1 of 21

Medi-Cal Benefits You Might Not Be Aware Of

Housing assistance
Food assistance
Extra Support Under CalAIM Enhanced Care Management and Community Supports

Hosted by Hubbert Homes

Presented by Piper Christensen

Hubbert Homes • Housing • Support • Community

2 of 21

Housekeeping & Ground Rules

We’re here to share information, not give legal advice
It’s okay to ask questions
We won’t talk about your private medical details in front of the group
You can step away at any time

Hubbert Homes • Housing • Support • Community

3 of 21

What We’ll Cover Today

What is CalAIM?
What is Enhanced Care Management (ECM)?
What are Community Supports?
Examples: housing help, food, home changes, recovery help
Transportation for medically necessary appointments (NEMT/NMT)
How to ask for these benefits

Hubbert Homes • Housing • Support • Community

4 of 21

What Is CalAIM?

CalAIM = California Advancing and Innovating Medi-Cal
Looks at the whole person, not just medical visits
Connects health care, housing, and daily life through ECM and Community Support services
Goal: Keep people stable and out of crisis

Hubbert Homes • Housing • Support • Community

CalAIM stands for California Advancing and Innovating Medi-Cal.

I know that's a long phrase, but the idea is pretty simple. Think of it as basically Med-Cal 2.0. Instead of only paying for doctor visits or hospital stays, California wants Medi-Cal to look at your whole life. That means recognizing that housing, food, mental health, substance use, and daily support all have significant affects your health. Think of these are preventative services.

CalAIM involves two important pieces: the Enhanced Care Management benefit and 15 Community Supports. The whole goal is to improve the quality of care and health outcomes of Medi-Cal members by addressing not just medical needs, but also the social factors that impact your health.

Under CalAIM, your Medi-Cal managed care plan, whether it be Anthem or Kaiser or Alameda Alliance, etc can now offer extra services that support your life, not just your medical appointments. Those extra services are what we’re mainly going to focus on today.

5 of 21

Enhanced Care Management (ECM)

A care team for people with many needs
Helps connect doctors, mental health, substance use, housing, and benefits
Can meet you in the community, home, clinic, or by phone

Hubbert Homes • Housing • Support • Community

Let’s start with Enhanced Care Management, or ECM.

Think of ECM as getting a whole care team whose job is to help support your health by addressing your medical and non-medical needs.

What makes ECM special is that it’s offered mainly through in-person interaction, wherever you are whether that be at home, in a shelter, at a clinic, or by phone. Members who are eligible for ECM are assigned a lead care manager that works to meet you where you are.

ECM is usually for people with more complicated situations – like serious mental health needs, substance use, being unhoused or at risk of homelessness, going in and out of the hospital a lot, or coming out of jail or prison.��There are 7 Core Enhanced Care Management services under CalAIM:

Outreach and Engagement,
Comprehensive Assessment and Care Management Plan,
Enhanced Coordination of Care,
Health Promotion,
Comprehensive Transitional Care,
Member and Family Supports
And Referral to Community/Social Services.

This means that an ECM team can:

- Help you keep track of your appointments and reminders

- Help you fill out forms, applications, or appeals

- Connect you to dental care, mental health, substance use treatment, and other programs

Support you with housing, food, transportation, and other needs that affect your health

ECM is meant to give you a real team instead of leaving you feeling like you’re trying to be your own case manager, which can be super overwhelming.

6 of 21

Could You Qualify for ECM?

You are unhoused, couch-surfing, or at serious risk of losing housing
You have serious mental health or substance use challenges
You are often in the ER or hospital
You are leaving jail, prison, or a locked facility
You have complex health conditions and need help coordinating care

Your Medi-Cal managed care plan makes the final decision, but you can, and should, ask to be evaluated for ECM

Hubbert Homes • Housing • Support • Community

So you might be wondering, “Is ECM for me?”

You might be eligible if:

-You don’t have stable housing. That includes living on the street, couch-surfing, staying in shelters, or being at serious risk of losing your housing.

-If you have serious mental health needs or substance use challenges

-If you go to the ER or hospital a lot

-If you’re coming out of jail, prison, or another institutional setting and are trying to re-enter the community.

-If you have multiple health conditions and need help coordinating care and staying on top of everything

-Children and youth, including those in foster care, those with intellectual or developmental disabilities, and pregnant or postpartum individuals may also be eligible for ECM.

Your Medi-Cal managed care plan makes the final decision, but you absolutely can, and should, ask to be evaluated for ECM if you feel like you would benefit from this service.

7 of 21

What Are Community Supports?

