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Getting Started
Atlas Health Group is a California-based healthcare organization dedicated to improving the lives of Medi-Cal members by delivering person-centered care that addresses both medical and non-medical needs. We work alongside health plans, physicians, hospitals, and community organizations to help individuals overcome barriers to health while improving their overall quality of life.
Our multidisciplinary team coordinates care, connects members to essential resources, and provides ongoing support to help them achieve better health outcomes. Rather than focusing solely on treating illness, we address the social, behavioral, and environmental factors that influence long-term health and well-being.
Atlas Health Group offers a comprehensive range of CalAIM and community-based healthcare services designed to support individuals with complex medical, behavioral, and social needs.
Our services include:
• Enhanced Care Management (ECM) — Personalized care coordination for members with complex health needs.
• Community Supports (CS) — Assistance accessing housing, nutrition, transportation, recuperative care, home modifications, and other approved services.
• Behavioral Health Services — Mental health screenings, care coordination, therapy referrals, and behavioral health support.
• Community Health Worker (CHW) Services — Community-based support, health education, advocacy, benefit navigation, and resource connections.
• Care Coordination — Collaboration between providers, hospitals, specialists, caregivers, and community organizations.
• Resource Navigation — Assistance connecting members with community programs, food resources, financial assistance, transportation, and social services.
Our goal is to provide whole-person care by addressing medical, behavioral, and social determinants of health.
Atlas Health Group primarily serves California Medi-Cal members who may benefit from additional care coordination and supportive services.
We work with individuals experiencing:
• Chronic or complex medical conditions
• Behavioral or mental health challenges
• Housing insecurity or homelessness
• Frequent emergency room visits or hospitalizations
• Multiple healthcare providers requiring coordination
• Limited access to transportation
• Food insecurity
• Social isolation
• Disabilities
• Justice system involvement
• High-risk pregnancies and postpartum needs
• Children and youth with complex healthcare needs
• Older adults requiring additional support
We also support family members, caregivers, healthcare providers, hospitals, health plans, and community-based organizations working together to improve member outcomes.
Atlas Health Group proudly serves communities throughout California by partnering with Managed Care Plans (MCPs), healthcare providers, hospitals, and community organizations.
Our service areas continue to expand as new partnerships are established. Coverage varies depending on the specific health plan, county, and service being provided.
If you're unsure whether services are available in your area, our team is happy to verify eligibility and service availability. Contact us today to determine whether we currently serve your county or health plan.
We are committed to providing culturally responsive and linguistically appropriate care for every member.
Our team supports multiple languages through bilingual staff members and professional interpreter services to ensure effective communication throughout your healthcare journey.
If your preferred language is not immediately available, we will arrange qualified interpretation services at no cost to you. Please let our team know your preferred language when contacting us or enrolling in services.
There are several convenient ways to connect with Atlas Health Group. You can:
• Call our office at (858) 215-6887 during normal business hours.
• Complete the Contact Us form on our website.
• Submit a referral through our online referral portal.
• Speak with one of our representatives through our website's live chat feature.
• Ask your healthcare provider, hospital, or health plan to submit a referral on your behalf.
Whether you are a member, caregiver, healthcare provider, or community partner, our team is here to answer questions and help you access the services you need.
Our administrative offices are open during standard business hours:
Monday – Friday
8:00 AM – 5:00 PM (Pacific Time)
Business hours may vary on holidays. Our care teams work closely with members throughout the week to coordinate services, schedule appointments, and provide ongoing support.
Yes. While our administrative offices operate during normal business hours, Atlas Health Group understands that healthcare needs don't always occur on a schedule.
Members currently enrolled in our programs may have access to after-hours support based on their care plan and the services they receive.
If you are experiencing a medical emergency, call 911 or go to the nearest emergency room immediately. For non-emergency concerns after business hours, you may leave a voicemail or submit an online request, and a member of our team will respond as soon as possible on the next business day.
Eligibility & Enrollment
Eligibility depends on your Medi-Cal Managed Care Plan, your medical and social needs, and the specific CalAIM program you may qualify for. Many of our services are designed for individuals who would benefit from additional care coordination due to complex health conditions or significant life challenges.
You may be eligible if you are experiencing:
• Multiple chronic medical conditions
• Serious mental health or behavioral health needs
• Frequent emergency room visits or hospitalizations
• Homelessness or housing instability
• Food insecurity or lack of reliable transportation
• Difficulty managing multiple healthcare providers
• Disabilities or functional limitations
• Justice system involvement
• High-risk pregnancy or postpartum needs
• Other complex medical, behavioral, or social needs identified by your health plan
Our team can help determine your eligibility and guide you through the enrollment process.
The easiest way to determine your eligibility is to contact Atlas Health Group or speak with your Medi-Cal Managed Care Plan.
Our enrollment specialists will:
• Review your current health coverage
• Verify your health plan eligibility
• Assess your healthcare and support needs
• Determine which services you may qualify for
• Explain your available options
There is no obligation to enroll, and we'll answer any questions you have before moving forward.
Most of the services we provide through CalAIM—including Enhanced Care Management (ECM) and Community Supports (CS)—are available to eligible Medi-Cal members enrolled in participating Managed Care Plans.
Eligibility requirements vary depending on your health plan and the specific program. If you're unsure about your coverage, our team can verify your benefits and help determine which services may be available to you.
Yes. If you believe you may qualify, you can contact Atlas Health Group directly to begin the enrollment process.
