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Enhanced Care Management
What is ECM?
Enhanced Care Management (ECM) is a Medi-Cal benefit that provides extra help for members with complex needs. ECM offers whole person, coordinated care by connecting members to health care, mental health services, substance use treatment, and social services.
Why ECM Matters?
ECM improves health outcomes by ensuring members:
Get help managing physical, mental, and behavioral health needs
Receive support navigating housing, transportation, and food resources
Stay connected with their primary care provider (PCP)
Have a dedicated case manager to support them along the way
Who is Eligible?
Members must be enrolled in Medi‑Cal managed care and meet one or more of the following Populations of Focus (POFs) as defined by DHCS. ECM is mandatory for MCPs to offer when criteria are met.
1. Individuals or Families Experiencing Homelessness
Lacking a fixed, regular, adequate nighttime residence (e.g. car, street, camp).
Living in unsheltered settings, shelters, motels paid by government/charities.
Leaving an institution into homelessness or imminently losing housing (within 30 days).
Fleeing violence or unsafe conditions. AND at least one complex physical, behavioral, or developmental health need with inability to self-manage.
2. Individuals at Risk for Avoidable Hospital or Emergency Department Utilization
Adults: Five or more ER visits in 6 months, or three or more unplanned hospital/SNF stays.
Children/Youth: Three or more ER visits in 12 months, or two or more unplanned hospital/SNF stays.
Or clinical judgment identifies someone at risk even if they don’t meet numeric thresholds.
3. Individuals with Serious Mental Health and/or Substance Use Disorder Needs
Participation in behavioral health treatment programs (MHP or DMC).
Plus at least one social risk factor (e.g. housing instability, food insecurity, history of trauma, law enforcement contact).
Adults: Two or more behavioral‑health-related ER visits or hospitalizations in the past year or regular crisis services use.
Children/Youth: qualify by meeting behavioral health service criteria alone.
4. Individuals Transitioning from Incarceration
Released from jail, prison, or correctional facility within past 12 months (adults and youth under age 21).
Adults: Must also have one condition such as mental illness, SUD, chronic condition, I/DD, TBI, HIV/AIDS, or be pregnant/postpartum.
Youth/former foster youth qualify without additional clinical criteria.
5. Adults Living in the Community at Risk for Institutionalization
Meet Skilled Nursing Facility Level of Care criteria or require intermittent skilled nursing services.
Have at least one complex social/environmental factor (e.g. ADL limitations, lack of caregiving, isolation).
Capable of living continuously in the community with wraparound support.
6. Adult Nursing Facility Residents Transitioning to the Community
Reside currently in a nursing facility.
Want to transition back to the community and are viable candidates.
Able to live safely with support outside institutional care.
7. Children and Youth Enrolled in CCS or CCS Whole Child Model with Additional Needs
Ages 0–20 enrolled in California Children’s Services (CCS) or CCS Whole Child Model.
Plus at least one complex social need (e.g. housing instability, food insecurity, trauma, law enforcement contact).
8. Children and Youth Involved in Child Welfare
Under age 21 currently or recently in foster care, adoption assistance, or family maintenance.
May include youth up to 26 who aged out of foster care.
9. Birth Equity Population of Focus (Pregnant/Postpartum Individuals)
Pregnant or postpartum (up to 12 months) individuals experiencing racial/ethnic disparities in maternal morbidity/mortality.