medi-cal managed care
California Advancing and Innovating Medi-Cal” (CalAIM) program was authorized in 2022 through the 1115 federal demonstration waiver. The CalAIM program is changing the structure of our Medi-Cal system by integrating services, and building more infrastructure to serve 14 million adults & youth in California. The Department of Health Care Services (DHCS) is the lead agency for CalAIM and author of the 1115 waiver renewal that establishes the authority to fund a majority of the transformation to the Medi-Cal system.
The CalAIM program is a multi-year initiative that is authorized by CMS through December 31, 2026. New benefits, services, eligibility, base rate funding, financial incentives, and population health frameworks are being introduced. Providing Access and Transforming Health (PATH) is a five-year, $1.85 billion initiative to build capacity, enabling the health system to adopt all of these Medicaid innovations. In addition to PATH, new incentive dollars were ported into the managed care system to expand behavioral health into TK-12 schools, increase the workforce with navigators, and to reach more people using community-based services.
Enhanced care management was introduced as part of CalAIM, and these defined benefits were made available to eligible residents, referred to as populations of focus. Community support services were added to address the social determinants of health and to assist with transitions of care (i.e., housing, food, skilled nursing to home). The combined effect of these services, coupled together by the formation of the Community Health Worker (CHW) role has joined organizations into the Medi-Cal managed care system for the first time. The Offices of Education, corrections and law enforcement agencies, and county health administration are a few examples. The "new Medi-Cal managed care" needs to adopt dialects such as "speaking school" as educators are linked into Medi-Cal, and the same goes for speaking with corrections, community-based organizations serving the homeless and unhoused, and other parts of the public health networks.
California's 58 counties are uniquely different, each offering a blend of infrastructure and resources. Reimbursements are shifting from cost-based to value-based fee schedules, and county leaders are defining the line between claiming Targeted Case Management (MA-TCM) as compared to the newly formed CHW roles. Navigating the state policies and applying at a local level requires an organized approach to maximize the draw-down of funds. Connecting the dots is essential to sustainability of programs for the underserved populations, and it starts with understanding one another.
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