Enhanced Care Management Eligibility

Enhanced Care Management (ECM) is intended for the highest risk, highest-cost Medi-Cal managed care members with the most complex medical and social needs.

ECM Providers deliver services in order to provide ECM-enrolled members with long-term help coordinating their services across delivery systems.

To be eligible for ECM, members must be enrolled in a Medi-Cal managed care health plan and meet criteria for at least one of the Populations of Focus.

California's Department of Health Care Services (DHCS) has identified both adult and children/youth Populations of Focus for ECM.

Ready to refer a member? View the ECM Benefit Member Referral Form.

L.A. County Go-Live Date: January 1, 2022

Individuals and Families Experiencing Homelessness

Individuals and families who:

(1) are experiencing homelessness

AND

(2) have at least one complex physical, behavioral, or developmental health need with inability to successfully self-manage, for whom coordination of services would likely result in improved health outcomes and/or decreased utilization of high-cost services

DHCS defines homelessness as one of the following1:

  • An individual or family who lacks adequate nighttime residence;
  • An individual or family with a primary residence that is a public or private place not designed for or ordinarily used for habitation;
  • An individual or family living in a shelter;
  • An individual exiting an institution to homelessness;
  • An individual or family who will imminently lose housing in next 30 days;
  • Unaccompanied youth and homeless families and children and youth defined as homeless under other Federal statutes; or
  • Individuals fleeing domestic violence

 

1. This definition is based on the U.S. Department of Housing and Urban Development (HUD) definition of homelessness with modifications as noted below.

  • If exiting an institution, individuals are considered homeless if they were homeless immediately prior to entering that institutional stay, regardless of the length of the institutionalization.
  • The timeframe for an individual or family who will imminently lose housing has been extended from 14 (HUD definition) to 30 days.
Adult High Utilizers

(1) Five or more emergency room visits in a six month period that could have been avoided with appropriate outpatient care or improved treatment adherence;

AND/OR

(2) Three or more unplanned hospital and/or short-term skilled nursing facility stays in a six month period that could have been avoided with appropriate outpatient care or improved treatment adherence

Adults with Serious Mental Illness (SMI) or Substance Use Disorder (SUD)

(1) meet the eligibility criteria for participation in or obtaining services through:

  • The County Specialty Mental Health (SMH) System AND/OR
  • The Drug Medi-Cal Organization Delivery System (DMC-ODS) OR the Drug Medi-Cal (DMC) program.

AND

(2) are actively experiencing at least one complex social factor influencing their health (e.g., lack of access to food, lack of access to stable housing, inability to work or engage in the community, history of ACEs, former foster youth, history of recent contacts with law enforcement related to mental health and/or substance use symptoms or associated behaviors);

AND

(3) meet one or more of the following criteria:

  • High risk for institutionalization, overdose and/or suicide;
  • Use crisis services, emergency rooms, urgent care, or inpatient stays as the sole source of care;
  • Two or more ED visits or two or more hospitalizations due to SMI or SUD in the past 12 months; AND/OR
  • Pregnant and post-partum women (12 months from delivery)
Adults and Children/Youth Transitioning from Incarceration

Individuals who:

(1) Are transitioning from incarceration or transitioned from incarceration within the last 12 months

AND

(2) have at least one of the following conditions¹:

  • Chronic mental illness;
  • Substance Use Disorder (SUD);
  • Chronic disease (e.g., hepatitis C, diabetes);
  • Intellectual or developmental disability;
  • Traumatic brain injury;
  • HIV; AND/OR
  • Pregnancy

1. As of DHCS Guidance (DHCS ECM Policy Guide) provided September 2021, and subject to further change by DHCS.

L.A. County Go-Live Date: January 1, 2023

Adults at Risk for Institutionalization & Eligible for Long-Term Care

Individuals at risk for institutionalization who are eligible for Long-Term Care (LTC) services who, in the absence of services and supports would otherwise require care for 90 consecutive days or more in an inpatient nursing facility (NF). Individuals must be able to live safely in the community with wrap-around supports.

Nursing Home Residents Transitioning to the Community

Nursing facility residents who are strong candidates for successful transition back to the community and have a desire to do so.

Children and Youth High Utilizers or With Serious Emotional Disturbance (SED)

Children and youth high utilizers or with Serious Emotional Disturbance (SED) as a Population of Focus has a Go Live date of July 1, 2023. Populations of Focus include the following:

  1. Children (up to Age 21) experiencing homelessness;
  2. High utilizers;
  3. Serious Emotional Disturbance (SED) or identified to be at Clinical High Risk (CHR) for Psychosis or Experiencing a First Episode of Psychosis;
  4. Enrolled in California Children's Services (CCS)/CCS Whole Child Model (WCM) with additional needs beyond the CCS qualifying condition;
  5. Involved in, or with a history of involvement in, child welfare (including Foster Care up to Age 26); and 
  6. Transitioning from incarceration.

Definitions and detailed eligibility criteria for the Children and Youth Populations of Focus are forthcoming.

Grandfathered Members

In addition, in Los Angeles County, the MCPs will support the transition of Members to ECM and enrollment in ECM January 1, 2022, for:

  • All Members enrolled in a Whole Person Care Pilot as of 12/31/21, who are identified by the WPC Lead Entity as belonging to a Population of Focus (includes children and youth currently served by WPC-LA)
  • All Members of ECM Populations of Focus who are enrolled in or are in the process of being enrolled in the HHP as of 12/31/21 (includes children and youth currently served by HHP)

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