CalAIM

California Advancing and Innovating Medi-Cal (also known as CalAIM) is a multi-year initiative by the Department of Healthcare Services (DHCS) to improve the quality of life and health outcomes of the Medicaid population in California by implementing a broad delivery system as well as program and payment reform.

CalAIM has three primary goals:

1. Identify and manage member risk and need through whole person care approaches and addressing Social Determinants of Health

2. Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility; and

3. Improve quality outcomes, reduce health disparities, and drive delivery system transformation and innovation through value-based, modernization of systems, and payment reform

Community Supports Services which is built under the umbrella of CalAim, which builds upon the whole person care, it is a flexible wrap around service to be implemented into population health strategies. Substitutes or avoids other services such as hospital or SNF admission or discharge delay. Integrates with Enhanced Care Management for high risk members. Is voluntary (but strongly encouraged) for plans and optional for beneficiaries. DHCS has provided a list of fourteen (14) pre-approved services that plans are encouraged to offer.

To learn more, view the CenCal Health Community Supports Contracted Provider List PDF.

Enhanced Care Management (ECM) is a new statewide Medi-Cal benefit. The goal of ECM is to provide a whole-person approach to care that addresses the clinical and non-clinical needs of high-need Medi-Cal beneficiaries enrolled in managed care health plans. ECM provides comprehensive care services to specific populations of focus through systemic coordination that is collaborative, interdisciplinary, community-based, high-touch, and person-centered.

To learn more, view the CenCal Health Enhanced Care Management (ECM) Contracted Provider List PDF.

Interested in becoming a contracted provider? Visit the Join Our Network Webpage to join our network today!

Watch our recent CenCal Health CalAIM 101 Whole-Person Care Transformation Webinar.

Learn more about Enhanced Care Management (ECM)

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:

Please view and complete the CalAIM Enhanced Care Management & CenCal Health Case Management Referral Form for members whom you assess as presumed ECM eligible. We ask that you allow ten (10) business days for ECM eligibility determination and provider assignment.

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

ECM Provider Forms and Reference Guides

ECM Justice-Involved Population of Focus

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 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:
Blanca Zuniga, Associate Director of Care Management and Justice-Involved Liaison
Phone: 805 685-9525 X 1691
Email: Bzuniga@cencalhealth.org
Available during business hours (8 AM – 5 PM) and will respond to after-hours or weekend requests within one business day.

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

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

The Capacity and Infrastructure Transition, Expansion, and Development (CITED) Grants

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.

Learn more about Community Supports

Community Supports are medically appropriate and cost-effective alternative services. Federal regulation allows states to offer Community Supports as an option for Medicaid-managed care organizations, and CenCal Health has elected to offer some Community Support services. Community Supports are designed to help avert or substitute traditional medical services and settings, including but not limited to hospital or nursing facility admissions, discharge delays, and emergency department use when provided to eligible members. Community-based organizations and providers will typically provide Community Supports. ECM Providers may also serve as Community Supports Providers, if they have appropriate experience.

CenCal Health must determine eligibility for pre-approved Community Supports using the DHCS Community Supports definitions, containing specific eligibility criteria for each Community Supports program. CenCal Health is also expected to determine that a Community Supports is a medically appropriate and cost-effective alternative to a Medi-Cal Covered Service. When making such determinations, CenCal Health must apply a consistent methodology to all members within a particular county.

Community Supports are optional services for CenCal Health and offer the following services for members:

Medically Tailored Meals/Medically Supportive Food

Effective July 1, 2022 in Santa Barbara & San Luis Obispo County Medically Tailored Meals/Medically Supportive Food help individuals achieve their nutrition goals at critical times to help them regain and maintain their health. Results include:

Improved member health outcomes.
Lower hospital readmission rates.
A well-maintained nutritional health status.
Increased member satisfaction.

Need to refer a member for services? Medically Tailored Meals/Medically Supportive Food providers, Community Supports providers, Primary Care providers, and Specialty providers can submit an authorization request TAR (50-1) through the Provider Portal. The authorization request must include the following documentation:

Medically Tailored Meals/Medically Supportive Food Information and Referral Form
Any relevant clinical information that would support the referral request, when available to referring party

Learn more about this service:
Medically Tailored Meals/Medically Supported Food Quick Reference Guide PDF

Recuperative Care

Effective July 1, 2022 in Santa Barbara & San Luis Obispo County Recuperative Care is short-term residential care for individuals who:

Do not need to be in the hospital, but still need to heal from an injury or illness (including behavioral health conditions).
Are in a condition that would be exacerbated by an unstable living environment.

Need to refer a member for services? Please fill out the Recuperative Care Information and Referral Form. After completion, submit the form with the referral to a contracted Recuperative Care Provider or secure fax (805) 681-3039. Please reference CenCal Health’s Provider Directory to find a list of these contracted providers.

