We are committed to caring for all our members, regardless of immigration status. As part of that commitment, we have added a new Access to Care page to our website. This new page rounds up information on virtual care options and immigration resources for members to use during challenging times. In-person health services may be difficult for some members, so we are encouraging providers to offer virtual care if feasible.

Resources on this webpage include:

• Virtual Care Options — Search tool for primary care providers (PCPs) who offer telehealth options to reduce transportation and scheduling barriers
• 24/7 Nurse Advice Line — Professional nursing support that members can use for symptom assessment and care guidance
• Medicine Home Delivery — Home delivery pharmacy services for Medi-Cal and OneCare (HMO D-SNP), a Medicare Medi-Cal plan, members
• Virtual Mental Health Services — Our 24/7 behavioral health line, a search tool for behavioral health providers, virtual visits through TeleMed2U, and the BrightLife and Soluna apps for kids, teens and young adults
• Immigration Resources — Information on free legal services, support organizations, state-sponsored resources and a Know Your Rights toolkit
• Letter — A letter to members approved by the Department of Health Care Services (DHCS) summarizing the recent news regarding the sharing of immigration data

Additionally, we have shared online and will mail to our members this letter discussing these resources, the importance of continuing to seek health care and the privacy of our members' information.

Please share these resources with your patients so they know their options. Together, we can ensure everyone has access to the care and support they need.

Later this month, providers will receive an emailed invitation to complete the CalOptima Health Member and Population Health Needs Assessment Provider Survey. This survey will take less than 10 minutes to complete, and your answers will help us better understand the services our members need and use. NORC at the University of Chicago will send the email invitation from the account mphna2025@norc.org. 

Your input is critical to shaping programs that support the entire CalOptima Health community. All answers will be kept anonymous. Thank you for participating in this survey and helping us provide the best possible care to our members.

We continue to prepare for the launch of a Covered California line of business, effective January 1, 2027. With approval from the CalOptima Health Board of Directors, staff submitted on June 16 the initial filing to expand the scope of our current Knox-Keene Act license with the California Department of Managed Health Care (DMHC). This officially initiates the DMHC license material modification, which is required to offer a commercial insurance product.

Effective January 1, 2025, California became a Medicare Part A Buy-in State, meaning that Medi-Cal members who only had Medicare Part B in 2024 automatically received premium-free Medicare Part A.

Moreover, members receiving Supplemental Security Income/State Supplementary Payment (SSI/SSP) were automatically enrolled as Qualified Medicare Beneficiaries (QMBs), which means the state pays for their Medicare Part A premiums. Non-SSI/SSP members received notices that they could apply to become QMBs. According to DHCS, approximately 100,000 members are included in this transition. Our OneCare Sales and Marketing team is reaching out to these members about our 2025 OneCare plans and the benefits of joining a D-SNP plan.

As a reminder, because the QMB program pays for members’ Medicare Part A and Part B premiums, copays and deductibles, providers cannot bill these members for those costs.

To assist providers and members, DHCS prepared this FAQ regarding this transition. If you have any further questions, please reach out to your Provider Relations representatives at 714-246-8600 or providerservicesinbox@caloptima.org.

SUN Bucks, a summer food program, also known as the summer EBT program, is back. The program provides $120 for each eligible child for groceries during the summer. Eligible families will get SUN Bucks on an S-EBT card mailed to their home this summer. Most eligible families do not need to take any action, as children who qualify for free or reduced-price school meals through a school meal application or an alternative income form, or who receive CalFresh, CalWORKS, or Medi-Cal, are automatically enrolled. Children who are not automatically enrolled for SUN Bucks can apply for free or reduced-price school meals by completing and submitting a school meal application or alternative income form by September 2, 2025. Families can obtain these applications from their school or school administrator's office. To learn more about the SUN Bucks program, you can visit the CDSS website and download flyers in English and Spanish here.

