Medi-Cal (California Medicaid) CalAIM’s Enhanced Care Management & Community Supports

Last updated: March 25, 2024

 

Overview of CalAIM’s Enhanced Care Management & Community Supports

In California, Medicaid is called Medi-Cal. CalAIM (California Advancing and Innovating Medi-Cal) is a 5 year Medi-Cal initiative available through a Section 1115 Medicaid Demonstration Waiver. Its aim is to transform and strengthen Medi-Cal by offering equitable, coordinated, and person-centered care for all Medi-Cal recipients.

The majority of Medi-Cal recipients (approximately 88%) receive their Medi-Cal benefits via Medi-Cal Managed Care Health Plans (MCPs), also known as Managed Care Organizations (MCOs). MCPs have their own network of care providers and persons receive services via these providers. Enrollment in a MCP is mandatory for many groups of Medi-Cal beneficiaries, including those in nursing home facilities.

Enhanced Care Management (ECM) and Community Supports (CS) are two CalAIM managed care benefits. ECM and CS replaced two Medi-Cal Programs: Health Homes Program (HHP) and Whole Person Care (WPC) Pilot.

Enhanced Care Management
Medi-Cal’s Enhanced Care Management (ECM) benefit is for the most vulnerable, high-need groups of children and adults enrolled in Medi-Cal MCPs. This includes six subgroups of California residents, but most relevant for aging seniors are two: 1) Adults (over the age of 21) at Risk of Being Institutionalized (placed in a nursing home) and Eligible for Long-Term Care Services and Supports 2) Adults (over the age of 21) who are Nursing Home Residents and Wish to Transition Back Into the Community. Other subgroups include Individuals and Families Experiencing Homelessness, Individuals Transitioning from Incarceration, and Adults with Serious Mental Illness.

ECM offers a person-centered approach to care coordination, allowing Medi-Cal recipients to participate in their own care planning. An “Enhanced Care Manager” or “Lead Care Manager” coordinates all of one’s care needs and services. This includes physical health, oral health, behavioral health, social needs, and long-term services and supports. Assistance may be provided in finding physicians, scheduling medical appointments, managing medications, and locating and applying for needed community-based services and supports.

Persons can receive ECM while residing in a variety of settings. This includes one’s home, the home of a loved one, an Adult Residential Facility (ARF), and a Residential Care Facility for the Elderly (RCFE). ARFs and RCFEs can be thought of as assisted living facilities or adult foster care homes. Persons can also reside in nursing homes, given they would like to move back into the community.

While Medi-Cal program participants have a choice of Medi-Cal Managed Care Plan, all MCPs are required to offer Enhanced Care Management. Furthermore, ECM is an entitlement and is available to all persons who meet the eligibility criteria. There is never a waitlist to receive this benefit.

 Via Community Supports, Medi-Cal Managed Care Plans can partner with Assisted Living Providers to provide assisted living services. This option expands Medi-Cal recipients’ access to assisted living beyond Medi-Cal’s Assisted Living Waiver, which has a significant waiting list for program participation.

Community Supports
As part of ECM, Enhanced Care Managers can assist eligible persons in receiving Community Supports (CS), also called In Lieu-of-Services (ILOS). There are 14 potential CS available through Medi-Cal MCPs, and not all are relevant to Individuals at Risk of Being Institutionalized and Eligible for Long-Term Care Services and Supports nor Nursing Home Residents who Wish to Transition Back Into the Community. Furthermore, unlike Enhanced Care Management, a Managed Care Plan is not required to offer Community Supports.

CS that may be available and relevant to the subgroups we are discussing are home and community based services (HCBS) that are intended to promote independent living and are provided in place of more costly alternatives, such as nursing home care. Examples include Home Modifications for safety and accessibility, Respite Care, Personal Care Assistance and Homemaker Services, and Nursing Home Transition and Diversion to One’s Home or Assisted Living.