Our team will guide you through each step, verify your eligibility, explain available services, and answer any questions before enrollment is completed. Enrollment is voluntary, and you may choose whether to participate.
Yes. Family members, caregivers, legal guardians, or authorized representatives are welcome to contact us on your behalf.
Depending on your situation and applicable privacy regulations, we may need your consent or legal authorization before completing enrollment or discussing your healthcare information. Our team will explain any required documentation during the process.
Absolutely. Healthcare providers frequently refer patients to Atlas Health Group for additional care coordination and supportive services.
Referrals may come from:
• Primary Care Providers (PCPs)
• Specialists
• Hospitals
• Emergency Departments
• Skilled Nursing Facilities
• Behavioral Health Providers
• Community Clinics
• Federally Qualified Health Centers (FQHCs)
• Health Plans
• Community-Based Organizations (CBOs)
Our team works closely with referring providers to ensure a smooth transition into services.
Enrollment timelines vary depending on your health plan, eligibility verification, and the specific services being requested.
In many cases, our team can begin the intake process shortly after receiving a referral or direct inquiry. Once eligibility is confirmed, we work to connect members with the appropriate services as quickly as possible. Our goal is to make enrollment simple, timely, and stress-free.
To help determine eligibility and coordinate your care, we may ask for:
• Your name and date of birth
• Contact information
• Medi-Cal or health insurance information
• Primary Care Provider (if applicable)
• Emergency contact information
• Current medical conditions
• Current medications
• Behavioral health needs
• Housing situation
• Transportation needs
• Food or nutrition concerns
• Other social or healthcare needs that may affect your well-being
This information helps us develop a personalized care plan based on your unique circumstances.
Yes. Many members receive multiple services at the same time based on their individual needs.
For example, a member may receive:
• Enhanced Care Management
• Community Supports
• Behavioral Health services
• Community Health Worker support
Our interdisciplinary team works together to coordinate services so you receive comprehensive, whole-person care without having to navigate the healthcare system alone.
Once you're enrolled, you'll be connected with the appropriate care team based on your needs and eligible services.
Your care journey typically includes:
1. A comprehensive assessment of your medical, behavioral, and social needs.
2. Assignment to the appropriate care team, such as a Lead Care Manager or Community Health Worker.
3. Development of a personalized care plan with goals tailored to your situation.
4. Coordination with your doctors, specialists, health plan, caregivers, and community partners.
5. Ongoing support, regular check-ins, and assistance accessing healthcare and community resources.
Our goal is to help you improve your health, remove barriers to care, and provide the support you need to live as independently and safely as possible.
Enhanced Care Management (ECM)
Enhanced Care Management (ECM) is a CalAIM benefit that provides comprehensive, person-centered care coordination for eligible Medi-Cal members with complex medical, behavioral, or social needs.
Unlike traditional case management, ECM focuses on the whole person—not just their medical condition. Your Lead Care Manager works closely with your healthcare providers, health plan, family, caregivers, and community organizations to ensure your care is coordinated and your needs are addressed.
ECM is designed to improve health outcomes, reduce unnecessary emergency room visits and hospitalizations, and help members navigate the healthcare system with confidence.
Eligibility is determined by your Medi-Cal Managed Care Plan and whether you meet one or more of the CalAIM Populations of Focus.
Individuals who may qualify include those who:
• Are experiencing homelessness or housing instability
• Have multiple chronic medical conditions
• Have serious mental illness or substance use disorders
• Frequently visit the emergency room or have repeated hospitalizations
• Are transitioning from hospitals or nursing facilities back into the community
• Are at risk of institutionalization
• Are justice-involved and transitioning back into the community
• Are pregnant or postpartum with high-risk medical or social needs
• Are children or youth with complex healthcare needs
• Require extensive coordination across multiple healthcare providers
If you're unsure whether you qualify, our team can verify your eligibility and work with your health plan to determine available benefits.
Yes. Enhanced Care Management is a covered CalAIM benefit for eligible Medi-Cal members enrolled in participating Managed Care Plans. There is no additional cost to eligible members for ECM services. Coverage is determined by your health plan and eligibility criteria.
Your Lead Care Manager (LCM) serves as your primary point of contact and healthcare advocate throughout your care journey.
Your LCM may help you:
• Coordinate appointments with healthcare providers
• Develop a personalized care plan
• Connect with specialists and community resources
• Schedule medical appointments
• Assist with medication coordination
• Navigate healthcare benefits
• Address housing, transportation, and food needs
• Coordinate behavioral health services
• Communicate with hospitals and healthcare providers
• Support transitions after hospital discharge
• Help you achieve your personal health goals
Your Lead Care Manager works alongside you to ensure your care remains organized, coordinated, and centered around your individual needs.
The frequency of contact depends on your individual needs and care plan. Some members require frequent communication, while others may only need periodic check-ins.
Your Lead Care Manager will maintain regular contact to:
• Monitor your progress
• Coordinate healthcare services
• Address new challenges
• Update your care plan as needed
• Ensure you remain connected to the appropriate resources
Your level of support may increase or decrease over time based on your health and personal circumstances.
Yes, when appropriate. Your Lead Care Manager may accompany you to certain healthcare appointments when additional support or care coordination would be beneficial.
They can help:
• Explain treatment plans
• Ask questions on your behalf
• Coordinate follow-up care
• Ensure providers have important information
• Advocate for your healthcare needs
• Help you better understand your care options
Attendance depends on your needs, the type of appointment, and available resources.
