Kev Pab Tswj Kho Mob
Kev Txhim Kho Kev Pab Tswj Kev Tu Xyuas (Enhanced Care Managment; ECM raws li sau hauv lus Askiv) thiab Zej Zog Kev Pab Txhawb (Community Supports)
California Advancing and Innovating Medi-Cal (CalAIM) is a new initiative by the Department of Health Care Services (DHCS) to improve the quality of life and health outcomes of Medi-Cal members by implementing a broad delivery system, program and payment reform across the Medi-Cal program. CalAIM establishes the framework to address social determinants of health and improve health equity statewide.
A key feature of CalAIM is the introduction of Enhanced Care Management (ECM) and Community Supports that serve as cost-effective alternatives to covered Medi-Cal services.
ECM is a Medi-Cal benefit administered by DHCS. ECM providers deliver:
- Comprehensive care management.
- Care coordination.
- Health promotion.
- Comprehensive transitional care.
- Individual and family support services.
- Referrals to community social supports.
These core service components are delivered mostly face to face with members through community-based ECM providers.
ECM-eligible members will be assigned an ECM provider and a lead care manager who will assess members to best support their health care and social needs.
ECM will be implemented in stages by eligible populations of focus.
|Date||Populations of Focus|
|Live July 1, 2023||
|Live January 1, 2024||
|Live 2024 (Date TBD)||
For detailed definitions, please refer to the DHCS ECM Policy Guide posted on the DHCS webpage on ECM program initiatives.
Community Supports (CS), previously known as In Lieu of Services or ILOS, are community-based services that address health-related social needs. Medi-Cal managed care health plans may offer these alternative services to their members to avoid hospital care, nursing facility care, visits to the emergency department or other costly services.
Member eligibility for Community Supports is determined using the DHCS Community Supports service descriptions, which contain specific eligibility criteria for each Community Support.
To authorize a member to receive a Community Supports service, Alliance staff will use DHCS criteria and collaborate with the appropriate Community Support provider. The Alliance will authorize Community Supports to members in a medically appropriate, equitable and non-discriminatory manner.
For more details on Community Supports services and eligibility, please review the DHCS Community Supports Policy Guide.
The table below shows when Community Supports services will be offered in each county.
|Cov Zej Zog Kev Pab Txhawb||Cheeb Nroog Merced||Cheeb Nroog Monterey||Cheeb Nroog Santa Cruz|
|Tej Kev Pab Cuam Qhia Txog Kev Hloov Vaj Tsev Nyob||Available||Available||Available|
|Cov Nyiaj Tso Them Vaj Tsev Nyob||Available||Available||Available|
|Kev Xauj Vaj Tsev Nyob thiab Kev Pab Cuam Kom Tau Nyob Ruaj Khov||Available||Available||Available|
|Cov Pluas Mov Noj Uas Npaj Tom Qab Tawm Hauv Tsev Kho Mob Loj||Available||Available||Available|
|Cov Chaw Pab Cheem Kom Txhob Qaug||Available||Available||TBD|
|Kev Saib Xyuas Kom Rov Qab Zoo Los||Available||Available||Available|
|Short-term Post Hospitalization Housing||Available||Available||Available|
|Environmental Accessibility Adaptations (Home Modifications)||
January 1, 2023 (Partial)
|January 1, 2023 (Partial)
|January 1, 2023 (Partial)
|Respite Service for Caregivers||Lub Ib Hlis Ntuj Hnub Tim 1, 2023||Lub Ib Hlis Ntuj Hnub Tim 1, 2023||Lub Ib Hlis Ntuj Hnub Tim 1, 2023|
|Personal Care and Homemaker Services||Lub Ib Hlis Ntuj Hnub Tim 1, 2023||Lub Ib Hlis Ntuj Hnub Tim 1, 2023||Lub Ib Hlis Ntuj Hnub Tim 1, 2023|
Read more about each Community Support below.
Tej Kev Pab Cuam Qhia Txog Kev Hloov Vaj Tsev Nyob
Housing Transition Navigation Services assist members with obtaining housing.
Cov Nyiaj Tso Them Vaj Tsev Nyob
Housing Deposits assist with identifying, coordinating, securing or funding one-time services and modifications necessary to enable a person to establish a basic household. Housing Deposits refer to services that do not constitute room and board.
