Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
Existing law, subject to implementation of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, requires the department to implement an enhanced care management (ECM) benefit designed to address the clinical and nonclinical needs on a whole-person-care basis for certain target populations of Medi-Cal beneficiaries enrolled in Medi-Cal managed care plans. Under existing law, target populations include, among others, high utilizers with frequent hospital admissions, short-term skilled nursing facility stays, or emergency room visits, and individuals experiencing homelessness.
Existing law, subject to CalAIM implementation, authorizes a Medi-Cal managed care plan to elect to cover community supports, as specified. Under existing law, community supports that the department is authorized to approve include, among others, housing transition navigation services and medically supportive food and nutrition services.
This bill would require a Medi-Cal managed care plan, for purposes of covering the ECM benefit, or if it elects to cover a community support, to contract with community providers, as defined, whenever those providers are available in the respective county and have experience in providing the applicable ECM or community support, and can demonstrate that they are capable of providing access and meeting quality requirements in accordance with Medi-Cal guidelines.
The bill would require a managed care plan to honor member preference with regard to the applicable ECM or community support by authorizing service delivery to the contracted provider who is submitting a request for approval of services to the managed care plan.
Existing law requires the department to develop, in consultation with Medi-Cal managed care plans and other appropriate stakeholders, a monitoring plan and reporting template for the implementation of ECM or community supports. Existing law requires the department to annually publish a public report on reported ECM or community support utilization data, populations served, and demographic data, stratified by age, sex, race, ethnicity, and languages spoken, to the extent that statistically reliant data are available.
This bill would expressly include providers of ECM or community supports within the consultation process. The bill would require the department to publish the public report on a quarterly basis instead and would require additional demographic data.
The bill would also require the department to develop standardized and streamlined templates to be used by managed care plans or their contracted providers, as specified, and to develop guidance to allow community providers to act as a primary subcontractor with managed care plans and to subcontract with other community providers as a 3rd-tier subcontractor, as specified.

Statutes affected:
SB 324: 14184.205 WIC, 14184.206 WIC
02/11/25 - Introduced: 14184.205 WIC, 14184.206 WIC
03/24/25 - Amended Senate: 14184.205 WIC, 14184.206 WIC
04/07/25 - Amended Senate: 14184.205 WIC, 14184.206 WIC