Extra services Medi-Cal plans can offer
Help with housing, food, home changes, recovery, and more
Aim to keep you stable and out of the hospital
Not every plan offers every service, but many are available

Hubbert Homes • Housing • Support • Community

8 of 21

Housing Help: Finding Housing

Housing Transition Navigation Services
Help looking for housing
Help with applications and paperwork
Support talking to landlords and property managers
Coordination with shelters, programs, and housing agencies

Hubbert Homes • Housing • Support • Community

9 of 21

Housing Help: Getting In & Staying Housed

Housing Deposits:

Help with security deposits, utility start-up fees, and other one-time, essential move in costs

Housing Tenancy & Sustaining Services:

Ongoing support after you move in
Help with lease rules and landlord issues
Support with rent, bills, and staying connected to services

Hubbert Homes • Housing • Support • Community

So once you find a place, the next big barriers are usually up-front costs and being able to stay housed.

Housing Deposits can provide one-time financial help for essential move in costs like:

- Security deposits

- Utility set-up fees

- cleaning or repair fees and any other essential move in costs

You are generally only approved for this support one time, but you may be able to get approved a second time depending on your situation.

Another helpful support is Housing Tenancy and Sustaining Services which help you stay housed once a unit is secured by assisting with:

- Understanding and following your lease,

- Working through landlord conflicts that may come up

- Keeping up with rent and utilities

- And staying connected to programs like ECM, recovery supports or things like day habilitation programs.

The goal is not just to help you get a place, but to help you keep that place long-term.

10 of 21

Transitional Rent & Day Habilitation

Transitional Rent:

Up to 6 months rent help while moving from homelessness into permanent housing

Day Habilitation Programs:

Daytime programs to build independent living skills
Support with social skills, routines, and community connection

Hubbert Homes • Housing • Support • Community

Two more housing-related supports are Transitional Rent and Day Habilitation Programs.�

Transitional Rent provides rent payments for up to six months per household while you transition from being unhoused or are in unstable housing into a more permanent place.�

Day Habilitation Programs are structured day programs where you can:

- Build independent living skills like learning how to navigate public transit

- Work on social skills and routines

- And connect with community resources, job opportunities, education, or recovery supports.�

Day programs can be really helpful for people who are rebuilding their lives after homelessness, incarceration, or long hospital stays. And these trainings can be done in group settings or 1:1 sessions and may be delivered in your home, the community, or the provider's service location.

11 of 21

Food Support & Home Changes

Medically Tailored / Medically Supportive Meals:

Meals or groceries designed for your health condition
Nutrition education

Home Accessibility:

Grab bars, ramps, bathroom changes for safety

Asthma Help:

Reducing asthma triggers in the home (mold, pests, heavy dust, etc.)

Hubbert Homes • Housing • Support • Community

Community Supports also include food and home safety help.

Medically Tailored or Medically Supportive Meals means:

- You can get meals or special groceries that are designed for your health needs, whether that be like diabetes, heart disease, or recovery from surgery.

This support is only for a limited time, but it can definitely make a big difference - I believe you can receive this services for 2-3 months at first but you're care plan may extend this time, if necessary
You can also receive nutritional education so that you can continue to make similar meals once this support ends

There are also services for home changes and asthma:

Environmental Accessibility Adaptations – which is also sometimes called Home Modifications – include things like adding grab bars, ramps, or widening doorways to your home so you can get around safely at home. This service can be accessed by renters, not just homeowners, as long as you receive approval from your landlord.

- Asthma Remediation is another support that can include reducing triggers in your home, like mold, pests, or heavy dust, and making your space safer to breathe in.

The goal of these supports is to help you live more safely and comfortably at home.

12 of 21

Caregiver Services

Personal Care and Homemaker Services:

Assistance with ADLs (bathing, dressing, feeding, toileting) and IADLs (meal prep, shopping, housekeeping)
Similar to IHSS
Used during IHSS waiting periods or when IHSS hours are done

Respite Services

Short-term (up to 336 hours/year), caregiver relief
Includes in-home and facility-based respite to prevent caregiver burnout

Hubbert Homes • Housing • Support • Community

Personal Care and Homemaker Services and Respite Services are community supports that involve caregiver supports.

Personal Care and Homemaker Services include assistance with ADLs (bathing, dressing, eating, using the restroom) and IADLs (meal prep, shopping, andhousekeeping). This service essentially acts as in home supportive services, or IHSS, during IHSS waiting periods, or when IHSS hours are used up.

Respite Services provide short-term, non-medical supervision for members when their regular caregiver is absent or needs relief. This includes in-home and facility-based respite to prevent caregiver burnout and avoid institutional placement of the Member while the caregiver is away, maybe they're in the hospital.

The goal of these supports is to help support you and and your caregivers when there are care gaps.

13 of 21

Recovery After Hospital or Crisis

Recuperative Care (Medical Respite):

Safe place to rest and heal if you can't recover where you are living now

Short-Term Post-Hospital Housing:

Temporary housing right after you leave the hospital

Sobering Centers:

24 hour stay to safely sober up and get connected to treatment

Hubbert Homes • Housing • Support • Community

If you’ve ever been discharged from the hospital or something similar and had nowhere safe to go to fully recover, these next supports might be for you.

