CalOptima Health Investing $526.2 Million for Provider Rate Increases |
As deficits loom in the state budget, CalOptima Health is showing its commitment to our provider network with the largest provider rate increase of its kind in our nearly 30-year history. This funding is in addition to the Targeted Rate Increases (TRI) mandated by the Department of Health Care Services (DHCS).
During its regular meeting on May 2, 2024, our Board of Directors approved a commitment of $526.2 million from unallocated reserves to enhance the rates for health networks, hospitals, physicians, community clinics, behavioral health providers and ancillary services providers. The funds will be used to support timely access to and the quality of critical health care services for members and promote long-term financial stability of the managed care network.
We are also putting into action the TRI enacted by DHCS in January 2024. We have received guidance from DHCS for implementing these new rates, which will be payable at the procedure code level to participating Medi-Cal providers. The increase supports advances in access, quality and equity for Medi-Cal members.
CalOptima Health will follow the implementation timeline below:
- Provider Rate Increase (Non-TRI) Payments: CalOptima Health will implement all other planned health network and provider rate increases effective July 1, 2024.
- TRI Payments:
- For services provided on and after July 1, 2024, CalOptima Health will implement TRI rates for CalOptima Health Direct and CalOptima Health Community Network (COD/CHCN)-contracted providers.
- Retrospective payments: By August 31, 2024, CalOptima Health will reconcile previously paid COD/CHCN claims (including Proposition 56 physician services) with dates of service between January 1, 2024, and June 30, 2024. Providers will receive a supplemental payment for the TRI rate adjustment. Retrospective supplemental payments will continue to be paid on a monthly basis as fee-for-service (FFS) claims are received within the timely filing limits.
- Post-Public Health Emergency (PHE) Supplemental Payment Program: With the consideration of the above rate increases, CalOptima Health will sunset the temporary, post-PHE supplemental payment program on June 30, 2024.
CalOptima Health will send a contract amendment in mid-June. We appreciate you signing and returning the amendment to us as soon as possible.
Providers can learn more about the TRI program, including the rates, provider eligibility and relevant procedure codes on DHCS’ website. The TRI rate schedule on DHCS’ website includes a note tab with additional details regarding the payments.
We appreciate your dedication to caring for our members. If you have any questions, please contact your Provider Relations representative at 714-246-8600 or providerserviceinbox@caloptima.org.
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Free Naloxone Available to Providers through Onsite Distribution Event or Delivery |
Providers can get unlimited free cases of life-saving naloxone for their patients from CalOptima Health at an in-person event on Friday, June 21 or through delivery directly to their offices. This Naloxone Distribution Event is part of our Drive to Revive campaign. Sign a simple distribution agreement and receive an unlimited number of cases that contain single-use, prescription-strength nasal spray doses of Kloxxado, naloxone’s brand name.
Naloxone can potentially save lives if administered to someone having a known or suspected opioid overdose or fentanyl poisoning. Naloxone is easy to use, requires no special training and is safe even for use on children. CalOptima Health has information and a training video at www.caloptima.org/naloxone.
Community Naloxone Distribution Event
- Friday, June 21, 2024
- Pick up between 9 a.m. and 2 p.m.
- CalOptima Health, 505 City Parkway West, Orange, CA 92868
Please register in advance using this link.
Providers who cannot attend the distribution event can also order naloxone through CalOptima Health by following the steps below:
- Email naloxone@caloptima.org with the name and email address of your organization’s authorized representative. We will then send that person a Naloxone Distribution Agreement via DocuSign.
- Once you have the agreement, identify the number of cases you want.
- Sign and return the agreement.
- Receive the naloxone. CalOptima Health will deliver the naloxone during the business hours identified on the DocuSign.
For questions about the event or the naloxone distribution program, email naloxone@caloptima.org.
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Upcoming Lunch & Learn to Focus on New Mental Health Programs |
CalOptima Health invites providers to learn about two new virtual mental health services for youth, families and young adults during a Lunch & Learn at Noon on June 26, 2024.
The virtual meeting will feature representatives from the BrightLife Kids and Soluna programs, part of California’s Children and Youth Behavioral Health Initiative. The webinar will include an overview of both services and the chance to ask questions.
