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Provider Resources - Clinical Practice Guidelines

assist primary care providers in delivering care in accordance with IEHP standards. Resources are reviewed regularly and updated to reflect changes from a regulatory and clinical standpoint. Preventive Care Guidelines American College of Obstetricians and Gynecologists (ACOG) American Academy of Pediatricians (AAP) / Bright Futures Comprehensive Perinatal Services Program (CPSP) Clinical Practice Guidelines Library The guidelines contained on this page are recommended by IEHP with the intent to enhance Member care. IEHP’s Clinical Practice Guidelines topics are organized using the following categories: United States Preventive Services Task Force (USPSTF); IEHP Internal Library; Healthcare Effectiveness Data Information Set (HEDIS); and Managed Care Accountability Set (MCAS) Links or documents embedded within the Internal Library category indicate literature that has been published by leading, formal organizations and have been endorsed/approved by IEHP’s Medical Directors and Quality Committee. IEHP produced information relevant to the topic will also be listed in this category. We have also indicated any HEDIS/ MCAS measures that are pertinent to the topic. Additionally, IEHP accepts USPSTF guidelines to help primary care clinicians identify clinical preventive services that are appropriate for their patients. IF there is a USPSTF guideline relevant to the topic, we have identified it below.  Library Catalog Click on a letter to jump to that specific section: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A Asthma USPSTF N/A IEHP Internal Library Global Strategy for Asthma Management and Prevention (PDF) HEDIS Asthma Medication Ratio (AMR) Medication Management for People with Asthma (MMA) MCAS Asthma Medication Ratio (AMR) (Back to Library Catalog) B Breast Cancer USPSTF Breast Cancer Screening Use of Medications to Prevent Breast Cancer BRCA Testing IEHP Internal Library N/A HEDIS Breast Cancer Screening (BCS) MCAS Breast Cancer Screening (BCS) (Back to Library Catalog) C Cervical Cancer USPSTF Cervical Cancer Screening IEHP Internal Library N/A HEDIS Cervical Cancer Screening (CCS) MCAS Cervical Cancer Screening (CCS) (Back to Library Catalog) Chlamydia USPSTF Chlamydia and Gonorrhea Screening IEHP Internal Library You may also refer to Sexually Transmitted Infections in this resource guide HEDIS Chlamydia Screening in Women (CHL) MCAS Chlamydia Screening in women (CHL) (Back to Library Catalog) Cholesterol USPSTF Statin Therapy for Primary Prevention of CVD Healthful Diet and Physical Activity for CVD Prevention in Adults with CVD Risks IEHP Internal Library American Heart Association – Blood Cholesterol Management (PDF) American Heart Association – Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults (PDF) HEDIS Statin Therapy for Patients with Cardiovascular Disease-Adherence (SPC) Statin Therapy for Patients with Cardiovascular Disease – Statin Therapy (SPC) MCAS N/A (Back to Library Catalog) Chronic Obstructive Pulmonary Disorder USPSTF N/A IEHP Internal Library Global Initiative for Chronic Obstructive Lung Disease – COPD (PDF) HEDIS Pharmacology Management of COPD Exacerbation – Systemic Corticosteroids (PCE) Pharmacology Management of COPD Exacerbations – Bronchodilators (PCE) Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) MCAS N/A (Back to Library Catalog) Colorectal Cancer USPSTF Colorectal Cancer Screening IEHP Internal Library N/A HEDIS Colorectal Cancer Screening (COL) MCAS N/A (Back to Library Catalog) D Depression USPSTF Screening for Depression in Adolescents Screening for Depression in Adults including Pregnant Women Screening for Perinatal Depression IEHP Internal Library American Academy of Pediatrics – Adolescent Depression in Primary Care (PDF) American Psychiatric Association – Major Depressive Disorder (PDF) HEDIS Antidepressant Medication Management Acute Phase (AMM) Antidepressant Medication Management Continuation Phase (AMM) MCAS Antidepressant Medication Management Acute (AMM-Acute) Antidepressant Medication Management Continuation (AMM-Cont) (Back to Library Catalog) Diabetes USPSTF Gestational Diabetes Screening Prediabetes and Type 2 Diabetes: Screening IEHP Internal Library American Diabetes Association – Diabetes Care (PDF) National Kidney Foundation – Diabetes and Chronic Kidney Disease (PDF) HEDIS Statin Therapy for Patients with Diabetes – Adherence (SPD) Statin Therapy for Patients with Diabetes – Statin Therapy (SPD) Comprehensive Diabetes Care – HbA1C Testing (CDC) Comprehensive Diabetes Care - HbA1C Control (<=9) (CDC) Comprehensive Diabetes Care (<8) (CDC) Comprehensive Diabetes Care - Eye Exam (CDC) Comprehensive Diabetes Care – Monitoring for Nephropathy (CDC) Comprehensive Diabetes Care – Blood Pressure Control (<140/90) (CDC) MCAS Comprehensive Diabetes Care HbA1C Testing (CDC HT) Comprehensive Diabetes Care HbA1C Testing >9%) (CDC H9) (Back to Library Catalog) E (Back to Library Catalog)   F (Back to Library Catalog)   G Gonorrhea USPSTF Chlamydia and Gonorrhea Screening IEHP Internal Library You may also refer to Sexually Transmitted Infections in this resource guide HEDIS N/A MCAS N/A (Back to Library Catalog) H Hepatitis C USPSTF Hepatitis C Virus Infection in Adolescents and Adults: Screening IEHP Internal Library American Association for the Study of Liver Diseases – Hepatitis C (PDF) HEDIS N/A MCAS N/A (Back to Library Catalog) Human Immunodeficiency Virus (HIV) USPSTF HIV Screening in Pregnant Persons HIV Screening in Adults and Adolescents HIV Prevention – Preexposure Prophylaxis IEHP Internal Library You may also refer to Sexually Transmitted Infections in this resource guide HEDIS N/A MCAS N/A (Back to Library Catalog) Hypertension USPSTF Screening for Hypertension in Adults IEHP Internal Library Joint National Committee – Hypertension Guidelines (PDF) HEDIS Controlling high blood pressure (CBP) MCAS Controlling high blood pressure (CBP) (Back to Library Catalog) I (Back to Library Catalog)   J (Back to Library Catalog)   K (Back to Library Catalog) L (Back to Library Catalog)   M (Back to Library Catalog)   N (Back to Library Catalog)   O Obesity USPSTF Weight Loss to Prevent Obesity Related Morbidity and Mortality in Adults - Counseling Screening for Obesity in Children and Adolescents Behavioral Health Counseling for Adults that are Overweight or Obese and Have Other CVD Risk Factors IEHP Internal Library N/A HEDIS Weight Assessment and Counseling (WCC-BMI) Adult Body Mass Index (ABA) MCAS Weight Assessment and Counseling (WCC-BMI) Adult Body Mass Index (ABA) (Back to Library Catalog) Osteoporosis USPSTF Osteoporosis to Prevent Fractures: Screening IEHP Internal Library N/A HEDIS Osteoporosis management in women who have had a fracture (OMW) MCAS N/A (Back to Library Catalog) P (Back to Library Catalog) Q (Back to Library Catalog) R (Back to Library Catalog) S Sexually Transmitted Infections USPSTF Syphilis Screening in Pregnant Women Syphilis Screening for those at Increased Risk for Infection Chlamydia and Gonorrhea Screening HIV Screening in Pregnant Persons HIV Screening in Adults and Adolescents HIV Prevention – Preexposure Prophylaxis IEHP Internal Library Centers for Disease Control Public Health Media Library – STD Treatment You may also refer to individual topics as they appear in this library: Chlamydia Gonorrhea HIV Syphilis HEDIS Chlamydia Screening in women (CHL) MCAS Chlamydia Screening in women (CHL) (Back to Library Catalog) Skin Cancer Behavioral Counseling USPSTF Skin Cancer Prevention: Counseling IEHP Internal Library N/A HEDIS N/A MCAS N/A   (Back to Library Catalog) Smoking Cessation/Tobacco Usage USPSTF Smoking Cessation Smoking Cessation – Pharmacotherapy Lung Cancer Screening Tobacco Use in Children and Adolescents – Primary Care Interventions IEHP Internal Library N/A HEDIS N/A MCAS N/A (Back to Library Catalog) Syphilis USPSTF Syphilis Screening in Pregnant Women Syphilis Screening for Those at Increased Risk for Infection IEHP Internal Library You may also refer to Sexually Transmitted Infections in this resource guide HEDIS N/A MCAS N/A (Back to Library Catalog) T Tuberculosis USPSTF Latent Tuberculosis Screening IEHP Internal Library N/A HEDIS N/A MCAS N/A (Back to Library Catalog) U (Back to Library Catalog) V (Back to Library Catalog) W (Back to Library Catalog) X (Back to Library Catalog) Y (Back to Library Catalog) Z (Back to Library Catalog) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Leadership Team - Janet Nix, EdD

for the organizational development and operations of Human Resources. As the Chief of Organizational Development, utilizing her vast experience and expertise, Dr. Nix leads the way to continue developing and improving the core functions of IEHP’s Human Resources. Dr. Nix’s key focus includes impacting the IEHP culture and enriching IEHP’s goal of developing each employee. Dr. Nix is in charge of many critical tasks including driving IEHP’s processes for recruitment, hiring, on-boarding, benefits administration, company-wide training, and building employee morale.In her role, she is greatly motivated by and focused on supporting IEHP’s core values. Dr. Nix brings 30 years of experience to IEHP—15 years in education, and 15 years in healthcare. She is very experienced in organizational development, employee engagement, training at all levels in hospital and health systems environments, and many other areas of Human Resources functions. Her knowledge serves her position at IEHP seamlessly as she leads IEHP’s employee development, leadership development, and company environment advancement. Prior to IEHP, Dr. Nix worked as the Chief Learning Officer for the Hospital Sisters Health System in Illinois, which encompasses 13 hospitals and three integrated physician networks, including 15,000 employees. Previously, Dr. Nix worked as Assistant Vice President of Learning and Curriculum at St. Mary’s Medical Center, and as Dean of Instruction at Victor Valley Community College District. Dr. Nix earned her Bachelor of Arts in Social Welfare and Master of Public Administration from California State University, Sacramento. Dr. Nix also earned her Doctor of Educational Leadership from the University of LaVerne.