Learn more about this service:
Recuperative Care Quick Reference Guide PDF

Housing Transition Navigation Services

Effective January 1, 2023 in Santa Barbara & San Luis Obispo County Housing Transition Navigation Services acts as a quick and effective pathway to permanent housing through a low-barrier approach by assisting members with obtaining housing. CenCal Health member eligibility is based off those at risk of homelessness, having significant barriers to housing stability and meet one of the following:

Have one or more chronic conditions
Have a Serious Mental Illness (SMI)
Risk of institutionalization
Receiving Enhanced Care Management
Are Transitioned Aged Youth with significant barriers to housing stability

Are you a Medical, Behavioral Health, or Community Based Organizational provider looking to refer a member? If so, please submit the Housing Transition and Navigation Service Informational and Referral Form and send it over to a contracted Housing Provider. Please reference CenCal Health’s Provider Directory to find a list of these contracted providers.

Are you a contracted Housing Provider that would like to refer a member or received a referral request? Complete (or receive) the Housing Transition and Navigation Service Informational and Referral Form, submit a 50-1 (TAR) authorization through our provider portal (including the REQUIRED Information), and receive an authorization decision from CenCal Health. If the authorization is approved the Housing Provider will provide services for the allowed amount of time.

Once approved, the Housing Provider will complete the Housing Transition Navigation Services Tenant Screening and Housing Assessment Form and the Housing Transition Navigation Services Individualized Housing Support Plan to collect information and assist the member in developing a support plan to identify and achieve attainable housing goals.

Learn more about this service:
Housing Transition Navigation Services Quick Reference Guide PDF

Housing Deposits

Effective January 1, 2023 in Santa Barbara & San Luis Obispo County Housing Deposits assist with identifying, coordinating, securing or funding a one-time service and modifications necessary to allow a person to establish a basic household. Housing Deposits refer to services that do not constitute room and board.

Are you a contracted Housing Provider and need to submit a request for housing deposits? Please complete the Housing Deposits Informational and Referral Form and submit a 50-1 (TAR) authorization through our provider portal (including the REQUIRED Information), and receive an authorization decision from CenCal Health. If not submitted via the Provider Portal, you may fax this form to (805) 681-3038.

Learn more about this service:
Housing Deposits Quick Reference Guide PDF

Housing Tenancy and Sustaining Services

Effective January 1, 2023 in Santa Barbara & San Luis Obispo County. Housing Tenancy and Sustaining Community Supports services helps to maintain safe and stable residency once housing is secured for members who had been experiencing homelessness and are now newly housed.

Are you a contracted Housing Provider and need to submit a request for Housing Tenancy and Sustaining services? Please complete the Housing Tenancy and Sustaining Service Information and Referral Form and submit a 50-1 (TAR) authorization through our provider portal (including the REQUIRED Information), and receive an authorization decision from CenCal Health. If not submitted via the Provider Portal, you may fax this form to (805) 681-3038.

Once approved, the Housing Provider will complete the Individualized Housing Support Plan to collect information and assist the member in developing a support plan to identify and achieve attainable housing goals.

Learn more about this service:
Housing Tenancy and Sustaining Services Quick Reference Guide PDF

Sobering Centers

Effective January 1, 2023 in Santa Barbara & San Luis Obispo County Sobering Centers are alternative destinations for members aged 18 years and older who are found to be publicly intoxicated (due to alcohol and/or other drugs) and would otherwise be transported to the emergency department or jail. Sobering centers provide these individuals, primarily those with unstable living situations, with a safe, supportive environment to become sober.

Are you a Hospital/SNF, Medical Provider, Law Enforcement, ECM or other provider looking to refer a member? If so, please submit the Sobering Center Informational and Referral Form and fax it over to (805) 681-3038 or submit your request via the Provider Portal.

Referrals for Community Supports may be made by a physician, a CenCal Health member or their caregiver, a community service agency, a hospital or health care provider, or an ECM or Community Supports provider. CenCal Health staff will utilize the information received on the referral and other data sources to determine eligibility. The authorization process entails eligibility screening, completion of a Member Care Plan by the ECM Provider (if receiving ECM services), and decision-making by CenCal Health. If approved after CenCal Health’s assessment, the member may receive Community Supports.

Some Community Supports may require periodic reauthorization by submitting an Authorization Request to the Utilization Management Department and any necessary documentation for review. Documentation for the reauthorization may be submitted through the ECM/Community Supports referral and fax line (805) 681-3038 or CenCal Health’s Provider Portal. For any questions, please call the Community Supports Unit at (805) 562-1698.

Learn more about this service:
Sobering Centers Quick Reference Guide PDF

Personal Care and Homemaker Services

Effective January 1, 2024 in Santa Barbara and San Luis Obispo Personal Care and Homemaker Services are provided for individuals who need assistance with Activities of Daily Livings (ADLs) such as bathing, dressing, toileting, ambulation, or feeding. Personal Care Services can also include assistance with Instrumental Activities of Daily Living (IADLs) such as meal preparation, grocery shopping, and money management.