Absolutely. If you do not currently have a Primary Care Provider (PCP), or you need assistance changing providers, your Lead Care Manager can help you:
• Find an in-network provider
• Schedule your first appointment
• Transfer medical records
• Coordinate communication with your healthcare team
• Establish ongoing primary care
Having a trusted primary care provider is an important part of maintaining your overall health.
Yes. One of ECM's primary goals is ensuring communication among all members of your healthcare team.
Your Lead Care Manager can coordinate with:
• Primary Care Providers
• Medical Specialists
• Behavioral Health Providers
• Hospitals
• Skilled Nursing Facilities
• Pharmacies
• Community-Based Organizations
• Home Health Providers
• Community Health Workers
• Other healthcare professionals involved in your care
This coordinated approach helps reduce gaps in care and ensures everyone is working toward the same health goals.
Yes. Hospital transitions are one of the most important times for coordinated care.
Your Lead Care Manager can assist with:
• Scheduling follow-up appointments
• Reviewing discharge instructions
• Coordinating medications
• Connecting you with Community Supports
• Arranging transportation
• Communicating with your physicians
• Helping prevent avoidable readmissions
• Addressing barriers that could interfere with your recovery
Our goal is to help you recover safely and successfully after leaving the hospital.
The length of your enrollment depends on your ongoing eligibility, your health plan, and your individual care needs.
As long as you continue to meet the eligibility requirements and benefit from Enhanced Care Management, you may remain enrolled. Your care team will periodically review your progress and work with your Managed Care Plan to determine whether ECM continues to be appropriate. If your needs change, we'll help ensure a smooth transition to other services or community resources so you continue receiving the support you need.
Community Supports (CS)
Community Supports (CS) are optional CalAIM services that help eligible Medi-Cal members address social and environmental factors that impact their health. These services are designed to complement medical care by providing practical assistance that helps individuals live safely, remain independent, and avoid unnecessary hospitalizations or institutional care.
Community Supports focus on improving overall well-being by addressing needs such as housing, nutrition, transportation, personal care, and recovery support.
Eligibility for Community Supports is determined by your Medi-Cal Managed Care Plan based on your health needs, living situation, and the specific Community Support being requested.
You may qualify if you:
• Are experiencing homelessness or housing instability
• Have complex medical or behavioral health needs
• Frequently use emergency departments or require hospital care
• Need assistance remaining safely in your home
• Are transitioning from a hospital, nursing facility, or other institution
• Require support to recover after a hospitalization
• Have functional limitations that affect daily living
• Meet other health plan-specific eligibility requirements
Our team can help determine which Community Supports may be available to you.
The specific Community Supports available vary by Managed Care Plan, but may include:
• Housing Transition Navigation Services
• Housing Deposits
• Housing Tenancy and Sustaining Services
• Recuperative Care (Medical Respite)
• Short-Term Post-Hospitalization Housing
• Day Habilitation Programs
• Respite Services
• Nursing Facility Transition/Diversion Services
• Personal Care and Homemaker Services
• Environmental Accessibility Adaptations (Home Modifications)
• Medically Supportive Food and Meals
• Sobering Centers
• Asthma Remediation
• Community Transition Services
• Home-Based Services
• Other approved CalAIM Community Supports
Availability depends on your health plan and county.
Yes. Housing-related Community Supports are designed to help eligible members obtain and maintain stable housing.
Depending on your eligibility and health plan, services may include:
• Assistance finding permanent housing
• Housing application support
• Landlord communication
• Housing navigation
• Move-in coordination
• Housing deposits
• Ongoing tenancy support
• Eviction prevention assistance
• Connections to community housing resources
While Community Supports do not typically provide long-term rental assistance, they can help members access housing programs and resources that promote long-term housing stability.
Yes, if you qualify. Some eligible members may receive medically supportive meals or nutrition services as part of their Community Supports benefits.
These services may be available for individuals who:
• Have chronic medical conditions
• Are recovering from hospitalization
• Have medically necessary dietary needs
• Experience food insecurity
• Require nutritional support to improve health outcomes
Eligibility and duration of meal services are determined by your Managed Care Plan.
Community Supports may include transportation-related assistance when it is medically appropriate and authorized by your health plan.
Depending on your needs, transportation assistance may help you access:
• Medical appointments
• Healthcare services
• Community resources
• Other approved services related to your care plan
Our team can help determine which transportation benefits are available through your health plan.
Yes. One of the primary goals of Community Supports is helping members remain safely and independently in their homes whenever possible.
Depending on your eligibility, services may include:
• Personal care assistance
• Homemaker services
• Home safety modifications
• Caregiver support
• Meal assistance
• Recovery support
• Care coordination
• Connections to community resources
These services are intended to reduce the need for institutional care while improving quality of life.
Community Supports are authorized by your Medi-Cal Managed Care Plan based on:
• Your medical needs
• Functional limitations
• Social needs
• Clinical assessments
• Care recommendations
• CalAIM eligibility requirements
Your Atlas Health Group care team works closely with your health plan to identify appropriate services and advocate for the supports that best meet your individual needs.
Not necessarily. Community Supports are intended to address specific needs and may be provided for a limited period based on your health plan's authorization and your individual circumstances.
Your care team will regularly review your progress and reassess your needs. If additional support is required, we will work with your health plan to determine whether services can continue or if other community resources may better meet your long-term needs.
