Overview of CalAIM’s Enhanced Care Management & Community Supports
In California, Medicaid is called Medi-Cal. CalAIM (California Advancing and Innovating Medi-Cal) is a 5 year statewide Medi-Cal initiative that integrates medical care and social services. Approved via a Section 1115 Medicaid Demonstration Waiver (eff. 12/29/21 – 12/31/26), its aim is to transform and strengthen Medi-Cal by offering equitable, coordinated, and person-centered care via managed care.
Medi-Cal managed care recipients receive their Medi-Cal benefits via Medi-Cal Managed Care Health Plans (MCPs), also known as managed care organizations (MCOs). MCPs have their own network of care providers and persons receive services via these providers. Approximately 88% of Medi-Cal recipients are on managed care. In fact, enrollment in a MCP is mandatory for many groups of Medi-Cal beneficiaries, including those in nursing home facilities.
Enhanced Care Management (ECM) and Community Supports (CS) are two CalAIM managed care benefits. These benefits replaced two Medi-Cal Programs: Health Homes Program (HHP) and Whole Person Care (WPC) Pilot. To be clear, persons who do not receive their Medi-Cal benefits via managed care are not eligible for CalAIM, and therefore, are not eligible to receive ECM nor CS.
Enhanced Care Management
Medi-Cal’s Enhanced Care Management (ECM) benefit is for the most vulnerable, high-need groups of children and adults enrolled in Medi-Cal MCPs. This includes six subgroups of California residents, but most relevant for aging seniors are two: 1) Adults (aged 21+) at Risk of Being Institutionalized (placed in a nursing home) and Eligible for Long-Term Care Services and Supports 2) Adults (aged 21+) who are Nursing Home Residents and Wish to Transition Back Into the Community. Other subgroups include Individuals and Families Experiencing Homelessness, Individuals Transitioning from Incarceration, and Adults with Serious Mental Illness.
ECM offers a person-centered approach to care coordination, allowing Medi-Cal recipients to participate in their own care planning. An “Enhanced Care Manager” or “Lead Care Manager” coordinates all of one’s care needs and services. This includes physical health, oral health, behavioral health, social needs, and long-term services and supports. Assistance may be provided in finding physicians, scheduling medical appointments, managing medications, and locating and applying for needed community-based services and supports.
Persons can receive ECM while residing in a variety of settings. This includes one’s home, the home of a loved one, an Adult Residential Facility (ARF), and a Residential Care Facility for the Elderly (RCFE). ARFs and RCFEs can be thought of as assisted living facilities or adult foster care homes. Persons can also reside in nursing homes, given they would like to move back into the community.
While Medi-Cal program participants have a choice of Medi-Cal Managed Care Plan, all MCPs are required to offer Enhanced Care Management. This benefit is an entitlement and is available to all persons who meet the eligibility criteria.
Community Supports
As part of ECM, Enhanced Care Managers can assist eligible persons in receiving Community Supports (CS), also called In Lieu-of-Services (ILOS). There are 14 potential CS available through Medi-Cal MCPs, and not all are relevant to Individuals at Risk of Being Institutionalized and Eligible for Long-Term Care Services and Supports nor Nursing Home Residents who Wish to Transition Back Into the Community. Unlike Enhanced Care Management, a Managed Care Plan is not required to offer Community Supports. However, it is anticipated that most MCPs will offer all Community Supports by 2027.
Community Supports that may be available and relevant to the subgroups we are discussing are Home and Community Based Services (HCBS) that are intended to promote independent living and are provided in place of more costly alternatives, such as nursing home care. Examples include Home Modifications for safety and accessibility, Respite Care, Personal Care Assistance and Homemaker Services, Assisted Living Facility Transitions, and Community or Home Transition Services.
Assisted Living Facility Transitions, previously called Nursing Home Transition and Diversion to Assisted Living, is a much needed support, as it opens the door for seniors to more easily access assisted living. This Community Support allows Managed Care Health Plans to partner with Assisted Living Providers to provide Medi-Cal funded assisted living services in assisted living facilities (i.e., Adult Residential Facilities and Residential Care Facilities for the Elderly). This allows an option for assisted living outside of Medi-Cal’s Assisted Living Waiver (ALW), which has a significant waitlist. Unlike the ALW, which has a cap on the number of program participants and geographic restrictions, there is no participant cap and no geographic restrictions for Assisted Living Facility Transitions. Since MCPs do not have to offer this Community Support, it may not be available through all MCPs. Note: Medi-Cal will never cover the cost of room and board in assisted living. For Assisted Living Facility Transitions, the amount one pays for room and board varies based on the Managed Care Plan. For the ALW, the state sets a room and board rate. Learn more.
