Member Discontinuation
Enhanced Care Management (ECM) services can be discontinued when deemed appropriate by the ECM provider or upon request by the member at any time. If any of the following circumstances are met, ECM should be discontinued:
- The member has met all care plan goals.
- The member is ready to transition to a lower level of care.
- The member no longer wishes to receive ECM.
The Plan has developed policies and procedures for discontinuing ECM, and the specific program completion criteria the Plan will apply to transition a member to a lower level of care management or coordination.
If a provider suspects that a member is ready to transition to a lower level of care or has completed all care plan goals, a Program Completion Questionnaire (PCQ) should be used to assess readiness. This must be completed every 12 months from enrollment at a minimum and maintained in the member’s records.
ECM providers should have policies on monitoring members for readiness to graduate from the ECM program which includes timelines for assessing readiness (every 12 months from enrollment at a minimum). Members that have completed their care plan goals, or critical care plan goals, and are able to effectively manage their own care should be assessed for graduation or readiness to move to a lower level of care management. Members that have graduated from ECM are eligible to re-enroll should they need and qualify for the service again.
ECM Provider Initiated Disenrollment
The ECM provider must notify the Plan to discontinue ECM via Return Transmission File (RTF) for a member under any the following circumstances (this is not an all-inclusive list, reference the ECM RTF data dictionary for all reasons):
- Member is no longer eligible for the benefit or Medi-Cal coverage.
- Member has met their ECM care plan goals.
- Member is ready to transition to a lower level of care.
- Member no longer wishes to receive ECM.
- Member is unresponsive or unwilling to engage and/or ECM provider has not had any contact with the member despite multiple attempts.
- Member expired or becomes deceased.
- Member moves out of the county.
- Member is exhibiting unsafe behaviors.
Member’s behavior or environment is unsafe for the ECM provider
The Plan defines disruptive behavior as a member whose behavior substantially impairs the ECM provider’s ability to arrange for or provide services to the member. An individual cannot be considered disruptive if such behavior is related to the compliance or non-compliance with medical advice or treatment. Members who behave in a disruptive way and make it difficult for the ECM provider to provide care management services will be given an opportunity to correct the behavior to allow them to continue participating in ECM.
Disruptive behavior consists of intimidating, hostile, or harassing behavior and threatening or any other behavior that makes the member unable to participate in the ECM process and/or interferes with the ECM providers’ business operations. This may include, but is not limited to the following:
- Verbal abuse such as outbursts, yelling, swearing, harassing or intimidating phone calls, or cursing directed at ECM staff.
- Written harassing or intimidating letters or other forms of written or electronic communications directed at the ECM staff.
- Physical intimidation or harassment of ECM staff.
The Plan defines threatening behavior as a credible threat of violence or the manifestation of violence or harm to oneself, another individual, or a provider, PPG, the Plan partner, or the Plan property.
Threatening behavior consists of a threat of violence or the manifestation of violence or harm to ECM staff. This may include, but is not limited to the following:
- Making a threat of violence, considered as a knowing and willful statement or course of conduct that would place a reasonable person in fear for his or her safety, or the safety of others.
- Unlawful violence.
- Intentional destruction or threat of destruction of property owned, operated or controlled by the ECM provider.
- Harassing surveillance, also known as “stalking,” which is the willful, malicious and repeated following of ECM staff.
- Threatening phone calls, letters or any other form of communication directed at ECM staff.
- Inappropriate use of a firearm, weapon or any other dangerous device within proximity of ECM staff.
ECM providers are required to develop a policy and procedure on how to manage disruptive/threatening members.
Member Initiated Disenrollment
A member can contact their ECM provider or the Health Net Member Services Department (CalViva Health, Community Health Plan of Imperial Valley) to request to disenroll from ECM at any time if they no longer wish to receive the ECM benefit.
The Plan Initiated Disenrollment
The Plan will notify ECM providers via the regular ECM MIF of ECM enrolled members who no longer qualify for the ECM benefit.
ECM Provider Expectations
The ECM provider shall communicate to the member other benefits or programs that may be available to the member, as applicable (e.g., complex care management, basic care management, etc.).
Complaints, Grievances and Appeals
The standard grievance and appeals processes apply to ECM for all members. If a member has concerns or complaints, the member can contact the Health Net Member Services Department (CalViva Health, Community Health Plan of Imperial Valley). If the member feels that he or she has been wrongfully denied enrollment or wrongfully disenrolled from ECM, the member can initiate an appeal via the Plan’s existing complaints, grievances and appeals process.