Enhanced Care Management and In Lieu of Services Workgroup

Enhanced Care Management

This workgroup will discuss the possibility of establishing a statewide enhanced care management (ECM) benefit. The goal of an ECM benefit is to provide a whole-person approach to care that addresses the clinical and non-clinical needs of high-need Medi-Cal beneficiaries enrolled in managed care health plans (MCPs). ECM is a collaborative and interdisciplinary approach to providing intensive and comprehensive care management services. The proposed ECM benefit would replace the current Health Homes Program (HHP) and Whole Person Care (WPC) care management pilots, building on positive outcomes from those programs.

Target populations for ECM include, but are not limited to:

high utilizers (top 1–5%) of care;
individuals at risk for institutionalization (including individuals with Serious Mental Illness, children with Serious Emotional Disturbance, and individuals eligible for long-term care (LTC);
those with frequent hospital or emergency room (ER) admissions;
nursing facility residents who want to transition to the community;
individuals transitioning from incarceration; and
individuals suffering from chronic homelessness or who are at risk of becoming homeless.

In Lieu-Of Services

Additionally, DHCS is seeking input regarding the possibility of including In Lieu-of Services (ILOS), which are flexible wrap-around services that the MCP would integrate into its population health strategy. These services are provided as a substitute, or to avoid, other Medi-Cal covered services such as ER utilization, a hospital or skilled nursing facility admission, or a discharge delay. ILOS would be integrated with Case or Care Management for members at medium-to-high levels of risk and may fill gaps in State Plan benefits to address medical or social determinants of health needs.

Examples of ILOS include but are not limited to: 1) housing transition and sustaining services; 2) recuperative care; 3) short-term non-medical respite; 4) home and community-based wrap around services for beneficiaries to transition or reside safely in their home or community; and 5) sobering centers.

The workgroup will provide feedback on these concepts, including on topics such as target populations, beneficiary and provider eligibility criteria for ILOS and the new ECM benefit, and payment structures.

Workgroup Charter
Workgroup Roster

Workgroup Meetings

All workgroup meetings will be held in Sacramento at 1700 K Street in the First Floor Conference Room. Please arrive 10 minutes early to sign in at the front desk.

Public Participation

The public is welcome to attend all meetings by phone or in-person. A public call-in option will be active for all workgroup meetings. Please see below.

Note: In-person space is limited and will be allocated on a first come-first serve basis. Members of the public who call in will be placed in listen-only mode. If you wish to participate by phone, please register using the links below (the webinar will be used for telephonic purposes only). After registration, you will receive an email confirmation with your unique dial-in and access code. California Advancing and Innovating Medi-Cal (CalAIM) workgroups will not be recorded.