The federal Centers for Medicare & Medicaid Services (CMS) has officially approved California’s effort to transform its version of Medicaid. The California Advancing and Innovating Medi-Cal (CalAIM) program will launch Jan. 1, 2022.
CMS approved the state’s request for a five-year extension of its Medicaid section 1115 demonstration and a five-year extension of its Medicaid managed care section 1915(b) waiver. Both were scheduled to expire on Dec. 31, 2021.
According to the State of California, the goal of CalAIM is to align all elements of Medi-Cal into a standardized, simplified, and focused system that helps enrollees live healthier lives. Its programs are designed to create an easier pathway to support care for people outside of traditional healthcare settings and help address enrollees’ health-related social needs, according to CMS. CalAIM will provide $4.3 billion in total funding for the state’s home and community-based services (HCBS) program.
“CalAIM shifts Medi-Cal to a population health approach that prioritizes prevention and addresses social drivers of health to better serve communities, many of whom historically have been under-resourced and faced structural racism in healthcare, said California Health & Human Services Agency Secretary Mark Ghaly, M.D., in a statement.
“CalAIM will advance health equity in California and strengthen the healthcare safety net,” said CMS Administrator Chiquita Brooks-LaSure, in a statement. “We appreciate the strong partnership with California to create pathways for people with Medi-Cal to more easily access equitable, comprehensive care.”
Among the key features of CalAIM are:
• Enhanced Care Management to address clinical and non-clinical needs of the highest-need Medi-Cal enrollees through intensive coordination of health and health-related services.
• Community Supports provides new statewide services covered by Medi-Cal managed care plans as medically appropriate alternatives to traditional medical services or settings, including assistance with housing supports, caregiver respite, food insecurity, and transitioning from nursing home care to the community.
• Providing Access and Transforming Health (PATH) Supports provides funding to community-based organizations, counties, and other local providers to support capacity building as they begin to implement and scale Enhanced Care Management and Community Supports, in particular increasing resources available to populations and communities that have been historically under-resourced and under-served. In addition, PATH will support justice-involved adults and youth by sustaining pre-release and post-release services.
• Delivery System Transformation and Alignment shifts California’s managed care delivery systems – Medi-Cal Managed Care, Dental Managed Care, Specialty Mental Health Services, and Drug Medi-Cal Organized Delivery System – to a single coordinating authority to simplify and align the programs, enhance oversight, and standardize benefits and enrollment into Medi-Cal.
• Substance Use Disorder Services and Initiatives advances treatment for individuals with substance use disorder, including evidence-based contingency management to reduce the use of stimulants, peer support specialists to promote recovery and prevent relapse, and short-term residential treatment when necessary to advance treatment for enrollees. California’s approval of the state’s contingency management pilot represents the first time it has been formally approved as a benefit in the Medicaid program.
• New Dental Benefits expands dental benefits statewide, including a tool to identify risk factors of dental decay for all Medi-Cal children, and silver diamine fluoride for children and certain high-risk populations. Statewide pay-for-performance initiatives will reward dental providers for focusing on preventive services and continuity of care.
• Supporting Coordination and Integration for Dual Eligibles better coordinates coverage programs for the complex healthcare needs of individuals eligible for both Medi-Cal and Medicare (“dual eligibles”). CalAIM provides a special kind of managed care plan that coordinates all benefits in one plan for eligible enrollees, building an infrastructure to integrate managed long-term services and supports for all Medi-Cal enrollees who qualify.
• Global Payment Program renews California’s statewide pool of funding for care provided to California’s remaining uninsured populations. This includes streamlining funding sources for California’s uninsured population served by public hospitals, with a renewed focus on addressing social needs and responding to the impacts of systemic racism and inequities.
