CalAIM at HPSM

To support some of California’s most vulnerable populations, the Department of Health Care Services (DHCS) is rolling out a multi-year initiative called CalAIM — or California Advancing and Innovating Medi-Cal — starting in 2022. Learn more about CalAIM.

CalAIM’s goal is to improve health outcomes for Medi-Cal members through changes in delivery systems, programs, payment processes and an expansion of services. In 2022 HPSM will begin contracting with providers in two new categories: Enhanced Care Management and Community Supports.

Enhanced Care Management

Enhanced Care Management is a Medi-Cal benefit offering comprehensive care management services for our highest needs members. Enhanced Care Management is high-touch and in-person and addresses both medical and social needs.

Enhanced Care Management helps member address their complex care needs through support that is person-centered and community based. Only members in specific populations of focus (requirements below) will be eligible for this service.

The Enhanced Care Management provider will appoint a lead care manager who will work coordinate a care plan to address medical and social needs. The lead care manager will coordinate care with the members’ current providers and can support in coordinating their HPSM benefits and other available resources aimed at improving health outcomes.  These services are voluntary.

Members enrolled in Whole Person Care on 12/31/2021 were transitioned into Enhanced Care Management services.

All other members must fall into one of these populations of focus to be eligible for services:

  • Adults (21 or older) with medical issues who are unhoused (experiencing homelessness):
    • Experiencing housing insecurity.
    • Living with a chronic medical condition that will benefit from case management support.
    • Adults with high utilization of health care services.
    • Six or more avoidable emergency department visits in the last 12 months OR three or more skilled nursing admissions or inpatient admissions in the last six months.
  • Adults (21 or older) with one or more serious mental health disorders:
    • Mental health diagnosis.
    • At least one complex social risk factor influencing health.
    • Pregnant or postpartum OR two ED visits for SUD in the last 12 months OR high risk for overdose, suicide or institutionalization OR using crisis and urgent services as primary source of care.
  • Adults (21 or older) with substance use disorder (SUD) o SUD diagnosis.
    • At least one complex social risk factor influencing health.
    • Pregnant or postpartum OR two ED visits for SUD in the last 12 months OR high risk for overdose, suicide or institutionalization OR using crisis and urgent services as primary source of care.
  • Adults (21 or older) at risk for long term care admission
    • Presence of qualifying factors for long term care currently or imminent without wrap around care.

For detailed information and eligibility criteria for HPSM’s populations of focus please see DHCS links APL 21-012 and APL attachment.

Community Supports

Community Supports are optional services or settings that are offered to eligible Medi-Cal and CareAdvantage members in place of services or settings covered under Medi-Cal. Community Supports are not a benefit but are medically appropriate and cost-effective alternative services. The goal of these services is to improve the health outcomes and quality of life of Medi-Cal and CareAdvantage recipients by addressing Social Determinants of Health (SDOH).

Medi-Cal and CareAdvantage members that qualify may be authorized to receive Community Support services. Members may already be authorized to a Community Supports provider and may have received a letter notifying them of their qualification for these services. All HPSM members continue to have access to HPSM’s care coordination support care management team.

Members who are eligible for the Enhanced Care Management benefit will be eligible for Community Supports.

A member may be eligible for Community Supports if they meet the following basic qualifications:

  • Are an active HPSM Medi-Cal or Care Advantage member.
  • Engaged with a Care Manager.
  • Willing to receive community supports.

For detailed information and service-specific eligibility criteria, please see DHCS' Community Supports Policy Guide.

HPSM offers seven Community Support service options to qualified members through our contracted Community Support providers:

  1. Housing Transition Navigation Services: providing support to include but not limited to advocacy, housing search and coordination of resources based on the member’s individualized needs.
  2. Housing Deposits: identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a person to establish a basic household (except room and board) based on the member’s individualized needs.
  3. Housing Tenancy and Sustaining Services: provides tenancy and sustaining services to include but not limited to advocacy, coordination, linkage to resources, life-skills coaching, and health and safety visits with a goal of maintaining stable tenancy once housing is secured based on the member’s individualized needs.
  4. Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for Elderly (RCFEs) and Adult Residential Facilities (ARFs): provides coordination of services to facilitate nursing facility transition back into a home-like, community setting and/or prevent skilled nursing admissions for Members with an imminent need for nursing facility level of care (LOC). Members have the choice of residing in an assisted living setting as an alternative to long-term placement in a nursing facility when they meet eligibility requirements.
  5. Community Transition Services/Nursing Facility Transition to a Home: provides coordination of services to qualified members which includes but not limited to covering nonrecurring home set-up expenses for eligible members who are able to transition from a licensed facility into the community and prevent further institutionalization based on member’s individual needs.
  6. Environmental Accessibility Adaptations (Home Modifications): provides physical adaptations to a member’s home that are necessary to increase independence or ensure the health, welfare, and safety of a member in their home, without which the member would require institutionalization.
  7. Medically Supportive Food/Meals/Medically Tailored Meals: provides medically tailored home-delivered meals for members with chronic conditions to help achieve their nutrition goals at critical times and help them regain and maintain their health.

Authorization for Services

Requesting Authorization

If you are a provider or a care manager who would like to request Enhanced Care Management or Community Supports for a member, please review the authorization tips listed in the ECM and CS Provider List and Authorization Tips document and complete the following forms:

For Enhanced Care Management services

Complete the HPSM Prior Authorization Request Form

Fax the completed form to: 650-829-2079

For Community Supports

Complete the HPSM Prior Authorization Request Form and the Community Supports Request Information Form

Fax the completed forms to: 650-829-2079

If you are not able to assist a member with requesting prior authorization for these services, and they are interested please direct members to contact HPSM Care Coordination/Integrated Care Management. The team can assess member’s needs, support with resources, and assist with completing a prior authorization form to request services.