Governing Board - Karen Spiegel

sworn into office on January 8, 2019. The Second District includes the unincorporated communities of Coronita, El Cerrito, Home Gardens and Highgrove, and the cities of Corona, Eastvale, Jurupa Valley, Norco, and the western half of the City of Riverside. In February 2019 she was appointed to the IEHP Governing Board, appointed Vice-chair in 2020, and served as Chair in 2021. Karen Spiegel began her political career as the elected City Treasurer for the City of Corona in 1996. After six years as Treasurer, she embraced the City Council elections in 2002 and served the City of Corona as Council Member for 16 years, serving as Mayor four terms. Her actions speak volumes and her unique passion for service truly sets her apart. She encourages community participation with City and County government and has introduced many new programs. Karen has been credited for her leadership in regional transportation issues, collaboration and regional partnerships. In addition to the service in her District, Karen represents Riverside County on the Regional and State level in many organizations and has served in a leadership role on several. She is an energetic member of the community and her "roll-up your sleeves" attitude has led her to immerse herself in many civic, business and community activities. She has been honored for her service with numerous awards and recognitions over the years.

Healthcare Scholarship Fund - Our Scholars

group of students from the Inland Empire. More than 30 recipient students grew up in the Inland Empire and more than 50% are first generation medical students and grew up in low-income households. Through the scholarship fund, aspiring healthcare professionals will be guided through the system and connected to the health plan’s provider network. This allows students to pursue successful careers in healthcare immediately after graduation to help support the region’s growing population. Loma Linda University School of Medicine Inland Empire Medical Community Service Awardees Class of 2022 Ye Jin Jeon Ye Jin's Why: “I applied for the Inland Empire Medical Community Service Award because the goal and priority to expand access to care and healthcare provider options for the Southern California region aligns with my calling. As a child growing up in the San Bernardino County, I saw the economic disproportion within my own neighborhood, and this compelled me…God has led me pursue my medical career” Class of 2024 Edwin Choque Edwin's Why: “Simply put, my heart lies in the Inland Empire. This community of individuals have fostered me and loved me since I was a child and all I can hope is to pay that love and care forward. . . . My dream is to be on the front lines as a representative for these individuals who frequently become marginalized…” University of California, Riverside Dean's Mission Recipients Four Year Award Elizabeth Celaya-Ojeda Elizabeth's Why: “I want to work particularly with the underserved in this area because I truly believe that being a physician is a privilege and with that there is a responsibility to be an advocate for those who are facing health disparities. I am particularly interested in providing care to underserved Native American and Hispanic communities. Not many healthcare providers are aware of the disparities these two communities face and I want to be an advocate for them, especially in the Inland Empire.” Alfonso Parocua Alfonso's Why: “Growing up, my family lacked meaningful access to healthcare and relied on a local free clinic as our only means of interacting with a physician. Through my personal experience with the free clinic, I developed a passion for service to the underserved communities who lack meaningful access to basic healthcare amenities due to low socioeconomic status. I sought opportunities that would allow me to pay my gratitude forward by becoming part of the solution to healthcare disparities in Inland Southern California. Through my volunteer efforts in free clinics and other community involvement programs, I witnessed the passion and dedication that health care providers and volunteers in the area have towards the underserved community. This realization deepened my connection to Inland Southern California because I was reminded so much of the health care professionals that helped my family when they couldn't help themselves.” Two Year Award Cesar Fortuna Cesar's Why: “A San Bernardino native, I have had the opportunity to volunteer in my community as a Spanish language translator for free clinics. Most patients I have spoken with fell into the category of uninsured, underinsured, or undocumented. It became clear the extent of need in this region when I would translate to the providers that this was the first-time dozens of our patients had ever seen a medical professional; however, this wasn’t uncommon. To these patients and their stories, I thank them because they inspire me to pursue Emergency Medicine where I can become a valuable player in providing care, providing resources, or providing comfort.” Lavinia Mitroi Lavinia's Why: “My goal of pursuing a career at the intersection of medicine and public health is driven by a desire to put patients and communities at the center of our health care system in the U.S. This desire was sparked most poignantly by my own experiences as an IEHP patient growing up in the Inland Empire. As I prepare for a future career as a pediatrician in this region, I hope to serve as an advocate for children and families, providing direct health services but also creating systems change.” Armando Navarro Armando's Why: “The earliest memory of my grandfather is him telling me, “Mijo, tienes que aprender Español para ayudar tu comunidad, you have to learn how to speak Spanish to help your community”. These words were often repeated to me by my grandfather who lamented the fact that he only spoke Spanish. I witnessed the health disparities affecting my community; doctors who did not speak Spanish, parents who could not afford a trip to the doctors’ office, and a healthcare system that was not inclusive of my community’s culture. I have a duty to give back to a school, a community, that has given me so much.” Christ Ordookhanian Christ's Why: “I see the medical profession through the lens of an individual who had lived through challenging times and witnessed how one individual provider can make such and impact when their heart is in the right place. My dedication to our underserved community stems from that of a lifelong mission I have set for myself which is to ensure I give back to a community that I am deeply associated with, they are my founding roots in the United States, and I vow to be at the forefront of the next generation of physicians that care and give the underserved hope.” University of California, Riverside Dean's Mission Recipients Daphne Du Daphne's Why: “I spent most of my life in underprivileged areas and saw firsthand how difficult healthcare access could be through inadequate financial resources, transportation, or translation services. Thanks to this investment in my studies, there is less stress in my life. I can focus on my studies and eventually give back to the community by becoming a physician who will advocate for patients without meaningful access to health care.” Judith Gonzales Judith's Why: “As a first-generation college student, there have always been many barriers in my path to higher education. I am the eldest daughter of an immigrant family, and it is truly an honor to be able to reach this point in my education and in my career, and to give back to my parents who have sacrificed so much for me and my sisters. Growing up in an underserved community showed me the long-lasting impacts of health inequities and strengthened my resolve to pursue a career in medicine. Working in the Inland Empire, I hope to not only address, but actively work towards combating the health inequity present in our communities.” Jordan Hough Jordan's Why: “Despite disadvantages encountered when living in a low-income community, I am grateful for the privilege I had in meeting physicians dedicated to their practice and willing to share that love through mentorship. These individuals have served as exemplary medical professionals and have encouraged me to follow in their footsteps. As a future physician, I aspire to empathetically care for patients by allowing my past experiences to enhance my understanding of their needs. I also plan to incorporate teaching into patient care by presenting opportunities for students to shadow and be mentored for a career in medicine.” Diana Martinez Diana's Why: “I am the daughter of Mexican Immigrants and grew up in Compton, California where I unfortunately was quickly desensitized to violence and was able to tell the difference between a firework and a gun shot. My mother had to travel a significant distance to ensure we had adequate healthcare. Despite these conditions, my parents always stressed education and did their best to give me what I needed. These life circumstances ignited my passion to serve those in disadvantaged communities, which I interacted with throughout my educational career. The Inland Empire Health Program Scholarship means I can achieve my dream –by practicing medicine in a community that deserves adequate, equitable, and accessible healthcare. I will serve as a bilingual physician in the Inland Empire that can serve families like my own and many more.”

