To improve access to care and the experience of our members and support our long-term strategic goals, we have transitioned members to AltaMed Health Network (AHN) and added Providence Medical Foundation as a newly contracted health network. 

Our Medi-Cal members whose primary care provider (PCP) is an AltaMed Federally Qualified Health Center (FQHC) under the CalOptima Health Community Network (CHCN) have transitioned into AHN. Members transitioned in the following phases: 

• August 1, 2025 — AltaMed Services Santa Ana and AltaMed Services Orange   
• September 1, 2025 — AltaMed Santa Ana Bristol and AltaMed Medical Huntington Beach 
• October 1, 2025 — AltaMed Medical Garden Grove and AltaMed Anaheim  

AHN is responsible for all claims and authorizations for its assigned members as of the date listed above. AHN will honor all open authorizations provided by CalOptima Health for eligible members assigned to AltaMed.  

• Providers should submit authorizations directly to AHN via its fax number, 323-720-5608, or connect.alturamso.com 

• Submit paper claims to:  

AltaMed Health Network  

P.O. Box 7280  

Los Angeles, CA 9002-0980  

• Submit electronic claims to: Office Ally Payer ID AltaMed: ALTAM Change Health (Emdeon) Payer ID 95712 

Providers can contact AHN by calling 855-848-5252 (TTY 800-735-2922) for general questions or by visiting www.altamedhn.com. 

Please note that AHN is staying in CHCN to continue caring for our complex members. There is no change to current authorizations and/or claim reimbursements for complex members. 

Providence Medical Foundation 

On September 4, our Board of Directors approved adding Providence Medical Foundation as our 10th contracted health network. The new Shared Risk Group (SRG) contract with Providence goes into effect on November 1.  

CHCN Medi-Cal members currently assigned to Providence PCPs will continue without a change, unless they request a new provider. Providence will also continue to coordinate the covered services it currently provides to Medi-Cal members.  

Under the new contract, Providence will be responsible for all authorizations, professional claims, diagnostic services such as lab and radiology and Durable Medical Equipment (DME). All other claims should continue to be sent to CalOptima Health.

Key contact information for Providence is as follows: 

• Address: 

Providence Medical Foundation

15480 Laguna Canyon Rd. 

Irvine, CA 92617 

• Claims address: 

Providence Medical Foundation

P.O. Box 10

Anaheim, CA 92815-0010 

• Electronic claims: Office Ally Payer ID STJOE 
• Phone number: 855-359-6323 (TTY 711) 
• Authorization phone numbers: 714-449-4923 (utilization management [UM]), 844-499-0066 (out-of-network inpatient authorizations) 
• Fax: 714-712-3393 (UM), 714-937-6142 (claims), 714-937-7066 (out-of-network inpatient authorizations) 
• Website: providence.org 

If you have any questions, please reach out to our Provider Relations department at 714-246-8600 or providerservicesinbox@caloptima.org.

Attention OneCare providers — The annual enrollment period (AEP) for CalOptima Health OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, opens on October 15 and runs through December 7. If you have patients who are eligible for both Medicare and Medi-Cal, then CalOptima Health OneCare might be the right health plan for them.

To be eligible for OneCare, your patient 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 2026 include:

• Prescription medication — $0 copays for generic medicines and little to no copays for brand-name medicines, depending on the member’s income level. CalOptima Health covers six Sildenafil pills per month. 
• Flex card — $167 allowance per quarter to buy over-the-counter (OTC) and food and produce items in-store, online or over the phone. Members must meet the criteria to use their flex card to purchase food and produce items. To help members qualify, you can fill out and submit the food and produce eligibility form.
• Comprehensive dental (Liberty Dental Plan) — Covers oral exams, removable and fixed prosthodontics, and restorative and adjunctive general services. Medi-Cal dental coverage includes dental exams, cleanings, crowns, root canals and partial dentures with adjustments, repairs, and relines. 
• Vision care — $500 to spend on eyeglasses, contacts and repairs over two years.  
• Hearing services — $500 allowance every year for hearing aids. Medi-Cal may cover up to an additional $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 more. 
• Unlimited transportation — Unlimited trips at no cost to and from your doctor visits, pharmacy and gym. 
• Worldwide urgent, emergency and emergency transport services outside the U.S. — Services to treat a condition that needs immediate medical care, such as an injury or a sudden medical illness. OneCare will reimburse the member up to $100,000 per year.  
• Companion care — Up to 90 hours of nonmedical 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 and lab services as needed. This is in addition to the Annual Wellness Visit covered every 12 months. Both exams may be performed during the same visit, and providers can submit one claim with both codes. 

For more information on CalOptima Health OneCare benefits, your patients can call 877-412-2734 or visit www.caloptima.org/en/ForMembers/OneCare/Benefits.

We are excited to offer a new solution to better support patient continuity of care by facilitating faster and easier access to discharge information for OneCare members.  

What’s new?