Recuperative Care, also known as Medical Respite, is a short-term support that gives you a temporary place recover after a hospital stay if you can’t heal on the street or in a shelter or anywhere else you would be going after being discharged.

Short-Term Post-Hospitalization is very similar to recuperative care and gives you temporary housing when you’re medically stable, but your old living situation isn’t safe or available.

These two supports are actually going to be combined into one next year, and we don't quite know what that will look like yet, but the core of their benefits to members will stay the same

It's also important to note that these two services (STPH and RC) and the transitional rent support that I touched on before have a combined cap of 182 days, which is about 6 months, within in a 12-month period. This just means that if like you used Recuperative Care for 3 months, you could only receive 3 months of transitional rent until one year after the first service was started.

Sobering Centers are a little different from the other Community Supports we have covered so far. This is a 24 hour service that gives people who are intoxicated a safe place to sober up and get connected to treatment and other resources, instead of going to jail or the Emergency Room. This is the only support that you wouldn't really ask about beforehand, but if you or someone you know does end up at a sobering center, they make sure to take great care of people and connect them with good resources

These supports are about giving you the time, space, and resources you need to recover.

14 of 21

Transitional Services

Community or Home Transition Services:

Helps individuals transition from a licensed nursing facility to a private residence or subsidized housing
Covers transition coordination (housing search, applications, moving)
Covers non-recurring set-up expenses (security deposits, utility setup, pest control, adaptive aids).

Assisted Living Facility (ALF) Transitions:

Facilitates nursing facility transition to a home-like community setting (RCFE or ARF)
Prevents nursing facility admissions
Includes time-limited transition services (housing search, moving, coordination) and ongoing assisted living services (ADL/IADL assistance, meals, meds, 24-hr staff).

Hubbert Homes • Housing • Support • Community

Community or Home Transition Services and Assisted Living Facility (ALF) Transition Services help individuals with nursing facility level of care needs transition to the community or home-like community settings

The community support ALF Transition Services facilitates nursing facility transition to a home-like community setting (RCFE or ARF) or prevents nursing facility admissions in the first place. This support includes time-limited transition services like help with the housing search and moving coordination plus ongoing assisted living services like ADL/IADL assistance (meal prep, using the restroom, showering)

And then Community or Home Transition Services help individuals transition from an institution like a licensed nursing facility to the community and includes two important parts which are transition coordination (so helping with the housing search, filling out applications, and assistance with moving) and non-recurring set-up expenses which would cover security deposits, utility setup, pest control, and adaptive aids

These supports include very similar parts of personal care and homemaker services, housing transition navigation services, and housing deposits and have the goal of preventing the need for higher levels of care. Just because they are similar to other supports doesn't necessarily mean you can't receive both at the same time. That will be up to your care plan.

15 of 21

Transportation to Your Care (NEMT & NMT)

Non-Emergency Medical Transportation (NEMT):

For medically necessary appointments when you can't use regular transportation
May be by ambulance, wheelchair van, or gurney/litter van
Must be prescribed by your provider

Non-Medical Transportation (NMT):

Rides to Medi-Cal-covered appointments when you don't have reliable transportation
Can include bus, mileage, gas cards, or other approved rides

“I need help getting to my medically necessary appointments. Can I get NEMT or NMT for my upcoming visits?”

Hubbert Homes • Housing • Support • Community

Another really important benefit is transportation to your care.

One benefit is called Non-Emergency Medical Transportation, or NEMT:

- This is for people who can't safely use regular transportation because of their medical condition.

- It includes transportation like ambulance rides or wheelchair vans to and from covered Medi-Cal services.

Your doctor or other provider will have to write a prescription for this service and explain why you need this level of transportation.

The other benefit is Non-Medical Transportation, or NMT:

- This is for people who can ride in a regular vehicles or use public transit, but don’t have a way to get there.

- It can cover things like bus passes, gas cards, or rideshares to your Medi-Cal-covered appointments.

NMT is great because it does not require a prescription – you just need to tell your plan that you have unmet transportation needs and they will work to resolve this issue

To access this service, you can call your plan, you say something like:

“I need help getting to my medically necessary appointments. Can I get NEMT or NMT for my upcoming visits?”

These services aren't new under CalAIM, but transportation is a big part of making all of these other ECM and Community Supports services actually usable - because, you know, you can’t benefit from Medi-Cal if you can’t access all offered care.

16 of 21

Quick Checklist: Could These Help You?