Nursing Home Transition and Diversion to Assisted Living is a much needed support, as it opens the door for seniors to more easily access assisted living. This Community Support allows Managed Care Plans to partner with Assisted Living Providers to provide Medi-Cal funded assisted living services in assisted living facilities (i.e., Adult Residential Facilities and Residential Care Facilities for the Elderly). This allows an option for assisted living outside of Medi-Cal’s Assisted Living Waiver (ALW), which has a significant waitlist. Unlike the ALW, which has a cap on the number of program participants and geographic restrictions, there is no participant cap and no geographic restrictions for Nursing Home Transition and Diversion to Assisted Living. Since MCPs do not have to offer this Community Support, it may not be available through all MCPs.

 

Benefits of Medi-Cal’s Enhanced Care Management & Community Supports

Enhanced Care Management benefits may include the following:
– Comprehensive Assessment and Care Management Plan
– Comprehensive Transitional Plan – support while one is moving out of a nursing home and into the community
– Coordination / Referral to Community and Social Support Services
– Enhanced Coordination of Care – organizing and implementing services that are required for care plan implementation
– Health Promotion
– Member and Family Supports
– Outreach and Engagement – determining and accepting referrals for Medi-Cal beneficiaries who are eligible for ECM and assigning ECM Providers to reach out
While persons who receive Enhanced Care Management can live in Adult Residential Facilities and Residential Care Facilities for the Elderly (RCFE), Medi-Cal does not pay for room and board.

Community Supports may include the following:
– Community Transition Services / Nursing Facility Transition to a Private Home – funding for security deposits / utility set-up fees and appliances related to heath (i.e., hospital beds, air conditioners, heaters)
– Home Modifications – for safety and accessibility (i.e., wheelchair ramps, grab bars, stair lifts)
– Nursing Facility Transition / Diversion to Assisted Living Facilities – assistance with daily living activities, medication management, and access to 24-hour staff is provided in assisted living
– Personal Care / Homemaker Services – assistance with bathing, dressing, toileting, preparing meals, grocery shopping, cleaning, and laundry
– Respite Services – to give primary caregivers a break from caregiving duties
– Medically Tailored Meals / Medically Supportive Food
While Community Support services will pay for assisted living services in Adult Residential Facilities and Residential Care Facilities for the Elderly, it will not cover the room and board costs.

 Other Options: Seniors who are enrolled in Medi-Cal’s Community-Based Adult Services Program (CBAS) or In-Home Supportive Services Program (IHSS) can simultaneously receive Enhanced Care Management and / or Community Supports. Persons enrolled in a Medicaid Waiver program, such as the Multipurpose Senior Services Program (MSSP), the Assisted Living Waiver (ALW), or the Home and Community Based Alternatives Waiver (HCBA Waiver), are not eligible for ECM.

 

Eligibility Requirements for Medi-Cal’s Enhanced Care Management

ECM is for California residents who are enrolled in a Medi-Cal Managed Care Health Plan and in a high-risk group. The focus here is 1) Adults (over 21 years old) at Risk of Institutionalization and Eligible for Long-Term Care Services and Supports and 2) Adults (over 21 years old) who are Nursing Home Residents and Wish to Transition Back Into the Community. General eligibility for ECM and CS for seniors and persons with disabilities follow. Additional requirements may need to be met for Community Supports and are benefit-specific. For instance, for nursing home transition to one’s home or assisted living, one must reside in a nursing home for more than 60 days. One does not necessarily have to be eligible for Enhanced Case Management to receive Community Supports and vice versa.

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 138% of the Federal Poverty Level (FPL). While this figure increases annually in January, the Medi-Cal income limits increase in April. Effective 4/1/24 – 3/31/25, a single applicant can have a monthly income up to $1,732. When both spouses are applicants, the income limit is $2,352 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of their spouse. Only the applicant spouse’s income is considered, which is limited to $1,732 / month. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance. In 2024, the maximum amount that can be transferred is $3,854 / month and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than this amount are not entitled to a Spousal Income Allowance.

