Written by On October 9th, the DHCS hosted a comprehensive webinar to unveil two major policy reforms aimed at enhancing the referral and authorization processes for Enhanced Care Management (ECM). These reforms are set to significantly improve access to ECM services for Medi-Cal members. Tyler Sadwith (State Medicaid Director, DHCS), along with Dr. Palav Babaria and Dr. Laura Miller, shared insights on how DHCS plans to simplify the system and boost ECM service uptake.
The Big Picture: Faster Access for Vulnerable Populations
Currently, ECM and Community Supports (CS) authorization processes can take weeks or even months, despite DHCS’s policy directive to complete them within five days, as per APL-21-011. This delay is particularly harmful to high-risk groups, such as individuals experiencing homelessness, children entering foster care, or those transitioning from hospitals or Jails. The new policies focus on streamlining and standardizing the process to get these vital services to members more quickly, reducing the time to approve authorizations and improving outcomes.
Standardized ECM Referral Process
One of the most significant changes is the introduction of ECM Referral Standards, effective January 2025. These standards will allow referral entities to submit the same set of information across Managed Care Plans (MCPs) and counties. For many community-based organizations (CBOs) and providers who work with multiple MCPs, this will relieve the burden of dealing with varied forms, portals, and batch templates. The new referral standards are expected to ease the process, allowing providers to focus on care rather than paperwork.
Dr. Miller’s example of how schools could use a universal referral form to submit to any MCP based on a member’s enrollment highlights the practical benefits of this approach. Additionally, the option for batch submissions is seen as a win for providers who have previously struggled with individual form submissions.
Presumptive Authorization: A Game-Changer for ECM Providers
The webinar also introduced ECM Presumptive Authorization, effective January 2025. This policy allows select ECM providers to initiate services before authorization is formally granted, with MCPs required to pay for services provided during a 30-day window. This is especially critical for populations needing immediate support, ensuring timely access to care. Providers eligible for presumptive authorization will be those with specialized expertise in specific ECM populations. While there are guidelines, such as ensuring no existing ECM authorization for the member and confirming eligibility, this policy would improve quick access to care.
Implementation Challenges for MCPs
With less than 75 days until implementation, MCPs face significant operational challenges. Updating referral forms, workflows, provider contracts, websites, as well as developing training materials for providers, will require swift action. Most MCPs currently rely on manual processes, which will need upgrading to meet the demands of the new presumptive authorization guidelines and streamlined referral systems.
Our Take: A Step Forward, but Challenges Remain
While these reforms promise to improve ECM & CS service access, many MCPs are not yet prepared to fully implement the changes. Manual processes, outdated portals, and the lack of infrastructure to handle batch or digital submissions present significant hurdles. However, MCPs should look at it as an opportunity to set up more efficient administrative operations.
We’re excited to see how DHCS’s forward-thinking policies will transform the ECM landscape and look forward to the improvements they bring in the coming months.
Sprite Health offers a highly comprehensive digital platform that enables the efficient management of all ECM/CS requirements in a single place. Our solution is purposefully designed to cater to the specific needs of the CalAIM ECM/CS initiative.
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