25-161m Support Members Enrolled in ECM Prior to Release from Correctional Facilities

Date: 02/18/25

Follow requirements for the Justice Involved Initiative as outlined below

On October 1, 2024, correctional facilities went live with pre-release services in phases. Enhanced Care Management (ECM) providers need to engage and support the warm handoff post release of eligible members assigned to them. 

ECM providers who are approved to support these members prior to and immediately following release must ensure they meet the requirements outlined below.

These requirements are in addition to the ECM requirements outlined in the ECM Provider Guide posted on the
CalAIM Resources for Providers page.

Prior to member release

• The pre-release ECM provider and post-release ECM provider will collaborate with the member to initiate assessments and create a reentry care plan for individuals who will be enrolled in managed care upon release.
• Upon release, formerly incarcerated members will be assigned to an ECM provider who will be notified of the members assigned to them through secure file transfer protocol (sFTP) following the current member information file (MIF) and/or mini MIF (referral file) process. There may be times where the member is released from the facility too quickly to be added to our standard assignment process prior to release. ECM providers should monitor their sFTP folders daily to ensure members are identified as timely as possible.
• The pre-release ECM provider should contact the post-release provider (when applicable) to establish a rapport and schedule a warm handoff to support the member in the transition to their post-release provider.

Reentry care plan

At a minimum, the reentry care plan should include the following elements:

• A completed whole-person care plan that includes a plan for any identified needs and pre-release goals and objectives based on the completed health risk assessment of mental health, substance use, physical health, long-term services and supports (LTSS) needs, home and community-based service (HCBS) needs, health-related social needs (HRSN), and functional needs. This assessment and care plan must be overseen and completed by a licensed professional (e.g., RN care manager or LCSW), although specific components of the assessment or care plan (e.g., screening for HRSN) may be done by other non-licensed team members, according to licensing and oversight requirements by state law.
• A plan for post-release, including the identification of needs the member may have related to functioning in the community upon release such as HRSN, housing needs, considerations for LTSS, medication management, scheduling community-based appointments, paying bills, and utilizing electronic communication.
• A plan for post-release medications, including ensuring that the medications have undergone any prior authorizations or other requirements for coverage, if necessary.
• A plan for durable medical equipment (DME), including ensuring that DME prescriptions have undergone any treatment authorization reviews (TARs) or other requirements for coverage, as necessary.
• Coordination, scheduling, and warm handoffs to required reentry services.
• A plan for follow-up with the individual to ensure engagement with community-based providers, behavioral health services, and other aspects of reentry planning, as necessary.
• Coordination of reentry logistics, including transportation.
• Ensure data is shared with MCPs and, when relevant, with physical and behavioral health/SMI/SUD providers to enable timely and seamless handoffs, as allowed under federal and state laws and always through consent with the member. A plan to engage with identified supports for the client (e.g., probation/parole officer, family, others).
• A list of individuals/organizations that have provided or will provide care or services for the individual and will receive the finalized reentry care plan prior to release. This list of individuals/organizations includes the post-release ECM lead care manager, MCP, county behavioral health agency (if applicable), the member, and the member’s family/support persons (in accordance with the member’s consent).
• Documentation of any additional consents needed to share information for seamless care.

Member warm handoff

The minimum requirements of the pre-release care manager for the warm handoff include:

• Schedule and conduct a warm handoff meeting, either in-person or via telehealth, which includes both the member and post-release ECM lead care manager.
• Obtain any necessary consents for information sharing.
• Share the reentry care plan with the post-release ECM lead care manager and the individual’s assigned MCP.
• Review and provide education on the reentry care plan and reentry services with the member.
• Identify any outstanding service needs or other supports required for successful community reentry (e.g., transportation or housing) with input from the member and the post-release ECM provider.
• Modify the reentry care plan based on any new knowledge.
• Ensure the individual has received their Benefits Identification Card (BIC).

The required responsibilities of the post-release ECM lead care manager for the warm handoff include:

• Coordinate with pre-release care manager to schedule and participate in a warm handoff meeting, either in-person or via telehealth, which includes both the pre-release care manager and the member.
• Begin establishing a trusted relationship with the member, including reviewing the release plan and providing education and support to the member.
• Receive, review, and discuss the reentry care plan with the pre-release care manager.
• Work with the pre-release care manager and the member to identify any community-based services to address any outstanding service needs or supports and assist in updating the reentry care plan.
• Receive all appropriate records and information from the pre-release period.

Following member release from correctional facility

• ECM providers should meet the individual at release. If that is not possible, the ECM provider should meet the individual within one to two business days of release, or notification of release, and receipt of necessary data from the correctional facility/pre-release care manager.
• ECM provider must schedule a second follow-up appointment with the individual within one week of release to ensure continuity of care and a seamless transition and to monitor progress and the implementation of the reentry care plan.

Post-release warm handoff (only if not done prior to release).

ECM providers should conduct the warm handoff in the post-release period, within one week of release. DHCS understands that there are situations in which it will not be possible to conduct the warm handoff in the pre-release period (e.g., the individual is incarcerated for only 48 hours, or the individual is released unexpectedly from court). The correctional facility/pre-release care manager must share the reentry care plan with the Plan and post-release ECM provider within one business day of release.

Payments for pre-release services

Bill services provided to member prior to release from a correctional facility directly to DHCS fee-for-service per DHCS billing guidelines.

Services should only be billed to the Plan beginning with the date of release from the correctional facility.

Justice involved liaison

ECM providers who need assistance in completing the reentry care plan, or gaining access to the reentry care plan, should call the Plan Justice Involved Liaison team at 800-526-1898 or email.

Training on supporting the Justice Involved Population of Focus

Justice involved trainings are available on the CalAIM Provider Training & Webinars page, select Justice Involved Training Series.

Additional CalAIM resources to support this and all ECM populations of focus can be found on the
CalAIM Resources for Providers page.

Additional information

For more information on these requirements, visit the DHCS website. You can also find the
DHCS Justice Involved Toolkit.

If you have questions regarding the information contained in
this update, contact CalViva Health at 888-893-1569.  

 

This information applies to Enhanced Care Management (ECM) Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.