Introduction
The Plan launched the Medi-Cal Enhanced Care Management (ECM) benefit designed by Department of Health Care Services (DHCS) and authorized by the Centers for Medicare & Medicaid Services (CMS). The Plan administers the Medi-Cal ECM benefit in accordance with DHCS requirements. ECM is the highest level of care management within the Medi-Cal managed care Population Health Management continuum and is delivered through seven core service components.
The following seven core services are provided at the point of care:
- Outreach and engagement.
- Comprehensive assessment and care management plan.
- Enhanced care coordination.
- Health promotion.
- Comprehensive transitional care.
- Member and family supports.
- Coordination of and referral to community and social support services.
The overall goal of the ECM benefit is to provide comprehensive care and achieve better health outcomes for the highest need beneficiaries in Medi-Cal.
The Plan contracts with community-based ECM providers who have experience serving the ECM populations of focus, and expertise providing the core ECM services, to provide services to eligible members under the Medi-Cal ECM benefit. The ECM populations of focus eligible for the ECM benefit are:
ECM Populations of Focus | Adults Ages 21 and Over | Children and Youth Up to Age 21 | |
|---|---|---|---|
1 | Individuals experiencing homelessness:
| X | |
2 | Individuals at risk for avoidable hospital or emergency department utilization (formerly called high utilizers) | X | X |
3 | Individuals with serious mental health and/or substance use disorder (SUD) needs (Including children with high adverse childhood experiences (ACEs) scores) | X | X |
4 | Individuals transitioning from incarceration | X | X |
5 | Adults living in the community and at risk for long-term care institutionalization | X | |
6 | Adult nursing facility residents transitioning to the community | X | |
7 | Children and youth enrolled in California Children’s Services (CCS) or CCS whole child model (WCM) with additional needs beyond the CCS condition | X | |
8 | Children and youth involved in child welfare (eligible up to age 26) | X | |
9 | Birth equity | X | X |
Detailed eligibility criteria of these populations of focus per DHCS are included in Section 4.1 of this guide.
This ECM Provider Reference Guide outlines the requirements and expectations for ECM providers contracted with the Plan. The Plan may provide updated versions of this guide in the future.