COVID-19 - COVID-19 Vaccine

c9; border: none; color: white !important; padding: 15px 32px; border-radius: 25px; display: inline-block; text-align: center; cursor: pointer; } COVID-19 Vaccines: Latest news and updates The COVID-19 vaccines are safe, effective and free for all IEHP Members. Recommended for everyone ages 5 and older, the vaccines can help protect people from severe illness, hospitalization and death due to COVID-19. The vaccines won’t make people sick or give them COVID-19. They may have some minor side effects, which are not harmful and should last no more than a few days. The vaccines can help us end the pandemic and save lives. Vaccinated people should keep wearing a mask, washing their hands often and maintaining at least 6 feet of distance in public places. IEHP Members can learn more by continuing to visit the IEHP website and or visiting the California Department of Health’s website. CLICK HERE TO FIND A VACCINE CLINIC NEAR YOU How vaccines build immunity While the COVID-19 vaccines are relatively new - the technology and science behind the vaccines have been in development for decades. In the video below, we demonstrate how years of vaccine research and advanced technology allowed researchers and scientists worldwide to be prepared to develop an mRNA vaccine that could help fight the spread of a global infectious disease. PFIZER VACCINE GETS FULL FDA APPROVAL On August 23, 2021, the U.S. Food and Drug Administration (FDA) approved the first COVID-19 vaccine – the Pfizer-BioNTech COVID-19 Vaccine (widely known as the Pfizer vaccine). The approved vaccine will now be marketed as Comirnaty (koe-mir’-na-tee) for the prevention of COVID-19 disease in people 16 years of age and older. Effective October 29, 2021 the Pfizer vaccine is available under emergency use authorization, including for use by children aged 5 through 18 years of age and for the administration of a booster dose in certain immunocompromised people. Please note, the Pfizer vaccine and Comirnaty are the same vaccine. The FDA reports that they have the same formulation and are interchangeable.  Where can I get the vaccine? For Members who want the vaccine, there are several options: IEHP recommends My Turn online at myturn.ca.gov. My Turn online, a website from the California Department of Public Health, is a convenient, one-stop website where those who want a COVID-19 vaccine can: Set up their first, second and booster shot appointments Set up family or group appointments Find walk-in clinics in their area Set up in-home vaccinations (if needed) Arrange for transportation (if needed) For those without internet access, the California COVID-19 Hotline at 1-833-422-4255 can help provide the same services. Large pharmacy chains, like CVS and Walgreens provide the vaccine. Many have walk-in appointments available. IEHP recommends calling the pharmacy first to confirm. Vaccine appointment sign-ups are also available online through the public health department in your county. For Riverside County, visit www.ruhealth.org/covid-19-vaccine. For San Bernardino County, visit www.sbcovid19.com/vaccine/.  Do I have to pay for the vaccine? No. The vaccine is free for everyone who wants it.  Is the vaccine safe? Yes, the top medical experts in our nation and state agree that COVID-19 vaccines are safe and effective. The vaccines were tested in large clinical trials to make sure they meet safety standards. Many people from different ages, races, and ethnic groups, as well as those with different medical conditions, were part of the trials. Does the vaccine have side effects? Most people do not have serious problems after being vaccinated for COVID-19. Any minor symptoms that result usually go away on their own within a week. Call your Doctor immediately if you start to have any of the following symptoms: severe headache, abdominal pain, leg pain/swelling, or shortness of breath, chest pain, feelings of having a fast-beating, fluttering or pounding heart. Your Doctor or health care provider will explain any potential side effects and what you need to do about them.  Since the emergency use authorization of the Moderna and Pfizer-BioNTech COVID-19 vaccines, myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the lining outside the heart) have occurred in some people who have received these vaccines. In most of these people, symptoms began within a few days following the second dose of these vaccines. There have been confirmed reports of myocarditis or pericarditis in individuals who received COVID -19 vaccine, particularly among males ages 30 and younger. While this is concerning and is under further investigation, myocarditis or pericarditis after COVID vaccination is extremely rare as more than 318 million doses of COVID-19 vaccines have been administered in the United States from December 14, 2020 through June 21, 2021. Will there be any long-term side effects? COVID-19 vaccines are being tested in large clinical trials to assess their safety. It will take time and more people will need to get the vaccine before we learn about very rare or long-term side effects. The Food and Drug Administration (FDA) and the U.S. Centers for Disease Control (CDC) will continue to monitor the safety of COVID-19 vaccines. Health care providers are required to report any problems or adverse events following vaccination to the Vaccine Adverse Event Reporting System (VAERS). What if I have side effects? Contact your Doctor right away. The CDC offers a smartphone-based tool called v-safe to check in on people’s health after they receive a COVID-19 vaccine. When you get your vaccine, you should also get a v-safe handout telling you how to enroll in the program. If you enroll, you will get regular text messages with links to surveys where you can report any problems or side effects after getting a COVID-19 vaccine. Can the vaccine give me COVID-19? No, the vaccine cannot give you COVID-19 because it does not contain an infectious virus. How many shots will be needed? The Pfizer and Moderna vaccines require two shots, 3 to 4 weeks apart. While the first shot helps build protection, you will need to come back a few weeks later for the second one to get the most protection the vaccine can offer. Your Doctor will advise you when you should return for the second shot, as it varies by type of vaccine. The J&J vaccine requires only one shot. Do I need the booster shot? Studies show after getting vaccinated against COVID-19, protection against the virus and the ability to prevent infection with variants may decrease over time and due to changes in variants. However, the booster shot may increase your immune response to COVID-19 and its variants, increasing prevention efforts against the virus. Who can get a booster shot? Booster shots are available to everyone ages 12 years and older who are fully vaccinated but the timing of the booster varies by vaccine and age group. When can I get the booster shot? If you received the Pfizer-BioNTech vaccine, everyone 12 years or older should get the booster at least five months after completing your primary COVID-19 vaccination series. If you received the Moderna vaccine, adults 18 years and older should get the booster at least six months after completing your primary COVID-19 vaccination series. If you received the Johnson & Johnson’s Janssen vaccine, adults 18 years and older should get the booster at least two months after receiving your J&J/Janssen COVID-19 vaccination. Does the booster shot have side effects? You may experience side effects after getting the booster shot. These are normal signs that your body is building protection against COVID-19. Do I need to keep wearing a mask and avoiding close contact with others once I get fully vaccinated? Yes. While experts learn more about the protection that COVID-19 vaccines provide, please keep using all the tools we know can help stop the spread of COVID-19. This means keep wearing a mask, washing your hands often, avoiding crowds, and maintaining at least 6 feet of distance in public places. Can children and babies get COVID-19? Yes. Children can get COVID-19. Most children with COVID-19 have mild symptoms, or they may have no symptoms at all, which is called being asymptomatic. Fewer children have been sick with COVID-19 compared to adults. But, infants (children younger than 1 year old) and children with certain medical conditions might have a higher risk for getting COVID-19. Can children get a COVID-19 vaccine? COVID-19 vaccines are approved for children 5 years old and older. To learn more, visit the CDC website and/or your county’s public health departments online:  Click here for San Bernardino County Click here for Riverside County Can I take the COVID-19 vaccine and the flu vaccine at the same time? Yes. The CDC has approved the use of routine vaccines for children, adolescents and adults (including pregnant women) on the same day as COVID-19 vaccines (as well as within 14 days of each other). Talk to your Doctor about what’s best for you. If I have previously tested positive for COVID-19, can I still get the vaccine? Yes. People are advised to get a COVID-19 vaccine even if they have been sick with COVID-19 before. This is because re-infection with COVID-19 is possible. Those who had a diagnosis in the past three months, be sure to talk to your Doctor about when you should get the vaccine. Will IEHP provide transportation to a COVID-19 vaccine clinic? Yes, IEHP will provide transportation to a COVID-19 vaccine clinic in the county where you live. How do I request transportation? Contact IEHP Transportation Call Center at 1-800-440-4347. Will the drive wait with me? No, the driver will not wait. Transportation will be provided as a roundtrip. You will need to contact the transportation provider to request a return pickup once you are ready. Can I take my family members? IEHP will provide transportation to an IEHP Member and one other passenger. How much time is needed to request transportation? IEHP will assist with transportation to the COVID-19 vaccine clinic in fewer than 5 business days. However, we cannot guarantee same-day requests. Where can I learn about COVID-19 and COVID-19 vaccines? IEHP Members can learn more by visiting the IEHP website or the California Department of Health’s website. Members can also learn more about COVID-19 at the California Coronavirus Response website or the CDC’s website

Latest News - IEHP’s Women in Leadership Engage with Local Students

articipated in Chaffey College’s Center for Culture and Social Justice Panel titled, “Celebrating Women in Healthcare Leadership,” which educated students of the current roles and contributions made to healthcare by women in the Inland Empire. The panel, conducted over Zoom, included several IEHP leaders, including Susie White, Chief Operating Officer; Dr. Priya Batra, Senior Medical Director for Family and Community Health; Shelly LaMaster, Director of Integrated Care; and Anna Wang, General Counsel.  “The event was wonderful and hearing from IEHP’s women leaders was impactful for all who attended,” said Dr. Leticia Romo, Chaffey College’s Director of Student Equity and Engagement. “We had the opportunity to hear real and authentic stories, wisdom, and encouragement.  Our students learned about mentorship, management responsibilities, leadership development, and overcoming imposter syndrome.  We definitely look forward to connecting with the IEHP leaders in the future.” The panel also provided students with stories about their own educational journey and career background and offered advice for future healthcare leaders. “Our work as a community-based health plan goes well beyond traditional health services,” said White. “It also includes making sure the next generation of leaders are equipped with the necessary support, tools and information to make even greater contributions to the healthcare space in the future.” In 2020, the health plan launched a Healthcare Scholarship Fund, partnering with Loma Linda University Medical School, University of California Riverside, and California University of Science and Medicine, to help remove the barrier of debt for local medical students and develop a growing workforce for healthcare professionals to care for the Inland Empire’s growing Medi-Cal population. In addition, amid the pandemic, IEHP provided internships to local public health students at Claremont Graduate University and Western University of Health Sciences to assist in developing program curricula at the plan’s Community Resource Centers.   “Sharing knowledge and guidance with Inland Empire learners just entering the health care workforce is another way we can positively impact health and wellness,” said Dr. Priya Batra, IEHP’s Senior Medical Director for Family and Community Health. “Supporting the advancement of diverse health care professionals will help us achieve vibrant health in our region.”  