Need to refer a member for services? Please fill out the Personal Care and Homemaker Services Referral Form. After completion, submit the form with the referral to a contracted Recuperative Care Provider or secure fax (805) 681-3039. Please reference CenCal Health’s Provider Directory to find a list of these contracted providers.

Learn more about this service:
Personal Care and Homemaker Services Quick Reference Guide PDF

Or

Are you a contracted Personal Care and Homemaker Services Provider and need to submit a request for Personal Care and Homemaker Services? Please complete the Personal Care and Homemaker Services Information and Referral Form. and submit a 50-1 (TAR) authorization through our provider portal (including the REQUIRED Information) and receive an authorization decision from CenCal Health. If not submitted via the Provider Portal, you may fax this form to (805) 681-3038.

Learn more about this service:
Personal Care and Homemaker Services Quick Reference Guide PDF

Day Habilitation

Effective January 1, 2024 in Santa Barbara and San Luis Obispo Day Habilitation assists members in finding help for their own personal needs, socialization, and adaptive skills necessary to reside successfully in their environment. Some services include training on how to use public transportation, conflict resolution skills, cooking, cleaning, shopping, etc.

Need to refer a member for services? Please fill out the Day Habilitation Referral Form. After completion, submit the form with the referral to a contracted Recuperative Care Provider or secure fax (805) 681-3039. Please reference CenCal Health’s Provider Directory to find a list of these contracted providers.

Learn more about this service:
Day Habilitation Quick Reference Guide PDF

Or

Are you a Day Habilitation Provider and need to submit a request for Day Habilitation? Please complete the Day Habilitation Referral Form. and submit a 50-1 (TAR) authorization through our provider portal (including the REQUIRED Information) and receive an authorization decision from CenCal Health. If not submitted via the Provider Portal, you may fax this form to (805) 681-3038.

Learn more about this service:
Day Habilitation Quick Reference Guide PDF

Short-Term Post Hospitalization

Effective January 1, 2024 in Santa Barbara and San Luis Obispo Short Term Post Hospitalization housing provides Members who do not have a residence and who have high medical or behavioral health needs with the opportunity to continue their medical/psychiatric/substance use disorder recovery immediately after exiting an inpatient hospital (either acute, psychiatric or Chemical Dependency and Recovery hospital), residential substance use disorder treatment or recovery facility, residential mental health treatment facility, correctional facility, nursing facility, or recuperative care to avoid inappropriate utilization of State plan services.

Need to refer a member for services? Please fill out the Short-Term Post Hospitalization Referral Form. After completion, submit the form with the referral to a contracted Short Term Post Hospitalization Provider or secure fax (805) 681-3039. Please reference CenCal Health’s Provider Directory to find a list of these contracted providers.

Learn more about this service:
Short-Term Post-Hospitalization Quick Reference Guide PDF

Or

Are you a Short-Term Post Hospitalization Provider and need to submit a request for Short-Term Post Hospitalization? Please complete the Short-Term Post Hospitalization Referral Form and submit a 50-1 (TAR) authorization through our provider portal (including the REQUIRED Information) and receive an authorization decision from CenCal Health. If not submitted via the Provider Portal, you may fax this form to (805) 681-3038.

Learn more about this service:
Short-Term Post-Hospitalization Quick Reference Guide PDF

Respite Services

Effective January 1, 2024 in Santa Barbara and San Luis Obispo Respite Services are provided to caregivers of Members who require intermittent temporary supervision. The services are provided on a short-term basis because of the absence or need for relief of those persons who normally care for and/or supervise them and are non-medical in nature. This service is distinct from medical respite/recuperative care and is rest for the caregiver only.

Need to refer a member for services? Please fill out Respite Services Information and Referral Form. After completion, submit the form with the referral to a contracted Respite Services Provider or secure fax (805) 681-3039. Please reference CenCal Health’s Provider Directory to find a list of these contracted providers.

Learn more about this service:
Respite Services Quick Reference Guide PDF

Or

Are you a Respite Services Provider and need to submit a request for Respite Services? Please complete the Respite Services Information and Referral Form . and submit a 50-1 (TAR) authorization through our provider portal (including the REQUIRED Information) and receive an authorization decision from CenCal Health. If not submitted via the Provider Portal, you may fax this form to (805) 681-3038.

Learn more about this service:
Respite Services Quick Reference Guide PDF

Asthma Remediation

Asthma Remediation provides physical modifications to a beneficiary’s home to mitigate environmental asthma triggers. The services are available in a home that is owned, rented, leased, or occupied by the Member or their caregiver.

Need to refer a member for services? Please fill out the Asthma Remediation Referral Form. After completion, submit the form with the referral to a contracted Recuperative Care Provider or secure fax (805) 681-3039. Please reference CenCal Health’s Provider Directory to find a list of these contracted providers.