We are pleased to announce that we have received 4 stars in the National Committee for Quality Assurance (NCQA) Medicaid Health Plan Ratings 2026. The rating, released on September 16, puts the health plan among the leading Medi-Cal plans in the state and is an improvement from CalOptima Health’s 3.5-star rating in 2025.

Following our rating last year, we implemented a data-driven, member-centric approach that included expanding at-home care testing for colorectal cancer and diabetes-related measures, launching the Cozeva PayerOne platform to get the most accurate, complete data possible, and deepening collaboration with our providers and health networks.

NCQA rates Medicaid plans nationwide on quality of care, member experience with their care and quality processes. NCQA aggregates these factors into a health plan rating on a scale of 1 to 5 stars. The rating reflects care delivered in 2025. We are one of nine plans in California to achieve a 4-star rating, with only four plans getting above a 4-star rating. Thank you to all our provider partners for your commitment to quality!

Open enrollment for CalOptima Health Covered, our first product on the Covered California marketplace, launches on November 1, 2026, and runs through January 31, 2027.

CalOptima Health Covered is designed to expand affordable health care in Orange County and ensure continuity of care for members transitioning from Medi-Cal. It will be the lowest-cost Silver plan available in the county. At the beginning of October we already began receiving enrollment files for renewing Covered California enrollees with January 2027 effective dates.

Our staff has been diligently preparing for the product's January 1, 2027, start, including working with the Department of Managed Health Care (DMHC) to modify our Knox-Keene Act license. On September 17, DMHC approved our CalOptima Health Covered awareness advertising campaign materials, and that campaign, which includes billboards and digital, TV, radio and print advertisements, is now live in the community.

To learn more about CalOptima Health Covered, what it could offer your patients and how you can participate, please visit the CalOptima Health Covered page on our website, www.caloptima.org.

In September, we released a Medi-Cal Changes Toolkit for providers and community partners, including flyers, posters and social media content, to raise awareness among our members about the Medi-Cal changes that began January 1, 2026, and will continue in 2027 and 2028. The materials direct members to the Medi-Cal Changes webpage for more details. This page provides information that aligns with Department of Health Care Services (DHCS) messages. We encourage you to use and share the toolkit material widely, so providers are among those urging members to take action so they don’t lose their Medi-Cal.

With the changes to Medi-Cal due to H.R. 1 and state budget cuts over the next two years, we want to ensure our contracted providers have the support they need. To that end, we have created a short provider survey to gauge what challenges you are facing and the types of support that will be most beneficial for you. We will use your feedback to craft our future communications and provider outreach.

Please take five minutes to fill out the survey by clicking on this link. Thank you for your input and for the care you continue to give to our members.

Effective January 1, 2027, CalOptima Health OneCare (HMO D-SNP), a Medicare Medi-Cal plan, will have funding split to ensure that the dollars spent are allocated to the applicable funding source.

Currently, OneCare claims for both Medicare- and Medi-Cal-covered services are 100% paid under OneCare. This created unnecessary pressure on OneCare, limiting our ability to keep this line of business competitive. To be consistent with the standard coordination of benefits, starting January 1, OneCare claims will be paid 80% under Medicare and 20% under Medi-Cal.

Contract amendments reflecting this change are forthcoming. The amendments will be distributed via email for execution through Adobe electronic signature. We appreciate you promptly signing these contract amendments.

Provider Impact

• What if I do not return the amendment?
• Claims received from providers who do not return the contract amendments will be paid at the OneCare 80% rate. The claim will be routed to Medi-Cal for adjudication. If no signed amendment exists, the claims will be paid only up to the Medi-Cal rate. This will often result in a zero payment as the provider has already received more than Medi-Cal would have paid.

• Do I have to rebill CalOptima Health once I receive the OneCare payment?
• No, providers submit a claim to the CalOptima Health OneCare Claims department. The claim will be adjudicated under OneCare. Providers will receive a check and Remittance Advice (RA) for the 80% payment made under OneCare. CalOptima Health will then route the claim from OneCare to Medi-Cal. Providers will receive a second check and RA for the remaining 20% payment under the Medi-Cal benefit.

• How will I match the multiple checks and RAs in my system?
• You can match the multiple checks and RAs by entering the member’s ID number from their card and the date of service.

• How will I verify if both my Medicare and Medi-Cal payments were processed?  
• You can view payments via the CalOptima Health Provider Portal. For each patient visit, you will see two claims that reflect payments from both Medicare and Medi-Cal. 

If you need access to the Provider Portal, please email providerservicesinbox@caloptima.org with your provider name, Tax ID and national provider identifier (NPI).

As we head into 2027, OneCare continues to improve to better serve members who have both Medicare and Medi-Cal.  