IEHP Notice of Non-Discrimination

ights laws. IEHP does not unlawfully discriminate, exclude people, or treat them differently because of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation. IEHP provides: Free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)   Free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact IEHP Member Services between 8am-5pm (PST), by calling 1-800-440-IEHP (4347), 7 days a week, including holidays. If you cannot hear or speak well, please call 1-800-718-4347. Upon request, this document can be made available to you in braille, large print, audiocassette, or electronic form. To obtain a copy in one of these alternative formats, please call or write to: Inland Empire Health Plan 10801 6th St., Rancho Cucamonga, CA 91730-5987 1-800-440-4347 (TTY: 1-800-718-4347/California Relay 711) How to file a grievance If you believe that IEHP has failed to provide these services or unlawfully discriminated in another way on the basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation, you can file a grievance with IEHP’s Civil Rights Coordinator. You can file a grievance by phone, in writing, in person, or electronically: By phone: Contact IEHP’s Civil Rights Coordinator between 8am-5pm (PST), by calling 1- 800-440-4347. Or, if you cannot hear or speak well, please call TTY: 1-800-718-4347/California Relay 711. In writing: Fill out a complaint form or write a letter and send it to - IEHP’s Civil Rights Coordinator, 10801 6th St., Rancho Cucamonga, CA 91730-5987 In person: Visit your doctor’s office or IEHP and say you want to file a grievance. Electronically: File a grievance online. Office of Civil Rights - California Department of Health Care Services You can also file a civil rights complaint with the California Department of Health Care Services, Office of Civil Rights by phone, in writing, or electronically: By phone: Call (916) 440-7370. If you cannot speak or hear well, please call 711 (Telecommunications Relay Service). In writing: Fill out a complaint form or send a letter to - Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights, P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Electronically: Send an email to CivilRights@dhcs.ca.gov. Office of Civil Rights - U.S. Department of Health and Human Services If you believe you have been discriminated against on the basis of race, color, national origin, age, disability or sex, you can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by phone, in writing, or electronically: By phone: Call 1-800-368-1019. If you cannot speak or hear well, please call TTY/TDD 1-800- 537-7697. In writing: Fill out a complaint form or send a letter to - U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Electronically: Visit the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf LANGUAGE ASSISTANCE English ATTENTION: If you need help in your language call 1-800-440-4347 (TTY: 1-800-718-4347). Aids and services for people with disabilities, like documents in braille and large print, are also available. Call 1-800-440-4347 (TTY: 1-800-718-4347). These services are free of charge. الشعار بالعربي ة (Arabic) يُر جى الانتباه:ى إذا احتجت إلى المساعدة بلغتك، فاتصل ب 1-800-440-4347 (TTY: 1-800-718-4347) .ى تتوفر ا ً أيض المساعدات والخدمات للأشخاص ذوي الإعاقة، مث ى ل المستندات المكتوبة بطريقة بريل والخ ى ط الكب ري.ى اتصل ب 1-800-440-4347 (TTY: 1-800-718-4347) . هذه الخدمات مجانيةى. Հայերեն պիտակ (Armenian) ՈՒՇԱԴՐՈՒԹՅՈՒՆ: Եթե Ձեզ օգնություն է հարկավոր Ձեր լեզվով, զանգահարեք 1-800-440-4347 (TTY: 1-800-718-4347)։ Կան նաև օժանդակ միջոցներ ու ծառայություններ հաշմանդամություն ունեցող անձանց համար, օրինակ` Բրայլի գրատիպով ու խոշորատառ տպագրված նյութեր։ Զանգահարեք 1-800-440-4347 (TTY: 1-800-718-4347)։ Այդ ծառայություններն անվճար են։ ឃ្លាសម្គាល់ជាភាសាខ្មែរ (Cambodian) ចំណំ៖ ប ើអ្នក ត្រូវ ការជំនួយ ជាភាសា រ ស់អ្នក សូម ទូរស័ព្ទបៅបេខ 1-800-440-4347 (TTY: 1-800-718-4347)។ ជំនួយ និង បសវាកមម សត្ា ់ ជនព្ិការ ដូចជាឯកសារសរបសរជាអ្កសរផុស សត្ា ់ជនព្ិការភ្ននក ឬឯកសារសរបសរជាអ្កសរព្ុមពធំ ក៏អាចរកបានផងភ្ដរ។ ទូរស័ព្ទមកបេខ 1-800-440-4347 (TTY: 1-800-718-4347)។ បសវាកមមទំងបនេះមិនគិរថ្លៃប ើយ។ 简体中文标语(Chinese) 请注意:如果您需要以您的母语提供帮助,请致电1-800-440-4347 (TTY: 1-800-718-4347)。另外还提供针对残疾人士的帮助和服务,例如盲文和需要较大字体阅读,也是方便取用的。请致电1-800-440-4347 (TTY: 1-800-718-4347)。这些服务都是免费的。 (Farsi) مطلب به زبان فارسی توجه: اگر میخواهید به زبان خود کمک دریافت کنید، با 1-800-440-4347 (TTY: 1-800-718-4347) تماس بگیرید. کمکها و خدمات مخصوص افراد دارای معلولیت، مانند نسخههای خط بریل و چاپ با حروف بزرگ، نیز موجود است. با 1-800-440-4347 (TTY: 1-800-718-4347) تماس بگیرید. این خدمات رایگان ارائه میشوند. ह िंदी टैगलाइन (Hindi) ध्यान दें: अगर आपको अपनी भाषा में सहायता की आवश्यकता है 1-800-440-4347 (TTY: 1-800-718-4347) पर कॉल करें। अशक्तता वाले लोगोों के ललए सहायता और सेवाएों, जैसे ब्रेल और बडे लरोंट में भी दस्तावेज़ उपलब्ध हैं। 1-800-440-4347 (TTY: 1-800-718-4347) पर कॉल करें। ये सेवाएों लन: शुल्क हैं। Nqe Lus Hmoob Cob (Hmong) CEEB TOOM: Yog koj xav tau kev pab txhais koj hom lus hu rau 1-800-440-4347 (TTY: 1-800-718-4347). Muaj cov kev pab txhawb thiab kev pab cuam rau cov neeg xiam oob qhab, xws li puav leej muaj ua cov ntawv su thiab luam tawm ua tus ntawv loj. Hu rau 1-800-440-4347 (TTY: 1-800-718-4347). Cov kev pab cuam no yog pab dawb xwb. 日本語表記 (Japanese) 注意日本語での対応が必要な場合は 1-800-440-4347 (TTY: 1-800-718-4347)へお電話ください。点字の資料や文字の拡大表示など、障がいをお持ちの方のためのサービスも用意しています。1-800-440-4347 (TTY: 1-800-718-4347) へお電話ください。これらのサービスは無料で提供しています。 한국어 태그라인 (Korean) 유의사항: 귀하의 언어로 도움을 받고 싶으시면 1-800-440-4347 (TTY: 1-800-718-4347) 번으로 문의하십시오. 점자나 큰 활자로 된 문서와 같이 장애가 있는 분들을 위한 도움과 서비스도 이용 가능합니다. 1-800-440-4347 (TTY: 1-800-718-4347) 번으로 ___________문의하십시오. 이러한 서비스는 무료로 제공됩니다. ແທກໄລພາສາລາວ (Laotian) ປະກາດ: ຖ້າທ່ານຕ້ອງການຄວາມຊ່ວຍເຫ ຼືອໃນພາສາຂອງທ່ານໃຫ້ໂທຫາເບີ 1-800-440-4347 (TTY: 1-800-718-4347). ຍັງມີຄວາມຊ່ວຍເຫ ຼືອແລະການບໍລິການສໍາລັບຄົນພິການ ເຊັ່ນເອກະສານທີ່ເປັນອັກສອນນູນແລະມີໂຕພິມໃຫຍ່ ໃຫ້ໂທຫາເບີ 1-800-440-4347 (TTY: 1-800-718-4347). ການບໍລິການເຫ ົ່ານີ້ບໍ່ຕ້ອງເສຍຄ່າໃຊ້ຈ່າຍໃດໆ. Mien Tagline (Mien) LONGC HNYOUV JANGX LONGX OC: Beiv taux meih qiemx longc mienh tengx faan benx meih nyei waac nor douc waac daaih lorx taux 1-800-440-4347 (TTY: 1-800-718-4347). Liouh lorx jauv-louc tengx aengx caux nzie gong bun taux ninh mbuo wuaaic fangx mienh, beiv taux longc benx nzangc-pokc bun hluo mbiutc aengx caux aamz mborqv benx domh sou se mbenc nzoih bun longc. Douc waac daaih lorx 1-800-440-4347 (TTY: 1-800-718-4347). Naaiv deix nzie weih gong-bou jauv-louc se benx wang-henh tengx mv zuqc cuotv nyaanh oc. ਪੰਜਾਬੀ ਟੈਗਲਾਈਨ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਹਾਨ ੂੰ ਆਪਣੀ ਭਾਸਾ ਧ ਿੱਚ ਮਿਿ ਿੀ ਲੋੜ ਹੈ ਤਾਂ ਕਾਲ 1-800-440-4347 (TTY: 1-800-718-4347). ਅਪਾਹਜ ਲੋਕਾਂ ਲਈ ਸਹਾਇਤਾ ਅਤੇ ਸੇ ਾ ਾਂ, ਧਜ ੇਂ ਧਕ ਬ੍ਰੇਲ ਅਤੇ ਮੋਟੀ ਛਪਾਈ ਧ ਿੱਚ ਿਸਤਾ ੇਜ਼, ੀ ਉਪਲਬ੍ਿ ਹਨ| ਕਾਲ ਕਰੋ 1-800-440-4347 (TTY: 1-800-718-4347). ਇਹ ਸੇ ਾ ਾਂ ਮੁਫਤ ਹਨ| Русский слоган (Russian) ВНИМАНИЕ! Если вам нужна помощь на вашем родном языке, звоните по номеру 1-800-440-4347 (TTY: 1-800-718-4347). Также предоставляются средства и услуги для людей с ограниченными возможностями, например документы крупным шрифтом или шрифтом Брайля. Звоните по номеру 1-800-440-4347 (TTY: 1-800-718-4347). Такие услуги предоставляются бесплатно. Mensaje en español (Spanish) ATENCIÓN: si necesita ayuda en su idioma, llame al 1-800-440-4347 (TTY: 1-800-718-4347). También ofrecemos asistencia y servicios para personas con discapacidades, como documentos en braille y con letras grandes. Llame al 1-800-440-4347 (TTY: 1-800-718-4347). Estos servicios son gratuitos. Tagalog Tagline (Tagalog) ATENSIYON: Kung kailangan mo ng tulong sa iyong wika, tumawag sa 1-800-440-4347 (TTY: 1-800-718-4347). Mayroon ding mga tulong at serbisyo para sa mga taong may kapansanan,tulad ng mga dokumento sa braille at malaking print. Tumawag sa 1-800-440-4347 (TTY: 1-800-718-4347). Libre ang mga serbisyong ito. แท็กไลน์ภาษาไทย (Thai) โปรดทราบ: หากคุณต้องการความช่วยเหลือเป็นภาษาของคุณ กรุณาโทรศัพท์ไปที่หมายเลข 1-800-440-4347 (TTY: 1-800-718-4347)นอกจากนี้ ยังพร้อมให้ความช่วยเหลือและบริการต่าง ๆ สาหรับบุคคลที่มีความพิการ เช่น เอกสารต่าง ๆ ที่เป็นอักษรเบรลล์และเอกสารที่พิมพ์ด้วยตัวอักษรขนาดใหญ่ กรุณาโทรศัพท์ไปที่หมายเลข 1-800-440-4347 (TTY: 1-800-718-4347) ไม่มีค่าใช้จ่ายสาหรับบริการเหล่านี้ Примітка українською (Ukrainian) УВАГА! Якщо вам потрібна допомога вашою рідною мовою, телефонуйте на номер 1-800-440-4347 (TTY: 1-800-718-4347). Люди з обмеженими можливостями також можуть скористатися допоміжними засобами та послугами, наприклад, отримати документи, надруковані шрифтом Брайля та великим шрифтом. Телефонуйте на номер 1-800-440-4347 (TTY: 1-800-718-4347). Ці послуги безкоштовні. Khẩu hiệu tiếng Việt (Vietnamese) CHÚ Ý: Nếu quý vị cần trợ giúp bằng ngôn ngữ của mình, vui lòng gọi số 1-800-440-4347 (TTY: 1-800-718-4347). Chúng tôi cũng hỗ trợ và cung cấp các dịch vụ dành cho người khuyết tật, như tài liệu bằng chữ nổi Braille và chữ khổ lớn (chữ hoa). Vui lòng gọi số 1-800-440-4347 (TTY: 1-800-718-4347). Các dịch vụ này đều miễn phí.    