Benefits of Medi-Cal’s Enhanced Care Management & Community Supports
Enhanced Care Management benefits may include the following:
– Comprehensive Assessment and Care Management Plan
– Comprehensive Transitional Plan – support while one is moving out of a nursing home and into the community
– Coordination / Referral to Community and Social Support Services
– Enhanced Coordination of Care – organizing and implementing services that are required for care plan implementation
– Health Promotion
– Member and Family Supports
– Outreach and Engagement – determining and accepting referrals for Medi-Cal beneficiaries who are eligible for ECM and assigning ECM Providers to reach out
Community Supports may include the following:
– Community Transition Services / Nursing Facility Transition to a Private Home – transitional coordination services and funding for security deposits / utility set-up fees and appliances related to heath (i.e., hospital beds, air conditioners, heaters)
– Home Modifications – also called Environmental Accessibility Adaptations – for safety and accessibility (i.e., wheelchair ramps, grab bars, stair lifts)
– Assisted Living Facility Transitions – time-limited transition services & expenses, such as help in securing an assisted living facility, coordinating the move, and covering moving expenses. Ongoing assisted living services, such as assistance with daily living activities, medication management, and access to 24-hour staff, is also provided.
– Personal Care / Homemaker Services – assistance with bathing, dressing, toileting, preparing meals, grocery shopping, cleaning, and laundry
– Respite Services – to give primary caregivers a break from caregiving duties
– Medically Tailored Meals / Medically Supportive Food – for persons with a nutrition-sensitive health condition (i.e., cancer, high cholesterol, hypertension, liver disease, heart disease)
Eligibility Requirements for Medi-Cal’s ECM & CS
Enhanced Care Management and Community Supports are for California residents who are eligible for Medi-Cal, enrolled in a Medi-Cal Managed Care Health Plan, and are in a high-risk group. Our focus is 1) Adults (aged 21+) at Risk of Institutionalization and Eligible for Long-Term Care Services and Supports and 2) Adults (aged 21+) who are Nursing Home Residents and Wish to Transition Back Into the Community. Persons enrolled in a Medi-Cal HCBS Medicaid Waiver (i.e. Assisted Living Waiver, Multipurpose Senior Services Program) are not eligible for ECM.
General eligibility for Medi-Cal (and ECM) for seniors and persons with disabilities follow. For Community Supports, there are additional benefit-specific requirements. For instance, for nursing home transition to one’s home or assisted living, one must reside in a nursing home for 60+ days. Note: One does not necessarily have to be eligible for Enhanced Case Management to receive Community Supports and vice versa.
Financial Criteria: Income, Assets & Home Ownership
Income
The Medi-Cal applicant income limit is equivalent to 138% of the Federal Poverty Level (FPL). While this figure increases annually in January, the Medi-Cal income limits increase in April. Effective 4/1/25 – 3/31/26, a single applicant can have a monthly income up to $1,801. When both spouses are applicants, the income limit is $2,433 / month. When only one spouse is an applicant, the income limit varies based on the Medicaid program for which one is applying.
For Regular Medi-Cal, there is a combined income limit for the applicant spouse and non-applicant spouse of $2,401 / month. For Nursing Home Medi-Cal or Home and Community Based Services via a Medicaid Waiver, the income of the non-applicant spouse is not counted towards the income eligibility of their spouse. Only the applicant spouse’s income is considered, which is limited to $1,801 / month. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance. In 2025, the maximum amount that can be transferred is $3,948 / month and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than this amount are not entitled to a Spousal Income Allowance. While persons receiving HCBS Waiver services are not eligible for ECM, they may be eligible for this managed care benefit if on a waiver waiting list.
Assets
The asset limit for Medi-Cal was eliminated on 1/1/24. California, however, intends to reinstate their asset limit no sooner than Jan. 1, 2026. When this happens, the asset limit will be $130,000 for an individual and $195,000 for a couple.