Kev Xauj Vaj Tsev Nyob thiab Kev Pab Cuam Kom Tau Nyob Ruaj Khov
This service provides tenancy and sustaining services with a goal of maintaining safe and stable tenancy once housing is secured.
Cov Pluas Mov Noj Uas Npaj Tom Qab Tawm Hauv Tsev Kho Mob Loj
Medically Tailored Meals help individuals achieve their nutrition goals at critical times to help them regain and maintain their health. Meals are tailored to each member’s needs based on their medical conditions. Results include:
- Improved member health outcomes.
- Lower hospital readmission rates.
- A well-maintained nutritional health status.
- Increased member satisfaction.
Cov Chaw Pab Cheem Kom Txhob Qaug
Sobering centers are alternative destinations for individuals who are found to be publicly intoxicated (due to alcohol and/or other drugs) and would otherwise be transported to the emergency department or jail. Sobering centers provide these individuals—primarily those who are homeless or those with unstable living situations—with a safe, supportive environment to become sober.
Kev Saib Xyuas Kom Rov Qab Zoo Los
Recuperative Care is short-term residential care for individuals who:
- Do not need to be in the hospital, but still need to heal from an injury or illness (including behavioral health conditions).
- Are in a condition that would be exacerbated by an unstable living environment.
Kev Pab Vaj Tsev Rau Nyob Ib Ntus Tom Qab Tawm Hauv Tsev Kho Mob
Short-Term Post Hospitalization Housing is for members with high medical or behavioral health needs who do not have a residence. Short-Term Post Hospitalization Housing helps prevent further utilization of State plan services. The service gives members the opportunity to continue their medical/psychiatric/substance use disorder recovery immediately after their time in recuperative care, allowing the patient’s stay to be extended.
Environmental Accessibility Adaptations (EAAs, also known as Home Modifications)
Environmental Accessibility Adaptations are physical adaptations to a home that are necessary to ensure the health, welfare, and safety of the individual, or enable the individual to function with greater independence in the home, without which the member would require institutionalization. EAAs can include ramps, grab-bars and other home modifications.
Respite Services for Caregivers
Respite Services are provided to caregivers of Members who require intermittent temporary supervision. The services are provided on a short-term basis because of the absence or need for relief of those persons who normally care for and/or supervise them and are non-medical in nature. This service is distinct from medical respite/recuperative care and is rest for the caregiver only.
Personal Care and Homemaker Services
Personal Care Services and Homemaker Services are provided for individuals who need assistance with Activities of Daily Living (ADLs) such as bathing, dressing, toileting, ambulation or feeding. Personal Care Services can also include assistance with Instrumental Activities of Daily Living (IADLs) such as meal preparation, grocery shopping and money management.
Asthma remediation includes physical modifications to a home environment, without which acute asthma episodes could result in the need for emergency services and hospitalization.
There are three ways members can access ECM or Community Supports services:
- The Alliance or an ECM or Community Supports provider may contact members directly if they qualify.
- Members or a member’s family member can self-refer or ask for information to see if they qualify. Alliance members can call the Alliance Member Services Department at 800-700-3874 from 8 a.m. to 5:30 p.m., Monday through Friday.
- Providers or requesting entities may submit an ECM or Community Supports referral to the Alliance.
Providers or requesting entities may submit ECM and Community Support referrals to the Alliance by:
Provider Portal referral
Registered providers can log in to the secured Alliance Provider Portal to submit, inquire about, cancel or add additional information to existing referrals.
Email, mail, or fax
Alliance providers can submit referrals for Enhanced Care Management or Community Supports by completing the following forms:
- Enhanced Care Management Provider Referral Form
- Community Supports: Housing Provider Referral Form
- Community Supports: Environmental Accessibility and Adaptability (EAA) Provider Referral Form
- Community Supports: Meals Provider Referral Form
Please return completed forms to the Alliance’s Enhanced Care Management team by using one of the following methods:
- Xa Email: [email protected].
1600 Green Hills Rd.
Scotts Valley, CA 95066
Attention: ECM Team
- Fax: 831-430-5819.
Tus Xov Tooj
Refer a member to ECM/CS services by calling 831-430-5512.
Tips for a successful referral
- When referring a member for Community Supports, please include any relevant social information. When referring a member for ECM services, always include a population of focus. Check back on this page for updated information as we roll out additional populations of focus.
