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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