Transformational Medi-Cal CalAIM reforms have yet to reach children and youth

By Health Team and Child Welfare Team

November 03, 2023

Top image via iStock from bluecinema

In 2022, following countless hours of planning and consultation, the Newsom Administration launched a signature multi-year health care initiative California Advancing and Innovating Medi-Cal (CalAIM) which promises to transform Medi-Cal for its members by improving Medi-Cal benefits and equitable patient outcomes, particularly for kids. But, almost two years into CalAIM’s commencement, many promises have yet to be fully realized for the 5.7 million children in California who rely on Medi-Cal for their health care.

Although children make up 30% of all Medi-Cal enrollees, and have a history of being poorly served, they are overwhelmingly not yet benefiting from new CalAIM reforms. For example, new CalAIM benefits that are intended to provide better coordinated care and address  health needs along with their social needs for Medi-Cal members have only marginally reached children and youth. The table below highlights several examples of important CalAIM reforms that could benefit kids, if the policies were fully implemented. These are important reforms that will allow youth to more seamlessly access behavioral health and other services, like getting rid of asthma triggers in a child’s home, or helping a family find stable housing.

In order to realize CalAIM’s goals for children and youth populations, the State must re-commit to specifically building the infrastructure and workforce needed to serve children and youth populations, while also holding managed care plans accountable for improving access and quality of care for children and families. The State must make sure that it is collecting the right data to monitor outcomes for children and that it is prepared to adjust policies or resources accordingly if CalAIM reforms fall short for children and youth. 

For the millions of children who rely on Medi-Cal for their health care, it is crucial that the State prioritizes children and youth with the attention and resources needed to realize the vision of CalAIM to transform the care families receive through Medi-Cal and improve children’s health and well-being.

Topic  CalAIM Policy Description  Update 

No Wrong Door to Mental Health Services 


Go-Live Date: July 1, 2022 

CalAIM created a “No Wrong Door” approach to expand the definition of “behavioral health need’ by eliminating the requirement for a mental health diagnosis to access care, which should make it easier for children and youth to access mental health services.  The State has yet to analyze whether this policy has resulted in a change in how children and youth are experiencing the system or accessing services. Behavioral health system workforce, payment, and programmatic challenges have already been reported in terms of the CalAIM implementation experience.  

Enhanced Care Management (ECM) Services for Individuals with High Needs 


Go-Live Date: January 1, 2022 

CalAIM established Enhanced Care Management (ECM) as a new benefit to address clinical and non-clinical needs of the highest-need Medi-Cal members through intensive coordination of health and health-related social services. Under ECM, members will have a single Lead Care Manager who will coordinate care and services among the physical, behavioral, dental, developmental, and social services delivery systems, making it easier for them to get the right care at the right time. Read more about ECM for children and youth in Kids in Medi-Cal To Get New Care Coordination Help. 

In 2022, there were over 109,000 Medi-Cal members statewide who received ECM services, but only 3% were children. ECM was expanded to more children and youth on July 1, 2023 (e.g., children with CCS, in foster care, or with behavioral health needs), but the roll out has been slow. Further, the State has acknowledged that a high number of providers, managed care plan staff, and Medi-Cal members are unaware of new benefits like ECM. Read more about the ECM rollout for children and youth in For Children with Long-Term Health Conditions, This Program Could Be a Lifeline. Will It Deliver? 


Community Supports, such as Asthma Remediation 


Go-Live Date: January 1, 2022 

CalAIM encourages Managed Care Plans to offer one or more 14 pre-approved services, known as Community Supports, that provide better care in keeping people safe and healthy. Community Supports are cost effective alternatives to traditional medical services or settings, like an emergency room. Children and youth are most likely to benefit from Community Supports like: Housing Navigation Services, Housing Deposits, Respite Services, and Asthma Remediation. The Asthma Remediation Community Supports, which provide physical modifications to a child’s home to avoid acute asthma episodes due to environmental triggers like mold has the potential to reduce environmental health disparities in asthma, which is an extremely common childhood chronic disease but is by far deadliest for Black children and youth.    Though children and youth make up over one-third (35%) of all Medi-Cal managed care enrollment, only 2% of members (728 children)  received any of the 14 Community Supports benefits during 2022. The Asthma Remediation benefit appears to be especially underutilized, meaning that thousands of children are missing out on the modifications like filtered vacuums, dehumidifiers, air filters, and ventilation improvements, that can help ease their asthma. Starting in 2024, Asthma Remediation Community Supports will be available in about two-thirds of counties. 

