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.
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:
- 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
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 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.
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 optional services for CenCal Health to offer and are optional for members to receive. As of July 1, 2022, CenCal Health offers the following Community Supports:
- Medically Tailored Meals - To learn more about this service, click here to watch our overview video (download presentation slides) on how our provider network can refer members, and how our MTM providers will receive the authorization request and more!
- Recuperative Care
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.
Members Eligible to Receive Community Supports
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.
Making a Referral for Community Supports
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.
The referral form can be found here
Community Supports Authorizations
Authorization through CenCal Health is required for members to obtain Community Supports. 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. Utilization management procedures will consider the goals of each Community Supports, and CenCal Health will not categorically deny or discontinue a Community Supports irrespective of member outcomes or circumstance. 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) 681-3039 or CenCal Health’s Provider Portal.