Your Health. Covered with CalOptima Health.

Ensuring continuity of care and expanding access

Joining Covered California

CalOptima Health is seeking to join the Covered California market for the 2027 plan year. By becoming part of Covered California, CalOptima Health will ensure more Orange County residents have access to affordable health insurance and the quality care they deserve. Offering a CalOptima Health Covered California plan will benefit members, providers and the broader Orange County community.

About Covered California

Launched in 2014, Covered California is the state-based health insurance marketplace through which eligible Californians purchase low-cost individual insurance coverage for themselves and their families. All Covered California plans must provide a comprehensive package of benefits and services, known as the Essential Health Benefits. Lawfully present California residents who are not eligible for Medi-Cal or employer-sponsored insurance can purchase a plan through Covered California.

Premium subsidies are available to qualifying individuals and families, and 9 out of 10 people who enroll get financial help based on their income level. There are approximately 163,000 Orange County residents currently enrolled in a Covered California plan.

Benefits of Joining Covered California

Member Benefits

As incomes change, members may lose Medi-Cal coverage and need to transition to Covered California. A CalOptima Health Covered California plan will offer continuity of care to former Medi-Cal members and help them retain their medical home.

By offering both Medi-Cal and Covered California plans, CalOptima Health will help mixed-coverage households maintain aligned provider networks for all family members. CalOptima Health’s Covered California participation will ensure access to affordable, high-quality care for plan members.

CalOptima Health is committed to reinvesting in the community and will work with stakeholders to help drive decision-making and community investment as part of participating in Covered California.

CalOptima Health will aim to provide access to a broad, high quality health network to ensure continuity of care for members transitioning from Medi-Cal. This may prevent disruption for members who would otherwise be required to join a new provider network and seek services from a different provider.

Upon implementation, CalOptima Health will establish a member and community advisory committee to gather input about the ongoing operations of the plan.

Provider Benefits

A CalOptima Health Covered California plan will support safety net providers by offering a new line of business and a way to maintain relationships and continuity of care with patients transitioning out of Medi-Cal.

Maintaining competitive reimbursement rates is critical to ensuring the delivery of quality care. Covered California is an established market, and CalOptima Health will need to have competitive provider reimbursement rates to maintain a robust provider network.

As a community-based public plan, CalOptima Health will reinvest any net revenue into Orange County’s broader community health, which will benefit members,

providers, clinics, hospitals and others. After being approved for Covered California participation, CalOptima Health will formalize the reinvestment process with stakeholder input from the Provider Advisory Committee.

The suggested reinvestment process will be brought to CalOptima Health’s Board of Directors prior to implementation.

CalOptima Health will work to align administrative and quality of care requirements and processes across all our programs.

Anticipated Timeline

Member Stories

It’s About the Members

The value of a CalOptima Health Covered California plan is in the advantages for members. Continuity of care is key, especially for members who have complex medical needs. For example, a CalOptima Health member undergoing breast cancer treatment could be at risk if she was disenrolled from Medi-Cal due to her income level changing. The member would have to navigate maintaining access to the same providers who are administering her treatment plan. She may also worry about her ability to afford any out-of-pocket treatment costs when she joins a Covered California plan. If she was not able to choose a CalOptima Health Covered California plan, CalOptima Health would not be able to activate continuity of care provisions that allow her to continue treatment with her current providers. If she was in a different Covered California plan, the plan has discretion over continuity of care decisions, including the length of time granted to continue treatment with current providers.

FAQs

Answers to your top questions about CalOptima Health and Covered California.

Q: What initial steps must CalOptima Health take to join the Covered California exchange?

A: To launch a Covered California plan by 2027, CalOptima Health must seek a change to its governing ordinance from the Orange County Board of Supervisors in 2024. CalOptima Health will also need to obtain approval from both Covered California and the California Department of Managed Health Care (DMHC). CalOptima Health’s Board of Directors will guide implementation based on the project timeline.

Q: How will CalOptima Health ensure a transparent process as it prepares to enter the Covered California market?

A: To boost community engagement, CalOptima Health will convene a Steering Committee of external stakeholders to ensure transparency and gather input both before and after the ordinance change. CalOptima Health’s Member Advisory Committee and Provider Advisory Committee will also be engaged throughout the process.

Q: How will CalOptima Health ensure that entering Covered California will benefit members, providers and the community?

A: CalOptima Health will adhere to seven guiding principles throughout the design and implementation of a Covered California plan, including:

Provide continuous, high-quality care to our members across changes in life circumstances.
Ensure sufficient provider reimbursement in alignment with the current Covered California market in Orange County.
Consistently engage external stakeholders on an ongoing basis to inform the design, development and implementation of the program in a transparent way.
Be strong stewards of public funds by identifying opportunities for efficiency and careful investment in needed capabilities.
Ensure ongoing reinvestment in the Orange County community.
Start small and target individuals and families churning on and off Medi-Cal coverage.
Ensure network adequacy to support access and availability to care for our members.

Resources

The materials below include information and resources about Covered California.

CalOptima Health welcomes your questions and input. Please email the Strategic Development department at StrategicDevelopment@caloptima.org. Thank you for your partnership!

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