December 4, 2024

In This Issue

Provider News

Behavioral Health Workforce Grant

OneCare Member Health Awards Deadline

Dyadic Services Billing Update

New Member Text Message Short Code

Updated MCAS Requirements

Statin Therapy Guidelines


Monthly Notices

APLs

Policies and Procedures

Health Education

Policy Code Update

Upcoming Meetings

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In this issue of the Provider Update, read about CalOptima Health awarding $5.1 million in grants to increase Orange County's behavioral health workforce.


Other stories include the December 15 deadline for OneCare members to submit for health rewards, a new short code for CalOptima Health text messages to members and guidelines for using statin therapy to treat cardiovascular disease.


This update also contains the monthly roundup of updates to CalOptima Health policies, health training webinars and details for upcoming meetings.

Provider News

CalOptima Health Awards $5.1 Million in Behavioral Health Workforce Development Grants 

To better support members experiencing mental health challenges, CalOptima Health has awarded $5.1 million in grant funding to increase the behavioral health workforce as part of our ongoing Provider Workforce Development Initiative. 

 

Six organizations were selected to receive funding to help address critical behavioral health workforce shortages, enhance training and education opportunities, and ultimately improve access to essential mental health and substance use disorder services for our members. The grantees include: 

 

  • Child Guidance Center Inc. 
  • Children’s Hospital Orange County 
  • John Henry Foundation 
  • Seneca Family of Agencies 
  • Special Service for Groups Inc. 
  • Western Youth Services 


This funding builds on the initial $25 million we awarded in April 2024 as part of a larger five-year, $50 million Provider Workforce Development Initiative aimed at enhancing the health care workforce across Orange County. The initiative is focused on reducing health disparities by supporting the recruitment, training and retention of qualified health professionals. With the distribution of the remaining $20.3 million still ahead, we will consider areas of greatest need to ensure equitable and accessible health care for our diverse membership.

OneCare Member Health Rewards Submission Deadline Is December 15

Please remind your patients who are members of CalOptima Health OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, to submit forms to receive member health rewards by December 15, 2024. 


Due to a recent regulatory change, the deadline was moved to December 15. Older health reward forms in use before this change will have the prior submission deadline of January 31, 2025. We are unable to reward members for 2024 dates of services in 2025, as rewards must be issued in the same calendar year. Updated forms are now available on our website. 


For passive health rewards (e.g., Annual Wellness Visit) that do not require form submission, we will continue our current process of identifying eligible members, but only through December 31, 2024. 


If your OneCare patients need more information about member health rewards or how to download the submission forms, they can visit our website.

Providers Can Bill for Dyadic Services Using Mother’s CIN for 60 Days 

Contracted providers who bill CalOptima Health for dyadic services can now do so under the mother’s client index number (CIN) for the newborn’s birth month and the following month (60 days). We will perform a look back to adjust claims billed under the mother’s CIN that might have been originally denied.  

CalOptima Health Launches Short Code for Member Text Messages

CalOptima Health is increasingly texting members with important health information and has introduced a new short code for text messages: 225678 (CALOPT). This change is designed to improve communication and ensure that members trust our texts as official and secure. Examples of text campaigns include reminders to renew Medi-Cal coverage, get preventive care and screenings, attend health fairs, and much more. 


Providers play an essential role in the success of our texting strategy. You can support your patients by informing them about the new short code and encouraging them to save it in their contacts as “CalOptima Health.” By doing so, members will recognize our messages and avoid accidentally missing critical information. 


Having a short code aligns with industry best practices, offering members a trusted way to receive vital health updates. It reflects our commitment to making health care communication clear, reliable and accessible. 


Please help us spread the word by sharing this information during appointments or adding details to your patient materials. Together, we can help ensure members are informed and empowered in their health care journey. Members can learn more by calling our Customer Service team toll-free at 1-888-587-8088 (TTY 711) Monday through Friday, from 8 a.m. to 5:30 p.m.

