CalAIM

Effective July 1, 2022, CenCal Health will launch the Medi-Cal ECM benefit. The overall goal of the ECM benefit is to provide comprehensive care and achieve better health outcomes for our most vulnerable members.

The seven core services for ECM are:

1. Outreach and engagement
2. Comprehensive assessment and care management plan
3. Enhanced care coordination
4. Health promotion
5. Comprehensive transitional care
6. Member and family supports
7. Coordination of and referral to community and social support services

CenCal Health is required to contract with community-based ECM providers that have experience in serving the populations of focus and that have expertise in providing the core ECM services.

The populations that are eligible for the ECM benefit are as follows:

To refer members to ECM services, please complete the ECM Adult (21+) or ECM Children/Youth referral form. Referrals are processed within 1-5 business days or 72 hours for urgent requests. 

Please download the Provider Enhanced Care Management FAQ to learn more.

ECM Provider Forms and Reference Guides

• ECM Provider Reference Guide
• ECM Program Forms Outline and Description
• ECM Authorization Information and Checklist (Form A)
• ECM Exclusionary Screening Checklist (Form B)
• ECM Adult Comprehensive Assessment English/Spanish (Form C)
• ECM Adult Comprehensive Assessment- English (Form C)
• ECM Care Management Plan (CMP) (Form D)
• ECM Discontinuation of Services Request (Form E)
• ECM Data Sharing Quick Reference Guide (Form G)
• ECM Long Term Services and Supports Reference Guide
• ECM Pediatric Comprehensive Assessment- English/Spanish (Form H)
• ECM Pediatric Comprehensive Assessment- English (Form H)
• ECM Provider Reassigment Request (Form I)

Accessing ECM for CenCal Eligible Members Transitioning from Incarceration

As a provider, correctional facility, or community organization, facilitating access to Enhanced Care Management (ECM) for CenCal Health members who are transitioning or have transitioned from incarceration within the last 12 months is essential. ECM helps connect members to important services outlined in their discharge plans, including housing, transportation, and follow-up care with primary healthcare providers.

Who Qualifies for ECM Justice-Involved Population of Focus?

ECM eligibility for formerly incarcerated adults, defined by the California Department of Health Care, includes CenCal Health members aged 21 and older who are transitioning from incarceration or have done so within the last 12 months and have one of the following conditions:

• Mental illness
• Substance Use Disorder (SUD)
• Chronic or non-chronic clinical conditions (e.g., hepatitis C, diabetes)
• Intellectual or developmental disability
• Traumatic brain injury
• HIV/AIDS
• Pregnancy or postpartum

CenCal Health members under 21 who have transitioned from incarceration within the last 12 months are automatically eligible for ECM services without additional requirements.

What is ECM?

ECM provides intensive, in-person care management through a Lead Care Manager, who coordinates members’ physical and behavioral health, long-term services, oral health, and social determinants of health. CenCal Health collaborates with community-based organizations and healthcare providers experienced in serving these populations.

How Do I Refer to ECM?

To refer a CenCal Health member to ECM services, complete the ECM Adult (21+) Referral Form or ECM Children/Youth Referral Form and select the appropriate populations of focus. You can submit the referral through the methods listed on the form. The referral will be reviewed, and if eligible, the member will be assigned to an ECM provider for outreach. Members have the right to enroll in or decline ECM services at any time.

CenCal Health has a dedicated team available Monday to Friday, from 8 AM to 5 PM, to assist with phone referrals, answer questions about the referral process, and provide updates on ECM provider assignments. The ECM team can be reached at 805-562-1698. Additionally, a dedicated Justice-Involved Liaison is available to support care coordination efforts.

What is the Justice-Involved Liaison?

The Justice-Involved Liaison is CenCal Health’s primary contact for correctional facilities, care managers, and ECM providers supporting the justice-involved population. They assist with inquiries regarding CenCal Health services, including prior authorization, Community Supports, non-emergency medical transportation, PCP assignments, and network providers.

