At the time of outreach, if the member expresses interest in opting into the Enhanced Care Management (ECM) benefit, ECM providers are requested to confirm member eligibility and appropriateness for ECM at the time of member opt-in. During initial engagement, ECM providers are expected to use methods appropriate to their workflow to identify, to the best of their ability, if the member meets any exclusion criteria or is enrolled in any duplicative care coordination programs as outlined.

ECM providers are expected to utilize and integrate the ECM referral form, in their initial engagement workflow when determining eligibility for all potential ECM members. This is applicable to members identified in the community as well as members assigned for outreach and assigned to the provider by Health Net. ECM providers may use the following during their ECM eligibility screening process:

If a question arises regarding a Plan member’s eligibility for ECM, the ECM provider should contact Health Net. Health Net may request supporting documentation from the ECM provider to assist in the eligibility determination for members ECM providers identify as potentially eligible for ECM.

It is important to get the member’s informed opt-in for the member to participate in ECM to ensure the member is aware of the provider’s expectations of them and the member’s expectations for their care from the ECM provider. ECM is an opt-in benefit. Members must not be enrolled in the program without consent.

Opting into the program can be provided verbally, however all verbal opt-ins must be documented and maintained by the ECM provider. This also applies to members from Health Homes Program (HHP) and Whole Person Care (WPC) even if they are already identified as enrolled in member information file (MIF). Health Net may request evidence of member opt-in, as needed or applicable per any Department of Health Care Services (DHCS) monitoring request.

The ECM provider is required to obtain, document and manage member authorization for the sharing of personally identifiable information between Health Net and ECM, Community Supports and other providers involved in the provision of member care to the extent required by federal law.

Member authorization for ECM-related data sharing is not required for the ECM provider to initiate delivery of ECM unless such authorization is required by federal law. When federal law requires authorization for data sharing, the ECM provider must communicate that it has obtained member authorization for such data sharing back to Health Net.

Upon initiation of ECM, the ECM provider must assign each ECM enrolled member a Lead Care Manager with the experience and skills, including culture and linguistic skills, that match the member’s needs. The Lead Care Manager interacts directly with the member and/or their family member(s), guardian, caregiver, and/or authorized support person(s), as appropriate, and coordinates all covered physical, behavioral, developmental, oral health, long-term services and supports (LTSS), Specialty Mental Health Services (SMHS), Drug Medi-Cal/Drug Medi-Cal Organized Delivery System services, any Community Supports, and other services that address social determinants of health (SDOH) needs, regardless of setting.

ECM members can request to change their ECM provider at any time by contacting member services. ECM providers may also make a request for a member to change ECM providers by submitting the ECM referral form to Health Net and include a signed note from the member requesting the change.

If the ECM member requests, the ECM provider must advise the member on the process for switching ECM providers. Members may call the Health Net Member Services Department to initiate a provider change. The ECM provider may also assist the member in identifying a new ECM provider through Health Net’s Find a Provider page. The member’s right to choose between the ECM benefit and other duplicative programs must always be maintained.

The Plan is required to implement any requested ECM provider change within 30 calendar days.