Add the event to your calendar and click this Microsoft Teams to join the Lunch & Learn: https://bit.ly/chlunchlearn0624
BrightLife Kids provides free behavioral coaching to all California kids ages 0–12 years, including video or chat-based 1:1 coaching, diverse bilingual coaches, on-demand digital tools and coach specialists to manage complex needs and referrals.
Soluna is an all-in-one mental health app that helps California youth and young adults ages 13–25 destress, reset and seek support. The app includes scheduled or drop-in 1:1 coaching; diverse, bilingual coaches; interactive and engaging tools; and moderated community forums, self-support guides and articles.
The initiatives are CalHOPE programs funded by DHCS and run by Brightline and Kooth Digital Health. Visit calhope.org to learn more.
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July Continuing Education Webinar Will Cover Maternal Mental Health |
Providers are invited to learn about maternal mental health (MMH) during a continuing education webinar at Noon on Wednesday, July 10, 2024.
The 90-minute course will cover seven types of MMH conditions, risk factors and populations at increased risk for MMH conditions. Providers can earn 1.5 continuing medical education and continuing education credits for attending.
Please register for the webinar by Monday, July 8, by visiting https://bit.ly/3WlIhHl. If you have questions, please call Quynh Tran or Bao Anh Le at 657-235-6865 or email continuingeducation@caloptima.org.
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Chapman Global Medical Center Closing Emergency Department July 1 |
Chapman Global Medical Center in Orange has informed CalOptima Health that it will close its emergency department as of July 1, 2024.
We ask that providers inform patients that they can no longer receive emergency medical treatment from Chapman Global Medical Center starting July 1.
Please also let patients know they can still receive emergency treatment at the following nearby facilities:
- Orange County Global Medical Center, 1001 N. Tustin Ave., Santa Ana, CA 92705
- St. Joseph Hospital Orange, 1100 W. Stewart Drive, Orange, CA 92868
- UCI Medical Center, 101 The City Drive, Orange, CA 92868
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Use These Tips to Complete IHAs with Your Patients |
DHCS continues to require that the Initial Health Appointment (IHA) be completed within 120 calendar days of a Medi-Cal member’s enrollment in CalOptima Health. To help providers ensure this important assessment is completed for our members, we are sharing the following helpful tips and resources.
IHA Report: Providers can access the IHA report, which has a list of members still needing their assessment, via the CalOptima Health Provider Portal. To access the report:
- Go to: https://provider.caloptima.org/
- Once logged on, click on “Reports” > select “Initial Health Appointment” > input provider details > click “Get IHA Report” to download the Excel document
New IHA Monitoring Process: We are collaborating with contracted CHCN providers to improve IHA completion rates and monitor for opportunities for enhancements. Effective January 1, 2024, we implemented quarterly IHA chart review audits. If you are selected for review, a representative from CalOptima Health will request medical records.
To pass your IHA chart review, make sure you are completing all IHA components. These include:
- Document all attempts to get members in for their IHA — At least three attempts should be made and documented during the first 120 days from enrollment (outreaches, missed visits and refusals to complete the IHA).
- All comprehensive assessment components should be covered and documented — For pediatric measures, ensure lead-specific anticipatory guidance is provided at each periodic health assessment and, if appropriate, confirm if a blood lead test was ordered at 12 or 24 months of age.
Continued failure of the audit will result in a corrective active plan.
IHA Completion Measurement: DHCS will measure primary care visits as a proxy for the IHA, leveraging Managed Care Accountability Sets (MCAS) and Healthcare Effectiveness Data and Information Set (HEDIS) measures specific to adult preventive visits and infant, child and adolescent well visits, as referenced in CalOptima Health Policy GG.1613 Initial Health Appointment.
Resources: Providers can find additional information at the links below.
If you have any questions, please contact us at iha@caloptima.org.
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Help Support Blood Lead Screenings for Your
Medi-Cal Patients
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Children enrolled in Medi-Cal should be tested for lead at 12 and 24 months of age, as many of them live in areas known to have higher risk factors for lead exposure.
To support member care, CalOptima Health has two health rewards focused on lead testing. Eligible Medi-Cal members can receive the following no-cost rewards for completing a blood lead test at 12 and 24 months of age.
- Blood Lead Test at 12 Months of Age — No-cost $25 gift card for children who complete a lead test between 12 and 23 months of age.
