CalOptima Health July 2023 Provider Update

July 5, 2023

In This Issue

In this month’s issue of the Provider Update, read how CalOptima Health is giving behavioral health providers more than $14 million in rate increases and temporary supplemental funding.

You’ll find information about a pilot program to support members with diabetes, a webinar discussing Initial Health Appointments and new required Medi-Cal Kids & Teens training.

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

Provider News

Behavioral Health Providers Receive $8.4 Million Rate Increase and $6 Million Supplemental Funding

As behavioral health providers play an essential role in our members’ overall well-being, CalOptima Health approved a second round of rate increases to ensure access to services for Orange County’s vulnerable residents.

On June 1, 2023, CalOptima Health’s Board of Directors approved budgeting $8.4 million for an increase in Medi-Cal fee-for-service rates for both Applied Behavior Analysis (ABA) and non-ABA behavioral health providers. Though the increase will vary by provider type and service, the average increase will be 6.1% for non-ABA services and 7% for ABA services.

The rate increases went into effect on July 1. Please bill using these new rates to avoid unnecessary manual interventions, possible duplicate edits and delays in processing claims.

Separate from the newest rate bump is a 7.5% temporary, supplemental rate increase for services provided between July 1, 2023, and August 31, 2024, that the Board also approved during its June 1 meeting to offer financial support during the transition out of the COVID-19 Public Health Emergency and during the Medi-Cal renewal process.

For questions about these rate increases, please contact our Provider Relations department by calling 714-246-8600 or emailing providerservicesinbox@caloptima.org.

MY 2023 Pay for Value Documents Available on Provider Portal

Providers can access important Pay for Value (P4V) documents for Measurement Year 2023 (MY 2023) via the CalOptima Health Provider Portal.

The May Medi-Cal P4V Prospective Rates report and Member Details files for MY 2023 have been posted to the Provider Portal. The May report includes all claims and encounters data received through April 30, while providers can use the Member Detail files to qualify for MY measures by reaching out to members in need of a screening or intervention before December 31.

Additionally, the MY 2023 Pay for Value Program Manual, which includes all the P4V performance measures from the Department of Health Care Services (DHCS), the Health Network Quality Rating score, and the scoring and payment methodology, has been posted to the Provider Portal.

Providers can continue to monitor their performance on the P4V clinical measures on the monthly CalOptima Health Community Network (CCN) Provider Report Cards distributed via the Provider Portal.

If providers have questions or concerns about their performance to date, they can reach out to the P4V team by emailing p4vprogram@caloptima.org.

CalOptima Health Launching Pilot Diabetes Program

Members with poorly controlled diabetes could be eligible for a pilot program aimed at giving them and their primary care providers (PCPs) more support in controlling this disease.

CalOptima Health is currently seeking applicants for its 12-month Diabetes Care Program. This program offers members access to a clinical pharmacist, health coach and registered dietitian in order to achieve healthier lifestyles while avoiding complications.

To qualify, a member must be enrolled in CCN, be an adult Latino over the age of 21 and have poorly controlled diabetes (an A1c level of 8% or higher).

Interested providers can apply to participate in the pilot program by filling out this form. For more information about the Diabetes Care Program, contact CalOptima Health Medical Director Himmet Dajee, M.D., at hdajee@caloptima.org or Senior Manager of Strategic Programs Joanne Ku at joanne.ku@caloptima.org.

Webinar to Cover Initial Health Appointments

CalOptima Health’s Population Health Management department invites providers to attend a continuing education webinar about Initial Health Appointments (IHAs) at noon on Wednesday, July 12.

The 90-minute Zoom meeting will cover IHA updates, pediatric and adult member requirements, and current requirements for preventive services and screenings. Attendees can earn 1.5 credits of continuing education and continuing medical education.

Please register for the webinar by July 10 using this link. For any questions, email continuingeducation@caloptima.org.

Select Only Contracted Vendors When Ordering Incontinence Supplies

Providers requesting incontinence supplies through the Provider Portal should make sure to select the correct vendors.

No authorization is required for orders that meet the Medi-Cal supply limit if they are requested through one of CalOptima Health’s contracted providers for incontinence supplies. These providers are:

Byram Healthcare Centers
Caremax Pharmacy
Schraders Medical Supply
Shield-California Health Care Center Inc.

If quantities above the Medi-Cal limit are needed, providers need to submit a prior authorization. The proper code for ordering incontinence supplies above the Medi-Cal limit can be found on CalOptima Health’s Medi-Cal Wrap Services Authorization List.

DHCS Requires Provider Training as Part of New Medi-Cal for Kids & Teens Guidelines

As part of new guidance from DHCS, CalOptima Health-contracted providers must complete training every two years for Early Periodic Screening, Diagnostic and Treatment (EPSDT) — known in California as Medi-Cal for Kids & Teens. For its provider trainings, CalOptima Health uses these materials from DHCS’ website.

CalOptima Health is required to submit annually to DHCS a comprehensive training plan that ensures all providers receive this training.

The training standards were part of several updates outlined in All Plan Letter (APL) 23-005: Requirements for Coverage of EPSDT Services for Medi-Cal Members Under the Age of 21, which set out requirements for managed care plans (MCPs), such as CalOptima Health, regarding Medi-Cal for Kids & Teens services.

