Many Medi-Cal Changes Underway: An Overview and the Impact on Children (Updated)

Originally published in April 2022. Updated in November 2023 to include the Medi-Cal doula benefit and provide up-to-date information on implementation across initiatives.

The State of California has embarked on multiple efforts over the last few years to transform the way health care is delivered in the Medi-Cal program.

These efforts illustrate Governor Newsom’s larger vision for reform, including those that hold promise to improve outcomes for children. This blog provides updates on new Medi-Cal benefits and initiatives currently being implemented by the California Health and Human Services Agency (CalHHS) and the Department of Health Care Services (DHCS) and reviews how children and their families may be impacted.

CalAIM (California Advancing and Innovating Medi-Cal) is a long-term plan to transform the Medi-Cal program. The stated goal is to create a health care delivery system that is more equitable, coordinated​, and person-centered.​​​​ CalAIM’s first reforms started in January 2022 and additional changes will continue through 2027. There are many aspects of CalAIM including Population Health Management (PHM) and Enhanced Care Management (ECM).

• PHM requires Medi-Cal managed care plans to assess and address the needs of members with tailored interventions focused on wellness and prevention. DHCS will be launching a statewide PHM Service to facilitate Medi-Cal member data sharing among community care providers and inform referrals to care management and other services.
• ECM is a new Medi-Cal benefit and a subset of PHM for certain populations with complex clinical and non-clinical needs. It will provide community-based, interdisciplinary, high-touch, and person-centered service coordination for members. ECM went live for certain child populations in July 2023, including children experiencing homelessness, children enrolled in California Children’s Services (CCS), and children involved in child welfare. An ECM birth equity population of focus will start in January 2024 for Black, American Indian and Alaska Native, and Pacific Islander pregnant and postpartum individuals.

Community Health Workers. Community Health Worker (CHW) services became a Medi-Cal benefit as of July 1, 2022. Community health workers (CHWs), promotores, and other non-licensed health professionals are frontline public health workers and trusted members of the communities they serve. Under this benefit, CHWs can provide preventive health services such as health education and navigation and help address health and health-related social needs. The focus of the benefit is prevention, and most young children with Medi-Cal coverage are eligible. For full details on this benefit, see our blog “Community Health Worker Medi-Cal Benefit: Implementation and the Role of Community Partners Like First 5.”

Comprehensive Quality Strategy (CQS). The CQS is a strategic planning document to improve the quality and equity of Medi-Cal health care. Every state Medicaid agency is required by the Federal government to have a quality strategy. California’s current CQS has three clinical focus areas: children’s preventive care, maternity care and birth equity, and behavioral health integration. It describes how these focus areas will be embedded into a health equity roadmap, payment reform, and quality metrics. Part of these metrics is the Department of Health Care Services’ Bold Goals: 50x2025. These are planned improvements in Medi-Cal, including closing racial/ethnic disparities in well-child visits and immunizations by 50% and ensuring all managed care plans exceed the 50th percentile for children’s preventive care measures. For more information on the quality metrics plans are held accountable for, review the Managed Care Accountability Sets (MCAS) by reporting year.

New contracts with DHCS for Medi-Cal Managed Care Plans. As of January 2024, DHCS will enter into new contracts with managed care plans that deliver Medi-Cal across the state. This includes both commercial plans that won contracts as result of a 2022 competitive bidding process and public/county organized plans. The managed care plans that will serve each county starting in 2024 are outlined in this DHCS resource. The new contract includes specific provisions to improve children’s services and increase transparency, health care quality, equity, and access. In addition, DHCS will require managed care plans to increase community engagement and investment. For example, managed care plans will need to establish MOUs to coordinate programs and services for members with community partners such as First 5 commissions starting in 2025.

Family Therapy Benefit. In June 2020 the Department of Health Care Services launched a family therapy benefit, retroactive to January 2020. Through this benefit, psychologists and other California Board of Behavioral Science licensed or license-eligible providers can bill Medi-Cal for family therapy and treat a caregiver and child together. Instead of needing a diagnosis, families are eligible for family therapy if they are experiencing certain risk factors. These risk factors are broad and include both child-oriented variables, such as exposure to interpersonal or community-level adversity, and caregiver-oriented variables, such as maternal mental health concerns or substance use disorder. In December 2021, DHCS updated its provider manual indicating children can receive all non-specialty mental health services, not just family therapy, without a diagnosis if health-impacting risk factors are present.

Dyadic Care Benefit. As of January 2023, Medi-Cal reimburses for dyadic care, simultaneous treatment for the child and parent/caregiver during a child’s medical visit. These services include integrated behavioral health services, screening, assessment, evaluation, and case management. This benefit will allow reimbursement for models such as Healthy Steps. For more details and information on the differences between dyadic care and family therapy, see our blog “New Children’s Medi-Cal Behavioral Health Benefits 101: Family Therapy and Dyadic Services.”

Doula Benefit. As of January 2023, Medi-Cal reimburses for doula services. This benefit provides support to individuals and families throughout pregnancy and one year postpartum, as well as support for and after miscarriage and abortion. DHCS added this benefit to help prevent perinatal complications and improve health outcomes for birthing parents and infants. As a preventive benefit, doula services require a written recommendation from a physician or other licensed practitioner of the healing arts. However, to increase access to services, DHCS issued a standing recommendation from the DHCS Medical Director that fulfills this requirement for all pregnant and postpartum Medi-Cal members.

Children and Youth Behavioral Health Initiative. The Children and Youth Behavioral Health Initiative (CYBHI) is a is a multiyear, multi-department package of investments that seeks to reimagine the systems that support behavioral health for all California's children 0-25 years old and their families, part of the Master Plan for Kids’ Mental Health. CYBHI is a historic $4.7 billon investment that takes a “whole child” approach to address the factors that contribute to the mental health. Areas of focus include workforce training and capacity, behavioral health infrastructure development including ensuring “no wrong door,” increasing coverage including dyadic care and school-linked services, and public awareness. As part of this initiative DHCS is releasing six rounds of grant funding to scale evidence-based and community-defined practices to improve child behavioral health including those that focus on early childhood.

The emphasis on children’s preventive care in these efforts represents a significant shift in how the State approaches reforms in the Medi-Cal program. State reforms and innovation in Medi-Cal have historically focused on the highest utilizing and highest cost individuals. As a generally healthy and low-cost population, the needs of young children have flown under the radar which has come at a cost. In 2021 in Medi-Cal managed care, only 40% of children received 6 of the 8 recommended well-child visits in their first 15 months of life, and only 29% of children received the recommended developmental screenings in the first three years of life.

An increased commitment to children is most clearly illustrated in DHCS's policy agenda for children and families enrolled in Medi-Cal. Medi-Cal’s Strategy to Support Health and Opportunity for Children and Families is guided by the principles of addressing health disparities and implementing a whole-child, preventive approach informed by families. It elevates the need to provide family-based care, including increasing access to programs like home visiting, and to improve pediatric preventive care. This Medi-Cal strategy outlines a vision for how existing and newly proposed child and family health initiatives should work together.

Although the implementation of the vision in this strategy will take many years to implement, these new efforts and benefits are historic and follow many years of First 5 and partner advocacy for improved systems and whole-child, whole-family approaches. There is much work ahead, and the State, managed care plans and providers will need support, collaboration, and dedication to realize the promises these initiatives represent.