Hypertension is the second most common condition among our members. Managing blood pressure at home helps improve long-term health outcomes. We fully cover blood pressure monitors for members through either the Medi-Cal Rx pharmacy benefit or the medical benefit via Durable Medical Equipment (DME) vendors. No prior authorization is needed if a monitor hasn’t been issued within the past five years.

Members have two options for ordering a blood pressure monitor:

• Option A: Through a Medi-Cal Rx pharmacy
• For Medi-Cal and OneCare members, submit a prescription to a Medi-Cal Rx-contracted pharmacy.
• Option B: Through a DME vendor
• Health network members: Follow the network’s specific DME process.
• CalOptima Health Community Network (CHCN) members: Submit a prescription to a CalOptima Health-contracted DME vendor.

Prescription Requirements:

To avoid delays, ensure your prescription includes:

• Member information: Full name, date of birth, client index number (CIN), address, phone number and diagnosis code (e.g., hypertension)
• Provider information: Full name, contact information, date of service and signature
• Equipment information: HCPCS: A4670-NU (Auto BP Monitor), specified cuff size and member’s needs

Where to Submit Prescriptions:

Some pharmacies and DME vendors that ship directly to members’ homes include:

• A1 Care Pharmacy: Phone: 714-541-3900; fax: 714-541-3901
• ProCare Pharmacy: Phone: 714-899-1111; fax: 714-784-5445
• Homedical Inc. (DME): Phone: 714-438-2230; fax: 714-438-2233
• SG Homecare (DME): Phone: 949-474-2050; fax: 949-474-4460

You can find a complete list through Medi-Cal Rx or our Provider Directory.

Important Reminders:

• Medi-Cal Rx covers one blood pressure monitor every five years. Prior authorization is required for replacements in less than five years.
• Qualifying diagnoses for a free blood pressure monitor include:
• Hypertension (including gestational hypertension and preeclampsia)
• Heart disease
• Chronic kidney disease
• Hypertensive crisis
• Diabetes or obesity (as part of an intensive lifestyle program)

Resources and Support:

Free hypertension posters and support are available for providers. Please select your poster choice or desired service by completing the CalOptima Health: Provider Resources & Support Request Form. Our Equity and Community Health department offers services including hypertension management support, continuing education training, member health education classes, coaching, materials and resources. Complete the form to make your request.

Providers are invited to attend the last installment of the CalOptima Health-sponsored Creating Health Bootcamp series from UC Irvine’s Susan Samueli Integrative Health Institute.

The next session, “Health & Wellness: What That Really Means,” will be held via Zoom on July 9, 2025, at Noon. Theresa Nutt, BSN, HNB-BC, NBC-HWC, Administrative Director of Education for the Samueli Institute and a board-certified health and wellness coach, will be the featured speaker.  

The Creating Health Bootcamp virtual seminar series is open to all Orange County physicians and other clinicians. Providers will receive one CME credit for attending. To register, please visit SSIHI’s Creating Health Bootcamp website. For questions regarding this seminar or others in the series, please contact ssihieducation@hs.uci.edu. 

DHCS released an Impact Update on BrightLife Kids and Soluna, two free virtual behavioral health services platforms available to all California children, youth and families through the Children and Youth Behavioral Health Initiative. The update highlights significant growth in user adoption and the use of coaching and referral services, as well as testimonials from users. As of May 2025, more than 319,000 youth and families have used the apps, more than 62,000 coaching sessions have been completed, and more than 70% of users consider it their first and only source of professional mental health support.

CalOptima Health encourages providers to explore the BrightLife Kids and Soluna outreach toolkits, which include posters, videos and social media content, to promote the services among their patients.

On January 30, 2025, DHCS announced to managed care plans (MCPs) that the Centers for Medicare & Medicaid Services (CMS) approved the Public Provider Ground Emergency Medical Transportation (PP-GEMT) Program Calendar Year (CY) 2024 State Plan Amendment (SPA 24-0002).