CenCal Health’s Justice-Involved Point of Contact:
Heather Te, LMFT, LPCC, CCM
ECM Manager and Justice Involved Liaison
Phone: (805) 685-9525 x5427
Email: hte@cencalhealth.org 
Available during business hours (8 AM – 5 PM) and will respond to after-hours or weekend requests within one business day.

Justice Involved contact cards for BH linkages (Counties that have gone live)

Where Can I Find More Information on CalAIM and Enhanced Care Management?

To learn more about ECM, visit our website at CenCal Health CalAIM.

Providing Access and Transforming Health (PATH) is a five-year, $1.85 billion initiative to build up the capacity and infrastructure of on-the-ground partners, such as community-based organizations (CBOs), public hospitals, county agencies, tribes, and others, to successfully participate in the Medi-Cal delivery system as California widely implements Enhanced Care Management and Community Supports and Justice Involved services under CalAIM.

PATH funding will address the gaps in local organizational capacity and infrastructure that exist statewide, enabling our local provider partners to scale up the services they provide to CenCal Health members.  This funding resources can assist with additional staffing needs, billing systems, and data exchange capabilities.

DHCS has offered three application rounds to providers so far. Most recently, On July 22, 2024 DHCS awarded $37 million to 49 clinics providing Enhanced Care Management and Community Supports services to Medi-Cal Members.

To learn more, view the DHCS CalAIM PATH Funding Website.

What Community Supports are offered?

• Community Supports Program offerings, Limitations, and Restrictions Short description of each available Community Supports service along with DHCS approved limitations and restrictions of the Community Supports.

Community Supports that address the needs of Members experiencing or at risk of homelessness:

Housing Transition Navigation Services: Helps members find and secure housing. This includes conducting a housing assessment, developing a housing support plan, searching for housing, completing applications, and coordinating the move-in process.

Housing Deposits: Helps members establish a basic household by covering one-time costs such as a security deposit, utility setup fees, first and last month’s rent, one-time cleaning, and essential items needed for health and safety.

Housing Tenancy and Sustaining Services: Helps members stay housed by providing education on tenant and landlord roles, support with lease compliance, assistance resolving disputes, and ongoing help with managing their home and preventing eviction.

Day Habilitation: Helps members build and strengthen daily living skills to support independence. This includes support with self-care, communication, social skills, and activities like budgeting, using transportation, and participating in the community. Services are provided in a community-based setting.

Recuperative Care: Provides members with short-term residential care when they are stable enough to leave the hospital but still need a safe place to recover from an illness, injury, or medical condition. Services may include medical oversight, case management, meals, and help with daily activities.

Short-Term Post-Hospitalization Housing: Provides temporary housing for members with high medical or behavioral health needs who do not have a safe place to go after being discharged from a hospital, residential treatment facility, correctional facility, nursing home, or recuperative care. This support helps them continue recovery while preparing for longer-term housing.

Community Supports that address Members’ health-related social needs:

Respite: Provides short-term care for members so their regular caregivers can take a break or attend to other responsibilities. Respite can take place in the member’s home or at an approved facility and helps caregivers rest while ensuring the member’s needs are safely met.

Assisted Living Facilities: Helps members live in a community setting instead of an institution.

Community or Home Transition Services: Helps members move out of nursing facilities and into a home or community-based setting. Support may include help with planning the move, securing housing, setting up the household, and covering one-time transition costs.

Personal Care and Homemaker Services: Helps members with daily tasks like bathing, dressing, grooming, meal preparation, light cleaning, and other activities needed to stay safely and comfortably at home.

Environmental accessibility Adaptations: Makes physical changes to a member’s home to improve safety, support independence, and reduce the need for institutional care. Examples include installing ramps, grab bars, or modifying bathrooms to make the home more accessible.