- Referrals are a “no wrong door” approach. We accept all incoming referrals.
The Alliance processes submitted ECM/CS referrals within 5 business days, after which we will contact the referrer to let them know the outcome of the referral.
There are three possible outcomes:
- The referral is approved: Correspondence is sent to the servicing and requesting provider.
- The referral is denied: Correspondence is sent to the servicing and requesting provider, and a notice is sent to the member. This may happen if the member does not meet the criteria to be referred, or does not fit into one of the ECM/CS populations of focus.
- The referral is void: This only occurs if there is not enough information to process the referral. The Alliance ECM team will make attempts to obtain the missing information. Once the authorization has been pending for five business days with no additional information provided, it is voided. Correspondence is sent to the servicing and requesting provider.
Please call the Alliance ECM team at 831-430-5512 or email [email protected].
If your organization is interested in becoming an ECM or Community Supports provider, please email the Alliance at [email protected]
CalAIM Incentive Payment Program. Implementation of Enhanced Care Management and Community Supports requires significant investments in care management capabilities, infrastructure, information technology and data exchange, and workforce capacity at both the managed care plan and provider levels. The DHCS CalAIM Incentive Program (IPP) is a component of CalAIM to support the development of a robust Medi-Cal network to deliver ECM and Community Supports services. The Alliance is administering this incentive funding to support our local provider network to address gaps and build infrastructure and capacity for ECM and Community Supports services. IPP cannot overlap with other DHCS incentive funding for ECM and Community Supports, such as CITED (see below). To facilitate incentive funding, the Alliance is intaking information from providers about their identified infrastructure and capacity needs via the ECM/CS Certification Tool. For questions, please email the Alliance at [email protected]
Kev Hloov Pauv, Kev Nthuav Txav thiab Kev Txhim Kho Txog Kev Ua Lub Luag Haujlwm thiab Chaw Kho Mob (Capacity and Infrastructure Transition, Expansion and Development, CITED, raws li sau hauv lub Askiv) Thaum Xub Thawj. CITED is a grant program administered by DHCS that provides funding to enable the transition, expansion and development of ECM and Community Supports capacity and infrastructure. CITED applicants must be contracted with a managed care plan for ECM and/or Community Supports services and are encouraged to coordinate applications with local organizations they contract with or intend to contract with to provide ECM and/or Community Supports services. Applicants who wish to receive CITED funding must submit an application indicating how they intend to use CITED funding. For more information visit https://www.ca-path.com/cited.
Muaj ntau cov lus qhia, cov kev cob qhia thiab cov cuab yeej txhawm rau pab rau cov kws kho mob nkag siab txog thiab nqis tes ua ECM thiab CS.
Kev qhia kom paub, tsab cai thiab tsab ntawv ntawm DHCS hais txog ECM/CS
- DHCS CalAIM ECM thiab Kev Txhawb Nqa Zej Zog tus webpage
- DHCS ECM thiab CS tej Lus Piav Txog Kws Kho Mob thiab Cov Tsooj Cai
- Cov lus qhia kom paub ntawm tsab cai
- Tag nrho txhua tsab ntawv ntawm Kev Npaj Haujlwm
Tej cuab yeej ntawm DHCS ntsig txog ECM/CS
- Tej Cuab Yeej Qhia Txog Kws Kho Mob ntawm ECM
- Tus Neeg Piav Txog Kev Txhawb Nqa Zej Zog
- Tej Cuab Yeej Qhia Txog Kev Nthuav Txav Ntawm ECM
- Tej Cuab Yeej Qhia Txog Tswv Cuab Ntawm ECM
Cov peev txheej kws kho mob ntawm Alliance ntsig txog ECM/CS
- Webinars thiab Cov Kev Cob Qhia Ntawm Kws Kho Mob (Select ECM-Community Supports from the dropdown menu)
- ECM/CS Cov Lus Nquag Nug Txog Ntaub Ntawv Tsib Nqi
- Kev Pab Fab Haujlwm: Tus Nqi Uas Suav Sau Ntawm Tsab Ntawv Tsib Nqi Fab Kws Kho Mob
- Kev Pab Fab Haujlwm: Tus Nqi Uas Suav Sau Ntawm CMS Fab Kws Kho Mob
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|Cov Kev Thov
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|Lub Tsev Muag Tshuaj
Authorizations, general pharmacy information or questions
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