Help finding or keeping housing
Help with deposits or short-term rent
Extra help coordinating your health, mental health, or recovery (ECM)
Meals that match your medical needs
Changes to your home so it’s safer
A safe place to recover after hospital or crisis
Support for your caregiver to get a break
Transportation to medically necessary appointments (NEMT/NMT)

Hubbert Homes • Housing • Support • Community

Okay, I know that this has been a lot of information. Let’s pause for a minute and do a mental checklist.�

Think about yourself, your family, or someone you support:

-Is housing unstable, or are deposits and move-in costs stopping you from getting a place? Housing Transition Navigation, Housing Deposits, and/or Transitional Rent may be beneficial

-Is it hard to keep track of appointments and medications and you need connections to housing or food resources? That sounds like Enhanced Care Management could help

-Would meals designed for your health condition be helpful for a little while? You may want to ask about Medically Tailored Meals.

-Do you or a loved one need a safer home set-up or to prevent asthma attacks? Home Modifications or Asthma Remediation may be right for you

-Is someone coming out of a hospital, jail, or a program with nowhere safe to go? Recuperative Care or Short-Term Post-Hospitalization could definitely help.

- Does your caregiver need a break or do you need additional caregivers to fill in some short-term gaps? You may qualify for Respite Services or Personal Care and Homemaker Services.

-Do you struggle to get to appointments because you don’t have a ride? You should ask about Non-emergency medical transportation or Non-medical transportation.

If you said “yes” to any of these, it’s worth the call to your Medi-Cal plan to asking about Enhanced Care Management, Community Supports, and NEMT or NMT transportation services.

17 of 21

How to Ask for These Benefits

Call the number on the back of your Medi-Cal plan card
Use clear words: 'Enhanced Care Management' and 'Community Supports’ and ‘NEMT/NMT’
Explain your situation in a sentence or two
Ask how to be checked to see if you qualify
Ask your doctor, clinic, or case manager to help if needed

There is no ‘perfect’ way to ask. The key is to mention ECM and Community Supports by name, and clearly say what you’re dealing with.

Hubbert Homes • Housing • Support • Community

Alright, I think this slide is the most important one because we're gonna go over how to ask for these services.

When you call the number on the back of your Care Plan card, you can say something like:

“Hi, my name is ___ and I’m a Medi-Cal member. I heard about Enhanced Care Management and Community Supports, and I'd like help with... let's say housing and medically tailored meals.” ��If you don’t have your care plan ID card, you can also search online for your Care Plans general California member services phone number and they will be able to direct you to the right department.

You would then want to briefly explain your situation (like are you unhoused, leaving the hospital, living with serious mental illness) and you'll want to ask them what services your plan offers and how you can be evaluated to see if you qualify.

You can also ask your doctor, therapist, or case manager to refer you or you ask a trusted community organization like Hubbert Homes to help make the call or fill out any forms.

But don't worry, you know, there is no ‘perfect’ way to ask. The key is to mention ECM or Community Supports or NEMT or NMT by name, and clearly say what you’re dealing with.

18 of 21

What If They Say 'No'?

Ask why and ask for the decision in writing
Ask how to file an appeal or grievance
Ask if there are any other programs or supports you might qualify for
Get help from a case manager, advocate, or community organization

Remember: you have the right to ask questions and to understand your options.

Hubbert Homes • Housing • Support • Community

19 of 21

Real-Life Example: From Street to Stability

Member is living on the street and going to the ER often
Hospital connects them to ECM and Recuperative Care
Housing Transition services help them find an apartment
Housing Deposits and Transitional Rent help them move in
Tenancy Services and Day Habilitation help them stay stable

Hubbert Homes • Housing • Support • Community

Okay so this is a very simple example of how these pieces can fit together:

Imagine someone who is living on the street and going to the ER a lot.

The hospital connects them to Enhanced Care Management and Recuperative Care. They now have a safe place to heal and a lead care manager that is working to connect them to other helpful supports and resources

Their ECM lead care manager helps them get Housing Transition Navigation, so they can apply for units and gather needed documents.

Their care manager also connects them with Housing Deposits and maybe Transitional Rent so they can afford to move into a place.

Once they’re housed, Housing Tenancy and Sustaining Services as well as Day Habilitation can help them stay stable, build skills, and connect to community.

This is the kind of crisis to stability pathway that CalAIM is trying to create. Not everyone’s journey will look exactly like this, but it shows how the services are meant to work together.

20 of 21

How Hubbert Homes Can Help

Help explain these Medi-Cal benefits
Help you talk to your plan or case manager
Offer housing and support services where available
Connect you to community partners and resources

hubberthomes.com • ben@hubberthomes.com • 510-221-0444

Hubbert Homes • Housing • Support • Community

21 of 21

Questions & Thank You

We’re glad you’re here!
Questions?

hubberthomes.com • ben@hubberthomes.com • 510-221-0444

Hubbert Homes • Housing • Support • Community