This amendment increases the CY 2024 add-on to $1,049.98, which will be applied in addition to the Medi-Cal fee-for-service rate for eligible GEMT transports provided by public providers. SPA 24-0002 can be viewed on the DHCS State Plan page here.

MCPs, like CalOptima Health, are required to retroactively adjust eligible PP-GEMT claims starting on January 1, 2024, to reflect the increased add-on amount if prior reimbursements were not already made at the updated add-on level. DHCS expects MCPs to continue reimbursing public GEMT providers for eligible transports using the approved CY 2024 add-on amount until the CY 2025 PP-GEMT add-on is approved by CMS. That add-on, found in SPA 25-0002, includes an updated add-on amount and is tentatively scheduled for submission to CMS during the first quarter of CY 2025. The CY 2025 SPA public notice with the proposed add-on increase is located here.

The PP-GEMT website will be continuously updated with approved reimbursement amounts (the CY 2024 update is currently pending) and includes a list of California public GEMT providers, most recently updated as of December 20, 2024.

The DHCS PP-GEMT Program was implemented in January 2023 to provide increased reimbursements through an add-on increase for non-contracted emergency medical transports provided by eligible public GEMT providers.

Effective July 1, 2025, members enrolled in OneCare who receive Medi-Cal wraparound benefit services through CalOptima Health transitioned to receiving these services directly from their designated health network.

Medi-Cal wraparound services refer to specific benefits and services covered by Medi-Cal that are not included under Medicare but are available to dual-eligible members enrolled in OneCare. Medi-Cal serves as the primary payer for these additional services. The service categories include incontinence supplies, DME, non-emergency medical transportation (NEMT) and hospice.

CalOptima Health will continue to process all carved-out services, including Community-Based Adult Services (CBAS), Long-Term Care (LTC), CalAIM Community Supports and transplants.

This transition is designed to ensure seamless coordination of Medi-Cal and Medicare benefits, as required by DHCS, for members enrolled in OneCare.

The transition includes:  

• Streamlined care coordination: Health networks will now be responsible for reviewing, authorizing, coordinating care and paying claims for Medi-Cal wrap-around benefits services.
• Reduced provider confusion: Providers will no longer need to submit claims to multiple payers.
• Faster service delivery: Eliminating delays in authorization helps reduce member abrasion and ensures timely access to the services needed.
• Enhanced member experience

To avoid unnecessary delays and denials, we remind providers to follow the correct procedures when submitting claims, disputes, corrected claims, retrospective authorization requests and government claims.

Claim Submissions — When submitting your initial claim, include all relevant information, such as invoices, medical records, progress notes and reports. Complete documentation ensures appropriate claim processing and helps avoid the need to submit a provider dispute, which can delay payment.

First-Level Health Network Provider Dispute Resolution and Post-Service Authorization Appeal Process — All health network claim disputes and retro authorization appeals must be submitted to the delegated health network responsible for claims processing and authorization review. Only after the health network has reviewed and responded — and if you still disagree with the decision — should a second-level health reconsideration request be submitted to us. Submitting disputes or appeals directly to us without prior review by the health network may lead to delays or rejections. For more information and timely filing deadlines, please contact the health network that processed your claim or authorization.

Corrected Claims — Do not submit corrected claims through the CalOptima Health Provider Dispute Resolution (PDR) process. This includes missing documentation from the initial claim submission, such as the primary carrier’s Explanation of Benefits (EOB). Use the correct claim frequency code and clearly indicate the correction being made. Incorrect routing or incomplete submissions may result in processing delays or denials. For instructions and timely filing deadlines, please refer to CalOptima Health’s Provider Manual.

Retrospective Authorization Requests — These requests must be submitted directly to our Utilization Management (UM) department, along with an Authorization Request Form (ARF) and complete medical records. Submit requests within the required timeframe following the date of service. Do not submit retrospective authorization requests through the PDR process, as this may cause processing delays or denials. For more information on criteria and deadlines, please refer to UM’s section of the Provider Manual and Policies located on our website.

