On behalf of all of us at CalOptima Health, thank you for your valuable contributions over the past year. We look forward to working together in 2024 to meet the health care needs of our members and wish you a happy, prosperous and healthy New Year! |
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Medi-Cal Now Covers All Californians Regardless of Immigration Status |
Beginning January 1, 2024, California law allows adults ages 26 through 49 to qualify for full Medi-Cal regardless of immigration status. This latest expansion of Medi-Cal means that all Californians now have access to coverage; prior expansions extended coverage to undocumented children, young adults and people over 50.
Individuals whose immigration status previously limited their access to full Medi-Cal will be automatically transitioned from what’s known as restricted Medi-Cal, which only covered them in emergencies. CalOptima Health anticipates approximately 50,000 members will join the health plan in the new year through this transition. Over time, additional Orange County residents may join as they learn about the expanded eligibility.
To check their eligibility for full-scope Medi-Cal coverage, your patients can call the County of Orange Social Services Agency (SSA) at 1-800-281-9799.
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2024 Report to the Community Highlights Focus on Member Health |
CalOptima Health has released our 2024 Report to the Community, which highlights our accomplishments during 2023, our programs and their impact on Orange County, all tied together with the theme “Your Health Is Everything to Us.”
The 2024 Report is divided into six sections, each dealing with a different aspect of keeping our members healthy: access to care, community, support services, preventive care, food and housing, and mental well-being. Individual stories cover the success of our pilot Street Medicine Program in Garden Grove, a CalFresh campaign targeted to food-insecure members, investments in our new Comprehensive Community Cancer Screening and Support Program, and the implementation of all 14 Community Supports and other aspects of California Advancing and Innovating Medi-Cal (CalAIM). Also included is information about the growth of CalOptima Health, our leadership and financials.
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$10 Million Grant Funding Available for Health Care Workforce Development Initiatives |
As the next step in our effort to address the shortage of health care workers in Orange County, CalOptima Health is offering $10 million in grant funding for education initiatives that will increase the number of students entering health professions. Educational institutions and partnerships between educational institutions and provider organizations are invited to apply for funding for eligible projects such as:
- Pipeline programs from high school to higher education focused on health care professionals with a commitment to serve Orange County
- Stipend programs for low-income students and students from underrepresented populations to participate in health care programs with a commitment to serve Orange County
- Stipend programs for recruiting students into health care professions experiencing shortages
- Expansion of existing trainings or programs to additional cohorts in areas of workforce shortage
- Investments to expand clinical rotations to a greater number of students
- Investments to develop and recruit faculty among health care professions
This initial funding is part of the five-year $50 million Workforce Development Fund approved by CalOptima Health’s Board of Directors in June. A second round of grant funding focusing on investments in workforce development innovation will be made available later in the year.
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Important Cancer Screening and Support Information Now Available on New Website |
CalOptima Health has launched a Comprehensive Community Cancer Screening and Support program with the goal of lowering late-stage breast, cervical, colorectal and lung cancer diagnoses in Orange County. As part of this effort, we have created a companion Cancer Screening and Support page on our website to improve member awareness and education. This page will eventually feature tailored cancer screening and support resources for CalOptima Health members including:
- Screening guidelines
- Benefits of early detection
- Screening health rewards
- Videos, fact sheets and descriptions of common screening processes
- What to expect at screening appointments and how to prepare for screenings
- Benefits and coverage for preventive screenings
- Resource and steps members can take based on their results
Webpage content will also be available in Arabic, Chinese, Farsi, Korean, Spanish and Vietnamese. Some sections are currently live, with the full website expected to launch before the end of the month.
For more cancer screening information and support, members can call CalOptima Health Customer Service toll-free at 1-888-587-8088 (TTY 711), Monday through Friday, from 8 a.m. to 5:30 p.m. We have staff who speak their language.
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Modivcare to Be Sole Transportation Benefit Vendor Starting in April |
To continue providing high-quality transportation benefits for our Medi-Cal and Medicare members, CalOptima Health has elected to contract with a single vendor, Modivcare Solutions. Effective April 1, 2024, all Non-Medical Transportation (NMT) and Non-Emergency Medical Transportation (NEMT) services for CalOptima Health members will be handled by Modivcare.
Your patients’ transportation benefits are not changing because of this transition, and the process of arranging NMT or NEMT services will remain the same. To schedule transportation, Medi-Cal patients should call 1-833-648-7528 and OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, patients should call 1-866-612-1256.
