Medi-Cal, California’s Medicaid program, provides health coverage for Californians with low incomes, including children and their parents, pregnant women, seniors, people with disabilities, and adults under age 65. Medi-Cal is operated by the California Department of Health Care Services in partnership with the state’s 58 counties.

Medicaid was established in 1965, as part of the federal Social Security Amendments (SSA). Medicaid rules regarding who gets coverage and which benefits are included are determined by SSA requirements and implemented by the federal Centers for Medicare & Medicaid Services (CMS). Every state that participates in the Medicaid program must create a State Plan that describes the scope of its Medicaid program and must seek federal approval for that plan.

Waivers and State Plan Amendments

The law also permits CMS to waive certain aspects of the law to enable states to test different approaches to program eligibility, benefits, delivery systems, and financing. This is known as a waiver. The most common types of waivers include 1915(b) waivers, primarily used for authorizing managed care delivery systems, and 1115 demonstration waivers, primarily used to demonstrate experimental projects. Waivers are time-limited and may be ended, renewed, or extended by the state at CMS’s discretion.

When a state wants to substantially change how it operates its Medicaid program, it must apply to change its State Plan by submitting a State Plan Amendment (SPA) to CMS for approval. SPAs have no time limit and are in effect until either the state further amends the State Plan or federal changes necessitate an amendment.

Waivers and CalAIM

Medi-Cal is taking significant steps to advance more equitable, coordinated, and person-centered care that helps enrollees maximize their health and life trajectory. This transformative initiative, known as CalAIM (California Advancing and Innovating Medi-Cal), includes broad-based delivery system, program, and payment reforms across the Medi-Cal program.

To implement CalAIM, the Department of Health Care Services received needed federal authorities, including approval of California’s Medicaid State Plan, a Section 1915(b) waiver (PDF), and a Section 1115 demonstration waiver (PDF).

Three publications, about Medicaid SPAs, waivers, and their use to implement CalAIM, are available to download below.

Medi-Cal: A State-Federal Partnership provides an overview of how California and the federal government jointly administer and fund Medi-Cal.

Medi-Cal State Plan Amendments and Waivers Comparison Chart compares the federal processes and requirements for Medicaid SPAs and common waivers.

CalAIM Authorities Chart shows CalAIM initiatives and their enabling federal authorities.