The California Department of Health Care Services (DHCS) publishes quarterly implementation reports on the Enhanced Care Management (ECM) and Community Supports (CS) programs — two of the most consequential components of the CalAIM initiative. The Q3 2023 report offers the most detailed enrollment, utilization, and demographic data yet released, and contains several findings with significant implications for managed care plans, providers, and CBOs operating in the CalAIM ecosystem.
ECM Enrollment: Scale and Trajectory
As of Q3 2023, more than 150,000 Medi-Cal members were enrolled in ECM across California's 21 reporting managed care plans. This represents a significant acceleration from the program's initial rollout, when enrollment was concentrated in a handful of counties and a limited set of lead entities.
The enrollment trajectory reflects both the expansion of eligible populations and the maturation of the lead entity network. DHCS has progressively expanded ECM eligibility to include individuals experiencing homelessness, those with serious mental illness, high-cost high-need members, and children and youth in foster care. Each expansion wave has brought new lead entities into the network and increased the operational complexity of the program.
Notably, enrollment growth has been uneven across plans and counties. Los Angeles, San Diego, and the Bay Area account for a disproportionate share of total enrollment, reflecting both population density and the relative maturity of the lead entity networks in those regions. Rural and frontier counties continue to face significant access challenges, with some plans reporting no active ECM lead entities in certain service areas.
Community Supports Utilization Patterns
The Q3 2023 report provides the most granular Community Supports utilization data released to date. Housing-related services — housing transition navigation, housing deposits, and housing tenancy and sustaining services — account for the largest share of CS utilization by both member count and expenditure. This reflects both the high prevalence of housing instability among ECM-eligible populations and the relatively mature infrastructure for housing services in California's managed care ecosystem.
Medically tailored meals and sobering centers show strong utilization among members with co-occurring substance use and chronic conditions. Newer CS codes — including personal care and homemaker services, and community transition services — are still ramping, with several plans reporting authorization approval rates below 40% as they develop internal review criteria and provider networks.
Demographic Insights and Equity Implications
The demographic data in the Q3 report reveals important equity patterns. Black and Latino members are enrolled in ECM at rates higher than their share of the overall Medi-Cal population, reflecting the program's targeting of high-need populations where these communities are disproportionately represented. However, the report also shows that members in rural counties — who are more likely to be white and Native American — have significantly lower ECM enrollment rates, suggesting that geographic access barriers are creating equity gaps that demographic targeting alone cannot address.
Members with serious mental illness (SMI) represent a growing share of ECM enrollment, and the report highlights the challenge of coordinating ECM with the county-administered Specialty Mental Health Services (SMHS) system. The interface between managed care ECM and county mental health — including data sharing, care plan coordination, and billing attribution — remains one of the most operationally complex aspects of CalAIM implementation.
Future Directions: What the Data Signals
Several trends in the Q3 data point toward the next phase of CalAIM implementation. First, the concentration of ECM enrollment in a small number of large lead entities suggests that the market is consolidating around organizations with the operational scale to manage complex managed care contracts. Smaller CBOs that entered the market early are increasingly being absorbed into larger networks or exiting the program.
Second, the utilization data for Community Supports suggests that plans are becoming more sophisticated in their authorization criteria, with approval rates for established CS codes stabilizing while newer codes continue to face higher denial rates. This creates an opportunity for lead entities and CBOs to invest in authorization support infrastructure — including clinical documentation templates and appeals processes — that can improve approval rates and reduce administrative burden.
Third, DHCS has signaled that future quarterly reports will include quality outcome data linked to ECM enrollment — including ED utilization, inpatient admissions, and 30-day readmission rates. This shift from process metrics to outcome metrics will fundamentally change how plans evaluate lead entity performance and how lead entities demonstrate value in contract negotiations.