California has a Look-Back Period, during which Medi-Cal scrutinizes one’s past asset transfers. While it is not applicable for persons who live at home or in the community and applying for Medi-Cal, it may be applicable for persons applying for Medi-Cal nursing home care. With the elimination of the asset limit, only assets transferred prior to 1/1/24 are still being scrutinized. Furthermore, the 30-month Look-Back Period is being phased out month-by-month and will be completely eliminated by July of 2026. Note: With the reimplementation of the asset limit, it is expected that Medi-Cal will reinstate their Look-Back Period. This page will be updated as more information becomes available.
While all assets are currently disregarded when determining Medi-Cal eligibility, one’s assets are not necessarily safe from the Medicaid Estate Recovery Program (MERP). Following the death of a long-term care Medicaid beneficiary, the state attempts reimbursement of long-term care costs for which it paid for that individual via their remaining estate. This may include one’s home. With the utilization of proper planning strategies, one can protect their home and other assets from being used as reimbursement and instead go to loved ones as inheritance. Contact an Experienced Medi-Cal Planner for assistance.
Medical Criteria: Functional Need
To access ECM or CS, an aging senior generally must be at risk of institutionalization (nursing home care) or require a Nursing Facility Level of Care (NFLOC). One area of consideration is one’s need for assistance with Activities of Daily Living (ADLs). ADLs include bathing, dressing, mobility, toiletry, and eating. Relevant to persons with Alzheimer’s disease or a related dementia, cognitive deficits, such as memory, decision making, and judgment, may also be considered. A diagnosis of dementia in and of itself does not mean one will meet the functional need. Learn more about long-term care Medicaid in California.
Qualifying When Over the Income Limit
Having income over Medi-Cal’s limit does not necessarily mean an applicant cannot still qualify for Medi-Cal Managed Care, the Enhanced Care Management benefit, and / or Community Supports. However, applicants who are over Medi-Cal’s income limit have a shared monthly cost (SMC), and the only Medi-Cal recipients who can enroll in managed care (and access these benefits) with a SMC are Medi-Cal nursing home residents. A SMC can be thought of as a deductible and is the amount that one must spend on care services / medical expenses each month in order to qualify for Medi-Cal. Often referred to as the Medically Needy Pathway to eligibility, Medi-Cal recipients who live at home or in the community cannot access managed care (and hence, ECM and CS) with a SMC. In this case, one must eliminate their SMC in order to access Medi-Cal managed care. An Experienced Medi-Cal Planner can assist one in doing so. Find a Certified Medi-Cal Planner.
How to Apply for Medi-Cal’s Enhanced Care Management & Community Supports
Before You Apply
Prior to submitting an application for Medi-Cal managed care, through which Enhanced Care Management and / or Community Supports is provided, applicants need to ensure they meet the eligibility criteria. Applying when over the income limit may be cause for denial of benefits. The American Council on Aging offers a Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria.
As part of the application process, applicants need to gather documentation for submission. Examples include proof of income and copies of Social Security and Medicare cards. A common reason applications are held up is required documentation is missing or not submitted in a timely manner.
Application Process
To receive Enhanced Care Management and / or Community Supports, one must be eligible for Medi-Cal and enrolled in a Managed Care Plan. Persons can apply for Medi-Cal online at Covered California, fill out and submit an Application for Health Insurance, or apply in person at one’s County Social Services Office. Persons who require assistance with completing the application can call Covered California’s Customer Service Center at 1-800-300-1506. The majority of Medi-Cal beneficiaries are required to enroll in a Medi-Cal Managed Care Plan once determined eligible for Medi-Cal.
Medi-Cal beneficiaries enrolled in a Medi-Cal Managed Care Plan can request Enhanced Care Management and / or Community Supports by contacting their MCP to make a “referral”. The Medi-Cal recipient can do this on their own or someone else can do this on their behalf.
Learn more about Enhanced Care Management & Community Supports.
Medi-Cal is administered by the California Department of Health Care Services (DHCS). The Enhanced Care Management benefit and Community Supports Services are provided by Medi-Cal Managed Care Health Plans.
Approval Process & Timing
The Medi-Cal application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, it sometimes takes even longer for eligibility to be determined.