Approved by the Board of Directors, CalOptima Health’s complete FY 2025–2027 Strategic Plan is now available online. The health care landscape in Orange County is evolving rapidly, presenting both challenges and opportunities. These changes require a steadfast commitment to our mission and vision. Our FY 2025–2027 Strategic Plan aims to position CalOptima Health to focus on what matters most — serving our members and strengthening our partnerships with providers and the community so members can live healthier lives.

The FY 2025–2027 Strategic Plan focuses on four key priorities:

• Equity and Population Health — Improving health equity with new technology, annual assessments of members’ health and social needs, and increased access to preventive services for vulnerable populations.
• Quality and Value — Providing the highest quality medical care by expanding behavioral health services, increasing provider engagement, improving access to care and achieving National Committee for Quality Assurance and Centers for Medicare & Medicaid Star ratings goals.
• Community Partnerships and Investments — Continuing our investment in Orange County through Medi-Cal Transformation programs, launching a community collaboration framework, prioritizing health equity community investments, and ensuring all investment programs have clear metrics and regular monitoring.
• Operations, Finance and People — Investing in our health plan’s performance by improving turnaround times for authorizations and claims payments, optimizing our Medicare line of business, implementing our Digital Transformation strategic roadmap, ensuring fiscal accountability and stewardship, launching expanded employee development and retention efforts, optimizing member engagement functions, and launching or growing programs to take care of members and their families across their lifespan.

As of August 11, 2025, Russian is CalOptima Health’s eighth threshold language, and Russian translation and interpreter services are available for members.

The addition of Russian meets requirements outlined by the Department of Health Care Services (DHCS) in All Plan Letter (APL) 25-002: Standards for Determining Threshold Languages, Nondiscrimination Requirements, Language Assistance Services and Alternative Formats. This APL covers federal and state requirements for DHCS to identify threshold languages for managed care plans (MCPs) based on population thresholds or a concentration of native speakers in certain ZIP codes.

To support Russian-speaking members, we have done the following:

1. Member materials, including member newsletters, member packets and health educational materials, have been translated into Russian.
2. Our Cultural and Linguistic team now includes a Russian translator.
3. Our phone tree system includes Russian as a language option.
4. The member pages on our website can be displayed in Russian.
5. Our contracted health networks were informed of the additional threshold language and provided with regulatory-required letter templates in Russian.
6. Member claims letters, decision letters, assessments and notices have all been translated into Russian.
7. The CalOptima Health Member Portal can be displayed in Russian.

To review how to help your patients access interpreter and translation services, please see sections N7 and N6 of the Provider Manual on the CalOptima Health website.

Providers who were unable to attend the virtual town hall last month discussing H.R. 1 and its impacts on health care in Orange County have the option to watch a recording of the meeting.

The 60-minute town hall, hosted by CalOptima Health and the Orange County Medical Association (OCMA) on August 14, covered the core provisions of H.R. 1, its impact on health care delivery and physician reimbursement, systemwide changes and local implementation at CalOptima Health, and how organized medicine is responding. The presenters were Elizabeth McNeil, Vice President, Federal Government Relations for the California Medical Association (CMA) and Michael Hunn, Chief Executive Officer of CalOptima Health.

You can access the recording of the town hall by clicking here.

On August 8, the Hospital Association of Southern California (HASC) published an op-ed on its website regarding the critical need for hospital funding. The piece included a reference to the important role CalOptima Health has played in supporting local hospitals with a rate increase. Below is an excerpt from the op-ed:

“Even before federal cuts were passed, Orange County hospitals struggled financially — with 46% of hospitals operating in the red. Last year, through a partnership with CalOptima, the HASC secured a critical rate increase that will bolster CalOptima-contracted OC hospitals through 2026.

This increase wasn’t just a budgetary boost — it’s saving lives. The funds are keeping emergency rooms open and staff on the job. They’re preserving specialty care that patients can’t find anywhere else, and retaining the frontline professionals who make healing possible.

Most importantly, the rate increase ensures that children, seniors and families with no other options still have access to the care they deserve. HASC is grateful to CalOptima for their support of health care providers in the short term — especially as we face long-term challenges at the state and federal level.”

Read this press release to learn more about CalOptima Health’s $526.2 million rate increase for hospitals, physicians and clinics, which continues through December 2026.  

The 2025 CalOptima Health Community Network Pay for Value Manual is now available for providers to access via the CalOptima Health Provider Portal.

This manual outlines the Medi-Cal and OneCare Pay for Value (P4V) programs for Measurement Year 2025, as approved by our Board of Directors. It provides essential information to help you understand the P4V program, including:

• The measures used to determine payments
• Detailed explanation of the payment methodology
• Clarifications on program requirements and expectations

We encourage you to review the manual thoroughly to ensure a clear understanding of the 2025 program structure. If you have any questions, please contact us at P4Vprogram@caloptima.org.

Thank you for your continued partnership and commitment to delivering high-quality care for our members.

Providers are invited to a continuing education webinar at Noon on Wednesday, September 10, 2025, about avoiding compassionate burnout.

The 90-minute Zoom course will cover the causes, signs and strategies to manage and prevent compassion fatigue, especially for those in caregiving, health care and human services roles. Providers can earn 1.5 continuing medical education and continuing education credits for attending.