Our goal is to provide the right support at the right time to help you achieve greater independence, improve your health, and maintain the highest possible quality of life.
Community Health Workers (CHW)
A Community Health Worker (CHW) is a trusted member of the healthcare team who helps individuals navigate the healthcare system while addressing the everyday challenges that can affect their health and well-being.
CHWs provide culturally responsive, community-based support by helping members access healthcare services, understand their care plans, connect with local resources, and overcome barriers to better health.
They serve as advocates, educators, and trusted partners, helping members build confidence in managing their health while strengthening connections to their communities.
Community Health Worker services are available to eligible Medi-Cal members who would benefit from additional support navigating healthcare and community resources.
You may qualify if you:
• Have difficulty accessing healthcare services
• Need help managing a chronic health condition
• Experience housing, food, or transportation challenges
• Need assistance understanding your care plan
• Frequently miss medical appointments
• Require health education or coaching
• Need help connecting with community resources
• Have barriers related to language, culture, or health literacy
• Would benefit from ongoing community-based support
Eligibility is determined by your Medi-Cal Managed Care Plan and your individual needs.
Community Health Workers provide practical, personalized support to help improve your overall health and quality of life.
Your CHW may assist with:
• Understanding your health conditions and treatment plan
• Health education and wellness coaching
• Scheduling medical appointments
• Connecting you with healthcare providers
• Applying for community benefits and services
• Accessing food, housing, and transportation resources
• Coordinating with your care team
• Navigating healthcare systems and insurance benefits
• Providing encouragement and ongoing support
• Helping you develop healthy habits and achieve personal health goals
Every member's needs are different, and your CHW will tailor support to your unique circumstances.
Yes. When appropriate, a Community Health Worker may accompany you to medical appointments to provide additional support and help ensure your healthcare needs are fully understood.
They may help by:
• Preparing questions before your appointment
• Helping you communicate with your healthcare provider
• Explaining medical information in understandable terms
• Taking notes during appointments
• Assisting with follow-up scheduling
• Coordinating next steps with your care team
The availability of appointment accompaniment depends on your individual care plan and program resources.
Yes, when appropriate. Community Health Workers often meet members where they are most comfortable, including at home or in other community settings.
Home visits allow CHWs to:
• Better understand your living environment
• Identify barriers affecting your health
• Provide health education
• Assist with care planning
• Connect you with community resources
• Offer personalized support in a familiar setting
Meeting locations are determined based on your needs, preferences, safety considerations, and your individualized care plan.
Absolutely. Community Health Workers can assist you in understanding and accessing a variety of healthcare and community assistance programs.
They may help with:
• Medi-Cal questions
• CalFresh (SNAP) applications
• Housing resources
• Transportation programs
• Food assistance programs
• Utility assistance
• Community resource referrals
• Local nonprofit services
• Other public benefit programs for which you may qualify
While CHWs may not determine eligibility or approve benefits, they can guide you through the application process and connect you with the appropriate agencies.
Yes. Connecting members with local resources is one of the primary responsibilities of a Community Health Worker.
Depending on your needs, your CHW may connect you with:
• Food banks and meal programs
• Housing assistance
• Homeless services
• Transportation resources
• Employment and vocational programs
• Financial assistance programs
• Mental health services
• Substance use treatment programs
• Senior services
• Disability resources
• Caregiver support services
• Community-based organizations
• Educational and wellness programs
Our goal is to ensure you have access to the services and support needed to improve your health, increase your independence, and strengthen your connection to the community.
Behavioral Health
Behavioral Health services support your emotional, psychological, and behavioral well-being. At Atlas Health Group, we recognize that mental health is just as important as physical health, and we take a whole-person approach to care.
Our Behavioral Health team works with members to identify challenges, coordinate appropriate services, connect them with qualified providers, and support their journey toward improved mental wellness.
Behavioral Health services are often integrated with Enhanced Care Management (ECM), Community Health Worker (CHW), and Community Supports (CS) to ensure all aspects of a member's health are addressed.
Our Behavioral Health services may include:
• Behavioral health assessments and screenings
• Individual therapy and counseling referrals
• Mental health care coordination
• Medication management coordination
• Crisis prevention planning
• Depression and anxiety support
• Substance use disorder care coordination
• Connection to psychiatrists and licensed therapists
• Care planning with your healthcare providers
• Community resource referrals
• Ongoing case management and follow-up
• Coordination between physical and behavioral healthcare providers
Services are personalized based on your needs and your Managed Care Plan benefits.
Our team supports individuals experiencing a wide range of behavioral and mental health concerns, including:
• Anxiety disorders
• Depression
• Bipolar disorder
• Schizophrenia and other psychotic disorders
• Post-Traumatic Stress Disorder (PTSD)
• Trauma-related conditions
• Substance use disorders
• Stress-related conditions
• Adjustment disorders
• Mood disorders
• Grief and loss
• Co-occurring medical and behavioral health conditions
If you're unsure whether we can help with your specific situation, our team can discuss your needs and connect you with the appropriate services.
Yes. Depending on your health plan, eligibility, and individual needs, members may be connected with licensed behavioral health professionals who provide counseling and therapy services.
Treatment may include:
• Individual counseling
• Short-term therapy
• Long-term behavioral health treatment
• Trauma-informed care
• Cognitive Behavioral Therapy (CBT)
• Other evidence-based therapeutic approaches
If specialized care is needed, we will coordinate referrals to qualified mental health providers within your health plan's network.