OneCare’s annual enrollment period (AEP) for 2027 starts on October 15. To learn more or to enroll in OneCare, your patients can call OneCare Customer Service at 1-877-412-2734 (TTY 711) or visit the OneCare page.

Your patients are eligible for OneCare if they are: 

• Age 21 or older 
• Living in Orange County  
• Enrolled in Medicare Parts A and B 
• Receiving Medi-Cal benefits 

Here are two key benefit improvements in 2027: 

• $0 Cost Share on Generic and Brand Medications Starting January 1, 2027 — OneCare members will pay $0 for both generic and brand-name covered medications, whether it’s a one- or three-month supply. This removes a common barrier to medication adherence and provides more flexibility in prescribing longer-term supplies. Please encourage members to enroll with a mail-order/home-delivery pharmacy. Home delivery reduces missed doses and pharmacy trips, and pairs well with the $0 cost share to support better adherence, especially for members managing multiple chronic conditions. If your patients need help signing up for mail delivery, they can call SortPak at 1-877-570-7787 (TTY 711). 

• OneCare Flex Card Allowance Increased to $170 — The flex card allowance is increasing to $170 per quarter. This gives members more dollars to spend on approved over-the-counter essentials, including healthy food and produce if they qualify for Special Supplemental Benefits for the Chronically Ill (SSBCI). 

Here are important benefits OneCare members will continue to have access to: 

• Unlimited transportation to medical appointments — Members will have no-cost, unlimited trips to medical appointments in 2027. This is a meaningful benefit for patients who may skip or reschedule visits due to transportation barriers.  
• Dental, vision and hearing benefits — Help your members stay healthy all around by reminding them of these valuable benefits.  
• In-home support services and companion care — OneCare members can get 90 hours of light help at home. This benefit is great for those with functional or safety concerns at home or who are socially isolated. 

OneCare SSBCI Provider Verification Forms  

You may receive requests to complete the SSBCI Provider Verification form. Completing this form is important as it provides eligible members access to health-related needs beyond traditional medical care, such as using their OneCare Flex Card for healthy food and produce and their transportation benefit for trips to the grocery store or the gym. Timely completion of the SSBCI Provider Verification form helps members access these benefits without delay.

Effective January 1, 2027, CalOptima Health and its delegated health networks will update the timeframe for submission of retrospective authorization requests to a unified operating model across all lines of business to reduce administrative burden for providers. This change reduces the retrospective authorization submission timeframe from 60 calendar days to 30 calendar days from the date of service.

With this transition, we are updating Utilization Management policies GG.1500: Authorization Instructions for CalOptima Health Direct and CalOptima Health Community Network Providers and GG.1508: Authorization and Processing of Referrals. The revisions establish consistent requirements for retrospective authorization reviews and align our practices with applicable regulatory and contractual requirements.

These changes apply to providers serving members enrolled in Medi-Cal, OneCare and CalOptima Health Covered, including hospitals and professional providers participating through a contracted health network.

Key Requirements

Effective January 1, 2027, a retrospective authorization review request must:

1. Be submitted within 30 calendar days from the date of service.
2. Include documentation demonstrating that an allowable extenuating circumstance prevented the provider from obtaining authorization before the service was rendered.

Allowable Circumstances

A retrospective authorization review may be considered only when at least one of the following circumstances applies:

1. Coordination of benefits — The member had other health coverage that affected the provider’s ability to identify CalOptima Health as the responsible payer or obtain timely authorization.
2. Inability to verify eligibility due to the member’s medical condition — The member’s medical condition prevented the provider from verifying the member’s eligibility for Medi-Cal, OneCare or CalOptima Health Covered at the time the service was rendered.
3. Additional immediate medical need during a planned procedure — During a planned procedure, the member developed an additional immediate medical need requiring services beyond those originally authorized.

Provider Responsibilities

Providers are expected to verify member eligibility, identify the member’s assigned health network and obtain all required authorizations before rendering nonemergency services.

When submitting a retrospective authorization request, providers must:

• Submit the request within 30 calendar days from the date of service.
• Clearly identify the applicable allowable circumstance.
• Provide complete clinical records supporting the medical necessity of the services.
• Include documentation explaining why prior authorization could not be obtained.
• Follow the authorization submission procedures established by CalOptima Health or the member’s assigned health network, as applicable.

Submission of a retrospective request does not guarantee authorization or payment. Requests will be reviewed for timeliness, medical necessity, member eligibility, benefit coverage and compliance with the revised policy requirements. Requests that do not meet the applicable timeframe, documentation standards or allowable circumstances may be denied.