- Blood Lead Test at 24 Months of Age — No-cost $25 gift card for children who complete a lead test between 24 and 35 months of age.
As a CalOptima Health provider overseeing the care of our pediatric members, you and your team can support lead screening of members through the following:
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Perform point-of-care testing: This is the best way to ensure lead testing is completed.
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Monitor lab orders: Institute an office process to monitor uncompleted lab tests. Visits to an off-site lab often pose a significant challenge to members due to distance or limited lab hours. Reminders about the importance of lead testing, lack of symptoms associated with lead exposure and open/standing lab orders may help bring members in for testing.
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Lead testing health reward: Share the health reward forms with the parent/guardian of your pediatric members during well-child visits, especially if the member must attend a lab to complete testing. Remind members to take the form to their lab visit.
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Anticipatory guidance: Advise parents/guardians of the risks associated with lead exposure and ways to reduce exposure at each well-child visit, even in instances where parents refuse testing.
For more information on this and other available no-cost health rewards, please visit www.caloptima.org/healthrewards. For support with optimizing blood lead testing efforts, contact the Quality Initiatives team at QI_Initiatives@caloptima.org.
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CMS Final Rule Requires CalOptima Health to Make Coverage Criteria Available |
As part of the Centers for Medicare & Medicaid Services (CMS) Final Rule requirements (422.101(b)(6)), CalOptima Health is required to create and make available to providers publicly accessible internal coverage criteria based on current evidence. This applies when coverage isn’t defined in Medicare regulations or guidelines. Acceptable evidence sources include:
- Widely used treatment guidelines from medical specialty organizations
- Clinical literature like peer-reviewed studies or meta-analyses
Additionally, CalOptima Health has made its Clinical Practice Guidelines (CPGs) available online.
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Health Education: Trainings and Meetings |
Click below for training webinars and meetings happening in June 2024:
Health education webinars
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Policy Code Update
Based on Medi-Cal Bulletins and NewsFlashes, CalOptima Health has updated the procedure codes and other relevant information for the subjects listed below:
- 2024 HCPCS Quarter 2 Update
- COVID-19 VFC: Update of Billing Methodology
- Gene Analysis CPT Code 81226 is a Medi-Cal Benefit
- Gene Analysis CPT Code 81227 is a Medi-Cal Benefit
- Children’s Presumptive Eligibility Qualified Provider Enrollment
- CHDP New Provider Enrollment Deadline
- Children’s Presumptive Eligibility and Newborn Gateway Mandatory Trainings
- Update: Licensed Midwives Contraceptive Codes
- PLA Code 0352U Policy Update
- Medi-Cal Coverage and Billing Guidance of Imported Extencilline
- Rates and Policy Update for HCPCS Codes S9335 and S9339
- End Date for ICD-10-CM Codes for 2020 Yearly Clinical Medical Policy
- CPT Codes 69716 and 69719 Benefit Status Clarification
- Ventral Hernia Repair Fee-for-Service Rates Update
- TAR Criteria Update for HCPCS Code J3241
- Policy Update for HCPCS Code J3060
- TAR Criteria and Frequency Limit Updated for PLA Code 0329U
- Place of Service Additions for CPT Codes 99234, 99235 and 99236
- TAR Criteria Change for Molecular Pathology Code 81405
- The Newborn Gateway to Launch in July 2024
- HCBS Program Services Reimbursable for EPSDT Providers
- Addition of CPT Codes for Local Educational Agency Medi-Cal Billing Option Program
- Provider Manual Revisions
- Medi-Cal Provider Portal List of Unregistered NPIs
- DRG Payment System Update to Hospital Acquired Condition V41.1
For detailed information regarding these changes, please refer to: General Medicine Bulletin 599, Clinics and Hospitals Bulletin 596, Local Educational Agency Bulletin 596, Rehabilitation Clinics Bulletin 596, and Medi-Cal NewsFlashes from April 25 and April 26.
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- CalOptima Health Board of Directors: August 1 at 2 p.m.
- Joint Meeting of the Provider and Member Advisory Committees: August 15 at Noon
All meetings have an option for virtual attendance. Visit the CalOptima Health website for more information.
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Follow Us on Social Media | | |
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.
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CalOptima Health, A Public Agency www.caloptima.org
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