Undocumented Insurance

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Join Our Network - IPA

p 2589 E Washington Blvd., Pasadena, CA 91107 (626) 817-9217 (626) 817-9207 Dignity Health Medical Network - Inland Empire 3400 Data Drive, Rancho Cordova, CA 95670 (916) 851-2026 (916) 851-7642 LaSalle Medical Associates 1855 W. Redlands Blvd. 2nd Floor, Redlands, CA 92373 (888) 554-4562 (626) 943-6369 Optum Care Network - Inland Faculty MG 1860 Colorado Blvd. Ste 200, Los Angeles, CA 90041 (800) 371-7547 (323) 257-7329 Physicians Health Network P.O. Box 11429, San Bernardino, CA 92423 (909) 300-5030 (909) 332-5555 Horizon Valley Medical Group 18564 US Highway 18 Ste 105, Apple Valley, CA 92307 (760) 813-6950 (760) 813-6947 DualChoice CalMediConnect CPN - Horizon Valley Medical Group 18564 US Highway 18 Ste. 105, Apple Valley, CA 92307 (760) 242-7777 (760) 242-0487 Dignity Health Medical Network - Inland Empire 3400 Data Drive, Rancho Cordova, CA 95670 (916) 851-2026 (916) 851-7642 EPIC Health Plan 1615 Orange Tree Lane, Redlands, CA 92374 (909) 799-1818 (909) 786-0816 Alliance Desert Physicians, Inc.       Beaver Medical Group       Chaffey Medical Group       FENIX Medical Group       Pinnacle Medical Group       Redlands - Yucaipa Medical Group       TriValley Medical Group       Heritage Provider Network 8510 Balboa Blvd. Ste 275, Northridge, CA 91325 (818) 654-3461   Desert Oasis Healthcare 275 N El Cielo Rd., Palm Springs, CA 92262 (760) 320-8814   Heritage Victor Valley Medical Group 12370 Hesperia Rd., Victorville, CA 92395 (760) 245-4747   Regal Medical Group 621 E Carnegie Dr. Ste 140, San Bernardino, CA 92408 (818) 654-3400   PrimeCare, part of Optum Care  3990 Concourse St., Ontario, CA 91764 (909) 605-8000   PrimeCare Chino 15315 Fairfield Ranch Rd. Ste 275, Chino Hills, CA 91709 (909) 465-1397 (909) 465-6629 Optum Care Network - Citrus Valley 9130 Anaheim Place Ste 130, Rancho Cucamonga, CA 91730 (909) 466-8000 (909) 484-6825 Optum Care Network - Corona 2275 Sampson Ave. Ste 111, Corona, CA 92879 (951) 371-8440 (951) 371-3910 Optum Care Network - Hemet Valley 41391 Kalmia St. Ste 310, Murrieta, CA 92562 (951) 461-0762 (951) 698-5194 Optum Care Network -  Inland Valley 9130 Anaheim Pl. Ste 130, Rancho Cucamonga, CA 91730 (909) 466-8000 (909) 484-6825 Optum Care Network -  Moreno Valley 1467 Ford St. Ste 103, Redlands, CA 92373 (909) 798-7766 (909) 792-8627 Optum Care Network - Redlands 1520 Barton Rd., Redlands, CA 92373 (909) 798-7766 (909) 792-8627 Optum Care Network - Riverside 2275 Sampson Ave. Ste 111, Corona, CA 92879 (951) 371-8440 (951) 371-3910 Optum Care Network - San Bernardino 1467 Ford St. Ste 103, Redlands, CA 92373 (909) 798-7766 (909) 792-8627 Optum Care Network - Sun City 41391 Kalmia St. Ste 310, Murrieta, CA 92562 (951) 461-0762 (951) 698-5194 Optum Care Network - Southwestern Valleys 41391 Kalmia St. Ste 310, Murrieta, CA 92562 (951) 461-0762 (951) 698-5194 Optum Care Network - Valley Physicians  24630 Washington Ave. Ste 203, Murrieta, CA 92562 (951) 704-1900 (877) 397-7682 Riverside Medical Clinic 3660 Arlington Ave., Riverside, CA 92506    

Innovations and Quality Performance - Our Commitment to Innovation

healthcare needs of our Members for more than two decades. With our Strategic Priorities guiding us, we will continue to seek opportunities for innovation and improvement – putting access to quality healthcare and our Members, Providers and Community above all else. Community Health Assessment The 2022 Inland Empire Community Health Assessment Stakeholder Committee, comprised of over 40 representatives across 25 community organizations, united over the past year to collect and analyze the region’s health and wellness data. The group identified those four at-risk population groups, Senior citizens, communities of color, individuals with low incomes and those living in remote and rural areas, as well as six priority areas of focus: Basic Needs for Health and Safety, Human Housing, Meaningful Work and Wealth, Cardiovascular Disease and Diabetes, Maternal and Infant Health and Mental and Behavioral Health. The committee shared the findings in a first-of-its-kind joint regional Community Health Assessment report. Community Health Needs Assessment (CHNA) The 2022 Inland Empire Community Health Needs Assessment (CHNA) identifies the top health and well-being needs of Inland Empire residents. The findings in the CHNA will be used to build community interventions that generate collective investments addressing the identified priorities. There are seven assessments within the CHNA, the first three target the entire Inland Empire region, along with Riverside and San Bernardino counties. The remaining four assessments comprise drilled-down analyses for Montclair Hospital Medical Center, Redlands Community Hospital, San Antonio Regional Hospital and San Gorgonio Memorial Hospital service areas. Click here to view the assessment. Provider Recruitment IEHP’s innovative Network Expansion Fund (NEF) was the first program of its kind in the state. Established in 2014, the NEF allocates $30 million in specially designated funds to attract board-certified PCPs, Specialists and mid-level Providers to the Inland Empire, addressing the region’s chronic Provider shortage and improving access to care for more than 1.2 million IEHP Members. To date, more than 280 Providers have been recruited as a direct result of this program. Behavioral Health Integration Complex Care Initiative The Behavioral Health Integration Complex Care Initiative (BHICCI) is a collaboration between IEHP and more than 30 clinics in the Inland Empire that provides a footprint for the California Department of Health Care Services (DHCS) Health Homes Program, going live January 1, 2019. The goal is to improve Members’ health outcomes by staffing a complex care team to provide comprehensive care management and by coordinating complex physical and behavioral health needs across multiple Providers and health care systems in Riverside and San Bernardino counties. BHICCI care teams are currently transitioning into community-based care management entities (CB-CMEs) that provide Health Homes services in preparation for Health Homes go-live. Health Homes Program The Health Homes program (HHP) is an integrated care management program for patients with complex needs that builds on IEHP’s Behavioral Health Integration Complex Care Initiative (BHICCI), as legislated by the Department of Health Care Services (DHCS). The HHP coordinates the physical, behavioral, and community-based Long-Term Services and Supports (LTSS) needs of Members with severe chronic physical and/or mental health conditions. The primary goal of HHP is to improve the overall health outcomes of members through the delivery of care coordination and complex care management. Since the launch of the program in January 2019, more than 9,000 Members have seen overwhelmingly positive clinical health outcomes related to blood pressure, diabetes and depression. Click here to learn more about the Health Homes Program.  EHR and Health Information Exchange IEHP has partnered with the San Bernardino County Medical Society and the Riverside County Medical Association to form the Inland Empire EHR Resource Center, to assist Providers and clinics in selecting and implementing electronic health record systems. Additionally, IEHP was part of the Inland Empire Health Information Exchange, which merged with the CalIndex Health Information Exchange to form Manifest Medex (MX). MX is a statewide health information exchange that has significant penetration and use in the Inland Empire, with all Inland Empire acute care hospitals and many medical groups and Physicians contributing patient clinical and administrative data. MX brings needed technology to access and securely share electronic patient health records for most of the 4.4 million people living in the Inland Empire. It allows Doctors, clinics, hospitals and other health care Providers to electronically review and access medical records, resulting in timely and improved quality of health care for patients in our community. DocOnline This innovative program provides another option for Members to receive medical advice after hours from a Physician. IEHP Members can speak to a board-certified Physician by phone or via video chat, quickly and easily. The Physician can access the IEHP formulary and the IEHP Pharmacy Network to e-prescribe medications for IEHP Members if needed. When fully implemented, this service will enhance Member access and convenience while reducing unnecessary emergency room and urgent care visits. Telehealth IEHP is supporting the expansion of telehealth services throughout the Inland Empire, to improve access to critically needed specialty care and to aid in rapid diagnosis and treatment. Telehealth eliminates one of the Inland Empire’s longstanding barriers to care – geographic distance to health care resources. With telehealth’s information and communication technologies, the treatment and prevention of disease or injury can occur long-distance, erasing geography as a critical factor impeding care. Telehealth can also be used to support Provider training and Member education. IEHP is currently supporting telehealth for certain services: behavioral health, retinal examinations, dermatology, and orthopedic consultations. Plans are underway to expand to additional services in alignment with Member needs. eConsult eConsult, a collaboration among IEHP, Arrowhead Regional Medical Center and Riverside University Health Care System, allows PCPs to connect directly with specialists electronically when a patient may need a specialist referral. Through a private, secure system, PCPs can receive timely clinical advice from specialists that may allow them to manage a majority of patients in the primary care setting (some patients may need a face-to-face visit with a specialist). IEHP is sponsoring the initiative for the first 24 months and will design, implement and evaluate eConsult at more than 70 clinic sites throughout Riverside and San Bernardino counties. Secure Online Member Portal and App IEHP Members can take an active role in managing their own health 24/7 via a secure online account that can be accessed through the IEHP website or mobile app. Members can view and print their IEHP Member Cards; view lab tests, Immunization Cards and authorizations; find or change Doctors; search the Provider Directory; enroll in health education classes; check eligibility; and more. The separate Baby-N-Me prenatal care app helps improve maternity health outcomes by making it easy for expectant moms to track pregnancy milestones, identify health issues, and stay healthy with reminders and helpful tools. Texting and Alerts IEHP uses two-way texting and Short Message Service (SMS) alerts to educate Members about their plan benefits and how to navigate the health care system. These alerts are targeted approaches that communicate seasonal health information about topics such as immunizations, preventive care, medication adherence, and new health plan features. Long-Term Services and Supports (LTSS) IEHP’s Long-Term Services and Supports (LTSS) program enables seniors and persons with disabilities to live independently in their homes as long as safely possible, and provides care in a Skilled Nursing Facility (SNF) when they cannot. LTSS includes the Multipurpose Senior Services Program (MSSP) and Community-Based Adult Services (CBAS), as well as SNF services when required. IEHP also helps coordinate any In-Home Supportive Services (IHSS) benefits. Since May 2018, IEHP has helped transition 750 Members out of long-term care facilities and back into the community. A 24-hour in-home emergency caregiver program and a case management program, developed in partnership with the Riverside County Department of Social Services, received the 2017 and 2018 Achievement Award from the National Association of Counties. IEHP has also partnered with the University of California, Los Angeles on a Geriatric Workforce Enhancement Program to provide patients, families and caregivers with the knowledge and skills they need to improve health outcomes and increase the quality of care for older adults.   

