CurrentmhnPolicy N/A

Enhanced Care Management (ECM) Provider Incentive Program

Defines the 2025 incentive program for Health Net Medi‑Cal ECM providers, describing eligibility, performance measures, payment timing and calculation of add‑on PMPM incentive payments for participating providers.

Policy Summary

Payermhn

PolicyEnhanced Care Management (ECM) Provider Incentive Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date2025

Next Review DateN/A

Key ActionBe contracted directly with Health Net as an ECM participating provider and maintain capacity to accept new Health Net Medi‑Cal enrollees eligible for ECM services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025incentive program year

PMPMpayment method

By Aug 2026payment timing

600 member monthsqualification threshold

Incentive Program Performance Measures (Coverage Criteria)

7-day post-discharge follow-up

Policy Summary

Payermhn

PolicyEnhanced Care Management (ECM) Provider Incentive Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date2025

Next Review DateN/A

Key ActionBe contracted directly with Health Net as an ECM participating provider and maintain capacity to accept new Health Net Medi‑Cal enrollees eligible for ECM services.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Measure numerator: Member had an ambulatory (office/outpatient) visit within 7 calendar days following hospital discharge.
Includes telehealth only if plan/contract explicitly allows telehealth to count; otherwise require in‑person or outpatient claim.
Measure denominator: Members discharged from an inpatient facility during the measurement period and continuously enrolled for the measurement window as defined by payer (minimum qualifying volume: 600 member‑months).
Exclude members who died during the follow‑up period or were readmitted within 7 days if payer excludes per specifications.
Data sources: Claims and encounter data; supplemental RTF/encounter submissions may be used to validate scheduling activities.
Providers should ensure timely submission of claims/encounters to avoid undercounting.
- Thresholds
  - >= 40% compliance — Incentive rate: $15.00 per reported unit.
  - 38%–39% compliance — Incentive rate: $7.50 per reported unit.
  - < 38% compliance — No incentive.
- ALL of the following
  - ECM must document outreach and scheduling attempts in the member record and submit supporting encounters/claims.
  - Providers should prioritize scheduling an ambulatory visit within 7 days of discharge and coordinate transportation or other supports as needed.
  - Use of RTF or timely claims submission is required to evidence follow‑up visits for measurement.

Provider Eligibility and Participation Requirements

Note

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.

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

Key Definitions

ECM Provider Incentive

DefinitionECM Provider Incentive — add-on payments for Health Net Medi‑Cal Enhanced Care Management (ECM) providers recognizing performance in enrollment, utilization, and connections to services

Payment methodPaid as add-on PMPM incentive payments separate from contractual PPAs and subcontracts

Program year2025 incentive program for qualifying ECM providers

Payment timingPayments scheduled by August 2026

AlignmentProgram aligns with state ECM benefit and program requirements

OpenPayer

Enhanced Care Management (ECM) Provider Incentive Program

Incentive Program Performance Measures (Coverage Criteria)

Payment Method, Performance Tiers, and Rates

Provider Eligibility and Participation Requirements

Key Definitions