CalOptima Health Rated a Top Medi-Cal Plan in California for Ninth Year |
For the ninth year in a row, CalOptima Health has been rated among the top health plans in the state, receiving 4 stars out of 5 stars in the National Committee for Quality Assurance’s (NCQA) Medicaid Health Plan Ratings 2023. This continued high rating represents CalOptima Health’s sustained leadership in serving nearly 990,000 members or roughly 1 in 3 Orange County residents.
“CalOptima Health is committed to serving members with dignity and respect through its broad network of physicians, hospitals and health care providers,” said Michael Hunn, CEO of CalOptima Health. “We don’t work alone, and we thank our caregiver partners and community clinic providers for their ongoing dedication to quality care. Orange County is fortunate to have such a supportive community focused on improving the lives of CalOptima Health’s low-income and vulnerable population.”
This latest NCQA rating measured performance in 2022 and is based on standardized, audited data regarding clinical performance and member satisfaction. NCQA assesses Medicaid plan quality based on 45 clinical measures, including preventive services to keep members healthy and treatments in response to illnesses and chronic diseases. NCQA also evaluates a plan based on customer satisfaction.
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Providers Can Apply for Equity and Practice Transformation Payment Program |
Primary care providers (PCPs) serving Medi-Cal members enrolled in managed care plans (MCPs) can now apply to receive payments for infrastructure and delivery system improvements through a new program from the Department of Health Care Services (DHCS).
The $700 million statewide Equity and Practice Transformation (EPT) Payment Program aims to:
- Advance equity
- Reduce COVID-19-driven care disparities
- Invest in upstream models/partnerships to address health and wellness
- Fund practice transformation aligned with value-based payment models
To learn more about the program, provider qualifications and how to apply, visit the EPT page on DHCS’ website or email questions to ept@dhcs.ca.gov. Applications to participate in the EPT program are due by October 23, 2023.
CalOptima Health is planning a webinar on the EPT program soon. For more information, please contact the Provider Relations department at 714-246-8600.
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OneCare Annual Election Period for 2024 Begins October 15 |
Attention OneCare providers — The annual election period (AEP) for members to enroll in OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, will open on October 15 and run through December 7.
To be eligible for OneCare, a member must be:
- Age 21 and older
- Living in Orange County
- Enrolled in Medicare Parts A and B
- Receiving Medi-Cal benefits
OneCare supplemental benefits for 2024 include:
- Prescription medicines: Zero co-pays for generic and brand-name medicines throughout the year
- Over-the-counter (OTC) medicines: $100 allowance per quarter to buy online, over the phone or by mail order
- Vision care through Vision Service Plan (VSP) providers: A new pair of eyeglasses or contact lenses every year with a $250 limit
- Hearing services: $1,000 allowance every year for hearing aids above the Medi-Cal limit of $1,510 per year
- Fitness benefits: No-cost gym memberships available at many locations in Orange County, one home fitness kit, access to digital workout videos and much more
- Unlimited transportation: Covered by Medi-Cal to plan-approved medical services, such as doctor visits, labs, X-rays, the hospital or the pharmacy. OneCare members have the supplemental benefit of unlimited transportation to and from the gym
- Worldwide emergency care, urgent care and emergency transportation services outside the U.S.: Services to treat a condition that needs immediate medical care, such as an injury or a sudden medical illness. Members pay for the services, and OneCare will reimburse them up to $100,000 per year
- Companion care: Up to 90 hours of non-medical services per year to help with activities of daily living, such as transportation, light housework, technology, exercise, grocery shopping, medicine deliveries, etc.
- Annual physical examination: One physical exam per year, including laboratory services as needed. The plan pays for one annual wellness visit every 12 months to make or update the member’s care plan to help prevent illness
Dental services are provided through the Medi-Cal Dental program, but not as a supplemental benefit.
- Coverage includes dental exams, cleaning, crowns, root canals and partial dentures with adjustments, repairs and relines
- Up to $1,800 in covered services per year and possibly more if medically necessary or if the member is living in a nursing home.
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CalOptima Health Helps Promote National Latino Physician Day |
This month, CalOptima Health joined the call for more Latino doctors to serve in both Orange County and across the country. We coordinated with the University of California, Irvine, School of Medicine to promote National Latino Physician Day on October 1. The day highlighted the fact that while 39% of California’s population is Latino, only about 6% of U.S. physicians are Latino. Research shows that the disparity can affect health care access and outcomes. To learn more, visit www.nationallatinophysicianday.com.
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Share Your Input on Workforce Development at Upcoming Listening Sessions |
In June 2023, the CalOptima Health Board of Directors approved a $50 million investment toward closing the gap in Orange County’s health care workforce. The CalOptima Health Workforce Development Initiative aims to increase access to quality, equitable care for our members by investing in workforce development initiatives over five years.
