​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​CalAIM 1115 Demonstration & 1915(b) Waiver

California received federal authority necessary to implement California Advancing and Innovating Medi-Cal (CalAIM), a framework that encompasses broad-based delivery system, program, and payment reform across the Medi-Cal program. CalAIM is an innovative and long-term commitment to transform and strengthen Medi-Cal, making the program more equitable, coordinated, and person-centered to help people maximize their health and life trajectory. CalAIM shifts Medi-Cal to a population health approach – first included in the Medi-Cal 2020 Section 1115 demonstration – to a statewide level that prioritizes prevention and addresses social drivers of health. Collectively, the CalAIM Section 1115 demonstration and CalAIM Section 1915(b) waiver, along with related contractual and Medi-Cal State Plan Amendments, will enable California to fully execute CalAIM initiatives, providing person-centered care to integrate care coordination across physical health, behavioral health, and local service providers.

Since 2018, DHCS has been working closely with stakeholders to design a transformation of key aspects of the Medi-Cal delivery system in order to accomplish three primary goals:

1. Identify and manage comprehensive needs through whole person care approaches and social drivers of health;
2. Make Medi-Cal a more consistent and seamless system for enrollees to navigate by reducing complexity and increasing flexibility; and
3. Improve quality outcomes, reduce health disparities, and transform the delivery system through value‑based initiatives, modernization, and payment reform.

In 2019 and early 2020, DHCS conducted extensive stakeholder engagement for the proposed CalAIM initiatives. CalAIM implementation was scheduled to begin in January 2021, but was delayed due to the impact of the COVID-19 public health emergency. On December 29, 2020, DHCS received approval from the Centers for Medicare & Medicaid Services (CMS) for a 12-month extension (through December 31, 2021) of the existing Medi-Cal 2020 Section 1115 demonstration. DHCS submitted two requests in June 2021 to CMS: (1) the CalAIM Section 1115 demonstration (formerly entitled Medi-Cal 2020 Section 1115 demonstration) for a five-year renewal, with amendment; and (2) the CalAIM Section 1915(b) waiver for a five-year renewal, with amendment. DHCS received approval on December 29, 2021 for both the demonstration and waiver, effective through December 31, 2026. 

Since December 2021, CMS has approved six amendments to the CalAIM Section 1115 demonstration, including 1) to permit the state to increase and eventually eliminate asset limits for certain low-income individuals whose eligibility is not determined using the modified adjusted gross income (MAGI)-based financial methods; 2) to permit the state to provide in-reach services to justice-involved populations for up to 90-days prior to release; 3) to assist the state in delivering the most effective care to its members in light of the COVID-19 PHE, and ensure renewals of eligibility and transitions between coverage programs occur in an orderly process that minimizes member burden and promotes continuity of coverage at the end of the COVID-19 PHE; 4) to implement county-based model changes in its Medi-Cal Managed Care program (aligns with related changes approved in to the CalAIM Section 1915(b) waiver); 5) to provide coverage to Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries​ for traditional health care practices received through Indian Health Service (IHS) facilities, facilities operated by Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or facilities operated by urban Indian organizations under Title V of the Indian Health Care Improvement Act (IHCIA)​; and 6) to provide waiver authority related to the approved reentry demonstration initiative for a limited purpose, provide Title XXI expenditure authority for health-related social needs (HRSN), include updates to the special terms and conditions (STCs) for already approved HRSN services in alignment with CMS’s housing duration and frequency policy, and other technical changes. ​

DHCS and CMS continue to work toward additional approvals for equity-oriented CalAIM Section 1115 demonstration requests, including authority to provide continuous coverage in Medicaid (Medi-Cal) and the Children's Health Insurance Program (CHIP) for eligible children through age four, regardless of when they first enroll in Medi-Cal or CHIP, and regardless of changes in circumstances that would otherwise cause a loss of eligibility. 

See the CalAIM Waiver Issue Brief​ ​and December 29, 2021 press relea​se​ for additional details. 

Materials ​Approved by CMS

CMS approved the CalAIM Section 1115 demonstration and CalAIM Section 1915(b) waiver on December 29, 2021, both effective through ​December 31, 2026. 

• CalAIM Section 1115 Demonstration
• CMS Approval Letter and CalAIM STCs Technical Corrections and Attachments​​ (January 17, 2025)
  
• CMS Approval Letter and CalAIM STCs following approval of Attachment X​ (January 8, 2025)
  
• CMS Approval Letter​ and Updated CalAIM STCs for the Reentry Demonstration and HRSN ​(December 16, 2024)​
  
• CMS Approval Letter of DSHP Attachments Y and Z​​ (December 12, 2024)​
  
• CMS Approval Letter and CalAIM STCs following approval of Traditional Health Care Practices​ (October 16, 2024)
  
• CMS Approval Letter and Updated Reentry Demonstration Initiative Implementation Plan​ (October 2, 2024)
  
• ​CMS Approval Letter and CalAIM STCs following approval of Attachment BB​​ (March 6, 2024)
  
• CMS Approval Letter and CalAIM STCs following approval of Attachment CC​ (March 6, 2024)
  
• ​Amendments​​
  
• Evaluation Reports (Ongoing)​
• CMS Approved Quarterly and Annual Progress Reports​ (Ongoing) 
  
• Requests for Information (RFI)​
  

• CalAIM Section 1915(b) Waiver
  
• ​Access and Improvement in Medi-Cal Request for Information​ (August 24, 2023)
  
• CMS Approval Letter and STCs following approval of rural county model changes​​ (June 26, 2023)​
• Approved Application and Attachments​ (June 23, 2023)​
  
• Appendix: Cost Effectiveness BH SMHS & DMC-ODS (June 26, 2023)
• Appendix: Cost Effectiveness MCMC & Dental MC​ (June 26, 2023)​
  
• Amendments​
  

Materials Submitted to CMS​

• ​Community Support Evaluation Design​​​
  

DHCS submitted the following to CMS on February 7, 2024:

• Revi​sed Evaluation Designs for PATH, GPP, and Duals and Draft Evaluation Design for the Reentry Demonstration
  
• DHCS and Evaluation Team Responses t CMS December 5, 2022 Questions​​​
  

DHCS submitted the following to CMS on October 20, 2023: 

​DHCS submitted the following amendment requests to CMS on November 4, 2022:

• Cover letter to CMS
  
• CalAIM Section 1115 demonstration MCP model change amendment request
  
• ​Completeness Letter​ 
  
• CalAIM Section 1915(b) waiver MCP model change amendment request​ (redline​) and (clean)
  
• ​Appendix: Cost Effectiveness MCMC & Dental MC
  
• Appendix: Cost Effectiveness BH SMHS & DMC-ODS​
  

DHCS submitted the following waiver applications to CMS on June 30, 2021, both five-year renewals and amendments to existing waivers:​​

• CalAIM Section 1115 demonstration application and cover letter
  
• CMS Completeness Letter
• CalAIM Section 1915(b) waiver application
  
• Cover letter
  
• Attachments
• Appendix: Cost Effectiveness BH SMHS & DMC-ODS
• Appendix: Cost Effectiveness MCMC & Dental MC​