IEHP DualChoice - NCD

d the following services to be necessary for the treatment of an illness or injury. National Coverage determinations (NCDs) are made through an evidence-based process. See below for a brief description of each NCD. There may be qualifications or restrictions on the procedures below. For more detailed information on each of the NCDs including restrictions and qualifications click on the link after each NCD or call IEHP DualChoice Member Services at (877) 273-IEHP (4347) 8am-8pm (PST), 7 days a week, including holidays, or. TTY/TDD (800) 718-4347 1. Screening for Hepatitis B Virus (HBV) Infection (Effective: September 28, 2016)  (Implementation date: October 2, 2017 – for design and coding; January 1, 2018 – for testing and implementation) Per the recommendation of the United States Preventive Services Task Force (USPSTF), CMS has issued a National Coverage Determination (NCD) which expands coverage to include screening for HBV infection. Previously, HBV screening and re-screening was only covered for pregnant women.  Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. It attacks the liver, causing inflammation. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. An acute HBV infection could progress and lead to life-threatening complications. The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected. What is covered? Effective for claims with dates of service on or after 09/28/2016, CMS covers screening for HBV infection. Who is covered? Medicare beneficiaries who meet either of the following criteria: They are considered to be at high-risk for infection; or They are pregnant. Click here for more information on HBV Screenings. 2. Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) ((Effective: December 7, 2016)  (Implementation date: June 27, 2017) CMS has expanded the PILD for LSS National Coverage Determination (NCD) to now cover beneficiaries that are enrolled in a CMS-approved prospective longitudinal study. Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. Now, the NCD will cover PILD for LSS under both RCT and longitudinal studies. LSS is a narrowing of the spinal canal in the lower back. PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. What is covered? Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study. Who is covered? Medicare beneficiaries with LSS who are participating in an approved clinical study. Click here for more information on PILD for LSS Screenings. 3. Leadless Pacemakers   (Effective: January 18, 2017)  (Implementation date: August 29, 2017 – for MAC local edits; January 2, 2018 – for MCS shared edits) CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies.  Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. What is covered? Effective for claims with dates of service on or after 01/18/17, Medicare will cover leadless pacemakers under CED when procedures are performed in CMS-approved studies. Who is covered? Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. Click here for more information on Leadless Pacemakers. 4. Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)  (Effective: April 3, 2017)  (Implementation date: December 18, 2017) CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment.  It has been updated that coverage determinations for providing Topical Application of Oxygen for the treatment of chronic wounds can be made by the local Contractors.     What is covered? Topical Application of Oxygen for Chronic Wound Care. Who is covered? Medicare beneficiaries may be covered with an affirmative Coverage Determination. Click here for more information on Topical Applications of Oxygen. 5. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (Effective: May 25, 2017) (Implementation Date: July 2, 2018) CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).  It has been concluded that high-quality research illustrates the effectiveness of SET over more invasive treatment options and beneficiaries who are suffering from Intermittent Claudication (a common symptom of PAD) are now entitled to an initial treatment. What is covered? Eligible beneficiaries are entitled to 36 sessions over a 12-week period after meeting with the physician responsible for PAD treatment and receiving a referral.  The SET program must: Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physician’s office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and, Be under the direct supervision of a physician. Who is covered? Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). 6. Magnetic Resonance Imaging (MRI) (Effective: April 10, 2017) (Implementation Date: December 10, 2018) CMS has added a new section, Section 220.2, to Chapter 1, Part 4 of the Medicare National Coverage Determinations Manual entitled Magnetic Resonance Imaging (MRI). According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. What is covered? Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. In the instance where there is not FDA labeling specific to use in an MRI environment, coverage is only provided under specific conditions including the following: MRI field strength of 1.5 Tesla using Normal Operating Mode The Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D) system has no fractured, epicardial, or abandoned leads The facility has implemented a specific checklist Who is covered? Medicare beneficiaries with an Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D). Click here for more information on MRI Coverage. 7. Implantable Cardiac Defibrillators (ICDs) (Effective: February 15, 2018) (Implementation Date: March 26, 2019) CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs). What is covered? An ICD is an electronic device to diagnose and treat life threating Ventricular Tachyarrhythmias (VTs) that has demonstrated improvement in survival rates and reduced cardiac death for certain patients. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. Who is covered: Beneficiaries who meet the coverage criteria, if determined eligible. ICDs will be covered for the following patient indications: Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF) Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03 Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35% Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction Please refer to section 20.4 of the NCD Manual for additional coverage criteria. Click here for more information on ICD Coverage. 8. Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer (Effective: January 27, 20)  (Implementation Date: November 13, 2020) CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer. What is covered: Effective for dates of service on or after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specific requirements are met. Who is covered: Beneficiaries with Somatic (acquired) cancer or Germline (inherited) cancer when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all the following requirements are met: For Somatic (acquired) cancer: Beneficiary has: either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and; has not been previously tested with the same test using NGS for the same cancer genetic content and; has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patient’s cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. For Germline (inherited) Cancer Beneficiary has: -ovarian or breast cancer and; a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer and; a risk factor for germline (inherited) breast or ovarian cancer and; -not been previously tested with the same germline test using NGS for the same germline genetic content. The diagnostic laboratory test using NGS must have: FDA-approval or clearance; and, results provided to the treating physician for management of the patient using a report template to specify treatment options. Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic test when additional specific criteria are met. Click here for information on Next Generation Sequencing coverage. 9. Percutaneous Transluminal Angioplasty (PTA)    (Effective: February 19, 2019)  (Implementation Date: February 19, 2019)  CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA.  What is covered: Percutaneous Transluminal Angioplasty (PTA) is covered in the below instances in order to improve blood flow through the diseased segment of a vessel in order to dilate lesions of peripheral, renal and coronary arteries.  Who is covered: The PTA is covered under the following conditions:  1. Treatment of Atherosclerotic Obstructive Lesions  2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) – Approved Category B Investigational Device Exemption (IDE) Clinical Trials  3. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies  4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 5. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials Click here for more detailed information on PTA coverage. 10. Transcatheter Aortic Valve Replacement (TAVR) (Effective: June 21, 2019) (Implementation Date: June 12, 2020) CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met. What is covered: Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. Who is covered: This service will be covered when the TAVR is used for the treatment of symptomatic aortic valve stenosis according to the FDA-approved indications and the following conditions are met: The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication The patient is under the care of a heart team, which consists of a cardiac surgeon, interventional cardiologist, and various Providers, nurses, and research personnel The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR The hospital where the TAVR is complete must have various qualifications and implemented programs The registry shall collect necessary data and have a written analysis plan to address various questions. This service will be covered when the TAVR is not expressly listed as an FDA-approved indication, but when performed within a clinical study and the following conditions are met: The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR The clinical research study must critically evaluate each patient's quality of life pre- and post-TAVR for a minimum of 1 year, but must also address other various questions The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. Click here for more information on NGS coverage. 11. Ambulatory Blood Pressure Monitoring (ABPM) (Effective: July 2, 2019) (Implementation Date: June 16, 2020) CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover Ambulatory Blood Pressure Monitoring (ABPM) when specific requirements are met. What is covered: Effective July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring (ABPM) when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the NCD Manual. Who is covered: This service will be covered when the Ambulatory Blood Pressure Monitoring (ABPM) is used for the diagnosis of hypertension when either there is suspected white coat or masked hypertension and the following conditions are met: The ABPM device must be: Capable of producing standardized plots of BP measurements for 24 hours with daytime and nighttime windows and normal BP bands demarcated; Provided to patients with oral and written instructions, and a test run in the physician’s office must be performed; and, Interpreted by the treating physician or treating non-physician practitioner. Coverage of other indications for ABPM is at the discretion of the Medicare Administrative Contractors. Click here for more information on ambulatory blood pressure monitoring coverage. 12. Acupuncture for Chronic Low Back Pain (cLBP) (Effective: January 21, 2020) (Implementation Date: October 5, 2020) CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. What is covered: Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP) for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the NCD Manual. Who is covered: This service will be covered only for beneficiaries diagnosed with chronic Lower Back Pain (cLBP) when the following conditions are met: For the purpose of this decision, cLBP is defined as: Lasting 12 weeks or longer; nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); not associated with surgery; and, not associated with pregnancy. An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Treatments must be discontinued if the patient is not improving or is regressing. All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare. Click here for more information on acupuncture for chronic low back pain coverage. 13. Vagus Nerve Stimulation (VNS) (Effective: February 15. 2020) (Implementation Date: July 22, 2020) CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. What is covered:  Effective February 15, 2020, CMS will cover FDA approved Vagus Nerve Stimulation (VNS) devices for treatment-resistant depression through Coverage with Evidence Development (CED) in a CMS approved clinical trial in addition to the coverage criteria outlined in the National Coverage Determination Manual. Who is covered: Beneficiaries participating in a CMS approved clinical study undergoing Vagus Nerve Stimulation (VNS) for treatment resistant depression and the following requirements are met: Treatment is furnished as part of a CMS approved trial through Coverage with Evidence Development (CED).Detailed clinical trial criteria can be found in section 160.18 of the National Coverage Determination Manual. The clinical study must address whether VNS treatment improves health outcomes for treatment resistant depression compared to a control group, by answering all research questions listed in 160.18 of the National Coverage Determination Manual. Patient Criteria:      The following criteria must be used to identify a beneficiary demonstrating treatment resistant depression: Beneficiary must be in a major depressive disorder episode for at least two years or have had at least four episodes, including the current episode. Patient’s depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose. The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. Patients must maintain a stable medication regimen for at least four weeks before device implantation. If patients with bipolar disorder are included, the condition must be carefully characterized. Patients must not have: Current or lifetime history of psychotic features in any MDE; Current or lifetime history of schizophrenia or schizoaffective disorder; Current or lifetime history of any other psychotic disorder; Current or lifetime history of rapid cycling bipolar disorder; Current secondary diagnosis of delirium, dementia, amnesia, or other cognitive disorder; Current suicidal intent; or, Treatment with another investigational device or investigational drugs. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. Nationally Non-Covered Indications VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. All other indications of VNS for the treatment of depression are nationally non-covered. Patients implanted with a VNS device for TRD may receive a VNS device replacement if it is required due to the end of battery life, or any other device-related malfunction. Click here for more information on Vagus Nerve Stimulation.  