If your patients already have trips scheduled after April 1 with another transportation service, that information will be relayed to Modivcare without your patients needing to take any action.
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CalOptima Health Has Transitioned to One-Level Claims Process |
Important reminder: Effective January 1, 2024, CalOptima Health has transitioned to a single internal review for claim disputes for the CalOptima Health Community Network (CCN) and other claims where CalOptima Health has financial responsibility.
The process is handled through our Grievance and Appeals Resolution Services (GARS) department. This one-level internal review streamlines our procedure by providing a fast, fair and cost-effective dispute resolution mechanism to process and resolve contracted and non-contracted provider disputes. It will also reduce the timeframe for providers to receive a final decision from CalOptima Health.
This change does not impact claim payments from CalOptima Health-contracted health networks or the provider dispute processes of those networks. For disputes related to a CalOptima Health-contracted health network’s claim payment, a provider must submit the dispute to the appropriate health network. If the provider is not satisfied with the health network’s decision, they may then submit a request for a second-level review by GARS.
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Providers Must Report Certain Communicable Diseases or Conditions |
All CalOptima Health-contracted providers must report to a local health officer any suspected case of certain communicable diseases or conditions listed by the California Department of Public Health (CDPH). If there is no provider at the office or laboratory at the time of a suspected case, any individual working at the office or laboratory who has knowledge of the suspected case should make the report.
To see the list of reportable communicable diseases or conditions, as well as reporting timeframes and methods, please see the CDPH’s website.
Suspected case reports can also be sent to:
Orange County Local Health Department
P.O. Box 6128
Santa Ana CA 92706-0128
Phone: 714-834-8180
Fax: 714-834-8196
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Prenatal Vitamins Are a Covered Medi-Cal Benefit |
CalOptima Health encourages all providers who care for pregnant members to prescribe prenatal vitamins. Pregnant members should take prenatal vitamins and supplements throughout pregnancy and breastfeeding, as they provide extra nutrients to support a healthy pregnancy and growing baby. Prenatal vitamins are a covered benefit for Medi-Cal members.
On May 1, 2023, Medi-Cal Rx made changes to its over-the-counter (OTC) prenatal vitamin policy to create easier access to prenatal vitamins. These changes included removing restrictions and ingredient descriptions. However, prescriptions are still required to obtain prenatal vitamins through Medi-Cal Rx.
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Help Remove Barriers to Doula Support Services for Medi-Cal Members |
As of January 1, 2023, doula services are a covered Medi-Cal benefit for pregnant and postpartum members. Providers, hospitals and birthing centers must ensure there are no barriers for members using doula services for prenatal visits, labor and delivery support, and postpartum visits, regardless of outcome (stillbirth, abortion, miscarriage or live birth).
Doula services can enhance medical services by providing emotional support, providing physical comfort measures, and helping with communication and decision-making. Research shows that doula services prevent perinatal complications and improve health outcomes for mothers and infants. Doula services do not impact allowable claims and encounters made by any other Medi-Cal provider. For questions regarding doula services for CalOptima Health members, please contact doula@caloptima.org.
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Review Changes to CalEVV that Might Affect Your Office |
On December 8, DHCS informed managed care plans (MCPs) of changes to the California Electronic Visit Verification (CalEVV) that went into effect on January 1, 2024. These changes added services and removed others to remain in compliance with federal and state requirements.
CalEVV services have been updated for the following programs:
- Multipurpose Senior Services Program (MSSP) 1915(c) Waivers
- Home Health Care Services (HHCS) — MCP and fee-for-service (FFS)
- Home and Community-Based Alternatives (HCBA)
Providers who use CalEVV for these programs can access the updated service codes using this document.
Impacts of these changes on individual provider officers include:
- Office staff need to update their client-payer records prior to service delivery
- New Healthcare Common Procedure Coding System (HCPCS) codes for MSSP, HCBA and Home Health Agency (HHA) services have been added
- Caregivers logging visits for these programs using CalEVV must now choose the new services
- Existing MSSP Z codes have been removed and replaced with new HCPCS codes and units
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Providers Cannot Balance Bill Medi-Cal and OneCare Members |
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Providers are reminded that federal and state law prohibits balance billing Medi-Cal and OneCare members. Medi-Cal members should not pay — including co-pays, co-insurance or deductibles — for physician visits or other medical care when they receive covered services from a provider in their provider network.
