Overview of Medi-Cal’s Enhanced Care Management
Medi-Cal’s Enhanced Care Management (ECM) benefit is intended for the most vulnerable, high-need groups of children and adults enrolled in Medi-Cal Managed Care Health Plans (MCPs). This includes several subgroups of California residents. Most relevantly, persons over 21 who are at risk of being institutionalized (placed in a nursing home) and eligible for long-term care services and supports and current nursing home residents who wish to transition back into the community. Other sub-groups include homeless persons, persons transitioning back into the community after incarceration, adults with serious mental illness.
Enhanced Care Management offers a person-centered approach to care coordination, allowing participants to participate in their own care planning. Via ECM, an “Enhanced Care Manager” or “Lead Care Manager” coordinates all of one’s care needs and services, such as physical 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.
The ECM benefit is provided by Medi-Cal Managed Care Health Plans (MCPs), also known as Managed Care Organizations (MCOs). A MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. While Medi-Cal program participants have a choice of managed care health plans, all Medi-Cal MCPs are required to offer the Enhanced Care Management benefit.
As part of ECM, Enhanced Care Managers can also assist eligible persons in receiving Community Supports (CS). Also called In Lieu-of-Services (ILOS), and relevant to our two focus groups, home and community based services (HCBS) may be provided in substitute for other services, such as nursing home care. Intended to help promote independent living, examples of such supports may include home modifications for safety and accessibility, respite care, personal care assistance, homemaker services, and community transitional services (to assist persons in relocating from a nursing home to community living). Community Supports are also provided via MCPs, but this benefit is optional and a MCP does not have to offer them.
Enhanced Care Management is an entitlement and is available to all persons who meet the eligibility criteria. This means there is never a waitlist to receive this benefit.
Persons can receive ECM while residing in a variety of settings. This includes one’s home, the home of a loved one, or Residential Care Facilities for the Elderly (RCFE). 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.
In California, the Medicaid program is called Medi-Cal. CalAIM (California Advancing and Innovating Medi-Cal) is a Section 1115 Medicaid (Medi-Cal) Demonstration Waiver. Enhanced Care Management (ECM) and Community Supports are two Medi-Cal benefits available through CalAIM. Enhanced Care Management is replacing two Medi-Cal pilot programs: Home Health Program (HHP) and Whole Person Care (WPC).
Benefits of Medi-Cal’s Enhanced Care Management
Follows is a list of potential Enhanced Care Management benefits.
– 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 Residential Care Facilities for the Elderly (RCFE), Medi-Cal does not pay for room and board.
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 are in a high-risk group. Since the focus of this page is adults over the age of 21 who are at risk of institutionalization and eligible for long-term care, as well as nursing home residents transitioning back to the community, the following eligibility criteria is relevant to these two groups.
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 138% of the Federal Poverty Level (FPL), which increases annually in January. However, in California, the Medi-Cal income limits increase each April. Effective April 2022 – March 2023, a single applicant can have a monthly income up to $1,564. When both spouses are applicants, the income limit is $2,106 / 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 $1,564 / 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. The maximum amount that can be transferred is $3,435 / month (eff. January 2022 – December 2022) 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.
In 2022, the asset limit is $130,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is set at $195,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can retain up to $130,000 in assets and the non-applicant spouse can keep up to $137,400. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 30-months of long-term care Medi-Cal application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for Medi-Cal eligibility purposes, Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or indicates in writing they have “intent” to return home. California is unique from other states in that there is no home equity interest limit. Home equity interest is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– A non-applicant spouse lives in the home.
– The applicant has a dependent relative, such as a disabled child, living in the home.
– The applicant has a child under 21 years of age living in the home.
While the home is likely exempt while one is receiving Medi-Cal benefits, it may not be safe from Medicaid’s estate recovery program. To learn more about when Medicaid can and cannot take one’s home, click here.
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). Examples of 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. However, a diagnosis of dementia in and of itself does not mean one will meet a NFLOC.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medi-Cal managed care and the Enhanced Care Management benefit. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible for Medi-Cal. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
Medi-Cal has a share of cost program, which may also be referred to as 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, which is their “share of cost”. This 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.
When persons have assets over the limits, Irrevocable Funeral Trusts are an option. They are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are annuities, which turn countable assets into a stream of income. There are many other options when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid / Medi-Cal benefits. Professional Medicaid planners are educated in the planning strategies available in California to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medi-Cal’s financial criteria but can also protect assets for family as inheritance. These strategies often violate Medi-Cal’s 30-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.
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 is provided, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will 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. Take the Medicaid eligibility test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 30-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.
To receive Enhanced Care Management, one must complete an application, and be determined eligible, for Medi-Cal managed care. An application can be downloaded here. Persons who require assistance with completing the application can call Covered California’s Customer Service Center at 1-800-300-1506. Persons can also apply online at CoveredCA.com or over the phone / in person at one’s Department of Health Care Services county office.
Medi-Cal is administered by the California Department of Health Care Services (DHCS). The Enhanced Care Management benefit is provided by Medi-Cal Managed Care Health Plans.
Approval Process & Timing
The Medicaid 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 even further. 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.