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California Advancing and Innovating Medi-Cal (CalAIM)

CalAIM: Improving Health Outcomes

CalAIM is an ambitious and innovative program designed to address the complex physical, behavioral and social needs of Medi-Cal’s most vulnerable members.

The program envisions enhanced coordination, integration and information exchange among Managed Care Plans (MCPs), physical, behavioral, community-based & social service providers, and county agencies, to support new benefits and services.

Primary Goals
  • Identify and manage member risks and needs, through whole person care approaches and analyzing social determinants of health
  • Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility
  • Improve quality outcomes, reduce health disparities and drive delivery system transformation and innovation, through value-based initiatives, modernization of systems and payment reform
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50+

Healthcare
Consultants

10+

Years Supporting
Medi-Cal Plans

20+

Medicaid Managed
Care Assessments

10+

Medi-Cal
Plans Supported

Components of CalAIM

In Lieu-03

In Lieu of Services

Enhanced Care Management-03

Enhanced Care Management

Partnering with Counties-03

Partnering with Counties and Other Providers

Statewide MLTSS-03

Statewide MLTSS, Long-term Care & Shift to DSNPS

NCQA-03

NCQA Accreditation

Behavioral-05

Behavioral Health

PH-03

Population Health Management

Major Organ-03

Major Organ Transplant

Shared Risk,-03

Shared Risk, Shared Savings & Incentive Payments

CalAIM Service Offerings

CalAIM Readiness Assessment
  • Comprehensive assessment with gap analysis for all CalAIM components, including identification of providers/services and ensuring network adequacy for ECM and ILOS
  • Recommendations across plan departments including provider services, Health Homes Program, health services/medical management
Technology Assessment & Roadmap
  • Analysis for plans and/or providers/contractors
  • EHR, ED information exchange, clinical data repositories, registries, decision support and case management related to CalAIM requirements
Provider Determination & Engagement
  • Identification of providers/contractors and ensuring network adequacy for ECM and ILOS
  • Negotiation and contracting with providers/contractors
  • Provider/contractor education/training
  • Provider/contractor communication/materials
CalAIM Administration & Compliance
  • Facilitating lead creation and submission of ECM/ILOS MOC plan
  • Operational and outcomes reporting
  • Transition/development of processes from HHP/WPC to ECM & ILOS
  • Audit readiness and provider/contractor readiness assessment
DSNP Planning & Implementation
  • Readiness assessment for move from CalMediConnect to DSNP or standing up a new DNSP
  • Program/project management for filing DSNP applications
  • Operationalizing DSNP programs
CalAIM Processes
  • Data sharing processes and standards
  • Claims/invoice payment process
  • Appeals and grievances processes
  • Assigning members to programs
  • Provider communication
  • Identifying members for services
  • Referral management – policies, processes
Population Health
  • Population health strategy
  • Creating wellness, prevention, case management and care transitions programs
  • Risk stratification and predictive analytics
  • NCQA accreditation assessment, gap analysis and action plan
  • Care management training for plan staff or providers/contractors
Day to Day Operational Support
  • Supporting plan staff as they focus on CalAIM initiatives
  • Interim departmental leadership, mid-level management, program/project management, analyst
  • Departments to support could include provider services, PMO, health services/medical management

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