• Your practice may have already started receiving direct secure messages (DSMs) containing the patient’s discharge documentation within 72 hours of the inpatient encounter. 
• Contents include the discharge summary, discharge instructions, visit diagnoses and hospital course.  
• Additional encounter details, such as medication history, testing results and procedures, are also available for review. 

Why use it?

• Coordinate faster and have more informed follow-up and medication reconciliation.  
• Help us close the Transitions of Care Star quality measure — improving quality ratings for both our network and your patients.  

What do you need to do?

• Review the secure message contents and record the receipt of discharge information date in the patient’s medical record. 
• File the discharge summary in the patient’s medical record.  
• Schedule patient follow-up visits and perform medication reconciliation.  

If your National Provider Identifier (NPI) number has multiple addresses, please let CalOptima Health know which address should be used for CHCN membership.

Onboarding  

• Ensure your DSM address is accurate and up to date so you can take advantage of this new service and receive discharge documentation into your electronic health record (EHR). 
• Verify your DSM addresses appear in DirectTrust directory searches here.

Additional information regarding DSMs from the Office of the National Coordinator for Health Information Technology can be found here.

If you have any questions or need assistance, please reach out to CalOptima Health at AdministrativeFellowsCMO@caloptima.org. 

Thank you for your partnership in delivering high-quality care to our OneCare members. 

We are reminding our contracted providers that they must ensure their offices update and maintain in their records the following data elements to meet National Committee for Quality Assurance (NCQA) health equity requirements:

1.     Languages Spoken Fluently by Providers: Providers must include all languages other than English in which they can communicate fluently with members regarding medical care.

2.     Race/Ethnicity of Providers: Providers must include race and ethnicity information for all practitioners who provide services to members.

The above elements are critical for supporting culturally and linguistically appropriate services and ensuring equitable care for all members.

The provider Add, Change and Termination (ACT) Form on our website, www.caloptima.org, includes the following:

• A section for indicating the language spoken fluently for communicating about medical care (please mark with an “^” next to the language).
• Information on available language services, such as American Sign Language (ASL), and other interpreter services.
• The race/ethnicity of the provider.

To find the ACT form, navigate to the For Providers section, select Documents and Training, and then click on Common Forms.

If you elect not to use the ACT Form, but have the health equity information listed above, please clearly identify and submit that data via email to provideronline@caloptima.org.

Thank you for your continued partnership and support in advancing healthy equity. If you have any questions, please send them to provideronline@caloptima.org.

We are partnering with the Orange County Health Care Agency (HCA) California Children’s Services (CCS) to host a virtual training on the Whole-Child Model (WCM) Program on October 21 at Noon.

The 60-minute webinar will discuss various aspects of WCM, including case management, private duty nursing, aging out, annual Medi-Cal redetermination and intercounty transfers. Physicians, health network staff and hospital staff are encouraged to attend.

Please register in advance using this Zoom link. For questions about this training or how to register, contact Soledad Arguello at 657-900-1778 or soledad.arguello@caloptima.org.

CalOptima Health and Kaiser Permanente invite you to an in-person training for community health workers (CHWs) and other trusted health messengers to support families in understanding the importance of blood lead screening and prevention.

This training will prepare you to:

• Explain the health impacts of lead exposure in simple, accessible terms
• Build trust and use motivational interviewing to address hesitations
• Guide families through the process of scheduling and completing a blood lead screening
• Connect members to resources like transportation and follow-up care

We’ll use a mix of discussion, real-world scenarios and interactive activities so you leave feeling confident and ready to engage families in meaningful, culturally sensitive conversations.

The details for the training are:

• Date: Wednesday, October 29, 2025
• Time: 9 a.m.–Noon
• Location:

CalOptima Health

505 City Parkway West

Room 107-N (First Floor)

Orange, CA 92868

• Light refreshments will be provided.

RSVP by October 22 to reserve your seat by clicking here. If you have questions, please contact Stefanie Johnson at stefanie.johnson@caloptima.org.

The 2025 guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) introduce a more personalized, risk-based approach to managing hypertension. These updated guidelines prioritize early detection of organ damage, emphasize the use of out-of-office blood pressure monitoring and aim to reduce disparities in care.



Blood pressure (BP) categories are defined as:

• Normal: <120/80 mm Hg
• Elevated: 120–129/<80 mm Hg
• Stage 1 Hypertension: 130–139/80–89 mm Hg
• Stage 2 Hypertension: ≥140/90 mm Hg

A major innovation in the 2025 guidelines is the adoption of the Predicting Risk of Cardiovascular Disease Events (PREVENT) model to estimate 10-year cardiovascular disease (CVD) risks. Unlike older models, PREVENT includes kidney function (estimated glomerular filtration rate [eGFR]), albuminuria, statin use and social deprivation index, offering more accurate risk prediction across diverse populations. This model supports earlier intervention in patients with chronic kidney disease (CKD), even when BP is only mildly elevated. The guidelines recommend routine urine albumin-to-creatinine ratio (UACR) testing at the time of hypertension diagnosis and annual monitoring in patients with diabetes, CKD or elevated BP. The presence of albuminuria (≥30 mg/g) or reduced eGFR (<60 mL/min/1.73 m²) should prompt initiation of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to reduce cardiovascular risk and slow kidney disease progression.

