“The reason we’re doing this is very straightforward,” CalOptima CEO Michael Hunn told Becker’s.
“We have individuals who fall in and out of Medicaid eligibility when they miss the financial cutoff for income, even by a couple hundred dollars. We refer to that as the population that will churn — they’ll fall in, they’ll fall out, they’ll fall in,” he said. “Our single goal in going on the exchange is to work with that population to offer them affordable access to care and continuity. We want to take our current networks, contract with them to add the exchange product, and then allow the individuals who sign up to stay with their doctor and stay with their medical home if they’re affiliated with a clinic.”
The new offering will be particularly beneficial for families, pregnant women, and seniors who lose coverage temporarily before transitioning to Medicare, ensuring that people do not face unexpected expenses or delays in treatment, particularly during critical times such as pregnancy and postpartum care.
Over the past six months, CalOptima has engaged stakeholders, including providers, medical associations, and community clinics, to develop the new offering.
“Out of our 900,000+ members, we delegate about 700,000 of them to nine large medical groups,” Mr. Hunn said. “The medical groups are extremely happy with this move and have given us letters of support because it allows them to retain their members with their doctor and their medical home. When people delay care, it all backs up and ends up in the emergency room, which is the last place we want folks.”
CalOptima still needs to obtain a special state license for the new product, submit a budget proposal, and work on infrastructure development. The organization has received county approval and expects to launch for 2027 coverage.