Please register for the webinar by Monday, September 8, by visiting https://bit.ly/3Z6vLMh. If you have any questions, please contact Quynh Tran at continuingeducation@caloptima.org.

The Q3 CalOptima Health Community Network Lunch and Learn webinar will happen at Noon on Thursday, September 25. 

Our Provider Relations team uses these Zoom webinars to keep you informed about important regulatory updates, CalOptima Health news and other relevant information.

To register in advance, please click here. After registering, you will receive a confirmation email with information about how to join the webinar.

DHCS has updated the Newborn Gateway billing procedures to the following:

1. If the mother is enrolled in an MPC, the provider should bill under the mother’s client index number (CIN) for the month of the birth and the following month, regardless of whether the baby has a CIN.
2. If the mother is in fee-for-service (FFS) Medi-Cal, the provider should bill the baby’s CIN.

DHCS is currently in the process of correcting Medi-Cal Eligibility Division Information Letter (MEDIL) 24-28 to reflect this updated guidance.

DHCS has updated the community health worker (CHW) policy that went into effect on April 1, 2025.

Under that policy, Medi-Cal providers can bill for covered CHW services using two new Healthcare Common Procedure Coding System (HCPCS) codes, G0019 and G0022. State Plan Amendment Public Notice (SPA) 25-0016 set the rates for these two codes to 100% of the Medicare rate, pursuant to Welfare & Institutions Code Section 14105.25.

At the same time, DHCS issued a statewide standing recommendation that all Medi-Cal members who meet defined eligibility criteria for receiving CHW services would benefit from CHW services. This standing recommendation authorizes CHWs to provide covered services, including health education, health navigation, screening and assessment, and individual support and advocacy.

In August 2025, DHCS clarified the following:

• The standing recommendation allows for billing with Current Procedural Terminology (CPT) codes 98960, 98961 or 98962, but does not allow billing with HCPCS codes G0019 or G0022 due to the additional policy requirements associated with these billing codes.
• Medi-Cal does not require a CHW certificate to be issued or approved by DHCS, the Department of Health Care Access and Information, or any state organization.

For additional information, please visit the CHW page on DHCS’ website.

On August 19, 2025, DHCS, on behalf of the California Department of Public Health (CDPH), provided MCPs with an update regarding changes to the Women, Infants and Children (WIC) contract infant formulas.

As noted in a June 9 CDPH letter, effective August 1, the following standard contract infant formulas are available to California WIC participants without a prescription:

• Milk-based formulas:
• Enfamil Infant
• Enfamil Gentlease
• Enfamil Reguline
• Enfamil A.R.
• Soy-based formula:
• Similac Soy Isomil

While no prescription is needed for the formulas listed above, a prescription is required for a medical formula.

Providers should also review the following resources:

• Referring Patients to WIC for Medical Formula and Nutritionals: Resource document about the process for requesting medical formulas for their WIC patients. If a patient has Medi-Cal, a prior authorization should be submitted for the prescribed product before referring a patient to WIC.
• CDPH/WIC Formula Information for Health Care Providers webpage: Includes additional infant formula information for health care providers.

On July 31, 2025, DHCS distributed Revised APL 25-011: House Resolution (H.R.) 1- Federal Payments to Prohibited Entities to MCPs. This APL provides 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. It also contains guidance pertaining to a Temporary Restraining Order (TRO) blocking immediate implementation of Section 71113 in H.R. 1.

Notable updates in this revised APL include:

• On July 21 and July 28, 2025, the federal district court issued two separate preliminary injunctions (PIs) that modified the TRO.
• The July 21 PI did not provide relief to any California provider.
• The July 28 PI provided relief to all Planned Parenthood affiliates in California. DHCS has revised this APL in response to the July 28 PI.
• Clarified payment and claims/encounter processing, including which should be suspended versus processed, and exceptions for abortion services based on the July 28 PI.
• Medi-Cal and Family PACT providers who do not meet the definition of “Prohibited Entity” should continue to submit claims or encounters in accordance with published Medi-Cal and Family PACT policy. These claims or encounters are not impacted by H.R. 1.
• Medi-Cal and Family PACT providers who meet the definition of “Prohibited Entity” should take the following action:
• Medi-Cal and Family PACT providers should submit claims or encounters in accordance with published Medi-Cal and Family PACT policy for services rendered with DOS on or before July 3, 2025. These claims or encounters are not impacted by H.R. 1.
• Medi-Cal and Family PACT providers who obtained relief under the July 28 PI should submit claims or encounters for all services rendered with DOS on or after July 4, 2025, until the PI terminates or expires, or further court orders require additional clarification.

Medi-Cal and Family PACT providers who did not obtain relief under the July 28 PI should hold claims or encounters for all services, except abortion services, rendered with DOS on or after July 4, 2025.

• On August 19, 2025, DHCS distributed Revised APL 25-012: Targeted Provider Rate Increases, which provides Medi-Cal MCPs with guidance on eligible network provider payment requirements applicable to Medi-Cal targeted rate increases for dates of service on or after January 1, 2024. This APL supersedes APL 24-007.

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

Health education webinars

• CalOptima Health Board of Directors: September 4 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.