We continue to seek stakeholder input to identify workforce shortages and opportunities for grant investments to help increase the health care workforce in Orange County. We are hosting three listening sessions in October to obtain input into the design of the initiative. Please click on the links below to register in advance to share your thoughts at one of these listening sessions:
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Contracted Facilities Must Meet Secure and Timely Information-Sharing Policies |
As required by state policy 42 CFR 422.107(d)(1) and outlined in the DHCS D-SNP Policy Guide, CalOptima Health and its contracted facilities (hospitals and skilled nursing facilities [SNFs]) must comply with secure and timely information sharing by October 31. This will facilitate the coordination of timely Medicare- and Medi-Cal-covered services between settings of care for OneCare members.
To fulfill this requirement, CalOptima Health requires contracted facilities to:
- Use secure email, data exchange through a health information organization or an electronic process approved by DHCS.
- Inform CalOptima Health either immediately, prior to or at the time of any admission, discharge or transfer for all members. E-fax is not permitted under this new information-sharing requirement.
Additionally, CalOptima Health requires contracted SNFs:
- To make notification of an admission, discharge or transfer within 48 hours of all SNF admissions.
- To make notification of transfers or discharges in advance, if possible, or at the time of the member’s transfer or discharge from the SNF.
We also encourage facilities to register with either one or both of our admission, discharge and transfer (ADT) vendors. ADT feeds are automated to CalOptima Health.
CalOptima Health is committed to collaborating with contracted facilities to meet the information-sharing requirements for OneCare members. The options available to your facility are:
- Send notifications via a secure email system
- Register and use the CalOptima Health Provider Portal. A virtual training with additional details will be scheduled in mid-October.
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Orange County Summit Will Tackle Perinatal Substance Use Issues |
Providers are invited to the Orange County Summit: Improving Care for Families Affected by Perinatal Substance Use on October 16 and 17 at the Orange County Behavioral Health Training Center. The two-day, in-person meeting is hosted by the National Center on Substance Abuse and Child Welfare.
Attendees will discuss current county, state and national trends involving families affected by perinatal substance use and conduct multiple working sessions designed to support the goals and objectives of Orange County’s Plans of Safe Care (POSC) initiative.
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Webinar Will Cover Chronic Kidney Disease Topics |
Providers can earn 1.5 continuing medical education (CME) and continuing education (CE) credits by attending a webinar discussing chronic kidney disease (CKD) from Noon–1:30 p.m. on November 2.
The Zoom webinar will provide information about CKD, including its detection, management and complications. The course will also discuss the treatment of risk factors, including diabetes and hypertension, as well as dietary and lifestyle management strategies to prevent the progression of CKD.
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Webinar to Explain Available Grants for Providers |
A webinar hosted by the California Medical Association (CMA) Physician Services will cover two grants supporting providers that are being offered by the state.
The no-cost webinar will be held from 12:15–1:15 p.m. on October 5 and cover the Data Sharing Agreement Signatory Grants and EPT Directed Payments Program. The webinar is open to all physicians, regardless of CMA membership status.
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How Providers Can Prevent Inappropriate Antibiotic Use for Viral Respiratory Conditions |
For the upcoming cold and flu season, CalOptima Health encourages providers to follow clinical recommendations and avoid prescribing antibiotics for acute bronchitis/bronchiolitis, especially for patients who do not have comorbidities.
Clinical guidelines do not support the use of antibiotics to treat otherwise healthy children and adults with a diagnosis of acute bronchitis. Antibiotics are commonly misused or overused for viral respiratory conditions when they are not necessary and won’t help patients feel better.
Misuse and overuse of antibiotics threaten the ability of these medications to treat bacterial infections. According to the Centers for Disease Control and Prevention (CDC), 2.8 million antibiotic-resistant infections occur annually in the United States, which leads to 35,000 deaths.
Improving antibiotic prescribing is important to effectively treat infections, combat antibiotic resistance and protect patients from the harm associated with unnecessary antibiotic use.
Antibiotics only treat certain infections caused by bacteria, such as strep throat (pharyngitis), whooping cough and urinary tract infections (UTIs). Antibiotics do not treat illnesses that are caused by viruses or those that usually get better on their own such as:
- Most sore throats (except strep throat)
- Most cases of bronchitis/bronchiolitis
- Flu or colds
Best practices for prescribing antibiotics include:
- Documenting in the patient’s medical record using the appropriate coding the medical reason for prescribing or dispensing an antibiotic
- Treating patients with chronic bronchitis, chronic obstructive pulmonary disorder (COPD), HIV, cancer or other comorbidities with antibiotics as needed
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Encouraging Medi-Cal or OneCare members to use the CalOptima Health Nurse Advice Line at 844-447-8441. This can serve as a triage system to prevent unnecessary clinical visits for conditions such as a common cold.
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Review Recommendations for Topical Fluoride Varnish for Children |
Young children in their first few years of life are seen earlier and more frequently by a medical provider than by a dentist. Low-income children are at higher risk for early dental decay (cavities) caused by dental caries. Given the prevalence of dental decay, physicians and other qualified health care professionals can play a vital role in a child’s oral health by applying topical fluoride varnish to children in the providers office.
The American Academy of Pediatrics (AAP)/Bright Futures Periodicity Schedule recommends fluoride varnish application at least once every six months for all children and every three months for children at high risk for dental caries, and recommends PCPs apply fluoride varnish in the office for children through the age of 5. The United States Preventive Service Task Force (USPSTF) also recommends applying fluoride varnish to the primary teeth of all infants and children periodically starting at the age of primary tooth eruption through 5 years of age.