Assets
There is no asset limit. Effective 1/1/24, the asset limit for Medi-Cal was eliminated.

There is a Look-Back Period during which Medi-Cal scrutinizes past asset transfers of persons. However, it is not applicable for persons who live at home or in the community and applying for Medi-Cal. For persons applying for Medi-Cal nursing home care, the “look-back” may be applicable. With the elimination of the asset limit, assets transferred on or after 1/1/24 are not considered. Assets transferred prior to 1/1/24 are still being scrutinized. The 30-month Look-Back Period is being phased out month-by-month and will be completely eliminated by July of 2026.

While all assets are disregarded when determining Medi-Cal eligibility, one’s assets are not necessarily safe from the Medicaid Estate Recovery Program (MERP). Following the death of a long-term care Medicaid beneficiary, the state attempts reimbursement of long-term care costs for which it paid for that individual via their remaining estate. This may include one’s home. With the utilization of proper planning strategies, one can protect their home and other assets from being used as reimbursement and instead go to loved ones as inheritance. Contact an Experienced Medi-Cal Planner for assistance.

 

Medical Criteria: Functional Need

An applicant must require a Nursing Facility Level of Care (NFLOC). One area of consideration is one’s need for assistance with Activities of Daily Living (ADLs).ADLs include bathing, dressing, mobility, toiletry, and eating. Relevant to persons with Alzheimer’s disease or a related dementia, cognitive deficits, such as memory, decision making, and judgment, may also be considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

 Learn more about long-term care Medicaid in California.  

 

Qualifying When Over the Income Limit

Having income over Medicaid’s limit does not necessarily mean an applicant cannot still qualify for Medi-Cal Managed Care, the Enhanced Care Management benefit, and / or Community Supports. Medi-Cal has a Share of Cost Program, also called a Medically Needy Program. With this program, an applicant with income over Medi-Cal’s income limit has to pay towards the cost of their care services / medical expenses. This is their “share of cost”. It can be thought of as a deductible and is based on one’s monthly income. Once one has paid their share of cost for the month, Medi-Cal will pay for services and supports the remainder of the month. Unfortunately, the only Medi-Cal beneficiaries with a share of cost who can enroll in managed care are those residing in a nursing home facility. However, in some situations, it may be possible to eliminate one’s share of cost, allowing them to be eligible for the Medi-Cal Managed Care. An Experienced Medi-Cal Planner can assist with meeting the limit.

 

How to Apply for Medi-Cal’s Enhanced Care Management

Before You Apply

Prior to submitting an application for Medi-Cal through which Enhanced Care Management and / or Community Supports is provided, applicants need to ensure they meet the eligibility criteria. Applying when over the income limit may be cause for denial of benefits. The American Council on Aging offers a free Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria.

As part of the application process, applicants will need to gather documentation for submission. Examples include proof of income and copies of Social Security and Medicare cards. A common reason applications are held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

To receive Enhanced Care Management and / or Community Supports, one must be eligible for Medi-Cal and enrolled in a Managed Care Plan. Persons can apply for Medi-Cal online at Covered California, fill out and submit an Application for Health Insurance, or apply in person at one’s County Social Services Office. Persons who require assistance with completing the application can call Covered California’s Customer Service Center at 1-800-300-1506. The majority of Medi-Cal beneficiaries are required to enroll in a Medi-Cal Managed Care Plan once determined eligible for Medi-Cal.

Medi-Cal beneficiaries enrolled in a Medi-Cal Managed Care Plan can request Enhanced Care Management and / or Community Supports by contacting their MCP to make a “referral”. The Medi-Cal recipient can do this on their own or someone else can do this on their behalf.

Learn more about Enhanced Care Management & Community Supports.

Medi-Cal is administered by the California Department of Health Care Services (DHCS). The Enhanced Care Management benefit and Community Supports Services are provided by Medi-Cal Managed Care Health Plans.

 

Approval Process & Timing

The Medi-Cal application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, it sometimes takes even longer for eligibility to be determined.

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