CurrentAnthemPolicy N/A

Sacramento County Enhanced Care Management (ECM) Referral Form - Adult

This document is an Enhanced Care Management (ECM) referral form for adult Medi‑Cal members in Sacramento County describing eligibility indicators, submission methods to Managed Care Plans (MCPs), and required referral fields for MCP review and assignment to an ECM provider.

Policy Summary

PayerAnthem

PolicySacramento County Enhanced Care Management (ECM) Referral Form - Adult

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed ECM Referral Form to the Member's Managed Care Plan via the MCP-specific submission methods (portal, secure fax, or secure email); MCP will make an ECM authorization decision within five business days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6form sections to complete (Sections 1-6)

5 business daysMCP decision timeframe after submission

multiplepopulation(s) of focus categories listed for adult ECM eligibility

no additional docsMCP may not require additional documentation per DHCS

Adult ECM Eligibility Indicators

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Adult ECM eligibility criteria

Adult (age 21 or older) ECM eligibility indicators — check all that apply within relevant Population(s) of Focus.

ALL of the following

Member is experiencing homelessness (unhoused, in a shelter, losing housing in next 30 days, exiting an institution to homelessness, or fleeing interpersonal violence)
Member has at least one complex physical, behavioral or developmental health need (includes pregnancy or post-partum, 12 months from delivery) for which the Member would benefit from care coordination

ANY of the following

Over the last six months, the Member has had 5 or more emergency room visits that could have been avoided with appropriate care>= 5 ER visits in 6 months
Over the last six months, the Member has 3 or more unplanned hospital and/or short-term skilled nursing facility stays that could have been avoided with appropriate care>= 3 unplanned hospital/SNF stays in 6 months
Is at risk for avoidable hospital or emergency room (ED) utilization and would benefit from ECM but may not meet the numerical thresholds (provide details in Section 5 - Additional Comments)

ALL of the following

Member meets eligibility criteria for, and/or is obtaining services through, at least one: Specialty Mental Health Services (SMHS) delivered by MHPs OR Drug Medi-Cal Organization Delivery System (DMC-ODS) OR Drug Medi-Cal (DMC) Program (diagnosis for Substance-Related and Addictive Disorder, excluding tobacco-only and non-substance-related disorders)
Member is actively experiencing at least one complex social factor influencing their health (examples: lack of access to food or stable housing, inability to work or engage in community, former foster youth, recent law enforcement contacts related to mental health or substance use)
And meets one or more of the following: High risk for institutionalization/overdose/suicide; uses crisis services/ERs/inpatient stays as primary care; 2+ ER visits or 2+ hospitalizations due to Serious Mental Illness or SUD in past 12 months; or is pregnant/post-partum (up to 12 months)

ALL of the following

Member is transitioning from a correctional facility or transitioned within the past 12 months
Member has at least one diagnosis: Mental Illness; Substance Use Disorder; Chronic/Significant Non-Chronic Clinical Condition; Intellectual or Developmental Disability (I/DD); Traumatic Brain Injury; HIV/AIDS; or is Pregnant/Postpartum (up to 12 months)

ALL of the following

Member lives in the community and meets Skilled Nursing Facility (SNF) level of care OR requires lower-acuity skilled nursing (time-limited/intermittent medical and nursing services, supports, or equipment)
Member is actively experiencing at least one complex social or environmental factor influencing health (examples: assistance with ADLs, communication difficulties, access to food or stable housing, living alone, need for conservatorship/guided decision making, inadequate caregiving)
Member is able to reside continuously in the community with wraparound supports

ALL of the following

Member is a nursing facility resident who is interested in moving out of the institution
Member is a likely candidate to move out of the institution successfully
Member is able to reside continuously in the community

ALL of the following

Member is pregnant or postpartum (through 12 months)
Member is subject to racial and ethnic disparities as defined by California public health data on maternal morbidity and mortality (referring individuals should prioritize Member self-identification; as of 2024 includes Black, American Indian or Alaska Native, and Pacific Islander Members)

ALL of the following

Other Medi-Cal programs/services listed on the form may require coordination and could exclude concurrent ECM; the Managed Care Plan will review and determine final ECM eligibility

ALL of the following

Managed Care Plan will make ECM authorization decision within five business days after submission

Populations of Focus (POF)

DefinitionPopulations of Focus (POF) are ECM-defined groups used to determine ECM eligibility (examples include homelessness; high avoidable utilization; serious mental health/substance use; justice-involved; long-term care risk; nursing facility transitions; birth equity)

HomelessnessAdults experiencing homelessness who also have at least one complex physical, behavioral, or developmental health need (includes pregnancy/post-partum up to 12 months)

Avoidable utilizationAdults with high avoidable hospital or ED utilization as defined by the numeric thresholds or at clinical risk for such utilization

Serious mental health/substance useAdults receiving or eligible for Specialty Mental Health or Drug Medi‑Cal services with active complex social factors or high risk of institutionalization/overdose/suicide

Justice-involved / LTC risk / Nursing facility transitions / Birth equityIncludes members transitioning from correctional facilities; those at risk of long‑term care institutionalization; nursing facility residents transitioning to community; and pregnant/postpartum members affected by birth equity disparities

OpenPayer

Sacramento County Enhanced Care Management (ECM) Referral Form - Adult

Adult ECM Eligibility Indicators

Utilization Thresholds and Coding

Referral Submission and MCP Decision

Populations of Focus (POF)