHS for adults and children can be found in BHIN 21-073 and for the DMC-ODS delivery system in BHIN 21-075. The medical necessity criteria for DMC services can be found in California Code of Regulations, Title 22, § 51341.1 and BHIN 21-071. See also Appendix B of this Policy Guide.
[7]“Institutionalization” in this context is broad and means any type of inpatient, SNF, long-term, or emergency department setting.
[8]From December 2022, modified from “sole” to “primary.”
[9]As established in the California Code of Regulations Title 22, § 51335.
[10]As established in the California Code of Regulations Title 22, § 51335.
[11]Criteria adapted from the Community-Based Health Home eligibility criteria.
[12]This definition is based on the U.S. Department of Housing and Urban Development (HUD) definition of homelessness with modifications as noted below.
- If exiting an institution, individuals are considered homeless if they were homeless immediately prior to entering that institutional stay, regardless of the length of the institutionalization.
- The timeframe for an individual or family who will imminently lose housing has been extended from 14 (HUD definition) to 30 days.