Treatment decisions are based on both BP level and CVD risk. For stage 1 hypertension, medication and lifestyle changes are recommended if the 10-year CVD risk is 10% or higher, or if comorbidities such as diabetes or CKD are present. Stage 2 hypertension always requires medication. For patients with elevated BP or low-risk stage 1 hypertension, lifestyle changes are recommended for three to six months before initiating medication if BP remains elevated. The Prevention of Hypertension in Patients with Prehypertension (PREVER-Prevention) trial further supports early treatment, showing that low-dose diuretics in adults aged 30 and older with prehypertension significantly reduced progression to stage 2 hypertension and end-stage organ damage.

For Medi-Cal members, BP monitors are a covered benefit for those with qualifying conditions such as hypertension, heart disease or diabetes. These can be obtained through a Medi-Cal Rx pharmacy or DME vendor with a complete prescription, supporting home monitoring and long-term control.

To review the 2025 ACC and AHA guidelines, click here.

On September 17, 2025, the Department of Health Care Services (DHCS) distributed Revised All Plan Letter (APL) 25-011: House Resolution (H.R.) 1 - Federal Payments to Prohibited Entities, which provides managed care plans (MCPs) with guidance on handling payments to Medi-Cal and Family Planning, Access, Care, and Treatment Program (Family PACT) providers who may be impacted by H.R. 1. This APL also provides guidance pertaining to a temporary restraining order (TRO) blocking immediate implementation of Section 71113, subsequent preliminary injunctions (PIs) and a recent order to stay the PIs.

Notable updates in this revised APL include:

• Updates on the First Circuit Court of Appeals-issued order staying both PIs that modified the TRO. Providers should hold claims or encounters for all services rendered on or after September 11, 2025. However, abortion claims or encounters should continue to be submitted for dates of service on or after July 4, 2025, in accordance with existing Medi-Cal policies.
• Clarified payment and claims/encounter processing, including which claims should be submitted or held, and exceptions for abortion services.
• Clarified that MCPs should continue to cover services and process claims or encounters for Medi-Cal and Family PACT providers who determine in good faith they do not meet the definition of Prohibited Entity.

On September 4, 2025, DHCS distributed the final version of the adult expansion freeze outreach materials to MCPs, which includes the General Information Notice and FAQs.

These materials support the following:

• Implementation of the Medi-Cal adult expansion freeze for individuals who are 19 years or age and older without Satisfactory Immigration Status (SIS) starting January 1, 2026.
• Elimination of dental benefits for individuals who are 19 years of age and older with Unsatisfactory Immigration Status (UIS) starting July 1, 2026.

These materials will be translated into all threshold languages and alternative formats. For more information regarding these updates, refer to All County Welfare Directors Letter (ACWDL) 25-13.

On August 25, 2025, DHCS informed MCPs of the upcoming end of the Skilled Nursing Facility (SNF) Workforce and Quality Incentive Program (WQIP) via Policy Letter (PL) 25-007. 



Noteworthy updates include: 

• The SNF WQIP sunsets on December 31, 2025, per the State of California’s Enacted Budget for State Fiscal Year 2025–26. 
• The elimination of the SNF WQIP will not impact measurements or payments for Calendar Year (CY) 2025. DHCS is currently measuring performance for CY 2025 and MCPs will issue payments in 2026. 
• For CY 2024, DHCS has already directed MCPs on the Interim Payment Report, with final payment direction planned for later this year. 

On September 15, 2025, DHCS announced that a new sterilization consent form, DHCS 8649, would replace the older form, PM 330, starting October 16.

As part of this change, the agency also relayed the following:

• DHCS will continue to accept the PM 330 form through August 31, 2026, to ensure a smooth transition and to avoid claim denials.
• Starting September 1, 2026, the DHCS 8649 form will be the only form accepted by Medi-Cal for sterilization procedures. Failure to use DHCS 8649 after September 1, 2026, will result in the claim being denied.
• The DHCS 8649 form will be available to download from the DHCS Sterilization Materials page on the DHCS website starting on October 16, 2025, and can also be ordered by calling 1-800-541-5555.

Updated provider manual sections will be released in a future Medi-Cal Update.

• On August 15, 2025, DHCS released Numbered Letter (NL) 03-0825: Low-Protein Therapeutic Foods, which updates guidance on the medical necessity criteria for low-protein therapeutic foods (LPTF) by the CCS Program and Genetically Handicapped Persons Program (GHPP).
• On August 22, 2025, DHCS sent MCPs the following updated attachments:
• 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

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during August 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

• CalOptima Health Board of Directors: October 2 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: October 9 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.