CurrentmhnPolicy N/A

Enhanced Care Management (ECM) Provider Incentive

Describes the 2025 ECM Provider Incentive program offered by Health Net (Medi‑Cal) that pays participating ECM providers add-on per-member-per-month incentives based on enrollment, utilization, referrals, and performance metrics.

Policy Summary

Payermhn

PolicyEnhanced Care Management (ECM) Provider Incentive

Policy CodePolicy N/A

Change TypeMinor — no material changes

Effective Date2025 (calendar year)

Next Review DateN/A

Key ActionTo be eligible, ECM providers must be in good standing, contracted directly with Health Net, and have capacity to accept new Health Net Medi‑Cal enrollees eligible for ECM.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PMPMpayment method

Aug 2026timing

$15.00top-tier rate

$7.50mid-tier rate

CY2025performance period

Enrollment effectiveness

Enrollment effectiveness measure and payment tiers

ALL of the following

Tiers
- >30% enrollment, Rate = $15.00
- 25% - 30% enrollment, Rate = $7.50
- <25% enrollment, Rate = none

Referral to Community Supports

Referral to Community Supports measure and payment tiers

ALL of the following

Tiers
- >=15% of total enrolled, Rate = $15.00
- 10% - 15% of total enrolled, Rate = $7.50
- <10% of total enrolled, Rate = none

In‑person services

Provision of in-person services measure and payment tiers

ALL of the following

Tiers
- >80% of enrolled, Rate = $15.00
- 50% to 80% of enrolled, Rate = $7.50
- <50% improvement, Rate = none

Avoidable ER reduction

Avoidable ER visits reduction measure and payment tiers

ALL of the following

Tiers
- >=10% decrease, Rate = $15.00
- 5% - 10% decrease, Rate = $7.50
- <5% decrease, Rate = none

7‑day follow‑up visits

Follow‑up within seven days of hospital discharge measure and payment tiers

ALL of the following

Tiers
- 40% compliance, Rate = $15.00
- 38% - 39% compliance, Rate = $7.50
- <38% compliance, Rate = none

Community referral sources

Community referrals for ECM or Community Supports (CS) measure and payment tiers

ALL of the following

Tiers
- >50% of enrolled, Rate = $15.00
- 30% to 50% of enrolled, Rate = $7.50
- <30% of enrolled, Rate = none

Payment Method, Thresholds, and Codes

Payment methodmixed

PMPM	Per member per month incentive payment

Payment timingmixed

Payments by August 2026

Health Net will make payments by August 2026

Enrollment effectiveness thresholds

Top tier>30% enrollment = $15.00 per eligible member month

Mid tier25%–30% enrollment = $7.50 per eligible member month

No payment threshold<25% enrollment = no payment

Referral to Community Supports thresholds

Top tier>=15% of enrolled members referred to ≥1 Community Support = $15.00 per eligible member month

Mid tier10%–15% referrals = $7.50 per eligible member month

No payment threshold<10% referrals = no payment

In‑person services thresholds

Top tier>80% of enrolled months with ≥1 in‑person service = $15.00 per eligible member month

Mid tier50%–80% of enrolled months with ≥1 in‑person service = $7.50 per eligible member month

No payment threshold<50% = no payment

Avoidable ER reduction thresholds

Top tier>=10% year‑over‑year decrease in avoidable ER visits = $15.00 per eligible member month

Mid tier5%–10% decrease = $7.50 per eligible member month

No payment threshold<5% decrease = no payment

7‑day follow‑up thresholds

Top tier40% compliance with ambulatory visit within 7 days post‑discharge = $15.00 per eligible member month

Mid tier38%–39% compliance = $7.50 per eligible member month

No payment threshold<38% compliance = no payment

Community referral source thresholds

Top tier>50% of enrolled members with ECM/CS referrals originating from the community = $15.00 per eligible member month

Mid tier30%–50% community‑originating referrals = $7.50 per eligible member month

No payment threshold<30% community referrals = no payment

Eligibility, Contacts, and Provider Requirements

Documentation Required

Eligibility requirements for ECM Provider Incentive

To be eligible for the ECM Provider Incentive, an ECM provider must be in good standing with Health Net, be contracted directly with Health Net as an ECM participating provider, and be open to accept and have the capacity to serve new Health Net Medi‑Cal enrollees eligible for ECM services.

Note

Program contact for questions

For program questions, contact your assigned Health Net representative or call Provider Services at 800-675-6110.

Program Definitions and Data Sources

ECM Provider Incentive — program & 2025 payment model

Program definitionECM Provider Incentive is an add‑on payment program for Health Net Medi‑Cal ECM providers that rewards enrollment, utilization, referrals, and performance for calendar year 2025.

Payment modelPayments are made as per‑member‑per‑month (PMPM) add‑on payments for ECM‑enrolled member months.

Payment timingIncentive payments for calendar year 2025 will be made by August 2026.

Return Transmission File (RTF) — enrollment data source

Data sourceReturn Transmission File (RTF) documents enrollment date and enrollment status for all members on the Member Information File and is used to measure enrollment and in‑person service months.

Use casesRTF is used to calculate % of assigned/referred members who enroll in ECM and % of enrolled members with at least one in‑person service per enrolled month.

ReportingECM providers submit the RTF as the enrollment data source for incentive calculations.

Policy Summary

Payermhn

PolicyEnhanced Care Management (ECM) Provider Incentive

Policy CodePolicy N/A

Change TypeMinor — no material changes

Effective Date2025 (calendar year)

Next Review DateN/A

Key ActionTo be eligible, ECM providers must be in good standing, contracted directly with Health Net, and have capacity to accept new Health Net Medi‑Cal enrollees eligible for ECM.

SourceLink

On This Page

OpenPayer

Enhanced Care Management (ECM) Provider Incentive

Performance Measures and Incentive Criteria

Payment Method, Thresholds, and Codes

Eligibility, Contacts, and Provider Requirements

Program Definitions and Data Sources