Government Claims — If a provider disagrees with the final determination from a first-level CalOptima Health PDR, they must file a Government Claim in accordance with CalOptima Health Policy AA.1217. Once a final decision is made, do not submit a second-level PDR. Follow the instructions in the Grievance and Appeals (GARS) resolution letter to ensure timely and appropriate handling. Adhering to these guidelines will help avoid unnecessary delays or denials.

On June 5, 2025, DHCS provided guidance to MCPs regarding forthcoming changes to the 834 enrollment file that go into effect on September 24, 2025.

These changes align the file with current program requirements and streamline data processing. Additionally, MCPs will transition from using the Alternative Format Selection (AFS) website to relying solely on the 834 files for the AFS data, beginning with the October 2025 Month of Enrollment (MOE). The current AFS system will be retired as part of this transition. The existing file layout will be updated to accommodate these changes, and DHCS will send out an updated 834 Companion Guide and further technical details. All MCPs are required to participate in testing.

Key updates and the summary of changes are outlined below.

• MCPs will transition from using the AFS website and receiving the AFS weekly file extract to relying on the 834 files for AFS data, starting with the October 2025 Month of Enrollment (MOE). The current AFS system and related processes will be sunset in alignment with the September 24, 2025, change cycle. An updated APL will be forthcoming.
• The Coordinated Care Initiative (CCI) ended on December 31, 2022. All CCI-related indicators, including CBAS and CCI program flags, will be removed.
• Extended history months (months 13–15) will be removed to maintain consistency in historical data reporting.
• A new Written Language field will be added to support the AFS process, enhancing accessibility and member communication preferences.

• On June 3, 2025, DHCS distributed All Plan Letter (APL) 25-010: Adult and Youth Screening and Transition of Care Tools for Medi-Cal Mental Health Services, which provides guidance to MCPs on standardized, statewide tools to guide referrals to the appropriate Medi-Cal mental health delivery system and timely care coordination for members transitioning between delivery systems. 

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during May 2024. 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 July 2025:

Health education webinars

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

• 2025 HCPCS Quarter 2 Update
• Genetically Handicapped Persons Program Reimbursement Process
• May 2025 CCS Service Code Groupings Policy Update
• Update to Medi-Cal Telehealth Policy for Brief Virtual Communications and Check-ins Using CPT Code 98016
• HCPCS Code J9172 Is Now a Medi-Cal Benefit
• TAR Criteria Update for Select PLA Codes
• Policy Update for HCPCS Code J1756
• Coming Soon: Updated Medi-Cal Coverage for Behavioral Health Treatment Services
• Provider Manual Revisions
• Updated ICD-10-CM Codes for HCPCS Code E3200
• 2025 Pediatric Subacute Facilities Reimbursement Rate Update
• Calendar Year 2024 Clinical Laboratory and Laboratory Services Data Collection
• Notification: DRG Payment System Update to Hospital-Acquired Condition V42.1 on April 1, 2025
• Justice-Involved (JI) Reentry Initiative: Correction for FQHC, RHC, Tribal FQHCs and IHSMOA Clinics
• New Public Fee-For-Service Provider Directory: Action Required
• Medically Necessary Gender-Affirming Care Services Covered for Medi-Cal Members
• National Correct Coding Initiative Quarterly Update for 2025: Quarter 2 MUE Replacement Files
• Reminder: Notice of Election Form Requirement for Medi-Cal Hospice Providers

For detailed information regarding these changes, please refer to General Medicine Bulletin 611, Durable Medical Equipment and Medical Supplies Bulletin 596, Long-Term Care Bulletin 579, and Medi-Cal Newsflashes from April 25, May 2, May 7, May 19 and May 30.

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

• CalOptima Health Board of Directors: August 7 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: August 14 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 the agency on Facebook, Instagram, X and LinkedIn.