Mental health & recovery support
Tired of managing mental health and everything else alone?
If you are living with a serious mental health condition or substance use, and you have Medi-Cal, Atlas may be able to help. One care manager helps hold the whole picture together — treatment, medical care, medications, benefits, and the everyday things that make recovery harder.
Are you eligible?
You may qualify if…
- You are an adult with Medi-Cal through a managed care plan — or you think you might qualify for Medi-Cal.
- You live with a serious mental health condition and/or a substance use disorder.
- Coordinating your care has been hard — for example moving between treatment programs, hospitals, crisis services, county behavioral health, and your regular doctor.
- You want help organizing care and everyday needs, not another program telling you what to do.
- Help is voluntary and free to you. You choose what to work on and can stop at any time.
How Atlas can help
Treatment, health care, and daily life — coordinated together
One plan, your priorities
A Lead Care Manager builds a practical plan with you around mental health, substance use, physical health, safety, and personal goals.
Behavioral health coordination
Referrals, appointments, and follow-up with county Specialty Mental Health, Drug Medi-Cal and DMC-ODS providers, outpatient treatment, and recovery services.
Physical health, too
Connections to primary care, specialty care, dental care, and preventive services so physical health does not get left out.
Medication coordination
Help with pharmacy needs and medication questions across providers, so the people prescribing know what the others prescribed.
Crisis & transition support
After an ER visit, hospital stay, crisis contact, or residential program, we help organize follow-up so the next step is already set.
Housing & stability
Requests for authorized housing-related supports and connections to community programs that make staying in care possible.
Benefits & income
Help navigating benefits, income supports, and employment resources you may be eligible for.
Peer & recovery resources
Connections to peer support, recovery communities, and culturally responsive organizations when you want them.
How it works
How it works
- 1
Start the conversation
Reach out yourself, or a provider, treatment program, hospital, or health plan can refer you. Nothing is decided on the first call.
- 2
Meet your care manager
One person gets to know your history once — treatment, medications, providers, and what you actually want to change.
- 3
Get the systems talking
We coordinate across behavioral health, medical care, pharmacy, and community programs so you are not the messenger between them.
- 4
Keep support through the ups and downs
Care coordination continues through transitions, setbacks, and progress for as long as you are eligible and want it.
Atlas coordinates care; clinical treatment decisions remain with your licensed providers. Eligibility, authorization, and provider assignment are determined by your Medi-Cal managed care plan.
What to expect
What coordinated support feels like
- Telling your story once instead of at every new door.
- Appointments across treatment and medical care that do not conflict.
- Someone checking in and following up when your needs change.
- Practical help with housing, food, benefits, and rides.
One call, one person
You do not have to coordinate every system alone.
For providers, partners & anyone who wants the details
Detailed Eligibility & Program Information
Program overview
California’s Adults with Serious Mental Health and/or Substance Use Disorder Needs Population of Focus provides Enhanced Care Management to eligible Medi-Cal managed care members age 21 and older whose needs cross behavioral health, medical, and social-service systems. Eligibility is based on access criteria for county Specialty Mental Health Services or Drug Medi-Cal services, at least one complex social factor affecting health, and at least one qualifying risk or recent service-use condition. Atlas provides whole-person care management and works with the member’s health plan, county behavioral health system, medical providers, hospitals, pharmacies, treatment providers, and community organizations to coordinate care. Enhanced Care Management complements behavioral health and substance use disorder treatment; it does not replace those services.
Formal eligibility criteria
- Age 21 or older and enrolled in a Medi-Cal Managed Care Plan.
- Meets the eligibility criteria to participate in or obtain Specialty Mental Health Services through a county Mental Health Plan, or substance use disorder services through Drug Medi-Cal Organized Delivery System or Drug Medi-Cal.
- Has at least one complex social factor influencing health, such as lack of access to food or stable housing, difficulty working or participating in the community, a high adverse-childhood-experiences screening result, former foster youth status, or recent law-enforcement contact related to mental health or substance use symptoms.
- Also meets at least one qualifying risk or utilization condition: high risk for institutionalization, overdose, or suicide; relies on crisis services, emergency departments, urgent care, or inpatient stays as the primary source of care; or had two or more emergency department visits or two or more hospitalizations related to serious mental health or substance use needs within the past 12 months.
- Enhanced Care Management is voluntary. Members and families may self-refer, while final eligibility, authorization, enrollment, and provider assignment are determined through the applicable Medi-Cal managed care plan using DHCS criteria.
Whole-person assessment and personalized care plan
A Lead Care Manager works with the member to understand mental health, substance use, physical health, medications, safety, housing, food, transportation, income, relationships, and recovery priorities, then develops a person-centered care plan with practical goals.
Behavioral health and substance use care coordination
We help coordinate referrals, appointments, information sharing, and follow-up across county Specialty Mental Health Services, Drug Medi-Cal, DMC-ODS, outpatient treatment, recovery services, crisis providers, and other authorized behavioral health programs.
Physical health, pharmacy, and preventive care connections
Atlas helps connect behavioral health care with primary care, specialty care, dental services, pharmacy needs, medication reconciliation, preventive services, and management of physical health conditions that may otherwise be separated from the member’s behavioral health care.
Crisis, hospital, and treatment transitions
When a member moves between an emergency department, hospital, crisis setting, residential program, outpatient treatment, or the community, the care team can help organize discharge information, medications, follow-up appointments, and communication among involved providers.
Benefits and community resource navigation
We help members request and navigate available resources for housing, food, transportation, income, employment, peer support, recovery, and other social needs. Community Supports and other programs have separate eligibility, authorization, and availability requirements.
Eligibility, authorization, provider assignment, and service availability are determined through the applicable Medi-Cal managed care plan. Behavioral health treatment, crisis services, Community Supports, and other programs have separate eligibility and authorization requirements and depend on local availability and member choice.
For referral partners
Refer an adult who needs whole-person coordination
- County behavioral health
- Treatment & recovery programs
- Hospitals & crisis services
- Primary care practices
- Community organizations
- Medi-Cal health plans
Partners can also reach the Atlas team directly to discuss workflows, referral coordination, and data sharing agreements. Partner information
Other populations of focus
Coming Home After Incarceration
Recently released or preparing for release? We can help coordinate healthcare, medications, benefits, transportation, and other support as you transition home.
Pregnancy & Postpartum Support
Pregnant or recently had a baby? We can help coordinate your healthcare and connect you with additional support during pregnancy and after delivery.
Experiencing Homelessness or Unstable Housing
If you're without stable housing or worried about where to stay, we can help coordinate your care and connect you with available housing and community resources.
Frequent ER Visits or Hospital Stays
If you've been to the ER or hospital several times, we can help coordinate follow-up care, medications, appointments, and other support to help you stay well at home.