Yes. Many Behavioral Health services can be provided through secure telehealth appointments, allowing members to receive care from the comfort and privacy of their home.
Telehealth may be appropriate for:
• Therapy sessions
• Behavioral health follow-up visits
• Care coordination
• Wellness check-ins
• Treatment planning
• Provider consultations
Availability depends on your provider, health plan, and the type of service being provided.
Yes. Many members receive Behavioral Health services alongside Enhanced Care Management, Community Health Worker services, and Community Supports.
Our interdisciplinary care team works together to coordinate your physical, behavioral, and social care needs, helping ensure that every provider involved in your care is working toward the same goals. This integrated approach helps improve communication, reduce gaps in care, and provide more comprehensive support.
The timeline depends on your eligibility, your Managed Care Plan, the urgency of your needs, and provider availability.
After your referral or enrollment:
1. Your eligibility and benefits will be verified.
2. A behavioral health assessment may be completed.
3. Our team will determine the most appropriate level of care.
4. You will be connected with the appropriate behavioral health provider or services.
Our goal is to connect members with care as quickly as possible while ensuring they receive the most appropriate services for their individual needs.
Yes. Your privacy is extremely important to us. Behavioral Health services are provided in accordance with all applicable federal and state privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA).
Your personal health information is only shared with individuals involved in your care when permitted or required by law. We maintain strict confidentiality and use secure systems to protect your information.
If you have questions about privacy, consent, or how your information is shared, our team will be happy to explain your rights and answer any concerns.
If you are experiencing a behavioral health emergency or believe you may be at immediate risk of harming yourself or others, call 911 or go to the nearest emergency department immediately.
If you are experiencing emotional distress or need immediate mental health support, you can also contact the 988 Suicide & Crisis Lifeline by calling or texting 988, where trained counselors are available 24 hours a day, 7 days a week.
For non-emergency behavioral health concerns, Atlas Health Group can help coordinate ongoing treatment and connect you with appropriate mental health resources through your care team and health plan.
Populations of Focus (CalAIM)
CalAIM (California Advancing and Innovating Medi-Cal) identifies specific Populations of Focus (POF) to ensure that Medi-Cal members with the most complex medical, behavioral, and social needs receive enhanced care and support.
These populations are individuals who often face significant barriers to healthcare and may benefit from Enhanced Care Management (ECM), Community Supports (CS), Community Health Worker (CHW), Behavioral Health (BH), and other coordinated services.
By identifying these populations, Managed Care Plans and healthcare providers can deliver personalized, whole-person care that improves health outcomes, reduces unnecessary hospitalizations, and helps individuals live healthier, more independent lives.
Atlas Health Group serves eligible Medi-Cal members across multiple CalAIM Populations of Focus, including:
• Individuals and families experiencing homelessness
• Adults with serious mental illness (SMI) or substance use disorders (SUD)
• Adults with complex medical conditions
• Children and youth with complex physical, developmental, or behavioral health needs
• Justice-involved individuals transitioning back into the community
• Individuals transitioning from hospitals, skilled nursing facilities, or other institutions
• Individuals at risk of long-term institutionalization
• High utilizers of emergency departments and inpatient services
• Pregnant and postpartum individuals with complex medical or social needs
• Older adults with multiple chronic conditions
• Individuals experiencing significant social determinants of health, including food insecurity, transportation barriers, and housing instability
Eligibility is determined by your Medi-Cal Managed Care Plan and specific CalAIM criteria.
You do not need to determine this on your own. Our enrollment specialists and care team work with your Managed Care Plan to review your medical history, healthcare utilization, and social needs to determine whether you qualify under one or more Populations of Focus.
Factors that may be considered include:
• Your medical diagnoses
• Hospital and emergency room utilization
• Behavioral health needs
• Housing status
• Functional limitations
• Pregnancy status
• Age
• Justice system involvement
• Previous healthcare services
• Other health-related social needs
If you believe you may qualify, we encourage you to contact our team for an eligibility review.
Yes. Many Medi-Cal members meet the criteria for multiple Populations of Focus.
For example, an individual may:
• Experience homelessness while managing multiple chronic illnesses.
• Have serious mental illness and frequent emergency room visits.
• Be recovering from hospitalization while needing housing support.
• Be justice-involved while also living with complex medical conditions.
Your care plan is developed based on your overall needs rather than a single category, ensuring you receive coordinated, comprehensive support across all eligible services.
Not necessarily. Meeting the criteria for a Population of Focus does not automatically result in enrollment.
Enrollment depends on several factors, including:
• Your Medi-Cal eligibility
• Enrollment in a participating Managed Care Plan
• Clinical eligibility requirements
• Health plan authorization
• Availability of specific CalAIM services
Atlas Health Group works closely with Managed Care Plans to verify eligibility and guide members through the enrollment process as quickly and efficiently as possible.
Whole-person care means treating more than just a medical condition. At Atlas Health Group, we recognize that health is influenced by physical, behavioral, emotional, and social factors. Our care teams work together to address all aspects of your well-being by coordinating medical care, behavioral health services, housing resources, nutrition support, transportation, and other community-based services.
This integrated approach helps improve overall health, reduce barriers to care, and support long-term wellness.
Yes. Your health and life circumstances can change, and your eligibility may change as well.
