ECM Exclusion Criteria and ECM Overlapping Programs
Department of Health Care Services (DHCS) examined other programs with an existing element of care management and/or care coordination to determine approaches to program coordination and to prevent non-duplication across programs. DHCS categorized three potential approaches to Enhanced Care Management (ECM) coordination and non-duplication, listed below along with programs that fall under each category.
Approach | Explanation | Programs |
|---|---|---|
ECM as a “wrap” | The Plan members can be enrolled in both ECM and the other program. ECM enhances and/or coordinates across the case/care management available in the other program. The Plan must ensure non-duplication of services between ECM and the other program. These programs are considered to be complementary of ECM. | Programs carved out of managed care:
Programs carved into managed care
Coverage for the Plan members dually eligible for Medicare and Medicaid Note: Dually eligible the Plan members can receive ECM if they meet ECM Population of Focus criteria.
Other programs
Programs serving pregnant and postpartum individuals
|
Either ECM or the other program | The Plan members can be enrolled in ECM OR in the other program, not in both at the same time. These programs are considered to be duplicative of ECM. | 1915(c) waiver programs
Programs carved out of managed care
Programs carved into managed care
Other programs
|
Excluded from ECM | Medi-Cal beneficiaries enrolled in the other program are excluded from ECM. These programs are ECM exclusionary criteria. | Coverage for the Plan members dually eligible for Medicare and Medicaid
Other programs
|
Unlike Health Homes Program (HHP), members with a share of cost are not excluded from ECM. Full scope the Plan members are eligible for ECM if they meet ECM eligibility criteria, regardless of their share of cost.
Given the number of care management and care coordination programs, initiatives or waivers in existence today, the exclusion and overlapping criteria are intended to ensure that the most appropriate individuals that would benefit from ECM can participate.
ECM providers are encouraged to review the latest DHCS guidance for more information on exclusion criteria and overlapping programs.
ECM Provider Expectations
If a member is receiving care management from multiple sources or systems of care, ECM providers are expected to coordinate across all sources or systems of care to provide care management. If a member is receiving care management or duplication of services from multiple sources/systems, ECM providers are expected to alert the Plan to ensure non-duplication of services. ECM providers are also expected to follow the Plan’s instructions and participate in efforts to ensure ECM and other care management services are not duplicative, including completion of appropriate duplicative program screening as part of the member referral documentation.