CurrentmhnPolicy N/A

Enhanced Care Management (ECM) Benefit Member Eligibility Checklists/Referral Forms

Defines the screening checklists, populations of focus, exclusionary screening, and referral submission process for determining Medi‑Cal member eligibility for the ECM benefit; affects providers referring members and Health Net plan reviewers in California.

Policy Summary

Payermhn

PolicyEnhanced Care Management (ECM) Benefit Member Eligibility Checklists/Referral Forms

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete Populations of Focus and Exclusionary Screening Checklists and submit the ECM Referral Form with supporting documentation via the provider portal or fax for Health Plan review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3steps in the ECM screening and referral process

10+Populations of Focus enumerated (POF 1.0–10.1)

1 weekHealth Net response time for submitted referrals

MultipleProvider portal or fax accepted

MultipleExclusion categories

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Eligibility and Populations of Focus

Populations of Focus eligibility criteria

Member is eligible for Enhanced Care Management (ECM) when they meet the criteria for one or more Populations of Focus (POF). Complete the Populations of Focus Screening Checklist and document the qualifying POF(s).

ONE or more of the following Populations of Focus (select at least one)

POF 1.0: Adults Experiencing Homelessness — Individual age 21 or older AND experiencing homelessness (examples: lacking fixed nighttime residence; primary residence is a place not meant for sleeping; living in shelter/transitional housing; exiting an institution into homelessness; imminent loss of housing within 30 days; fleeing domestic violence) AND has at least one complex physical, behavioral, or developmental health need with inability to self-manage
POF 1.1: Homeless Families or Unaccompanied Children/Youth Experiencing Homelessness — Adult with dependent children or unaccompanied child/youth; meets homelessness definitions and other POF 1.1 criteria
POF 2.0: Adults at Risk for Avoidable Hospital or ED Utilization — Individual age 21 or older AND in the last 6 months has 5+ ER visits and/or 3+ unplanned hospital admissions and/or short-term SNF stays AND the visits/admissions could have been avoided with appropriate outpatient care or improved treatment adherence
POF 3.0: Adults with Serious Mental Health and/or Substance Use Disorder Needs — Individual age 21 or older; meets eligibility for SMHS and/or DMC/DMC-ODS; actively experiencing one complex social factor influencing health (as listed) AND meets additional criteria (e.g., high risk for institutionalization/overdose/suicide, uses crisis services as sole source of care, 2+ ED visits or 2+ hospitalizations for SMI/SUD in past 12 months, pregnant or postpartum within 12 months)
POF 4.0: Adults Transitioning from Incarceration within past 12 months — Individual age 21 or older AND transitioning from or transitioned within last 12 months AND has at least one complex physical, behavioral, or developmental health need (e.g., mental illness, SUD, chronic condition, I/DD, TBI, HIV/AIDS, pregnant/postpartum)
POF 5.0: Adults Living in the Community at Risk for LTC Institutionalization — Individual age 21 or older AND meets SNF Level of Care or requires lower-acuity skilled nursing services AND actively experiencing at least one complex social/environmental factor AND able to reside continuously in the community with wraparound supports (supporting documents required)
POF 6.0: Adult Nursing Facility Residents Transitioning to the Community — Individual age 21 or older AND nursing facility resident with length of stay <365 days AND interested and likely candidate to move out of the institution AND able to reside continuously in the community (supporting documents required)
POF 7.0: Children/Youth Enrolled in CCS or CCS WCM with Additional Needs — Child/youth under 21 AND enrolled in CCS or CCS WCM AND actively experiencing at least one complex social factor influencing health
POF 8.0: Children/Youth Involved in Child Welfare — Child/youth under 21 currently receiving foster care OR under 21 previously in foster care within last 12 months OR under 26 aged out of foster care OR eligible for/receiving Adoption Assistance OR receiving/received Family Maintenance services within last 12 months
POF 9.0: Adults with Intellectual or Developmental Disabilities (I/DD) — Individual age 21 or older AND has a diagnosis of I/DD AND also qualifies for eligibility in at least one other adult ECM POF (POF 1.0, 2.0, 3.0, 4.0, 5.0, or 6.0); specify I/DD in Conditions Table
POF 10.0: Adults Pregnant and Postpartum at Risk for Adverse Perinatal Outcomes — Individual age 21 or older AND pregnant or postpartum through 12 months AND qualifies for at least one other adult POF (specify in Conditions Table)
POF 10.1: Children/Youth Pregnant and Postpartum at Risk for Adverse Perinatal Outcomes — Individual under 21 AND pregnant or postpartum through 12 months AND qualifies for at least one Children/Youth POF (POF 1.1, 2.1, 3.1, 4.1, 7.0, or 8.0); specify in Conditions Table

