Below are some common questions and answers about CalOptima and the Healthy Families Program. If you do not see your question answered here, please call our Customer Service Department at 1-800-530-2899. We are here to help you and make sure you get access to the best health care.

To be eligible for the Healthy Families Program, your child must:

There are many places in Orange County that can help you apply for the Healthy Families Program. You can receive a list of these places by calling the Healthy Families Program at 1-800-880-5305. The Healthy Families Program can also send you a form to apply. CalOptima has Certified Staff who can help you with the application process. You can reach a CalOptima certified staff member by calling 1-714-246-8607. You can also download an application from the Health Families Program website.

The Healthy Families Program will determine your child's eligibility within 10 calendar days or less after they get your application, as long as your application
is complete.

Yes. Your monthly payment will be based on your income, the number of children covered and the health plan you choose. As the Community Provider Plan in Orange County, CalOptima’s premium cost is $3 less per child per month. A family can receive a discount up to $9 per family per month. By choosing CalOptima, you will pay lower monthly premiums than if you choose another Healthy Families Program plan in Orange County.

Yes, you will have to re-apply each year. Once a year the Healthy Families Program will need to see if your child still qualifies to be a member of the program. This process is the Annual Eligibility Review (AER). The Healthy Families Program will contact you by mail about the AER process. You will receive a letter about 60 calendar days before the end of your child’s anniversary date in the Healthy Families Program. In the letter, the Healthy Families Program will ask you for an update of your family size and income. The Healthy Families Program must receive your AER form and income papers by the due date on the packet. If your child still qualifies for the program, coverage will last for 12 more months. Your premium may change based on your household income. The Healthy Families Program will review your monthly premium to see if it has changed. If your child still qualifies to be a member, your child can stay in the Healthy Families Program for 12 more months, until the next AER. If you need help filling out the AER form, please call CalOptima at 1-800-530-2899.

You can find out if a service is covered by looking in the Evidence of Coverage (EOC) booklet. This booklet explains your benefits and coverage limitations. CalOptima mailed the booklet to you along with your CalOptima Healthy Families Program ID card when you first became a CalOptima member. You can also learn more about your benefits at this link. You can request an Evidence of Coverage booklet by calling our Customer Service toll-free number at 1-800-530-2899.

Yes, you can change your child's PCP for any reason. Just call your health network and ask them to change your child's PCP. Your health network’s phone number is on the front of your CalOptima Healthy Families Program ID card. After your request for change has been approved, your new PCP will be effective the first day of the next month.

Yes, you can change your health network for any reason. To change your health network, call CalOptima at 1-800-530-2899 to request a health network change. The change will begin the next month. To see a list of the health networks offered to you, refer to the Provider Directory. You can find the Provider Directory in the packet you were given when your child first joined CalOptima.

Your child’s Primary Care Physician (PCP) will manage your child’s health care needs and when needed, will arrange specialty services for him/her. In some cases, your health network must approve the specialty service before your child receives the needed care. Your child’s PCP will get the needed referrals and authorizations for you.

Please contact your child's PCP/specialist or your health network. The phone numbers for your PCP and health network are on the front of your CalOptima Healthy Families Program ID card.

You should first call the provider that gave you the service for which you got a bill. Give this provider your CalOptima Healthy Families Program ID number and ask him/her to send the bill to CalOptima. You should also call your health network or CalOptima Customer Service Department at 1-800-530-2899 if you have any questions.

Urgent Care is medical care needed for a sudden illness or injury that cannot wait for a regular doctor’s appointment. If you have an urgent situation, call your Primary Care Physician (PCP) first. If you cannot reach your PCP, call your health network at the 24-hour access helpline listed for your health network on Page 3 of the Provider Directory. Your PCP and Health Network phone numbers are listed on the front of your CalOptima Healthy Families Program ID card. You will be able to speak to someone who can help you access urgent care services after hours.

If you are outside of Orange County and have an urgent need, go to the nearest urgent care center or hospital emergency room. Please make sure to show your CalOptima Healthy Families Program ID card at the time of service. Ask the staff to call your health network within 24 hours to let them know about your visit to the urgent care center or emergency room. If you are not sure if it is an urgent need or emergency, call your Primary Care Physician. Do not use the hospital emergency room for routine care.

Your health network provides most mental health services. For a list of Mental Health Providers in your Health Network, call the Health Network Customer Service phone number listed on your CalOptima Healthy Families Program ID card.

All medications that are on the CalOptima Approved Drug List are covered. If your doctor says you need a medication not on this list, your pharmacy must get prior authorization. All pharmacies that have a contract with CalOptima must obtain all authorizations for medications. If you want to know if a certain medication that you need is covered by CalOptima, call CalOptima Customer Service Department at
1-800-530-2899.

In California, you can go to any participating chain pharmacy and fill your prescription. Prescriptions filled outside of California need prior authorization from CalOptima. If you need help filling your prescription while outside of California, please call CalOptima Customer Service Department at 1-800-530-2899.

The Healthy Families Program provides dental care benefits, not CalOptima. To access dental care or schedule a visit, refer to your dental ID card for the name of your dentist. For questions about your dental coverage, please call the Healthy Families Program at 1-866-848-9166.

The Healthy Families Program provides vision care benefits, not CalOptima. For questions regarding your vision coverage or how to access services, please call the Healthy Families Program at 1-866-848-9166.

Yes. As a CalOptima member, you can get no-cost interpreter or sign language services for your health care visits. If you need this service, call the health network phone number listed on your CalOptima Healthy Families Program ID card at least 5 working days before your doctor's visit. You do not need to use your family member or friends to interpret.

You can request a new ID card by calling our Customer Service Department toll-free number at 1-800-530-2899.

Please call The Healthy Families Program at 1-866-848-9166 to provide your new home address and phone number. It is also a good idea to report address changes to the U.S. Postal Service.