CalOptima Health Compliance Program

CalOptima Health’s Compliance Program reflects our commitment to conducting our operations in compliance with ethical standards, contractual obligations, and all applicable statutes, regulations and rules pertaining to our programs, including Medi-Cal, OneCare and Program of All-Inclusive Care for the Elderly (PACE). 

CalOptima Health’s compliance commitment covers our own internal operations as well as our oversight and monitoring responsibilities for First Tier, Downstream and Related Entities (FDRs). “FDR” refers to CalOptima Health’s delegated subcontractors that perform administrative functions and/or provide health care services that CalOptima Health is required to perform and/or provide under our federal and state contracts with CMS and DHCS. FDRs include those directly contracted with CalOptima Health and those that are Downstream or Related Entities (i.e., subcontractors) with First Tier Entities, such as health networks, physician groups, participating providers, suppliers, pharmacy benefit managers and consultants.

CalOptima Health has incorporated all the elements of an effective Compliance Program as recommended by the Office of the Inspector General and required by CMS regulations. The program is continually evolving and may be modified and enhanced based on compliance monitoring and identification of new areas of operational, regulatory or legal risk. CalOptima Health requires that employees, Board members and FDRs conduct themselves in accordance with the program’s requirements.