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 Determinates 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.

 

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.

Interested in becoming a contracted provider?  Join our network today!

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:

ecmtimeline

Please click here to complete the ECM/CCH CM 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.

Resources

ECM Program Helpful Info and links (Document) – link to come

ECM FAQ - link to come

CCH ECM Forms – link to come

ECM Assessment – link to come

ECM Care Plan – link to come

ECM Auth Checklist – link to come

 

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.

Please download the Provider Community Supports FAQs to learn more!

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

Medically Tailored Meals

Effective July 1, 2022 in Santa Barbara & San Luis Obispo County Medically Tailored Meals 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? Enhanced Care Management 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:

To learn more about this service, click here to watch our overview video (presentation slides) on how our provider network can refer members, and how our MTM providers will receive the authorization request and more!

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.

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.

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.

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.

Sobering Centers

Effective January 1, 2023 in Santa Barbara & San Luis Obispo County Sobering Centers are alternative destinations for individuals 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.

DHCS information

ECM policy guide (Updated May 2022)

Community Supports Policy Guide (Updated April 2022)

ECM Provider Toolkit (hosted by Aurrera)

Provider Engagement Roundtables

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

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