CalOptima Health created a summary to guide providers in optimizing their performance with the application of fluoride varnish in the provider office setting. Please view the Topical Fluoride Varnish for Children Measure Guide. This guide outlines the clinical recommendations, reviews appropriate coding to get credit for applying topical fluoride varnish and provides tips to ensure provider success.
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Providers Encouraged to Enroll With CAIR to Meet Regulations |
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On September 12, DHCS provided CalOptima Health with information regarding how providers can comply with the provisions of Assembly Bill (AB) 1797, which aims to improve immunization rates.
Effective January 1, 2023, providers must enter immunizations and tuberculosis (TB) tests they administer, as well as a patient’s race and ethnicity, into the California Immunization Registry (CAIR). This reporting requirement includes newly recommended immunizations, such as:
- Nirsevimab to prevent severe respiratory syncytial virus (RSV) disease for infants and toddlers
- RSV vaccines for adults 60 years and older
Providers and health networks are also required to review the AB 1797 requirements to ensure that all desktops, policies and procedures are in accordance. For more information, see the AB 1797 Immunization Registry FAQs.
Joining CAIR can help providers meet requirements for AB 1797, Medi-Cal and the Vaccines for Children (VFC) program, in addition to saving time, improving patient care, boosting immunization rates and quickly running vaccine reports.
Refer to the How to Enroll in CAIR2 page for guidance on the CAIR2 setup that works best for your practice and contact your local CAIR representative with any questions. If you are not sure if your practice is enrolled or need to update your read-only account to be able to submit doses, contact your local CAIR representative or the CAIR Help Desk at CAIRHelpdesk@cdph.ca.gov or 800-578-7889.
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DHCS Releases Policy and Procedure Review Tools for MCPs |
DHCS will use the following tools to review the policies and procedures submitted by MCPs as required by the 2024 Managed Care Plan Transition Policy Guide for the following Policy Guide Chapters:
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DHCS Clarifies PASRR Screening Guidelines |
Key reminders in this information notice include the following:
- As of May 1, 2023, MCPs are reviewing prior authorization (PA) requests for SNF placement for the following information: Confirmation that the PASRR Level I Screening was completed, whether the Level I Screening result is negative or positive for serious mental illness (SMI) and/or intellectual disability, developmental disability, and/or related conditions (ID/DD/RC), and the PASRR Case Identification.
- MCPs can approve the PA request if the Level I Screening is negative for SMI and ID/DD/RC and the required information is received.
- PASRR documentation is no longer required to be sent to the MCP when a Level I Screening is negative for SMI and/or ID/DD/RC.
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APL Lays Out DME Allowance for Newly Enrolled Members |
CalOptima Health reminds Durable Medical Equipment (DME) providers that, as part of this APL, MCPs, such as CalOptima Health, must allow transitioning members to keep their existing DME rentals and medical supplies from their existing provider for a minimum of 90 days. Additionally, if DME or medical supplies have been arranged for a transitioning member, but the equipment or supplies have not been delivered, the MCP must allow the delivery and for the member to keep the equipment or supplies for a minimum of 90 days. After 90 days, CalOptima Health can reassess the authorization at any time and require the member to switch to an in-network DME provider.
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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 September 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 October 2023:
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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:
- New COVID-19 Vaccine Booster Administration Code is a Benefit for Select Recipients
- Reimbursement Rate for Procedure Code 1494F
- Aid Code Master Chart for Pregnancy Related Aid Codes
- HPE and PE4PW Signature Flexibilities
- Rate Update for HCPCS Code J7304 with Modifier U1
- 2023 Second Quarter Rate Updates for Drugs Billed with HCPCS Code J3490
- Reimbursement Rates for Sleep Apnea, Preventive Medicine and Prolonged Evaluation and Management
- Reminder: Use of the Statement of Citizenship, Alienage and Immigration Status Form
- Provider Manual Revisions
- LTC Code and Claim Form Conversion: Alignment with CalAIM LTC ICF/DD Carve-In Transition
- 2022–2023 Distinct-Part Adult Subacute Annual Rate Update
- HCPCS Code J9297 Policy Update and J9321 Removal
- Reporting Year 2023 Payment Error Rate Measurement Cycle Complete
- 2022–2023 DP/NF-B, Rural Swing Bed and Administrative Day Rate Update
- CCS Service Code Groupings Policy Update
- MCIP Eligible Counties List Updated
- Pfizer-BioNTech Bivalent COVID-19 Vaccine Booster Approved for Children 6 Months Through 4 Years
- Paper and Mail Documents to be Replaced by Electronic Equivalents
- Medi-Cal Providers Website and Access to Transaction Services Update
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- CalOptima Health Board of Directors: October 5 at 2 p.m.
- CalOptima Health Joint Provider and Member Advisory committees: October 12 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 heath tips, community resources, event dates, program updates and other pertinent information. Follow the agency on Facebook, Instagram, Twitter and LinkedIn.
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CalOptima Health, A Public Agency www.caloptima.org
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