This week, our In Focus section summarizes the revised California Advancing and Innovating Medi-Cal (CalAIM) proposal, released on February 17, 2021. Medi-Cal, the state’s Medicaid program, covers over 12 million individuals, with over 11 million in managed care. CalAIM seeks to standardize and streamline the Medi-Cal program and address health disparities and social determinants of health for high-risk, high-cost Medi-Cal members through broad-based delivery system, program, and payment reform. CalAIM was originally scheduled to begin its tiered implementation in January 2021, but due to COVID-19 has been delayed until January 2022. The revised proposal incorporates additional stakeholder input, learnings from the workgroup meetings, and ongoing policy development.
In the Fiscal 2021-22 budget, California Governor Gavin Newsom proposed to spend $1.1 billion total funds ($531.9 million General Fund) in 2021‑22, and $864 million total funds ($423 million General Fund) on an ongoing annual basis.
CalAIM Goals
CalAIM strives to achieve three primary goals, according to the state:
- Identify and manage member risk and need through whole person care approaches; address social determinants of health
- Reduce complexity and increase flexibility in Medi-Cal
- Improve quality outcomes, reduce health disparities, and drive delivery system transformation and innovation through value-based initiatives, modernization of systems, and payment reform
To accomplish this, CalAIM includes a number of key changes and overhauls to the Medi-Cal program, such as moving fee-for-service (FFS) members to Medi-Cal managed care, a statewide Managed Long Term Services and Supports (MLTSS) program, full integration of services within managed care plans, a focus on high risk populations through changes in care management, among many others.
CalAIM Key Initiatives and Implementation Date Changes
A list of some key reforms and the proposed implementation dates under the CalAIM proposal can be found below.
- Medi-Cal FFS Members Transition to Managed Care
Under the CalAIM proposal, Medi-Cal fee-for-service members in voluntary or excluded counties will be moved to Medi-Cal managed care. The only exception is members for whom managed care enrollment is not appropriate due to limited scope of benefits or limited time enrolled.
Implementation Date: January 1, 2022 for non-dual eligibles
Implementation Date: January 1, 2023 for dual eligibles
- Standardization of Medi-Cal Benefit Package Across Managed Care Plans
Implementation Date: January 1, 2023
- Regional Managed Care Capitation Rates
For targeted counties and managed care plans:
Implementation Date: January 1, 2022
Full implementation statewide:
Implementation Date: No sooner thanJanuary 1, 2024
- Statewide MLTSS, Long-term Care, and Shift to Dual Eligible Special Needs Plans
Long-term care will be carved-in.
Implementation Date: January 1, 2023.
Cal MediConnect, the state’s dual demonstration, will end and members will transition to Dual-Eligible Special Needs Plan (D-SNP) and managed care plan aligned enrollment.
Implementation Date: January 1, 2023
Medi-Cal managed care plans in non-Coordinated Care Initiative (CCI) counties will be required to operate Medicare D-SNPs.
Implementation Date: By 2025
Statewide MLTSS.
Implementation Date: By 2027
- Full Integration Plans
Med-Cal managed care plans will integrate physical health, behavioral health, and oral health under one contracted entity. Multiple Medi-Cal delivery systems (Medi-Cal managed care, county mental health plans, county Drug Medi-Cal and Drug Medi-Cal Organized Delivery System (DMC-ODS) programs) would be consolidated under one contract.
Implementation Date: No sooner than January 1, 2027
- Administrative Integration of Specialty Mental Health and SUD Treatment Services
Each county or region will implement a single integrated behavioral health plan.
Implementation Date: By 2027
- Behavioral Health
Payment reform to transition from a cost-based payment methodology to outcomes and quality-based payments.
Implementation Date: No later than July 1, 2022
Revised medical necessity criteria to more clearly delineate and standardize requirements.
Implementation Date: January 1, 2022
- Population Health Management
Medi-Cal managed care plans will need to “develop and maintain a person-centered population health strategy for addressing member health and health-related social needs based on data-driven population level assessment, and risk stratification and segmentation.” Plans will need to partner with community-based providers to address needs as well as coordinate with county behavioral health and public health departments to develop strategies.
Implementation Date: January 1, 2023
- Enhanced Care Management
A statewide enhanced care management (ECM) benefit will build on the current Health Homes Program and Whole Person Care pilots and provide a whole-person approach to care that addresses the clinical and non-clinical circumstances of high-need Medi-Cal beneficiaries. Plans will need to partner with existing Health Homes community-based care management entities (CB-CMEs) and Whole Person Care providers.
Implementation Date: January 1, 2022
Plans in counties with the pilot programs transition target populations.Implementation Date: July 1, 2022
Plans in pilot counties implement additional target populations.
Plans in non-pilot counties begin implementation of select target populations.
Implementation Date in all Counties: January 1, 2023
- In Lieu of Services (ILOS)
Plans can use a set of 14 nonmedical ILOS listed by the state as an alternative or substitute for covered Medi-Cal benefits over time. ILOS are optional for both the plan to offer and the beneficiary to accept. These services will be integrated with care management for high-risk members.
Implementation Date: January 1, 2022
- Incentive Payments
Plans will receive incentive payments to invest in the delivery system and quality performance.
Implementation Date: January 1, 2022
Seniors and persons with disabilities/long-term care blended rate.
Implementation Date: 2023