Administrative checklist items to capture

Document additional social determinants of health (e.g., food/housing/employment insecurity, history of ACEs/trauma, recent law‑enforcement contacts, former foster youth) in the Conditions Table

ECM eligibility and exclusion criteria

Eligibility for ECM requires meeting at least one Population of Focus and passing the exclusionary screening. Complete the Exclusionary Screening Checklist; ALL exclusion boxes must be completed to confirm eligibility.

Member meets one or more Populations of Focus (see Populations of Focus Screening Checklist)

Member is NOT enrolled in absolute exclusion programs — examples include Multipurpose Senior Services Program (MSSP), Assisted Living Waiver (ALW), Home and Community‑Based alternatives listed on the Exclusionary Screening Checklist, CCS Whole Child Model, Community Based Adult Services (CBAS), PACE, and other DHCS‑listed exclusion programs

If member is enrolled in a duplicative or wrap program

If enrolled in a duplicative program: member may choose ECM OR the existing duplicative program (member decision documented)
If enrolled in a wrap/compatible program: ECM may be provided concurrently with coordination and assurances to prevent duplication

Referral Process and Submission Instructions

Prior Authorization

ECM referral and submission steps

Complete the Populations of Focus Screening Checklist and the Exclusionary Screening Checklist before submitting a referral. If the member meets the Populations of Focus criteria and is not excluded by the Exclusionary Screening Checklist, complete the ECM Referral Form and submit all three documents together. To expedite review, include supporting documentation (e.g., medical records, program enrollment evidence) demonstrating the member meets ECM criteria.

Submit the completed Population of Focus Screening Checklist, Exclusionary Screening Checklist, and ECM Referral Form together.
Include applicable supporting documentation to evidence ECM eligibility (medical records, program enrollment forms, etc.).
Health Net will review submissions and respond with next steps or request additional information within one week.

Documentation Required

Referral submission and required information

Use the ECM Referral Form to capture required referral fields and referral source information. Required fields (asterisked on the form) include member identifiers and referral source details. Submit via the Health Net provider portal or fax as listed below.

Key Terms

inv-06: ECM — definition of Enhanced Care Management

TermEnhanced Care Management (ECM)

DefinitionA Medi‑Cal benefit that provides comprehensive, primarily in‑person care management services in the member's community for members with complex health and/or social needs.

PurposeTo improve health and social outcomes for ECM‑enrolled members through contracted ECM provider agencies serving the member's specific Population of Focus.

Eligibility summaryMembers must qualify for one or more identified Populations of Focus and not be enrolled in duplicative services as defined by the Exclusionary Screening Checklist.

inv-07: Experiencing homelessness — definition and examples (lack of fixed nighttime residence, shelters, transitional housing)

Term

Denial Risk

Exclusionary and duplicative program screening

Before submitting, screen for absolute exclusions and duplicative programs using the Exclusionary Screening Checklist. If any absolute exclusion box is checked (for example, Hospice; D-SNP members assigned to the same MCP; FIDE‑SNPs; PACE; Family Mosaic Project Services), do not refer to ECM — member is ineligible. If the member is enrolled in duplicative programs, the member may choose to remain in that program or switch to ECM; document the member's choice and coordinate services to avoid duplication.

Absolute exclusions (stop — member not eligible for ECM) include Hospice; D‑SNP members with same MCP; Fully Integrated Dual Eligible SNPs (FIDE‑SNPs); PACE; Family Mosaic Project Services.
Members enrolled in duplicative programs (e.g., certain 1915 waivers, Basic/Complex Case Management, California Community Transitions, Money Follows the Person) must be informed they can choose to remain in the existing program or enroll in ECM; consult the other program when possible.
Certain programs are complementary (can be concurrent) but require coordination and non‑duplication of services (e.g., CCS, County TCM, SMHS TCM, SMHS ICC, DMC‑ODS, CCS Whole Child Model, CBAS).
Dually eligible members (Medicare and Medi‑Cal) can receive ECM if they meet Populations of Focus criteria, except when enrolled in exclusionary Medicare plans listed (D‑SNPs, D‑SNP look‑alikes, other Medicare Advantage plans, Medicare FFS).