On January 14, the Orange County Board of Supervisors unanimously approved a regulatory ordinance change that paves the way for CalOptima Health to pursue participation in Covered California. This step is intended to provide continuity of care and expand access to affordable health coverage for more than 15,000 Orange County residents who fall in and out of Medi-Cal eligibility annually.

CalOptima Health CEO Michael Hunn emphasized the importance of this initiative in meeting the needs of individuals who may lose Medi-Cal coverage due to eligibility changes. “CalOptima Health’s effort to join Covered California reflects our unwavering commitment to ensuring continuity of care for our members,” Hunn said. “By offering a Covered California plan, we aim to provide ongoing coverage to members so they can continue to receive services from their trusted providers at affordable premiums.”

Without this option, individuals who often transition in and out of Medi-Cal may face challenges that lead to gaps in care and unexpected medical expenses. Additionally, a CalOptima Health Covered California plan can help households that have both Medi-Cal and other coverage to have access to the same provider network for all family members.

To promote transparency regarding this initiative, CalOptima Health engaged stakeholders through public listening sessions, provider forums and a steering committee of health industry leaders over the past six months. This comprehensive approach to community engagement ensures that the plan will address the diverse needs of Orange County residents and providers.

With the Board of Supervisors’ approval of the ordinance change, CalOptima Health will now proceed with the next steps in the regulatory process, including securing approval to participate from Covered California and the California Department of Managed Health Care. Pending these approvals, CalOptima Health aims to launch its new plan on January 1, 2027.

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

The next session, “Anxiety in You and Your Patients,” will be held via Zoom on February 12, 2025, at Noon. Jaesu Han, M.D., a professor in the Department of Psychiatry and Human Behavior at the UC Irvine School of Medicine, 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 continuing medical education credit for each session they attend. 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.

CalOptima Health invites providers to attend a virtual training on home- and community-based services hosted by home health care services provider Libertana on February 14, 2025, at 11 a.m.

The 60-minute webinar will discuss the California Community Transitions Project, Assisted Living Waiver, and Home- and Community-Based Alternatives Waiver. Please register in advance using this Zoom link; Webinar ID: 828 7632 2799

For questions about this training or how to register, please contact Soledad Arguello at 657-900-1778 or soledad.arguello@caloptima.org.

As a reminder for providers participating in OneCare (HMO D-SNP), a Medicare Medi-Cal Plan, the Centers for Medicare & Medicaid Services (CMS) continues to recommend using at least one oral antiviral when treating patients for COVID-19. Per a CMS memo from February 2024, Paxlovid will be available to Medicare beneficiaries at no cost through February 28, 2025. Also, prescription oral antivirals for COVID-19 with emergency use authorization will continue to be included in the definition of Part D drugs until March 31, 2025.

For calendar year 2025 and beyond, the CMS annual formulary and bid review process will incorporate a review of formularies for the inclusion of oral antivirals for COVID-19 that meet the definition of a Part D drug.  

As part of CalOptima Health’s ongoing efforts to streamline member care and ensure consistency in service quality, providers should only refer members for laboratory services to contracted laboratories. This will ensure consistency in testing, cost efficiency and quality assurance. Referrals for non-emergent services to out-of-network laboratories will require prior authorization.

To find a CalOptima Health-contracted laboratory, follow these steps:

• Visit www.caloptima.org
• Click on Find a Provider at the top of the screen
• Select either Medi-Cal or OneCare
• Click on Find a Hospital or Facility
• Select the member’s health network, input the mile radius and set the specialty as “laboratory.”

If you have any questions, please reach out to your Provider Relations representative at 714-246-8600.

Childhood exposure to lead is common and can cause health problems that can affect a child’s behavior and development. That’s why providers should test all children for lead at 12 months and again at 24 months. The Healthcare Effectiveness Data and Information Set (HEDIS) has two measures, Blood Lead Test at 12 Months of Age and Blood Lead Test at 24 Months of Age, to ensure these crucial screenings are completed.

CalOptima Health encourages members to take an active role in completing these screenings by offering a $25 member health reward when they have blood lead tests done at both 12 and 24 months. For 2025, we have made it even easier for members to receive their reward by no longer requiring a form submission. Instead, members eligible for this reward will be automatically identified through claims data.

To help this process, we encourage providers and labs to submit Current Procedural Technology (CPT) code 83655 when completing a blood lead test. This will ensure that CalOptima Health accurately identifies members who completed this screening. Once we receive the claim, we will mail the member their reward.

For more information, please review this Blood Lead Member Health Reward FAQ.

On January 10, 2025, the Department of Health Care Services (DHCS) provided an update to managed care plans (MCPs) regarding billing requirements for medical transportation providers. DHCS now requires all medical transportation providers to submit the origination and destination ZIP codes on their claims for data quality purposes. Medical transportation providers contracted with CalOptima Health or one of our health networks will need to put the pickup and drop-off ZIP code on their claim submissions.

DHCS says there are no changes to how paper or electronic medical transportation claims are submitted, as most providers are already submitting the origination and destination addresses in Box 32 and the pickup and drop-off addresses in Loop 2310E and Loop 2310F, respectively. There are no rate- or reimbursement-related changes to Ground Emergency Medical Transportation (GEMT) because of this requirement. However, DHCS may implement a reimbursement methodology that adjusts medical transportation reimbursements using origination and destination ZIP codes in the future.