For example, you may qualify for additional services after:
• A hospitalization
• Becoming pregnant
• Experiencing housing instability
• Developing a chronic medical condition
• Entering or leaving the justice system
• Transitioning from a skilled nursing facility
• Experiencing changes in your behavioral health
Our care team regularly reassesses your needs to ensure you continue receiving the most appropriate services available.
Populations of Focus are established by the California Department of Health Care Services (DHCS) as part of the CalAIM initiative.
Managed Care Plans use DHCS guidelines, clinical information, healthcare utilization, and social determinants of health to identify members who may benefit from Enhanced Care Management and Community Supports.
Atlas Health Group collaborates with health plans, providers, hospitals, and community organizations to help identify eligible members and connect them with the services that best meet their needs.
Yes. Referrals can be submitted by:
• Primary Care Providers (PCPs)
• Specialists
• Hospitals
• Emergency Departments
• Behavioral Health Providers
• Community-Based Organizations (CBOs)
• Skilled Nursing Facilities
• Shelters
• Health Plans
• Family members or caregivers (with appropriate authorization)
• Self-referrals
Once a referral is received, our team will verify eligibility, coordinate with your Managed Care Plan, and guide you through the next steps if you qualify for services.
The Populations of Focus framework allows healthcare providers to proactively identify individuals who are most likely to benefit from coordinated, community-based care.
By focusing on members with the greatest medical, behavioral, and social needs, Atlas Health Group can:
• Improve access to healthcare services
• Reduce avoidable emergency room visits and hospitalizations
• Coordinate care across multiple providers
• Address housing, food, and transportation challenges
• Support behavioral health needs
• Promote long-term independence and stability
• Improve overall quality of life
Our mission is to ensure that every eligible member receives compassionate, coordinated, and personalized care that addresses their unique circumstances and helps them achieve better health outcomes.
Care Coordination
Care Coordination is the process of organizing and managing your healthcare services so that all members of your care team work together toward your health goals.
At Atlas Health Group, we take a whole-person approach by coordinating medical care, behavioral health, social services, and community resources. Our goal is to simplify the healthcare experience, reduce gaps in care, and ensure you receive the right services at the right time.
Whether you're managing a chronic condition, recovering from a hospital stay, or navigating multiple providers, our team is here to help every step of the way.
Our interdisciplinary care team works closely with your healthcare providers, health plan, caregivers, and community organizations to ensure your care is seamless and personalized.
Depending on your needs, we may:
• Develop a personalized care plan
• Coordinate appointments and referrals
• Communicate with your Primary Care Provider (PCP)
• Coordinate specialist care
• Connect you with behavioral health services
• Arrange Community Supports
• Connect you with Community Health Workers
• Monitor your progress and update your care plan
• Help remove barriers such as transportation, housing, or food insecurity
Every care plan is tailored to your individual health goals and personal circumstances.
Yes. With your permission and in accordance with HIPAA privacy regulations, our care team works directly with your Primary Care Provider (PCP) and other healthcare professionals involved in your care.
We may communicate regarding:
• Care plans
• Treatment recommendations
• Hospital admissions and discharges
• Medication concerns
• Follow-up appointments
• Preventive care
• Health goals
• Progress updates
This collaboration helps ensure everyone involved in your care has the information needed to provide coordinated, high-quality care.
Absolutely. Atlas Health Group partners with hospitals and healthcare systems throughout California to help members receive coordinated care before, during, and after hospitalization.
Our team may assist with:
• Hospital discharge planning
• Scheduling follow-up appointments
• Medication coordination
• Connecting members to primary care
• Arranging Community Supports
• Behavioral health coordination
• Home and community resource referrals
• Preventing avoidable hospital readmissions
Our goal is to help members recover safely while ensuring continuity of care after leaving the hospital.
Yes. Many members receive care from multiple healthcare providers, and keeping everyone informed is an important part of effective care coordination.
Our team can help coordinate care with:
• Primary Care Providers
• Cardiologists
• Endocrinologists
• Neurologists
• Oncologists
• Orthopedic specialists
• Behavioral health providers
• Psychiatrists
• Physical therapists
• Occupational therapists
• Home health agencies
• Other specialists involved in your care
By facilitating communication among providers, we help reduce duplication of services, improve treatment planning, and create a more connected healthcare experience.
Yes. While Atlas Health Group does not prescribe medications, our care team can help you better manage your medication regimen by:
• Reviewing your medication list
• Encouraging medication adherence
• Coordinating with your prescribing providers
• Helping resolve prescription-related issues
• Connecting you with pharmacies and medication assistance programs
• Answering questions about your medication schedule
• Helping ensure providers are aware of all medications you are taking
Medication management is an important part of preventing complications and improving health outcomes.
If you miss a medical appointment, your care team is here to help you get back on track.
We may assist by:
• Rescheduling your appointment
• Coordinating transportation, if available
• Identifying barriers that prevented you from attending
• Communicating with your healthcare provider when appropriate
• Updating your care plan if additional support is needed
We understand that unexpected situations happen, and our goal is to help you continue receiving the care you need.
Yes. Depending on your care plan and the services you receive, your care team may provide appointment reminders to help you stay on schedule.
Reminders may include:
• Phone calls
• Text messages
• Coordination with caregivers or authorized family members
• Follow-up outreach from your Lead Care Manager or Community Health Worker
Appointment reminders help reduce missed visits and ensure you remain connected to your healthcare providers.
Your care plan is designed to evolve with you. If your health, living situation, or personal circumstances change, your care team will reassess your needs and adjust your care plan accordingly.
