We are excited to share that as of January 1, 2026, our Member Health Rewards Program for Medi-Cal members has transitioned to a fully online submission process.

Providers can now upload health rewards forms for their patients who complete important screenings directly at www.caloptima.org/healthrewards, eliminating the need to mail or fax any paper forms with signatures and stamps. This transition helps Medi-Cal members receive their health rewards more easily and quickly. It is also in line with the health rewards for our OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, members, where self-attestation forms are already submitted online.

For 2026, Medi-Cal members can receive between $15 and $50 for taking an active role in their health by completing various preventive screenings or tests. To learn more about member health rewards and how your CalOptima Health patients can take advantage of this program, please visit www.caloptima.org/healthrewards.

The Department of Health Care Services (DHCS) has extended the deadline for required provider compliance trainings, including those on diversity, equity and inclusion in the health care setting, which were originally due by December 31, 2025. All contracted providers now have through December 31, 2026, to complete these trainings. The trainings can be accessed by logging into the CalOptima Health Provider Portal.

The diversity, equity and inclusion curriculum consists of three courses: “Cultural Competency: The Foundation of Equitable Health Care,” “Diversity, Equity, Inclusion, and Belonging,” and “Health Equity Fundamentals.” These trainings adhere to the requirements outlined in All Plan Letter (APL) 24-016.

Please complete these trainings as soon as possible. If you have any questions, please contact our Provider Relations team at providerservicesinbox@caloptima.org.

As of January 1, 2026, CalOptima Health providers are no longer required to request prior authorizations for psychological and neuropsychological testing, as well as second opinions for developmental evaluations.

CalOptima Health Non-Specialty Mental Health Services (NSMHS) include psychological and neuropsychological testing, when clinically indicated to evaluate a mental health condition. However, prior authorization is still required for psychological and neuropsychological testing done for medical purposes to rule out a medical condition (e.g., dementia, Alzheimer’s), and providers should continue to follow the prior authorization request process through either CalOptima Health or their health network.

NSMHS also includes up to two developmental evaluations per calendar year without prior authorization.

General developmental and autism screenings are reimbursable using Current Procedural Terminology (CPT) code 96110. Developmental testing (CPT codes 96112 [limited to one per day] and 96113 [limited to six per day]) is reimbursable when a child exhibits signs of developmental delay or loss of previously acquired developmental skills, or when the results of a developmental screening test are abnormal.

Mental health services are reimbursable for Medi-Cal-eligible recipients when they are reasonable and necessary to protect life, prevent significant illness or significant disability, or alleviate severe pain. Providers of NSMHS must retain a record of the type and extent of each service rendered, as well as the date and time allotted for appointments and the time actually spent with patients, per California Code of Regulations (CCR), Title 22, Section 51476(a) and 51476(f).

We are reminding providers who see OneCare members enrolled in the CalOptima Health Community Network (CHCN) that their eligible patients can access palliative care services through OneCare.

To qualify, CHCN OneCare members must meet all the general eligibility criteria and at least one of the four disease-specific criteria listed below, as determined by DHCS and the Centers for Medicare & Medicaid Services (CMS). 

General eligibility criteria:  

1. The member is likely to, or has started to, use the hospital or emergency department to manage their advanced disease; this refers to unanticipated decompensation and does not include elective procedures. 
2. The member has an advanced illness with appropriate documentation of continued decline in health status and is not eligible for or declines hospice enrollment.  
3. The member’s death within a year would not be unexpected based on clinical status.  
4. The member has either received appropriate patient-desired medical therapy, or it is no longer effective. The member is not in reversible acute decompensation. 
5. The member and, if applicable, the family/member-designated support person, agree to:  

a.     Attempt, as medically/clinically appropriate, in-home, residential-based or outpatient disease management/palliative care instead of first going to the emergency department. 

b.     Participate in advance care planning discussions. 

Disease-Specific Criteria (each disease-specific condition has additional requirements): 

1. Congestive heart failure (CHF) 
2. Chronic obstructive pulmonary disease 
3. Advanced cancer 
4. Liver disease 

OneCare providers can refer and submit an authorization request for patients they feel meet the general requirements and would benefit from this service. Please follow the standard authorization process or submit a request via the CalOptima Health Provider Portal, along with the appropriate clinical documentation. 

As we begin the new year, CalOptima Health encourages providers to prioritize two foundational services that support member health and compliance: the Annual Wellness Visit (AWV) for OneCare members and the Initial Health Appointment (IHA) for Medi-Cal members.

AWV

AWVs are a Medicare-covered service designed to help OneCare members stay on top of their health. These visits support early detection, personalized care planning and preventive screenings. Providers should encourage members to complete their AWV within 90 days of enrollment and annually thereafter.

A complete AWV includes:

• A review of medical and family history
• Medication reconciliation
• Preventive screenings and referrals
• Capturing Social Determinants of Health (SDOH) using Z codes

While we are asking providers to encourage AWVs this year, there is still time to reward members who completed their visits in 2025. Members who submitted the required form will receive a $50 reward loaded onto their OneCare &more flex card if their provider completes an attestation form with supporting documentation by January 31, 2026.