DHCS also noted that, as outlined in the Data Reporting section of All Plan Letter (APL) 24-007, MCPs must follow the reporting requirements that will be made available on DHCS’ Targeted Rate Increases (TRI) website. Those requirements may be revised to include the above guidance in the future.

On January 8, 2025, DHCS sent MCPs a notice that Assembly Bill (AB) 2105 took effect on January 1. AB 2105 pertains to Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS).

The bill adds Section 1367.38 to the Health and Safety Code, which:

• Requires coverage for PANDAS and PANS. Covered treatments include antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.
• Prohibits denying or delaying coverage for PANDAS or PANS therapies because the enrollee or insured previously received treatment for PANDAS or PANS or was diagnosed with or received treatment for the condition under a different diagnostic name.

For billing and diagnostic purposes, PANDAS and PANS should be coded as autoimmune encephalitis until the American Medical Association and CMS create and assign specific codes for PANDAS and PANS. After the creation of those codes, PANDAS and PANS may be coded as autoimmune encephalitis, PANDAS or PANS. At this time, DHCS recommends utilizing the diagnosis codes specified below:

• PANDAS: D89.89, which is used for “other specified disorders involving the immune mechanism, not elsewhere classified”
• PANS: D89.9, which is used for “disorder involving the immune mechanism, unspecified”

On December 2, 2024, DHCS notified MCPs that it is implementing a new approach for managing Alternative Format Selections (AFS) to comply with federal regulations requiring public entities to prioritize the communication needs of individuals with disabilities. 

Currently, DHCS gathers AFS information through an interim web application used by consumers, DHCS administrative users and a designated DHCS vendor. This data is then shared with health plans through weekly extracts via the DHCS Secure File Transfer Protocol (SFTP) site.

Under the new approach, the AFS preferences will be integrated directly into CalOptima Health’s daily and monthly 834 Enrollment Files as a new indicator, eliminating the need for separate weekly extracts at a future date. This integration will streamline data exchange, enhance data accuracy and ensure that health plans have immediate access to the latest AFS preferences, allowing them to better meet the communication needs of members with disabilities.

The transition is expected to begin in the first quarter of 2025, with the specific implementation date to be confirmed.

On December 27, 2024, DHCS released the Closed-Loop Referral (CLR) Implementation Guidance to MCPs.

The CLR Implementation Guidance outlines requirements for MCPs implementing CLRs, including tracking, supporting and monitoring. The goal of these new CLR requirements is to increase the share of Medi-Cal members successfully connected to the services they need by identifying and addressing gaps in referral practices and service availability. 

The guidance document contains, but is not limited to, the following sections:

• Tracking Member Referrals
• Supporting Member Referrals
• Monitoring Member Referrals
• Appendix A: Glossary
• Appendix B: Enhanced Care Management and Community Supports

As an MCP, CalOptima Health must implement these CLR requirements by July 1, 2025. The requirements will first apply to two priority services — Enhanced Care Management (ECM) and Community Supports. 

Click on the link below to find an outline of changes made to CalOptima Health policies and procedures during December 2024. The full description of the policies below is available on CalOptima Health’s website at:

www.caloptima.org/en/ForProviders/Resources/ManualsPoliciesandGuides.aspx.

Policies and Procedures Monthly Update

Click below for training webinars and meetings happening in February 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 1 Update
• Update: Change in Procedure for Infants Enrolled Through the Newborn Gateway
• Updated Reimbursement Rates for Electrocardiogram Procedure Codes
• HCPCS Code J0911 Is a Medi-Cal Benefit
• Update to Palliative Care CPT Codes 99490 and 99491
• ICD-10-CM Codes No Longer Required for Select Abortion Codes
• Update for Select Transcranial Magnetic Stimulation CPT Codes
• Provider Manual Revisions
• New PACE Managed Care Plans
• Select Durable Medical Equipment (DME) Codes Are Medi-Cal Benefits
• HCPCS Codes E0691 and E0694 Now a Medi-Cal Benefit
• National Correct Coding Initiative Quarterly Update for January 2025
• Updated Recipient Enrollment Application for Every Woman Counts Program
• Action Required: Unregistered Providers Must Register in the Medi-Cal Provider Portal
• Justice-Involved Reentry Initiative: Updated Q&As for September and November 2024 Webinars
• Policy for Skilled Nursing Facility Accountability Sanctions Program
• Mandatory Enrollment for Foster Youth in Single Plan Counties in 2025
• 2025 Whole Child Model Transition
• Reminder: Include ZIP Codes for Medical Transportation Services
• DME and Medical Supplies for Recipients Impacted by Wildfires

For detailed information regarding these changes, please refer to General Medicine Bulletin 607, Medi-Cal Program & Eligibility Bulletin 30, Audiology and Hearing Aids Bulletin 592, Durable Medical Equipment and Medical Supplies Bulletin 592, and Medi-Cal NewsFlashes from December 17, December 18, December 27,  December 27, December 30, December 30, December 31, January 10 and January 13. 

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: February 6 at 2 p.m.
• Joint Meeting of the Provider and Member Advisory Committees: February 13 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.