Medically Tailored Meals/Medically Supportive Food: Provides meals or groceries designed to meet a member’s nutrition sensitive medical and nutritional needs.

Sobering Centers: Provides a short-term, safe place for members under the influence of drugs or alcohol who do not need emergency medical care. Members receive monitoring and support while they sober up, along with referrals to treatment and other services as needed.

Asthma Remediation: Helps improve home environments for members with poorly controlled asthma. This may include providing air filters, pest management, mold removal, or education on reducing asthma triggers to improve health and avoid hospital visits.

• DHCS – Community Supports Policy Guide Volume 1
• DHCS – Community Supports Policy Guide Volume 2
• ECM Policy Guide (August 2024)
• ECM Population of Focus Spotlight – Homelessness (January 2024)
• ECM Population of Focus Spotlight – Homelessness (January 2024)
• ECM for Children and Youth Populations of Focus Spotlight (November 2023)
• ECM Birth Equity POF FAQs (Updated February 2024)
• ECM Member Toolkit hosted by Aurrera (January 2022)
• ECM Outreach Toolkit hosted by Aurrera (January 2022)
• ECM Provider Toolkit hosted by Aurrera (December 2021)

CenCal Health continues to work closely with traditional and non-traditional health care partners through the CalAIM Initiative (California Advancing and Innovating in Medi-Cal) to ensure that vulnerable populations have the tools and support needed to achieve optimal health outcomes. In support of this initiative, we welcome local Community Supports (CS) partners and Enhanced Care Management (ECM) providers to join together and attend ongoing engagement session with CenCal Health with CenCal Health the first Wednesday of each month at 12:00pm.

To register for these engagement sessions, visit the CenCal Health CalAIM Spotlight Collaborative.

CalAIM Provider Micro Training Resources:

• CalAIM CenCal Health Website Overview
• CenCal Health Member Eligibility Overview
• CalAIM Program Member Capacity Change Request
• Community Supports Service Overview 
• Community Supports Housing Deposit Documentation Requirements & Billing Tips
• Community Supports Member Discontinuation Process & Form Overview
• Community Supports Return Authorization File Overview
• Enhanced Care Management Helpful Reminders & Tips
• Enhanced Care Management January 2025 Updates
• Enhanced Care Management New Provider Orientation Training Video

For question or to request more information about ECM and CS services or to join our upcoming events, please contact CenCal Health at ecmandcs@cencalhealth.org

ECM Provider Forms

• ECM Provider Reference Guide
• ECM Program Forms Outline and Description
• ECM Authorization Information and Checklist (Form A)
• ECM Exclusionary Screening Checklist (Form B)
• ECM Adult Comprehensive Assessment English/Spanish (Form C)
• ECM Adult Comprehensive Assessment- English (Form C)
• ECM Care Management Plan (CMP) (Form D)
• ECM Discontinuation of Services Request (Form E)
• ECM Data Sharing Quick Reference Guide (Form G)
• ECM Long Term Services and Supports Reference Guide
• ECM Pediatric Comprehensive Assessment- English/Spanish (Form H)
• ECM Pediatric Comprehensive Assessment- English (Form H)
• ECM Enhanced Care Management Provider Reassignment Request (Form I)

CS Provider Forms and Reference Guides

Referral Form

• Community Supports Universal Referral Form
• Community Supports Recuperative Care and Short-term Post Hospitalization Referral Form

Authorization & Eligibility

• Community Supports Authorization Reference Guide
• Community Support Eligibility Quick Reference Guide

Case Management Forms

• Provider Reassignment Request Form
• Member Discontinuation Request Form

Supporting Documents

• Housing Deposits Home Goods Guide PDF
• Individualized Housing Support Plans
• Housing Transition Navigation Services Housing Screening – Initial Submission

Permanent Modifications

• Member Consent Form for Permanent Modifications
• Homeowner Consent Form for Permanent Modifications