14. Chimeric Antigen Receptor (CAR) T-cell Therapy (Effective: August 7, 2019) (Implementation Date: September 20, 2021) CMS has updated Section 110.24 of the Medicare National Coverage Determinations Manual to include coverage of chimeric antigen receptor (CAR) T-cell therapy when specific requirements are met. What is covered: Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administration’s (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met. Who is covered: Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one least one chimeric antigen receptor CAR, when all the following requirements are met: Autologous treatment is for cancer with T-cells expressing at least one chimeric antigen receptor (CAR); and Treatment is administered at a healthcare facility enrolled in the FDA’s REMS; and The therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia. Non-Covered Use: The use of non-FDA-approved autologous T-cell expressing at least one CAR is non-covered or when the coverage requirements are not met. Click here for more information on chimeric antigen receptor (CAR) T-cell therapy coverage.  15. Screening for Colorectal Cancer (CRC)-Blood-Based Biomarker Tests (Effective: January 19, 2021)  (Implementation Date: October 4, 2021)  What is covered: Effective January 19, 2021, CMS has determined that blood-based biomarker tests are an appropriate colorectal cancer screening test, once every 3 years for Medicare beneficiaries when certain requirements are met.  Who is covered: Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met: The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory The Patient is:  age 50-85 years, and, asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and, average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer) The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and Proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), based on the pivotal studies included in the FDA labeling. What is not covered: All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. This includes: All screening sDNA tests, effective April 28, 2008, through October 8, 2014. Effective for dates of service on or after October 9, 2014, all other screening sDNA tests not otherwise specified above remain nationally non-covered. Screening computed tomographic colonography (CTC), effective May 12, 2009. Click here for more information on NGS coverage. 16. Ventricular Assist Devices (VADs) (Effective: December 1, 2020) (Implementation Date: July 27, 2021) What is covered: Effective for dates of service on or after December 1, 2020, CMS has updated section 20.9.1 of the National Coverage Determination Manual to cover ventricular assist devices (VADs) when received at facilities credentialed by a CMS approved organization and when specific requirements are met. Who is covered: Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR They receive a left ventricular device (LVADs) if the device is FDA approved for short- or long-term use for mechanical circulatory support for beneficiaries with heart failure who meet the following requirements: Have New York Heart Association (NYHA) Class IV heart failure; and Have a left ventricular ejection fraction (LVEF) ≤ 25%; and Are inotrope dependent OR have a Cardiac Index (CI) < 2.2 L/min/m2, while not on inotropes, and meet one of the following: Are on optimal medical management, based on current heart failure practice guidelines for at least 45 out of the last 60 days and are failing to respond; or Have advanced heart failure for at least 14 days and are dependent on an intra‐aortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days. Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. Facilities must be credentialed by a CMS approved organization. Non-Covered Use: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. Click here for more information on Ventricular Assist Devices (VADs) coverage. 17. Blood-Derived Products for Chronic, Non-Healing Wounds (Effective: April 13, 2021) (Implementation Date: February 14, 2022) What is covered: Effective for dates of service on or after April 13, 2021, CMS has updated section 270.3 of the National Coverage Determination Manual to cover Autologous (obtained from the same person) Platelet-Rich Plasma (PRP) when specific requirements are met. Who is covered: Beneficiaries receiving treatment for chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by a device cleared by the Food and Drug Administration (FDA) for the management of exuding (bleeding, oozing, seeping, etc.) wounds affecting the skin. Non-Covered Use: The following uses are considered non-covered: Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and, Becaplermin, a non-autologous growth factor for chronic, non-healing, subcutaneous (beneath the skin) wounds, and, Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. Other: Coverage for the treatment beyond 20 weeks, or for all other chronic non-healing wounds will be determined by the local Medicare Administrative Contractors ( Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. 18. Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation (Effective: January 19, 2021) (Implementation Date: October 8, 2021) What is covered: Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. Who is covered: Beneficiaries receiving treatment for Transcatheter Edge-to-Edge Repair (TEER) when either of the following are met: For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met: Treatment is a Food and Drug Administration (FDA) approved indication, The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. The beneficiary is under pre- or post-operative care of a heart team meeting the following: Cardiac Surgeon meeting the requirements listed in the determination. Interventional Cardiologist meeting the requirements listed in the determination. Interventional echocardiographer meeting the requirements listed in the determination. Heart failure cardiologist with experience treating patients with advanced heart failure. Providers from other groups including patient practitioners, nurses, research personnel, and administrators. Patient must be evaluated for suitability for repair and must documented and made available to the Heart team members meeting the requirements of this determination. The procedure must be performed by an interventional cardiologist or cardiac surgeon.< An interventional echocardiographer must perform transesophageal echocardiography during the procedure. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.> Mitral valve TEERs are covered for other uses not listed as an FDA-approved indication when performed in a clinical study and the following requirements are met: The procedure must be performed by an interventional cardiologist or cardiac surgeon. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.> All physicians participating in the procedure must have device-specific training by the manufacturer of the device. The clinical research must evaluate the required twelve questions in this determination. The clinical research must evaluate the patient’s quality of life pre and post for a minimum of one year and answer at least one of the questions in this determination section. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. Submit the required study information to CMS for approval. Non-Covered Use: The following uses are considered non-covered: Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. Treatment for patients with untreated severe aortic stenosis. Other: This determination will expire ten years after the effective date if a reconsideration is not made during this time.  Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . 19. Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer- Manual Update Only  (Effective: December 15, 2017) (Implementation Date: January 17, 2022)  Effective for dates of service on or after December 15, 2017, CMS has updated section 220.6.19 of the National Coverage Determination Manual clarifying there are no nationally covered indications for Positron Emission Tomography NaF-18 (NaF-18 PET). Non-Covered Use: Positron Emission Tomography NaF-18 (NaF-18 PET) services to identify bone metastases of cancer provided on or after December 15, 2017, are nationally non-covered. Other Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. Information on the page is current as of December 28, 2021 H5355_CMC_22_2746205 Accepted 20. Home Use of Oxygen  (Effective: September 27, 2021) (Implementation Date: January 3, 2023) What is covered: Effective September 27, 2021, CMS has updated section 240.2 of the National Coverage Determination Manual to cover oxygen therapy and oxygen equipment for in home use of both acute and chronic conditions, short- or long- term, when a patient exhibits hypoxemia. CMS has updated section 240.2 of the National Coverage Determination Manual to amend the period of initial coverage for patients in section D of NCD 240.2 from 120 days to 90 days, to align with the 90-day statutory time period Who is covered: Beneficiaries who exhibit hypoxemia (low oxygen in your blood) when ALL (A, B, and C) of the following are met:   A. Hypoxemia is based on results of a clinical test ordered and evaluated by a patient’s treating practitioner meeting either of the following: a. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. i. PO2 measurements can be obtained via the ear or by pulse oximetry. ii. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. b. A clinical test providing the measurement of arterial blood gas. i. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. B. The clinical test must be performed at the time of need: a. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patient’s condition. i. For inpatient hospital patient’s, the time of need is within 2 days of discharge. ii. For patient’s whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy. C. Beneficiary’s diagnosis meets one of the following defined groups below: a. Group I: i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or; ii. Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation at or below 88% when tested during sleep for patients that demonstrate an arterial PO2 at or above 56 mmHg, or iii. Arterial oxygen saturation at or above 89% when awake;or greater than normal decrease in oxygen level while sleeping represented by a decrease in arterial PO2 more than 10 mmHg or a decrease in arterial oxygen saturation more than 5%. a. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. 2. During these events, oxygen during sleep is the only type of unit that will be covered. 3. Portable oxygen would not be covered. iv. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise, 1. For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day. 2. During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air. b. Group II: i. Patients demonstrating arterial PO2 between 56-59 mm Hg, or who’s arterial blood oxygen saturation is 89%, with any of the following condition: 1. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or, 2. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or, 3. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patient’s age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity. Non-Covered Use: The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Angina pectoris (chest pain) in the absence of hypoxemia; or, Breathlessness without cor pulmonale or evidence of hypoxemia; or, Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or, Terminal illnesses, unless it affects the patient’s ability to breathe. Other: The MAC may determine necessary coverage for in home oxygen therapy for patient’s that do not meet the criteria described above. Initial coverage for patient’s experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioner’s prescription. Oxygen therapy can be renewed by the MAC if deemed medically necessary. The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system. For more information on Home Use of Oxygen coverage click here. 21. 180.1 - Medical Nutrition Therapy (MNT) (Effective: January 1, 2022) (Implementation Date: July 5, 2022) What is covered: Effective for dates of service on or after January 1, 2022, CMS has updated section 180.1 of the National Coverage Determination Manual to cover three hours of administration during one year of Medical Nutrition Therapy (MNT) in patients with a diagnosis of renal disease or diabetes, as defined in 42 CFR 410.130. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. Medicare will cover both MNT and Diabetes Outpatient Self-Management Training (DSMT) during initial and subsequent years, if the physician determines treatment is medically necessary and as long as DSMT and MNT are not provided on the same date. Dieticians and Nutritionist will determine how many units will be administered per day and must meet the requirements of this NCD as well at 42 CFR 410.130 – 410.134. Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients’ medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care. Who is covered: Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. For more information on Medical Nutrition Therapy (MNT) coverage click here. 22.  Reconsideration – Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (Effective: February 10, 2022) (Implementation Date: October 3, 2022)  What is covered: Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met.  Prior to the beneficiary’s first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. Who is covered: Members must meet all of the following eligibility criteria:  50– 77 years old; Asymptomatic (no signs or symptoms of lung cancer); Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes); Current smoker or one who has quit smoking within the last 15 years; Receive an order for lung cancer screening with LDCT. Click here for more information on LDCT coverage.  23. (Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (AD))  (Effective: April 7, 2022) (Implementation Date: December 12, 2022)  What is covered: Effective on April 7, 2022, CMS has updated section 200.3 of the National Coverage Determination (NCD) Manual to cover Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for treatment of Alzheimer’s Disease (AD) when the coverage criteria below is met.  Who is covered: Beneficiaries with Alzheimer’s Disease (AD) may be covered for treatment when the following conditions (A or B) are met:  The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. The treatment is considered reasonably likely to predict a clinical benefit and is administrated in a randomized controlled trial under an investigational new drug application. The treatment is based upon efficacy from a direct measure of clinical benefit in CMS-approved prospective comparative studies. Study data for CMS-approved prospective comparative studies may be collected in a registry. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. CMS-approved studies of a monoclonal antibody directed against amyloid approved by the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit must address all of the questions included in section B.4 of this National Coverage Determination. CMS approved studies must also adhere to the standards of scientific integrity that have been identified in section 5 of this NCD by the Agency for Healthcare Research and Quality (AHRQ). Click here for more information on study design and rationale requirements. Non-Covered Use: Monoclonal antibodies directed against amyloid for the treatment of AD provided outside of an FDA-approved randomized controlled trial, CMS-approved studies, or studies supported by the NIH. Other: N/A. Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (AD). Information on the page is current as of December 1, 2022 H5355_CMC_22_3617111 Accepted 