Claims Submission and Processing

This change applies only to the timeframe for submission of retrospective authorization review and does not change claims submission or claims processing requirements. Providers must continue to submit claims in accordance with the requirements of CalOptima Health or the member's assigned health network, as applicable. Authorization does not guarantee payment; claims remain subject to eligibility, benefit coverage, coding, billing and other applicable payment requirements.

Health Network Responsibilities

Contracted health networks must communicate these requirements to their participating hospitals, physicians, ancillary providers and other professional providers. Health networks must also ensure that their retrospective review processes and provider instructions are consistent with CalOptima Health requirements and applicable delegated responsibilities.

Emergency services remain subject to applicable federal and state requirements and CalOptima Health policies. This communication does not change authorization requirements for emergency services.

For questions related to this notice, please contact CalOptima Health Provider Relations department by calling 714-246-8600, emailing providerservicesinbox@caloptima.org or using the Provider Portal.

The revised policies and related authorization instructions will be available through the CalOptima Health Provider Portal under the Authorization section. Thank you for your continued partnership and commitment to providing timely, medically necessary care to CalOptima Health members.

In partnership with NORC at the University of Chicago, CalOptima Health has completed our Member and Population Health Needs Assessment (MPHNA) Final Report. Conducted from mid-2025 to mid-2026, this comprehensive assessment brought together voices from members, providers, focus groups and interviews, along with administrative data and publicly available county reports and assessments. The final report provides insights into the strengths of our current health plans, provider network and initiatives, as well as opportunities for CalOptima Health, providers and community partners to further support Orange County’s vulnerable populations.

You can explore the full report on our website. Thank you to all our providers who participated in this assessment. 

On September 1, 2026, DHCS distributed Version 2.0 of the Unsatisfactory Immigration Status (UIS) Transition from MCPs to FFS Policy Guide. 

This policy guide communicates expectations for managed care plans (MCPs) to support a coordinated, timely and member-centered transition of members with UIS from managed care coverage to Medi-Cal fee-for-service (FFS), effective January 1, 2027. The policy guide outlines MCP responsibilities related to member notification and outreach, continuity of access to Medi-Cal FFS providers and transitions of care, data sharing to support transition activities, and communications to enable continuity of provider access.

The policy guide outlines specific updates, additions and removals beginning on Page 4. Among other changes, version 2.0 includes:

• New details in the Whole Child Model (WCM) section on the roles of counties and DHCS
• A new Treatment Authorization Request (TAR) special handling process
• A new California Children’s Services (CCS) Member Notification section with a corresponding template (Appendix D)
• Additional content to the General Communications and Member Microsite: FFS Transition in the Member Resources section
• New data sharing requirements for CCS members

On September 1, 2026, DHCS distributed Numbered Letter (NL) 03-0926: CCS Members with Unsatisfactory Immigration Status, providing guidance to county CCS programs on changes to the Medi-Cal eligibility and enrollment of UIS CCS members who are currently enrolled in MCPs.  

Notable requirements in this NL include:

• Effective January 1, 2026, DHCS froze new Medi-Cal enrollments for individual adults ages 19 and older who previously qualified for full-scope Medi-Cal under the state-funded Adult Expansion initiative.
• Effective January 1, 2027, all members with UIS, including CCS members with UIS who are enrolled in a WCM MCP, will be disenrolled from their MCP and transitioned into the Medi-Cal FFS delivery system.
• An outline of Medi-Cal eligibility requirements for CCS members ages 0–18 and 19–20.
• A requirement for MCPs to provide county CCS programs with a transition of care plan for each UIS CCS member. 

We invite providers to attend the following trainings:

• Thriving in a Busy Practice (CME/CE credit offered) — This Zoom webinar will explore the drivers of provider burnout, its impact on patient care and provider performance, and strategies to help providers cope and thrive.
• Date: October 13, 2026
• Time: Noon–1 p.m.
• Location: Zoom webinar
• To register for this training, please use this link.

• The Announcement Approach for Increasing HPV Vaccination (1 American Academy of Family Physicians [AAFP] elective credit) — This Zoom webinar will cover this approach for HPV vaccination recommendations, which has been shown to effectively increase HPV vaccinations.
• Date: October 14, 2026
• Time: Noon–1:15 p.m.
• Location: Zoom webinar
• To register for this training, please use this link.

• Managing Challenging Situations With Patients (CME credit offered) — This Zoom webinar will provide practical, real-world strategies to effectively manage difficult encounters with patients while maintaining professionalism and empathy.
• Date: October 20, 2026
• Time: Noon–1 p.m.
• Location: Zoom webinar
• To register for this training, please use this link.

