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Coordinating community partnerships for more person-centered care.

  • Faster client referrals
  • Stronger care coordination
  • Better access to housing
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It's time to make the housing and healthcare connection.

You see it every day. A client has urgent health needs but no stable housing. Or they need housing support, but there’s no direct link to medical or behavioral care.

CalAIM offers a bridge to that gap through Enhanced Care Management and Community Supports. Medi-Cal members experiencing or at risk of homelessness can be connected to person-centered services that address both health and housing-related social needs.

But to make it work, you need a clear path: referral tools, program info, and the right people to contact. That’s what Sacramento Steps Forward is here to provide.

Note: Sacramento Steps Forward (SSF) is not a direct service provider; meaning, we help providers help clients—but we don’t support clients directly.

We're here to help make CalAIM work for you and your clients.

You don’t have to navigate the connection between housing and health alone. Sacramento Steps Forward is working with health plans, local government, and homelessness service providers to support CalAIM implementation across our region.

We’ve gathered the tools, contacts, and program details that help connect your clients to CalAIM services and help you do your job more efficiently. 

Here's how to get started with CalAIM.

Becoming a CalAIM Provider

Is your organization interested in becoming a CalAIM ECM or CS provider? If so, here are some resources to get you started.

Referring Your Clients to a CalAIM ECM or CS

Step 1: Determine Medi-Cal Status

Clients must be active Medi-Cal members to receive CalAIM Enhanced Care Management (ECM) or Community Support (CS) services. If your client is unsure of their current Medi-Cal status, they can use the following resources to determine their status and find their Managed Care Plan provider*.

*Sacramento County Managed Care Plans are Anthem, HealthNet, Kaiser Permanente, and Molina Healthcare.


Step 2: Refer to CalAIM ECM

  1. Complete Population of Focus Screening Checklist (section 3 on Sacramento ECM Referral Form) to confirm eligibility in population of focus.
  2. Complete Exclusionary Screening Checklist (section 4 on Sacramento ECM Referral Form) to verify member eligibility.
  3. If eligibility is determined, submit Sacramento ECM Referral Form and Screening Checklists to the Managed Care Plan.
  4. Submit supporting documentation to expedite review/ approval (e.g. documentation of homelessness; documentation of entries/exits from shelters, etc.)
  5. Send securely to the MCP via the designated method stated on the referral form.


Step 3: Refer to CalAIM Community Supports

  1. Identify that your client needs Community Support services.
  2. Use Managed Care Plan referral pathways to submit referrals
    1. Anthem
    2. HealthNet
    3. Kaiser Permanente
      1. Housing Insecurities CS Referral Form
      2. Keeping Members at Home and Chronic Health Conditions CS Referral Form
    4. Molina Healthcare

Explore CalAIM resources below.

General Resources

The Department of Healthcare Services (DHCS) runs CalAIM. Review their site for the most up-to-date information on the program.

LEARN MORE

Quick links for Community-Based Organizations, from the Insure the Uninsured Project (ITUP).

DOWNLOAD FLYER

This Excel-based template by Camden Coalition is for organizations to estimate costs and potential revenue associated with providing CalAIM ECM and CS services.

LEARN MORE

For information on how to make CalAIM ECM (Enhanced Care Management) and Community Supports referrals, how to access the CalAIM provider directory, and other service questions, please join the Sacramento PATH Collaborative, hosted by Transform Health by registering through PATH’s TPA’s registration site. 

By joining the collaborative, you can access the Sacramento PATH CPI (Collaborative Planning and Implementation) SharePoint site, which houses many CalAIM resources for the Sacramento region. 

REGISTER FOR TRANSFORM HEALTH TRAININGS

*Registration through PATH TPA is required for access.

Download DHCS ECM Fact Sheet

Download DHCS ECM Policy Guide

Download DHCS ECM POF: Individuals Experiencing Homelessness

Download DHCS CS Fact Sheet

Download DHCS CS Policy Guide

Resources for Claims and Billing

Developed in collaboration between NHHA and the Sacramento Managed Care Plans, these guides provide helpful tips for submitting successful ECM and CS claims.

VIEW GUIDE

Updated in January 2024, this document contains the DHCS-established HCPCS codes that must be used for documenting the rendering of ECM and CS services in MCPs encounters.

DOWNLOAD CODING GUIDANCE

This document outlines the standards for providers and MCPs related to billing and invoicing ECM/CS claims. The purpose of this guidance is to standardize invoicing to mitigate provider burden and promote data quality.

DOWNLOAD BILLING AND INVOICE GUIDANCE

Claims require at least one diagnosis code. This document, issued by DHCS, lists the diagnosis codes for claim submissions.

DOWNLOAD CLAIMS DIAGNOSIS CODE GUIDANCE

Anthem Claims Overview

HealthNet Claims Procedure

Kaiser Claims Procedure

Download Molina Claims and Compensation

Frequently Asked Questions

What is Enhanced Care Management?

Enhanced Care Management (ECM) provides person-centered, community-based care management to Medi-Cal members with the highest needs. In this CalAIM initiative, members are assigned a Lead Care Manager who meets them where they are to coordinate all their health and health-related care.

ECM Core Services

  1. Outreach and engagement.
  2. Comprehensive assessment and care management plan.
  3. Enhanced coordination of care.
  4. Health promotion.
  5. Comprehensive transitional care.
  6. Member and family supports.
  7. Coordination of and referral to community and social support services.


Populations of Focus

ECM Serves the Following Populations of Focus (POF):

  • Adults without Dependent Children/ Youth Living with Them Experiencing Homelessness
  • Homeless Families or Unaccompanied Children/ Youth Experiencing Homelessness
  • Individuals At Risk for Avoidable Hospital or Emergency Department (Formerly “High Utilizers”)
    • Adults
    • Children & Youth
  • Individuals with Serious Mental Health and/or Substance Use Disorder (SUD) Needs
    • Adults
    • Children & Youth
  • Individuals Transitioning from Incarceration
    • Adults
    • Children and Youth
  • Adults Living in the Community and At Risk for Long Term Care (LTC) Institutionalization
  • Adult Nursing Facility Residents Transitioning to the Community
  • Children and Youth Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS Condition
  • Children and Youth Involved in Child Welfare

LEARN MORE ABOUT ECMs

What are Community Supports?

Community Supports (CS) are services provided by Managed Care Plans to address Medi-Cal members’ health-related social needs, help them live healthier lives, and avoid higher, costlier levels of care.

Community Supports Offered Through CalAIM

  • Housing transition navigation services
  • Housing deposits
  • Housing tenancy and sustaining
  • Short-term post-hospitalization housing
  • Recuperative care (medical respite)
  • Respite services
  • Day habilitation programs
  • Nursing facility transition/diversion to assisted living facilities
  • Community transition services/NF transition to a home
  • Personal care and homemaker services
  • Environmental accessibility adaptations (home modifications)
  • Meals/medically tailored meals
  • Sobering centers
  • Asthma remediation

LEARN MORE ABOUT COMMUNITY SUPPORTS

What are the Managed Care Plans, and how can I connect with them?

Managed Care Plans (MCPs) are health insurance providers that deliver Medi-Cal services, including CalAIM’s Enhanced Care Management and Community Supports. In Sacramento, the four MCPs offering these services are:

 

Each plan has its own CalAIM webpage with referral processes, eligibility guidelines, and provider contact information. Use the links in the Resource section of this page to access each plan’s tools and connect directly.

Need help with CalAIM?

If you have questions about local CalAIM implementation, referrals, or how this work connects to homelessness services, contact us using the form below.

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