DHCS reviews billing practices as a component of the Annual Medical Audit, and a violation of billing practices may lead to enforcement actions, including sanctions. Additional information can be found in section H14: Member Billing Restrictions within the CalOptima Health Provider Manual.
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Webinar to Cover How to Incorporate Teach-Back Method for Better Patient Communication |
Providers can earn 1.5 continuing medical education (CME) and continuing education (CE) credits by attending a webinar discussing how health care professionals can improve patient interactions using the teach-back method.
The Zoom webinar, held from Noon–1:30 p.m. on January 31, 2024 will provide information on how to effectively use this communication tool, which can lead to improved patient comprehension, better treatment adherence, a reduction in the need for follow-up calls and a decrease in appointment cancellations.
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DHCS Distributes MY 2024 MCAS Measures |
On November 29, 2023, DHCS distributed to MCPs the Managed Care Accountability Set (MCAS) of measures for Measurement Year (MY) 2024/Reporting Year (RY) 2025, which can be found here.
MCAS is a set of performance measures that DHCS selects for annual reporting by MCPs to assess quality and health equity efforts. Prior year MCAS lists can be found here.
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Schedule 2024 Annual Wellness Visits With Your Patients |
With the start of the new year, providers seeing CalOptima Health Medi-Cal and OneCare patients should begin scheduling annual wellness visits (AWV) and chronic condition management visits for 2024.
AWVs and chronic condition management visits can be done in one or multiple face-to-face visits during the calendar year. Providers should review, evaluate, address, document and report the members’ chronic condition status and treatment plan for the year. Any chronic conditions marked as “present” must be supported in your documentation. Please identify, address, document and report patients' social determinants of health as contributing risk factors for chronic conditions. Providers should also update a member’s medical/surgical history, social history, medication review, family history, allergies, etc.
For Medi-Cal AWVs, please download, complete and upload your attestation with your supporting progress notes to the CalOptima Health Provider Portal. For OneCare attestations, please fax the supporting progress notes with your completed attestation form to the number at the top of the attestation form.
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Policies and Procedures Monthly Update |
Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during December 2023. The full description of the policies below is available on CalOptima Health’s website at:
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Health Education: Trainings and Meetings |
Click below for training webinars and meetings happening in January 2024:
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Based on Medi-Cal Bulletins and NewsFlashes, CalOptima Health has updated the procedure codes and other relevant information for the subjects listed below:
- Whole Child Model Expansion
- Medi-Cal Provider Portal Upcoming Rebrand
- 2023 HCPCS Quarter 4 Update
- New and Updated Every Woman Counts Benefits
- Medi-Cal Benefit Given to Category III Codes for Radiology
- Code 0352U Changed to Medi-Cal Benefit
- Provider Manual Revisions
- Specific Medical Supply Codes Not Reimbursable with Ventilator Rentals
- Federally Mandated Medicare Economic Index Percentage Increase
- Important Reminder for LTC Providers about Medi-Cal Asset Limit Changes
- LTC Code and Claim Conversion: TAR, Crossover and Claim Completion Instructions
- Ages 26 Through 49 Adult Full Scope Medi-Cal Expansion
- Multipurpose Senior Services Program: Code Conversion Webinar
- Medi-Cal COVID-19 PHE Audits for Freestanding Skilled Nursing Facilities
- Services Covered Under PE4PW
- Updated to the Transition to New CalHEERS Family PACT Portal
- Notification: DRG Payment System Update to Hospital Acquired Conditions V41.0 after October 1, 2023
For detailed information regarding these changes, please refer to: Medi-Cal Program & Eligibility Bulletin 16, General Medicine Bulletin 593, Durable Medical Equipment and Medical Supplies Bulletin 578, Clinics and Hospital Bulletin 590, Long Term Care Bulletin 561, and Medi-Cal NewFlashes from October 17, October 18, October 23, October 30, October 31 and December 14.
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- CalOptima Health Board of Directors: February 1 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory committees: February 8 at Noon
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Follow Us on Social Media |
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CalOptima Health regularly posts on social media to engage members with health tips, community resources, event dates, program updates and other pertinent information. Follow the agency on Facebook, Instagram, X and LinkedIn.
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CalOptima Health, A Public Agency www.caloptima.org
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