Telehealth visits are acceptable if conducted via real-time audio and video platforms. Providers may also earn a $150 incentive per member per year for submitting the attestation form and ensuring proper documentation of chronic conditions, screenings and diagnosis codes.

IHA

IHAs are required for new Medi-Cal members within 120 days of enrollment. These appointments establish a baseline for care and help identify immediate health needs. While not tied to a direct member incentive, completing an IHA may unlock eligibility for other health rewards, such as for diabetes and breast cancer screenings.

A complete IHA includes:

• Comprehensive physical and mental health exam
• History of present illness, past medical and social history
• Risk assessments, screenings, referrals and health education
• Documentation of member refusals or missed appointments

Providers must use appropriate CPT codes and document all components in the medical record. IHAs are reimbursed and tracked via the Delegation Oversight Committee Dashboard.

Let’s work together to ensure every member, whether Medi-Cal or OneCare, receives timely, thorough preventive care. These visits lay the foundation for better outcomes, stronger provider-member relationships and a healthier year ahead.

Due to concerns and confusion among providers in recent months regarding directives from the federal government on policies affecting care for undocumented populations, the Local Health Plans of California (LHPC) — of which CalOptima Health is a member — the California Medical Association (CMA) and the California Primary Care Association (CPCA) have released a joint provider letter with the latest information and recommendations.

The letter, which you can read here, clarifies the current status of federal rules and the status of legal challenges to the U.S. Department of Health and Human Services’ recent reinterpretation of the public benefit rule.

According to the letter, there are many concerns about the implications of the proposed public benefit rule and its impacts on clinics, providers and the patients they serve. Providers are encouraged to uphold the status quo in providing services for this population if it is legally allowable. The letter also acknowledges the upcoming changes to Medi-Cal eligibility for the undocumented population and efforts to ensure they remain covered.

On December 3, 2025, DHCS provided guidance to managed care plans (MCPs) on producing rates for Quality Incentive Pool (QIP) entities for specific measures in preparation for Calendar Year (CY) 2025 performance reporting in CY 2026. These requirements fall under All Plan Letter (APL) 25-015 and the documents below:

• MCP-Produced Rate Request Letter for “Better of” Measures
• QIP Policy Letter (QPL) 25-004
• MCP reported rates template

As part of the long-term strategic process of transitioning QIP to MCP-produced rates, DHCS expects MCPs to produce rates for QIP entities for specific measures. QIP entities may use the better of the two rates to tie to payment in QIP.

In CY 2024, MCPs were instructed to provide rates for the Follow-Up After Emergency Department Visit for Substance Use (FUA), Follow-Up After Emergency Department Visit for Mental Illness (FUM) and Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) data to their associated QIP entities. If an MCP did not provide CY 2024 data for FUA, FUM and FUI, then baseline data is also needed.

For CY 2025 performance, the MCP-produced rates have been expanded to include seven additional measures:

• Cervical Cancer Screening (CCS)
• Childhood Immunization Status (CIS)
• Immunizations for Adolescents (IMA)
• Chlamydia Screening (CHL)
• Number of Members Enrolled in Enhanced Care Management (ECM)
• Number and Percentage of Eligible Members Receiving Community Supports, and Number of Unique Community Supports Received by Members (COMS)
• Percentage of Acute Hospital Stay Discharges Which Had Follow-Up Ambulatory Visits Within 7 Days Post-Hospital Discharge (FUAH).

These measures will need both CY 2024 baseline (MY24) and CY 2025 (MY25) performance data.

DHCS reaffirmed to MCPs its existing policy regarding referral and authorization processes for CalAIM Community Supports, including Medically Tailored Meals (MTM) and Medically Supportive Food (MSF).

The following principles apply to all Community Supports referrals, whether DHCS Referral Standards are in place:

1. Members, their caregivers or community-based social service providers may self-refer or refer members for Community Supports eligibility. MCPs are required to accept these referrals and meet members at the door. This means promptly acknowledging receipt of the referral and initiating the eligibility determination process without delaying access by requiring clinical documentation upfront from the member or the referring community provider.
2. Placing documentation requirements on members or community providers that delay or prevent timely access to Community Supports constitutes an unreasonable restriction or limitation on the benefit, which is not permitted under DHCS (see APL 21-017, APL 21-011, APL 24-004, APL 25-006 and subsequent guidance).

DHCS guidance includes the following topics: 

• General principles for Community Supports where specific DHCS Referral Standards are not in place or not yet in place. 
• DHCS expectations from MCPs moving forward. 