This may include:
• Adding or changing services
• Coordinating new specialists
• Connecting you with Behavioral Health or Community Supports
• Updating your health goals
• Increasing or decreasing the frequency of care team contacts
• Identifying additional community resources
Our goal is to ensure you continue receiving the right level of support throughout every stage of your healthcare journey.
Yes, if you choose. With your permission, we encourage family members, caregivers, or other authorized representatives to participate in your care whenever appropriate.
They may assist with:
• Care planning
• Appointment coordination
• Medication support
• Communication with healthcare providers
• Health education
• Accessing community resources
• Ongoing support at home
Including trusted individuals in your care can improve communication, strengthen support systems, and help you achieve better health outcomes while respecting your privacy and healthcare preferences.
Health Plans & Coverage
Atlas Health Group partners with a variety of Medi-Cal Managed Care Plans (MCPs) throughout California to provide CalAIM services, including Enhanced Care Management (ECM), Community Supports (CS), Community Health Worker (CHW), Behavioral Health, and other care coordination services.
Our contracted health plans and service areas continue to grow. Availability varies by county and by the specific services covered under each health plan.
If you're unsure whether your health plan is partnered with Atlas Health Group, our team can verify your eligibility and coverage.
For eligible Medi-Cal members, there is typically no cost for covered services provided through Atlas Health Group.
Services such as Enhanced Care Management (ECM), Community Supports (CS), and Community Health Worker (CHW) services are covered benefits for eligible members enrolled in participating Medi-Cal Managed Care Plans.
Your eligibility and available benefits are determined by your health plan.
If you change your Medi-Cal Managed Care Plan, your eligibility for Atlas Health Group services may change depending on whether your new health plan contracts with us.
Our team will:
• Review your new coverage
• Verify your eligibility
• Determine whether your services can continue
• Help coordinate a smooth transition if changes are necessary
• Work with your new health plan whenever possible to minimize interruptions in care
Our priority is ensuring continuity of care throughout any coverage changes.
In many cases, yes. Atlas Health Group coordinates care with your existing Primary Care Provider (PCP) and specialists whenever possible.
If your physician participates in your health plan's provider network, we will work collaboratively with them to coordinate your care.
If you need assistance selecting or changing a Primary Care Provider, our care team can help you identify an in-network provider that best meets your needs.
That's okay. If you're unsure which Medi-Cal Managed Care Plan you're enrolled in, our team can often help identify your coverage and verify your eligibility.
When you contact us, we may ask for basic information such as:
• Your full name
• Date of birth
• Medi-Cal identification number (if available)
• Contact information
Once verified, we'll explain the services available through your health plan and guide you through the next steps.
In many cases, yes. Certain CalAIM services require eligibility verification and authorization by your Medi-Cal Managed Care Plan.
Atlas Health Group works directly with your health plan to:
• Verify eligibility
• Submit required documentation
• Coordinate service authorizations
• Ensure services align with your individual care needs
Our team manages much of this process on your behalf to make enrollment as simple and efficient as possible.
If you don't qualify for a specific CalAIM service, we'll still do our best to connect you with other healthcare providers, community organizations, or local resources that may be able to assist you.
Depending on your situation, we may provide referrals to:
• Community-Based Organizations (CBOs)
• Behavioral health providers
• Housing resources
• Food assistance programs
• Transportation services
• Local county programs
• Other healthcare and social service agencies
Our goal is to help every individual find the support they need, even if they are not eligible for services through Atlas Health Group.
Verifying your eligibility is simple. You can contact Atlas Health Group directly by phone or through our website. One of our enrollment specialists will:
1. Review your Medi-Cal coverage.
2. Verify your Managed Care Plan.
3. Determine your eligibility for available services.
4. Answer any questions you have.
5. Guide you through the enrollment process if you qualify.
The eligibility review is free, confidential, and comes with no obligation to enroll. Our team is here to help you understand your options and access the care and support that's right for you.
Referrals
Anyone who believes an individual may benefit from our services can submit a referral.
We accept referrals from:
• Primary Care Providers (PCPs)
• Specialists
• Hospitals and Health Systems
• Emergency Departments
• Urgent Care Centers
• Skilled Nursing Facilities (SNFs)
• Behavioral Health Providers
• Community-Based Organizations (CBOs)
• Federally Qualified Health Centers (FQHCs)
• Health Plans and Managed Care Plans (MCPs)
• Social Workers and Case Managers
• Home Health Agencies
• Caregivers and Family Members
• Self-referrals from members
Our goal is to make the referral process simple, timely, and accessible.
Submitting a referral is easy. You can refer an individual by:
• Completing our secure online referral form
• Calling our referral team directly
• Contacting us through our website
• Sending a referral through an approved health plan or provider portal (where applicable)
Once we receive the referral, our team will review the information, verify eligibility, and begin the outreach process.
To help us process a referral as quickly as possible, we recommend providing:
• Member's full name
• Date of birth
• Phone number
• Home or mailing address
• Medi-Cal or health plan information (if available)
• Primary Care Provider (if known)
• Reason for the referral
• Current medical, behavioral, or social concerns
• Referring organization and contact information
If some information is unavailable, you can still submit the referral. Our team will work to gather any additional details needed.
Yes. If you believe you could benefit from our services, you are welcome to contact Atlas Health Group directly.
Our enrollment specialists will:
• Review your eligibility
• Verify your health plan
• Explain available services
• Answer your questions
• Guide you through the enrollment process
Self-referrals are always welcome.
