Are you ready for CalAIM?

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What is CalAIM?

CalAIM – California Advancing and Innovation Medi-cal, is a multi-year program by the Department of Health Care Services (DHCS) designed to enhance the quality of life and health impacts on the population. CalAIM was built on the successful results from prior pilots (such as Whole Person Care Pilots (WPC), Health Homes Program (HHP) and Coordinated Care Initiative) and was created to reform Medi-Cal by implementing broad delivery system, program and payment improvements across the program. ^[1]

CalAIM has three fundamental objectives:

Using whole person care approaches to identify and manage member risk and need, as well as addressing Social Determinants of Health
Reducing complexity and increasing flexibility by shifting Medi-cal to a more stable system
Enhancing quality outcomes, reduce health disparities, and modify the delivery system by using value-based initiatives, updating systems, and payment reform

For a more detailed explanation of what CalAIM entails, see 2021 CalAIM Proposal Review and CalAIM Executive Summary and Summary of Changes.

CalAIM Changes and Updates

CalAIM’s implementation was delayed due to the COVID-19 public health emergency, but is now set for execution on January 1, 2022. So, are you ready?

CalAIM is made of a variety of components, each to be released subject to their own timeline: ^[2]

2022: New Enhanced Care Management (ECM) benefit and In Lieu of Services (ILOS)
2022: Major Organ Transplant (MOT) benefit carved into Managed Care
2022: Update medical necessity criteria for specialty mental health services (SMHS) to improve access
2023: Long Term Care (LTC) benefits carved into Managed Care
2023: Dual Special Need Program (DSNP) Aligned Managed Care enrollment in CCI Counties

2025: Aligned Managed Care enrollment in non-CCI Counties

2023: Population Health Management (PHM) strategy
2026: NCQA accreditation for Medi-Cal MCPS and subcontractors
2027: Statewide Managed Long Term Services & Supports (MLTSS)

Two foundational pillars of CalAIM are Enhanced Care Management (ECM) and In Lieu of Services (ILOS). Both of these reforms are set to be implemented at the beginning of January, 2022. ECM refers to a whole-person approach to comprehensive care management that addresses clinical and non-clinical needs. ILOS are medically appropriate and cost-effective alternatives to state plan services. ILOS are optional services to provide for Medical Managed Care Plans (MCPs) and optional for managed care members. ^[3]

A significant terminology change through revised ECM implementation is ‘Target Population’ to ‘Populations of Focus’. This term is defined in the finalized ECM Key Design Implementation Decisions, “To promote health equity, adhering to the guiding principle of using person-centered language whenever possible, “Populations of Focus” instead or “Target populations” will be used to describe the Members who are eligible to receive ECM.” ^[4]

For more information regarding ECM and ILOS requirements, implementation, and more, see Enhanced Care Management and In Lieu of Services.

Case Management and Care at ARW

At ARW, we are eager and getting ready for the implementation of CalAIM. Our Case Management (CM) showcases how Cozeva works as a trusted channel of communication between your patients, providers and care team to proactively manage your patient population. CM focuses on the social needs of a person and questions how your organization is managing the patient individually – this relies on a whole-person, comprehensive approach to care.

Cozeva Care is Care Management and CM for whole person care, this speaks on how to manage a population geographically, such as population management assessments.

¹https://www.dhcs.ca.gov/provgovpart/Pages/CalAIM.aspx

² Health Net presents CalAIM Coordinate Care Initiative (43:48) : https://www.youtube.com/watch?v=6-a6pKFHRhA

³ https://www.dhcs.ca.gov/Pages/ECMandILOS.aspx

⁴ https://www.dhcs.ca.gov/Documents/MCQMD/ECM-Key-Design-Implementation-Decisions.pdf