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CalOptima Health’s Delegation Model
CalOptima Health works with many subcontractors, including doctors, specialists, pharmacies, hospitals, health networks, medical groups and other health care providers. Subcontractors may be assigned to perform certain tasks on behalf of CalOptima Health. We work together with our subcontractors to determine which functions will be their responsibility and which will remain with CalOptima Health. The tasks could include authorizations, billing, provider credentialing, coordinating medical appointments or other operational functions. CalOptima Health conducts quality assessments of all subcontracted providers to ensure members can see the providers they need for quality care in locations that are easy to access.
Your primary care provider (PCP) will refer you to specialists and services connected with their medical group, health network or with CalOptima Health. If you are going to a specialist already, talk with your PCP or call CalOptima Health Customer Service at 1-855-877-3885 (TTY 711).
Customer Service will help you see that provider if you are eligible for continuity of care. For more information, go to the Continuity of Care section in the member handbook.
Delegation Reporting and Compliance Plan
Annual Network Certification: Alternative Access Standards
Subcontractor Network Certification Network Adequacy and Access Assurances Report (NAAAR)
Provider Network Updates: CalOptima Health’s provider network is subject to ongoing change.
Service Availability: Some hospitals and providers may not offer certain services covered under your plan. These excluded services may include:
- Family planning
- Contraceptive services (such as emergency contraception)
- Sterilization procedures (e.g., tubal ligation at labor and delivery)
- Infertility treatments
- Abortion services
Prior Authorization Requirements: Enhanced Care Management and Community Supports need prior authorization and are available only to members who meet specific eligibility criteria.
- Enhanced Care Management (ECM): CalOptima Health covers ECM services for members with complex needs. ECM is a benefit that offers extra services to help you get the care you need to stay healthy. ECM helps coordinate primary care, acute care, behavioral health, developmental services, oral health, community-based Long-Term Services and Supports (LTSS) and referrals to available community resources.
- Community Supports: Community Supports are medically appropriate alternative services or settings to those covered under the Medi-Cal State Plan. CalOptima Health offers 14 optional Community Supports services:
- Housing Transition Navigation Services
- Housing Deposits
- Housing Tenancy and Sustaining Services
- Short-Term Post-Hospitalization Housing
- Recuperative Care (Medical Respite)
- Day Habilitation Programs
- Caregiver Respite Services
- Nursing Facility Transition/Diversion to Assisted Living Facilities
- Community Transition Services/Nursing Facility Transition to a Home
- Personal Care and Homemaker Services
- Environmental Accessibility Adaptations (Home Modifications)
- Medically Supportive Food/Meals/Medically Tailored Meals
- Sobering Centers
- Asthma Remediation
Cultural Competency Training: All network providers listed in this directory have completed cultural competency training as of the publication date.
Language Interpreter Services (including American Sign Language): There is no cost to members for language interpreter services (under Section 1367.04).
Full and equal access to covered services, including members with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.
Accessing Updated Provider Information: For the most current provider information or to request a printed copy, call the CalOptima Health Member Services number listed on the back of your ID card.
Viewing the Printed Provider Directories: To access a copy of the Provider Directories, click on the plan below.
Medi-Cal: 2025 Medi-Cal Health Network and Provider Directory