By OPEN MINDS Circle
On January 1, 2023, the California Department of Health Care Services (DHCS) expanded the new Medi-Cal Enhanced Care Management (ECM) benefit to two long-term care populations. One population includes Medicaid beneficiaries who meet the level of need for long-term care and who are at-risk of being institutionalized; the other population includes current nursing facility beneficiaries transitioning to the community.
ECM is a comprehensive care management benefit available through the state’s California Advancing and Innovating Medi-Cal (CalAIM) Medicaid waiver. It is intended to address the clinical and non-clinical needs of high-need, high-cost beneficiaries through the coordination of services and comprehensive care management. The ECM benefit is part of the broader CalAIM population health management system design through which managed care plans (MCPs) offer care management interventions at different levels of intensity based on member need. ECM, the highest intensity level, covers outreach and engagement, comprehensive assessment and care management, and comprehensive transitional care. The MCPs contract with local provider organizations to deliver the ECM services.
Additional details about the two new ECM focus populations are as follows:
The population of adults at risk of being institutionalized to receive long-term care services includes those who meet three criteria. They meet the skilled nursing facility level of care criteria or require lower acuity skilled nursing, or equipment for prevention, diagnosis, or treatment of acute illness or injury. They must be actively experiencing at least one complex social or environmental factor influencing their health, such as needing assistance with activities of daily living (ADLs), communication difficulties, access to food, access to stable housing, living alone, the need for conservatorship or guided decision-making, poor or inadequate caregiving which may appear as a lack of safety monitoring. They must also be able to reside continuously in the community with wraparound supports.
The population of adult nursing facility residents transitioning to the community includes those who are interested in moving out of the institution and who are likely to be able to do so successfully. They must be able to reside continuously in the community but could still qualify for this benefit even if they need short-term hospitalization or skilled nursing stays to address changes in medical conditions or other acute episodes. This population excludes individuals residing in Intermediate Care Facilities (ICF) and subacute care facilities.
The Centers for Medicare & Medicaid Services (CMS) approved the CalAIM Medicaid waiver amendment and renewal for the state’s Medicaid 1115 demonstration and 1915(b) waiver, effective January 1, 2022, through December 31, 2026. The CalAIM provisions are intended to standardize Medicaid managed care plan benefits; to add institutional care and major organ transplants into managed care; to carve pharmacy out of Medi-Cal health plan managed care; and to implement Medicaid managed long-term services and supports (MLTSS) statewide. Currently the existing MCPs cover physical health and non-specialty mental health services. Under the approved 1915(b) waiver, all of the state’s managed care delivery systems— Medi-Cal MCPs, dental managed care, specialty mental health services, and the Drug Medi-Cal-Organized Delivery System (for addiction treatment)—will be shifted to one coordinating authority.
For more information, contact: Michelle Baas, Director, California Department of Health Care Services, 1501 Capitol Avenue, MS 0000, Post Office Box 997413, Sacramento, California 95899; Website: https://www.dhcs.ca.gov/Pages/ECMandILOS.aspx