On September 16, 2025, DHCS posted updated General Medicine and Pharmacy bulletins and a corrected provider bulletin update to the Medi-Cal website. A summary of the updates that impacted CalOptima Health is below:

• Select Ultraviolet Light Therapy Codes Rate Update — Retroactive for dates of service on or after February 1, 2025
• Contracted Advanced Wound Care Supplies in the List of Billing Codes, Units and Quantity Limits Has Been Updated — Dates of service on or after April 1, 2025
• Third Quarter Family PACT HCPCS Code Rate Updates — Dates of service on or after July 1, 2025
• CPT Code 90382 is Reimbursable for Billing Enflonsia — Dates of service on or after July 1, 2025
• Clinical Laboratory Improvement Amendments (CLIA) Waived Test Reimbursement for Pharmacy Providers — Dates of service on or after August 1, 2025
• Justice-Involved (JI) Reentry Initiative: Billing Clarification for CHW Services —September 2025
• Policy Update for HCPCS Code J3490 for FPACT and Medi-Cal Family Planning Programs — Dates of service on or after October 1, 2025
• Cell and Gene Therapy HCPCS Code J3392 New Effective Date — Dates of service on or after October 1, 2025
• Contracted Medi-Cal Fee-For-Service Tracheostomy Supplies — Dates of service on or after October 1, 2025

• On November 13, 2025, DHCS distributed APL 25-016: Alternative Format Selection for Members with Visual Impairments to MCPs, which provides information about DHCS’ processes to ensure effective communication with members with visual impairments or other disabilities requiring the provision of written materials in alternative formats, by tracking members’ Alternative Format Selection (AFS).
• On November 18, 2025, DHCS distributed Revised APL 25-006: Timely Access Requirements, which provides MCPs with guidance regarding the ongoing requirement to meet timely access standards. Additionally, this APL outlines DHCS’ required minimum performance levels (MPLs), which went into effect in Measurement Year (MY) 2025 for the Timely Access Survey.
• On November 18, 2025, DHCS provided MCPs with updated attachments to the following APLs:
• APL 17-020: American Indian Health Program: Attachment 1: List of American Indian Health Program Providers
• APL 21-008: Tribal Federally Qualified Health Center Providers: Attachment 2: List of Tribal Federally Qualified Health Center Providers

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

• Justice-Involved (JI) Reentry Initiative: Behavioral Health Codes Available for Provider Types
• Justice-Involved (JI) Reentry Initiative: Type of Bill 086x for DMC and DMC-ODS Providers
• Justice-Involved (JI) Reentry Initiative: JI Microlearning Videos Section Available
• Fourth Quarter Rate Update for Select Contraceptive HCPCS Codes
• Policy Update for HCPCS Codes Q9996 and Q9997
• Provider Resource: California Child and Adolescent Mental Health Access Portal
• Updates to Intermittent Urinary Catheters and Medical Supplies Billing Codes, Units and Quantity Limits
• Codes 0211U and 0487U Are New Medi-Cal Benefits
• PLA Code 0421U Is a New Medi-Cal Benefit
• TAR and Nonstandard Benefits Clarification
• Clarification on Documentation Requirements for Select Doula Codes
• Important Coverage Update: Effective January 1, 2026, Medi-Cal Will No Longer Cover FDA-Approved GLP-1 Medications
• Provider Manual Revisions
• Update: Medi-Cal Adult Expansion Freeze Begins January 2026
• New PACE Managed Care Plans
• HCPCS Code E0483 Is Non-Taxable
• Update to the List of Contracted Advanced Wound Care Products and the List of Medical Supplies Billing Codes, Units and Quantity Limits
• 2025 Administrative Day, DP/NF-B and Rural Swing Bed Rate Update
• Calendar Year 2025 Distinct-Part Adult Subacute Annual Rate Update
• Long-Term Care Rates Are Available for Calendar Year 2026
• National Correct Coding Initiative Quarterly Update for October 2025: EPC Implementation Date Change
• Prevention of Duplicate Records for the Every Woman Counts Program
• BCCTP Medi-Cal Changes for Individuals Without SIS
• Justice-Involved (JI) Reentry Initiative: FQHC and RHC One-Time Timeliness Override
• Hospital Presumptive Eligibility: New Prescreening Requirement Begins January 1, 2026
• CCMF Update Impacts AEVS Transactions for Medicare Advantage Plan Names

For detailed information regarding these changes, please refer to General Medicine Bulletin 618, Medi-Cal Program & Eligibility Bulletin 41, Durable Medical Equipment and Medical Supplies Bulletin 603, Inpatient Services Bulletin 615, Long Term Care Bulletin 586, and Medi-Cal NewsFlashes from November 20, December 2, December 3, December 5, December 8, December 11 and December 23.

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

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during December 2025. The full description of the policies below is available on CalOptima Health’s website at:

www.caloptima.org/for-providers/provider-resources/manuals-policies-and-guides

Policies and Procedures Monthly Update

Click below for training webinars and meetings happening in December 2025:

Health education webinars

• CalOptima Health Board of Directors: February 5 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: February 11 at Noon

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

CalOptima Health regularly posts on social media to engage members with health tips, community resources, event dates, program updates and other pertinent information. Follow us on Facebook, Instagram, X and LinkedIn.