Yes. Family members, caregivers, legal guardians, or authorized representatives may refer someone who could benefit from our services.
Depending on the individual's situation and applicable privacy laws, we may need the member's consent before discussing personal health information or initiating services. Our team will guide you through any required authorization during the enrollment process.
Absolutely. We work closely with physicians, hospitals, specialists, behavioral health providers, discharge planners, social workers, and care coordinators to support patients with complex healthcare needs.
Provider referrals help ensure patients receive timely care coordination and access to appropriate community resources following diagnosis, hospitalization, or other healthcare events.
Yes. Atlas Health Group partners with Community-Based Organizations throughout California to connect eligible individuals with healthcare and supportive services.
We regularly receive referrals from organizations such as:
• Homeless service providers
• Food assistance programs
• Domestic violence organizations
• Faith-based organizations
• Senior service agencies
• Veteran organizations
• Recovery programs
• Housing providers
• Community resource centers
We value these partnerships and work collaboratively to improve health outcomes for the communities we serve.
Our team begins reviewing referrals as soon as they are received. Response times may vary depending on eligibility verification, health plan requirements, and the urgency of the member's needs. Whenever possible, we make timely outreach to engage referred individuals and begin the enrollment process.
For urgent care needs, we encourage referring providers to notify our team so we can prioritize appropriate follow-up.
After receiving a referral, our team follows a structured enrollment process:
1. Review the referral information.
2. Verify the member's eligibility and health plan coverage.
3. Contact the member or authorized representative.
4. Complete an intake and needs assessment.
5. Determine eligibility for available services.
6. Develop a personalized care plan.
7. Connect the member with the appropriate care team and services.
Throughout the process, we work closely with the referring provider or organization, when appropriate and authorized, to ensure continuity of care.
Yes, when permitted by privacy regulations and with the appropriate authorizations. For healthcare providers, health plans, and authorized referral partners, Atlas Health Group may provide updates regarding:
• Referral receipt and acknowledgment
• Eligibility determination
• Enrollment status
• Successful member engagement
• Care coordination milestones
• Additional information needed to complete the referral
Our goal is to maintain clear communication while protecting every member's privacy in accordance with HIPAA and other applicable laws.
No. Submitting a referral to Atlas Health Group is free. There is no cost for providers, community organizations, family members, caregivers, or individuals to refer someone for consideration.
If the individual is eligible for covered services through their Medi-Cal Managed Care Plan, those services are generally provided at no cost to the member.
Atlas Health Group specializes in helping individuals with complex medical, behavioral, and social needs navigate the healthcare system and access the resources they need to thrive.
By referring a member to our team, you're connecting them with experienced professionals who can:
• Coordinate care across multiple providers
• Address barriers such as housing, food, and transportation
• Improve access to primary and specialty care
• Support behavioral health needs
• Reduce avoidable emergency room visits and hospitalizations
• Connect members with valuable community resources
• Improve overall health, independence, and quality of life
Our mission is to provide compassionate, whole-person care that empowers every member to achieve better health outcomes and long-term stability.
For Healthcare Providers
Atlas Health Group serves as an extension of your care team by providing comprehensive, community-based care coordination for Medi-Cal members with complex medical, behavioral, and social needs.
Our interdisciplinary approach helps providers improve patient outcomes by addressing barriers that often fall outside the traditional clinical setting, including housing instability, food insecurity, transportation challenges, behavioral health needs, and care navigation.
We work collaboratively with providers to improve continuity of care, reduce avoidable hospital utilization, and support long-term patient engagement.
Atlas Health Group offers a comprehensive suite of CalAIM and community-based services, including:
• Enhanced Care Management (ECM)
• Community Supports (CS)
• Community Health Worker (CHW) Services
• Behavioral Health Care Coordination
• Care Coordination
• Health Education
• Resource Navigation
• Social Determinants of Health (SDOH) Support
Services are tailored to each member's individual needs and eligibility through their Medi-Cal Managed Care Plan.
Patients who may benefit from our services include those who:
• Have multiple chronic medical conditions
• Frequently visit emergency departments
• Experience repeated hospitalizations
• Have serious mental illness or substance use disorders
• Experience homelessness or housing instability
• Have transportation or food insecurity challenges
• Require coordination across multiple providers
• Have difficulty navigating the healthcare system
• Need assistance following treatment plans
• Are transitioning from hospitals or skilled nursing facilities
• Are justice-involved or recently released from incarceration
• Have significant social determinants of health affecting their care
If you're unsure whether a patient qualifies, our team is happy to review eligibility.
Providers can submit referrals through several convenient methods:
• Our secure online referral form
• Direct phone referral
• Approved health plan referral portals
• Secure electronic communication (where available)
• Coordinated referrals through participating Managed Care Plans
Our referral specialists are available to assist with the process and answer any questions.
Once a referral is received, Atlas Health Group will:
1. Review the referral information.
2. Verify eligibility with the member's Managed Care Plan.
3. Contact the member to begin outreach.
4. Complete an assessment and intake.
5. Develop an individualized care plan.
6. Assign the appropriate care team.
7. Begin ongoing care coordination and supportive services.
Our objective is to engage members promptly and begin addressing their healthcare and social needs as quickly as possible.
Yes. When permitted under HIPAA and other applicable privacy regulations, Atlas Health Group maintains communication with referring providers regarding important care coordination activities.
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