Other responsibilities for CalOptima Health in the APL include:

Posting DHCS materials and the Medi-Cal for Kids & Teens: Your Medi-Cal Rights letter on CalOptima Health’s website
Mailing DHCS outreach and education materials and Medi-Cal for Kids & Teens: Your Medi-Cal Rights letter annually
Mailing materials to new Medi-Cal for Kids & Teens members within a week of their enrollment
Beginning in 2024, mailing or electronically sharing DHCS materials with existing members annually

Toolkit Instructs on How to Integrate COVID-19 Therapeutics into Health Care After PHE

To assist providers in transitioning from the COVID-19 Public Health Emergency (PHE), the California Department of Public Health has created the California COVID-19 Therapeutics Best Practices Toolkit.

This toolkit contains guidance and recommendations on how to integrate COVID-19 treatments into the full suite of health services. It also contains links to critical resources and highlights actionable steps to achieve five key objectives:

Easy COVID-19 treatment pathways for members
Member engagement in their care
Up-to-date coverage information
Appropriate and equitable access to therapeutics
Readiness for the next COVID-19 surge

DHCS Lays Out Provider Reimbursement Requirements for Emergency Medical Transportation

In January, DHCS provided interim guidance regarding the Public Provider Ground Emergency Medical Transportation (PP-GEMT) program reimbursement requirements. This interim guidance contained several significant updates:

The provider reimbursement requirements associated with the PP-GEMT program went into effect January 1, 2023.
Public providers of GEMT transitioned out of the GEMT Quality Assurance Fee Program and into the PP-GEMT program.
As of January 1, non-contracted public providers of GEMT services are reimbursed at the fee-for-service reimbursement rate, including the add-on increase amount for public providers of GEMT services outlined on Page 2 of the interim guidance.
MCPs are responsible for identifying and satisfying any Medicare crossover payment obligations that result from the increase in GEMT reimbursement obligations described in the interim guidance.

For more information, visit DHCS’ PP-GEMT program website.

Managed Care Accountability Set Measures Available for MY 2023 and Previous Years

On January 1, DHCS shared the Managed Care Accountability Set (MCAS) for the MY 2023/Reporting Year 2024 (RY 2024). The MCAS are performance measures DHCS selects for annual reporting by MCPs. MY 2023/RY 2024 MCAS measures can be viewed on the DHCS website here. MCAS lists from previous years can be found here.

DHCS expects all MCPs to continuously strive to meet and exceed the minimum performance level on all applicable MCAS measures and to continuously improve on all quality measures.

Monthly Notices

All Plan Letters (APLs)

On January 6, DHCS distributed APL 23-001: Network Certification Requirements, along with Attachment A: Network Adequacy Standards, Attachment B: ANC Instruction Manual and Attachment C: Alternative Access Standards (AAS) Request Template. This APL and its attachments provide guidance on the Annual Network Certification requirements and advises MCPs of new requirements for good faith contracting with certain cancer centers and referrals.
On June 9, DHCS sent out APL 23-014: Proposition 56 Value-Based Payment Program Directed Payments. This APL provides MCPs with guidance on value-based directed payments to providers for qualifying services tied to performance on quality measures in prenatal and postpartum care, early childhood prevention, chronic disease management and behavioral health care. This APL supersedes APL 22-019.

Policies and Procedures Monthly Update

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during June 2023. The full description of the policies below is available on CalOptima Health’s website at:

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

Policies and Procedures Monthly Update

Health Education: Trainings and Meetings

Click below for a list of training webinars and links happening in July 2023:

Health education webinars

Policy Code Update

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

May 2023 Update: Discontinuation of the COVID-19 Uninsured Group Program
BCCTP is Resuming Wet Signature Requirement with the End of the COVID-19 PHE
Update Regarding Exemptions from Assembly Bill 97 Payment Reductions
CCS Service Code Groupings Policy Update
Coming Soon: Teleheath Modifiers for FQHC, RHC, HIS-MOA and Tribal FQHC Providers
Rate Update for Contraceptive Vaginal Gel
Cell-Free DNA Screening Rate Updated
Updated Rates for Unclassified Drugs Billed with HCPCS Code J3490
Pasteurized Donor Human Milk Billable with HCPCS codes T2101 and K1005
Medi-Cal Learning Portal — New Secured Email Process
Reminder: Mpox Vaccines and Laboratory Tests are No Longer Family PACT Benefits
Updates to Covered Ostomy Supplies
Virtual Telephonic Communication for FQHC, RHC and Tribal Health Programs Update
Rate Increase for Home- and Community-Based Services Waivers and Programs
Update to LTC Benefit Standardization and Transition of Members to Manage Care
2022–2023 Distinct Part Pediatric Subacute Rates Update

For detailed information regarding these changes, please refer to May General Medicine Bulletin 587, May Durable Medical Equipment and Medical Supplies Bulletin 572, and Medi-Cal NewsFlashes from May 1, May 8, May 9 and May 10.

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

Upcoming Meetings

CalOptima Health Board of Directors: August 2 at 2 p.m.
CalOptima Health Joint Provider and Member Advisory committees: August 10 at 8 a.m.

At this time, 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 heath tips, community resources, event dates, program updates and other pertinent information. Follow the agency on Facebook, Instagram, Twitter and LinkedIn.

For Questions

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