• Leading to a Positive Patient Experience (CME credit offered) — This Zoom webinar will explore vulnerabilities impacting patient experience and provide strategies to enhance communication.
• Date: October 27, 2026
• Time: Noon–1 p.m.
• Location: Zoom webinar
• To register for this training, please use this link.

For questions regarding these trainings, please email continuingeducation@caloptima.org.

Many primary care providers (PCPs) remain cautious about menopausal hormone therapy, largely because of enduring misperceptions from early Women’s Health Initiative reporting, which has since been substantially revised to reflect more nuanced, age‑ and timing‑specific risks. Updated evidence shows hormone therapy is generally safe for most healthy women under 60 or within 10 years of menopause, yet limited menopause‑specific training and time pressures continue to contribute to provider hesitancy.

Hormone Replacement Therapy (HRT) remains the most effective treatment for vasomotor symptoms, reducing the frequency of hot flashes substantially compared with a placebo, though it may take up to three months for maximal benefit. It can also improve mood, sleep quality, vaginal discomfort and urinary symptoms as well as help prevent early bone loss. Current guidelines support its safety when started at an appropriate time and tailored to a woman’s health history and goals.

Providers can support members by using shared decision-making tools such as National Institute for Health and Care Excellence (NICE) visual aids and the Benefits, Risks, Alternatives, Intuition, Next Steps (BRAIN) framework. Personalizing care is also key; discussing symptom impact, medical history and preferences guides treatment selection. Explaining HRT options clearly can help members understand what will work best for them. Providers should review potential side effects, discuss monitoring needs, ensure routine screenings and offer nonhormonal alternatives when HRT is not preferred or appropriate.

DHCS conducts an annual Timely Access Survey of all MCPs to ensure compliance with provider availability and wait time standards for both urgent and nonurgent appointments. This survey involves calling a randomized sample of network providers within each MCP’s county or region-based reporting unit. In addition, DHCS provides CalOptima Health with a plan-specific Quarterly Monitoring Response Template (QMRT) and a Medi-Cal Managed Care Quarterly Monitoring Performance Report as part of ongoing performance monitoring.

Your participation in the Timely Access Survey is essential. By taking part when contacted, you help ensure accurate reporting and support our shared commitment to providing members with timely access to high-quality health care. We sincerely appreciate the providers who have already participated. Your cooperation helps strengthen our network and improve member experience.

Thank you for your continued partnership and dedication to our members. If you have any questions or would like to speak with a Provider Relations representative, please call 714‑246‑8600 or email providerservicesinbox@caloptima.org.

• On September 1, 2026, DHCS distributed All Plan Letter (APL) 26-016: CCS Members with Unsatisfactory Immigration Status, which provides guidance to MCPs serving members enrolled in the CCS Program about the changes to the Medi-Cal eligibility and enrollment for UIS CCS members.
• On September 3, 2026, DHCS provided MCPs with 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

Additionally, DHCS has uploaded these updated attachments to the APL section of the DHCS website.

• On September 16, 2026, DHCS distributed APL 26-017: Provider Dispute Resolution Mechanism and Reporting Requirements and the PDR Reporting Template, providing MCPs with guidance on the PDR mechanism, provider training requirements and PDR reporting requirements.

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

• Important Update and Reminder: Clade I and II Mpox Cases Within California
• Prostate Cancer Awareness Month Spotlight: California’s Prostate Cancer Treatment Program
• Billing Update for HCPCS Code J3392
• November 2026 Updates to the Medi-Cal List of Contracted Incontinence Creams and Washes
• Reminder: Medi-Cal Providers May Not Charge Members to Complete Forms or Provide Information
• Modifier NURB/RBNU Is Required for Replacement-Only DME Codes
• Updates to the List of Codes Reimbursable for Licensed Midwives
• Diagnosis-Related Group (DRG) Pricing Resources SFY 2026/27
• Reminder: New Requirement for Provider Verification in Telephone Service Center
• Provider Dispute Resolutions With Managed Care Plans
• Public Fee-for-Service Provider Directory: Action Required
• National Correct Coding Initiative Quarterly Update for October 2026
• Reminder: Policy Clarifications for Covered Medi-Cal CHW Services
• Medi-Cal Hospice Program Attestation Now Available in the Provider Portal
• Justice-Involved (JI) Reentry Initiative: New Aid Codes for Members with UIS Coming Soon
• Enrollment Deadline Extended for Nexplanon REMS Certification

For detailed information regarding these changes, please refer to General Medicine Bulletin 627, Durable Medical Equipment and Medical Supplies Bulletin 612, Obstetrics Bulletin 627, and Medi-Cal NewsFlashes from August 17, August 17, August 20, August 26, August 31, August 31, September 1, September 9 and September 14.

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

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during September 2026. 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: November 5 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: October 8 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.