DHCS Shares Updated MCAS Requirements for MY 2025 and RY 2026

On November 12, 2024, the Department of Health Care Services (DHCS) shared the Managed Care Accountability Set (MCAS) requirements for Measurement Year (MY) 2025/Reporting Year (RY) 2026 with Medi-Cal managed care plans (MCPs). 


The list of high-level updates to MCAS requirements includes the following: 


  • No new accountable measures held to the Minimum Performance Level (MPL)​ for MY 2025 — This is the third year in a row of consistent measures to allow MCPs to deepen quality improvement and health equity efforts on these core measures. 
  • Removal of 10 report-only measures​ 
  • Continued consistency with the three long-term care (LTC) report-only measures 


DHCS mandates that MCPs report their MCAS performance measures annually to assess quality and health equity efforts. Current and prior year MCAS lists can be found on the MCAS section of DHCS’ website.

Use these Statin Therapy Guidelines to Help Your Patients with Cardiovascular Disease 

Cardiovascular disease is the leading cause of mortality in the United States, with 48.6% of American adults (128 million) having at least one form of cardiovascular disease. Several factors contribute to the risk of developing atherosclerotic cardiovascular disease (ASCVD), including elevated low-density lipoprotein (LDL) cholesterol, diabetes, hypertension, cigarette smoking and advancing age.  

 

Multiple clinical trials have demonstrated the beneficial effects of statin therapy for the primary and secondary prevention of ASCVD. In a meta-analysis of 14 randomized trials, statin therapy resulted in a 21% reduction in ASCVD risk for each mmol/L reduction in LDL cholesterol. The American College of Cardiology, American Heart Association and American Diabetes Association recommend statin therapy for the following patient groups: 

 

  • 20–39 years with diabetes and ASCVD risk factors — Consider statin therapy 
  • 40–75 years with diabetes without ASCVD risk factors — Moderate-intensity statin 
  • 40–75 years with diabetes and ASCVD risk factors — High-intensity statin 
  • 75 years or younger with ASCVD — High-intensity statin 

 

The National Committee for Quality Assurance promotes the importance of statin therapy through two Healthcare Effectiveness Data and Information Set (HEDIS) quality measures: 

 

  • Statin Therapy for Patients with Cardiovascular Disease (SPC): Percentage of males ages 21 to 75 years and females ages 40 to 75 years with clinical ASCVD who were prescribed a high-intensity or moderate-intensity statin and at least 80% adherent in the treatment period. 

 

  • Statin Therapy for Patients with Diabetes (SPD): Percentage of members ages 40 to 75 years with diabetes and without clinical ASCVD who were prescribed a statin of any intensity and at least 80% adherent in the treatment period. 

 

How can I help improve performance? 


  • Code for exclusionary diagnoses in a timely manner (annually at a minimum). 
  • Consider the following formulary statins for your patients and evaluate medication adherence: 

 

  • Low-intensity statins (lowers LDL by less than 30%): lovastatin 20 mg, pravastatin 10 mg, pravastatin 20 mg, simvastatin 10 mg. 


  • Moderate-intensity statins (lowers LDL by 30%–49%): atorvastatin 10 mg, atorvastatin 20 mg, lovastatin 40 mg, pravastatin 40 mg, pravastatin 80 mg, rosuvastatin 5 mg, rosuvastatin 10 mg, simvastatin 20 mg, simvastatin 40 mg.  


  • High-intensity statins (lowers LDL by 50% or greater): atorvastatin 40 mg, atorvastatin 80 mg, rosuvastatin 20 mg, rosuvastatin 40 mg. 

 

Exclusions 


Members with the following conditions are excluded from the statin therapy measures. For exclusions, use the appropriate ICD-10-CM code. Unless otherwise specified, all conditions are excluded from both the SPC and SPD measures.  


