CalAIM and Institutional Long-Term Care: Lessons for Medi-Cal Managed Care

CalAIM (California Advancing and Innovating Medi-Cal) is a comprehensive, multiyear effort led by the California Department of Health Care Services that seeks to implement broad delivery system, program, and payment reform across California’s Medi-Cal program.

Like many states, California uses managed care delivery systems to administer Medi-Cal. Currently, more than 8 in 10 Medi-Cal enrollees are in Medi-Cal managed care plans (MCPs), a number that will increase as CalAIM further expands mandatory managed care enrollment. One CalAIM reform initiative, the “institutional long-term care carve-in,” will require that care in nursing homes and other institutional settings be provided as a benefit through Medi-Cal MCPs statewide as of January 1, 2023.

This report describes the challenges, opportunities, and lessons learned from select California counties and other states where institutional long-term care has already been administered by MCPs. It focuses on the experiences of seniors and adults with disabilities, including those with Medi-Cal only and those with both Medi-Cal and Medicare (dually eligible enrollees), and describes opportunities to design a system that achieves the following:

• Improves access to appropriate institutional care for those who need it
• Promotes care in home and community-based settings and diverts care away from institutions when possible and desired by the person receiving care
• Promotes higher quality of care in institutional settings
• Addresses equity in California’s long-term care services

This report is intended to inform state officials, MCP leaders, institutional long-term care providers, community providers serving those with long-term care needs, and advocates, who will all play unique roles as this policy moves forward.