Access to Dental Care 


Go-Live Date: January 1, 2022 

CalAIM seeks to improve children’s access to dental care with incentives to Medi-Cal dental providers that will increase the use of preventive oral health services and establish dental homes, and focus on diagnosing early childhood caries. These CalAIM incentives are a continuation of incentives from the Dental Transformation Initiative that ended in 2020.  


The State has not been transparent about how different racial and ethnic groups will be impacted by these incentives to better understand disparities and identify priority solutions for gaps in care. Since Medi-Cal dental services are generally provided through a fee-for-service system, it will be important for the State to also hold managed care plans responsible for their role in coordinating all care and ensuring kids are connected to a dental home. This is another example of how CalAIM reforms will require much more work across delivery systems and in partnership with local agencies and public health programs, schools, and community-based organizations.   

Referrals to Services and Supports 


Go-Live Date: January 1, 2025 

CalAIM envisions a system of “Closed Loop Referrals” that effectively connects patients with dental care, behavioral health care, ECM and Community Supports providers, Community Health Workers, nutrition supports, and other programs in the community. Managed care plans will be responsible for ensuring Closed Loop Referrals happen and for coordinating care for their members.    The State originally planned to require Closed Loop Referrals in 2024, however that requirement was pushed back to 2025 in acknowledgement that systems and networks would not be prepared in time. The extra year is a critical time for the State to work with stakeholders to develop and operationalize referral standards, data-sharing systems, guidance, and implementation resources so that referrals are family-friendly and supported. Until these referral policies are implemented and realized, children and youth may still fall through the cracks between systems and programs meant to meet their needs and improve outcomes.   

Access for Children and Youth in Foster Care 


Go-Live Date: Varies 

Due to abuse, neglect, and other traumas, children and youth in foster care often have unique and complex health needs. On top of this, they face multiple barriers to accessing quality health care due to frequent moves, changes in providers and insurance plans, and the large number of health and social service providers involved with different but overlapping responsibilities for ensuring they receive the health care that they need. Many of the CalAIM reforms propose adding new programs and professionals into this already complex network. 

Because of their significant and unique health care needs, the state has identified children and youth in foster care as a population of focus for some CalAIM initiatives. For example, in ensuring a no wrong door for mental health services, children and youth in foster care were made categorically eligible to access services due to their history of trauma. However, other CalAIM initiatives have not identified children and youth in foster care as a population of focus such  as closed loop referrals,  despite being a critical tool in overcoming health access issues that children and youth in foster care disproportionately face.  

Furthermore, many CalAIM benefits (like ECM and Community Supports) are only available for Medi-Cal members who are enrolled in a Medi-Cal managed care plan, which means that about half of children in foster care do not have access to these new CalAIM benefits. (Note: All children in foster care are eligible for Medi-Cal, but whether it is through a managed care plan depends on the county.) 

The state has not developed a comprehensive, long-term plan for how children and youth in foster care receive health care services because the CalAIM Foster Care Model of Care Workgroup had its final meeting in November 2022 without finalizing a plan. This is especially concerning because many CalAIM reforms have not been designed to actually address the unique needs of children in foster care. For CalAIM initiatives in which children and youth in foster care are a population of focus, they are often not separated out in outcomes data and monitoring to ensure they are realizing the intended impacts.  


However, some of the recommendations from the CalAIM Foster Care Model of Care Workgroup have been identified as key strategies for meeting the health care needs of children and youth in foster care, which are being incorporated into CalAIM and other related initiatives like BH-CONNECT  an effort to increase access to and improve mental health services for Medi-Cal members. This initiative includes several components specific to children and youth in foster care, including:  

  • the development of a foster care liaison role within managed care plans;  
  • providing activity stipends to children in foster care to promote well-being and counteract the harmful effects of trauma; and  
  • development of a cross-sector incentive pool to collectively reward managed care plans, county behavioral health agencies, and child welfare agencies for meeting specific measures for children in foster care.  

These strategies are still being developed and implemented.