  • Pregnancy and/or lactation: Over 1,000 ICD-10-CM codes 
  • Prediabetes or other abnormal glucose (exclusion for SUPD only): R73.03, R73.09 
  • Polycystic ovarian syndrome (exclusion for SPD only): E28.2 
  • End-stage renal disease: I12.0, I13.11, I13.2, N18.5, N18.6, N19, Z91.15, Z99.2 
  • Cirrhosis: K70.30, K70.31, K71.7, K74.3, K74.4, K74.5, K74.60, K74.69 
  • Myalgia (exclusion for SPC only): M79.10–M79.12, M79.18 
  • Myositis: M60.80, M60.819, M60.829, M60.839, M60.849, M60.859, M60.869, M60.879, M60.9 
  • Myopathy: G72.0, G72.89, G72.9 
  • Rhabdomyolysis: M62.82 

 

Members are also excluded if they had any of the following during the measurement year: 


  • Hospice or palliative care 
  • In vitro fertilization  
  • Dispensed at least one prescription for clomiphene  
  • Dialysis
Monthly Notices

APLs

On September 18, DHCS distributed All Plan Letter (APL) 24-013: Managed Care Plan Child Welfare Liaison to MCPs. This APL clarifies the intent and objectives of the MCP Child Welfare Liaison, formerly referred to as the Foster Care Liaison, as outlined and required by the 2024 MCP Contract. 

Policies and Procedures Monthly Update

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during October 2024. The full description of the policies below is available on CalOptima Health’s website at:

www.caloptima.org/en/ForProviders/Resources/ManualsPoliciesandGuides.aspx.


Policies and Procedures Monthly Update

Health Education: Trainings and Meetings

Click below for training webinars and meetings happening in December 2024:


Health education webinars

Policy Code Update

Based on Medi-Cal Bulletin and NewsFlashes, CalOptima Health has updated the procedure codes and other relevant information for the subjects listed below: 

 

  • Correction: EWC Core Program Performance Indicators Table 
  • CPT Code 87521: New CLIA-Waived Test 
  • Minimum Age Requirement Adjusted for Respiratory Syncytial Virus Vaccine 
  • JYNNEOS Vaccine Reimbursement 
  • Policy Update for CPT Code 90661 
  • Age Requirement Removed from Remote Physiologic Monitoring Codes 
  • Use of the Rates Table for Physician Administered Drugs 
  • Provider Manual Revisions 
  • Aid Code 50 Language Update 
  • November 2024 Updates to CARC and RARC Codes in the RAD Repository 
  • 2025 Whole Child Model Transition 
  • 2024–2025 FFS Updates to List of Contracted Tracheostomy Supplies 
  • Local Educational Agency Billing Option Program Withholds Update 
  • Notification: DRG Payment System Update to Hospital Acquired Condition V42.0 After October 1, 2024 
  • SNF WQIP Updates to Select Technical Program Guides and Long Stay Measure 
  • Justice-Involved Reentry Initiative: Claim Submission and Services Update 
  • Update: Alternative Payment Methodology for FQHC 
  • Transition to New Family PACT Portal in January 2025 
  • Revision to Billing Requirements for Select Abortion CPT Codes 
  • Policy Update for CPT Code 90661 
  • Justice-Involved (JI) Reentry Initiative: Updated Q&As for September 2024 Screening Portal Webinars 
  • Justice-Involved (JI) Reentry Initiative: AEVS with New Aid Codes 

 

For detailed information regarding these changes, please refer to General Medicine Bulletin 605, Medi-Cal Program & Eligibility Bulletin 28, Durable Medical Equipment and Medical Supplies Bulletin 590, Local Educational Agency Bulletin 602, and Medi-Cal NewsFlashes from October 25, October 28, October 30, November 1, November 1, November 1, November 5, November 14 and November 15


To access the updated Physician Administered Drug Prior Authorization List (PAD PA List), please refer to: www.caloptima.org/en/ForProviders/ClaimsandEligibility/PriorAuthorizations.aspx.

Upcoming Meetings
  • CalOptima Health Board of Directors: December 5 at 2 p.m.
  • Joint Meeting of the Provider and Member Advisory Committees: December 12 at Noon


All meetings have an option for virtual attendance. Visit the CalOptima Health website for more information.

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For Questions
Please contact Provider Relations at 714-246-8600 or at providerservicesinbox@caloptima.org
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