CurrentmhnPolicy N/A

Enhanced Care Management (ECM) Provider Incentive Program

Defines the 2025 incentive program for Medi-Cal ECM providers administered by Health Net on behalf of Community Health Plan of Imperial Valley, describing eligibility, performance metrics, and payment terms for participating providers.

Policy Summary

Payermhn

PolicyEnhanced Care Management (ECM) Provider Incentive Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionContract directly with Health Net and maintain capacity to accept CHPIV Medi‑Cal enrollees to be eligible for incentive payments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025Program year for incentives

$15.00Top-tier PMPM

$7.50Mid-tier PMPM

By Aug 2026Payment timing

PMPMPayment method

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.

ECM Provider Incentive Metrics and Thresholds

Providers earn PMPM incentive payments based on performance tiers for each metric. Data sources and calculation outcomes are specified per metric.

ECM Provider Incentive Metrics and Thresholds

Enrollment effectiveness

ALL of the following
- Outcomes
  - More than 30% enrollment — Rate: $15.00 PMPM
  - 25%–30% enrollment — Rate: $7.50 PMPM
  - Less than 25% enrollment — Rate: no payment

Referral to Community Supports

ALL of the following
- Outcomes
  - >= 15% referred — Rate: $15.00 PMPM
  - 10%–15% referred — Rate: $7.50 PMPM
  - < 10% referred — Rate: no payment

Provision of in-person services

ALL of the following
- Outcomes
  - > 80% — Rate: $15.00 PMPM
  - 50%–80% — Rate: $7.50 PMPM
  - < 50% — Rate: no payment

Reduction in avoidable ER visits

ALL of the following
- Outcomes
  - >= 10% decrease — Rate: $15.00 PMPM
  - 5%–10% decrease — Rate: $7.50 PMPM
  - < 5% decrease — Rate: no payment

Follow-up visits within 7 days post-discharge

ALL of the following
- Outcomes
  - >= 40% compliance — Rate: $15.00 PMPM
  - 38%–39% compliance — Rate: $7.50 PMPM
  - < 38% compliance — Rate: no payment

Community referrals for ECM/CS from community

ALL of the following
- Outcomes
  - > 50% — Rate: $15.00 PMPM
  - 30%–50% — Rate: $7.50 PMPM
  - < 30% — Rate: no payment

Performance Tiers and PMPM Rates

Performance tiers and PMPM rates

Top-tier PMPM rate$15.00 PMPM for metrics meeting the highest performance thresholds (e.g., >30% enrollment, >=15% CS referrals, >80% in‑person services, >=10% ER reduction, >=40% 7‑day follow‑up, >50% community referrals)

Mid-tier PMPM rate$7.50 PMPM for metrics meeting mid-level performance thresholds (e.g., 25%–30% enrollment, 10%–15% CS referrals, 50%–80% in‑person services, 5%–10% ER reduction, 38%–39% 7‑day follow‑up, 30%–50% community referrals)

Below thresholdNo payment when metric performance falls below the stated minimum thresholds (e.g., <25% enrollment, <10% CS referrals, <50% in‑person services, <5% ER reduction, <38% 7‑day follow‑up, <30% community referrals)

Eligibility and Participation Requirements

Prior Authorization

Eligibility requirements for ECM Provider Incentive

To be eligible for the ECM Provider Incentive, an ECM provider must meet Health Net contracting and readiness requirements and be able to accept new CHPIV 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 Community Health Plan of Imperial Valley (CHPIV) Medi‑Cal enrollees eligible for ECM services.

Key Terms and Data Sources

PMPM (Per member per month)

DefinitionPer member per month (PMPM) payment method used for all ECM‑enrolled member months.

Program yearIncentives apply to calendar year 2025 regardless of contract date.

Payment timingHealth Net will make payments by August 2026.

Return Transmission File (RTF)

DefinitionReturn Transmission File (RTF): data file that documents enrollment date and enrollment status for all members on the Member Information File (MIF), used as a data source for measuring enrollment effectiveness.

UsagePrimary data source for the Enrollment Effectiveness metric and for measuring monthly in‑person service participation (used with claims).

Source relationRTF records are matched to the Member Information File (MIF) to calculate percent enrolled from assigned/referred members.

Findhelp (tool/source)

Recommended toolFindhelp is recommended for submitting Community Supports (CS) referrals and tracking referrals from the community (data source for Referral to Community Supports and Community referrals metrics).

Data roleFindhelp/Other and Authorizations/referrals/Findhelp are specified data sources for CS referral and community referral metrics.

PurposeSupports documentation and measurement of percent of ECM‑enrolled members referred to at least one Community Support service.