IEHP DualChoice - NCD

d the following services to be necessary for the treatment of an illness or injury. National Coverage determinations (NCDs) are made through an evidence-based process. See below for a brief description of each NCD. There may be qualifications or restrictions on the procedures below. For more detailed information on each of the NCDs including restrictions and qualifications click on the link after each NCD or call IEHP DualChoice Member Services at (877) 273-IEHP (4347) 8am-8pm (PST), 7 days a week, including holidays, or. TTY/TDD (800) 718-4347 1. Screening for Hepatitis B Virus (HBV) Infection (Effective: September 28, 2016)  (Implementation date: October 2, 2017 – for design and coding; January 1, 2018 – for testing and implementation) Per the recommendation of the United States Preventive Services Task Force (USPSTF), CMS has issued a National Coverage Determination (NCD) which expands coverage to include screening for HBV infection. Previously, HBV screening and re-screening was only covered for pregnant women.  Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. It attacks the liver, causing inflammation. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. An acute HBV infection could progress and lead to life-threatening complications. The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected. What is covered? Effective for claims with dates of service on or after 09/28/2016, CMS covers screening for HBV infection. Who is covered? Medicare beneficiaries who meet either of the following criteria: They are considered to be at high-risk for infection; or They are pregnant. Click here for more information on HBV Screenings. 2. Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) ((Effective: December 7, 2016)  (Implementation date: June 27, 2017) CMS has expanded the PILD for LSS National Coverage Determination (NCD) to now cover beneficiaries that are enrolled in a CMS-approved prospective longitudinal study. Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. Now, the NCD will cover PILD for LSS under both RCT and longitudinal studies. LSS is a narrowing of the spinal canal in the lower back. PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. What is covered? Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study. Who is covered? Medicare beneficiaries with LSS who are participating in an approved clinical study. Click here for more information on PILD for LSS Screenings. 3. Leadless Pacemakers   (Effective: January 18, 2017)  (Implementation date: August 29, 2017 – for MAC local edits; January 2, 2018 – for MCS shared edits) CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies.  Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. What is covered? Effective for claims with dates of service on or after 01/18/17, Medicare will cover leadless pacemakers under CED when procedures are performed in CMS-approved studies. Who is covered? Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. Click here for more information on Leadless Pacemakers. 4. Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)  (Effective: April 3, 2017)  (Implementation date: December 18, 2017) CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment.  It has been updated that coverage determinations for providing Topical Application of Oxygen for the treatment of chronic wounds can be made by the local Contractors.     What is covered? Topical Application of Oxygen for Chronic Wound Care. Who is covered? Medicare beneficiaries may be covered with an affirmative Coverage Determination. Click here for more information on Topical Applications of Oxygen. 5. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (Effective: May 25, 2017) (Implementation Date: July 2, 2018) CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).  It has been concluded that high-quality research illustrates the effectiveness of SET over more invasive treatment options and beneficiaries who are suffering from Intermittent Claudication (a common symptom of PAD) are now entitled to an initial treatment. What is covered? Eligible beneficiaries are entitled to 36 sessions over a 12-week period after meeting with the physician responsible for PAD treatment and receiving a referral.  The SET program must: Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physician’s office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and, Be under the direct supervision of a physician. Who is covered? Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). 6. Magnetic Resonance Imaging (MRI) (Effective: April 10, 2017) (Implementation Date: December 10, 2018) CMS has added a new section, Section 220.2, to Chapter 1, Part 4 of the Medicare National Coverage Determinations Manual entitled Magnetic Resonance Imaging (MRI). According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. What is covered? Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. In the instance where there is not FDA labeling specific to use in an MRI environment, coverage is only provided under specific conditions including the following: MRI field strength of 1.5 Tesla using Normal Operating Mode The Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D) system has no fractured, epicardial, or abandoned leads The facility has implemented a specific checklist Who is covered? Medicare beneficiaries with an Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D). Click here for more information on MRI Coverage. 7. Implantable Cardiac Defibrillators (ICDs) (Effective: February 15, 2018) (Implementation Date: March 26, 2019) CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs). What is covered? An ICD is an electronic device to diagnose and treat life threating Ventricular Tachyarrhythmias (VTs) that has demonstrated improvement in survival rates and reduced cardiac death for certain patients. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. Who is covered: Beneficiaries who meet the coverage criteria, if determined eligible. ICDs will be covered for the following patient indications: Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF) Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03 Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35% Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction Please refer to section 20.4 of the NCD Manual for additional coverage criteria. Click here for more information on ICD Coverage. 8. Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer (Effective: January 27, 20)  (Implementation Date: November 13, 2020) CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer. What is covered: Effective for dates of service on or after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specific requirements are met. Who is covered: Beneficiaries with Somatic (acquired) cancer or Germline (inherited) cancer when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all the following requirements are met: For Somatic (acquired) cancer: Beneficiary has: either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and; has not been previously tested with the same test using NGS for the same cancer genetic content and; has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patient’s cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. For Germline (inherited) Cancer Beneficiary has: -ovarian or breast cancer and; a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer and; a risk factor for germline (inherited) breast or ovarian cancer and; -not been previously tested with the same germline test using NGS for the same germline genetic content. The diagnostic laboratory test using NGS must have: FDA-approval or clearance; and, results provided to the treating physician for management of the patient using a report template to specify treatment options. Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic test when additional specific criteria are met. Click here for information on Next Generation Sequencing coverage. 9. Percutaneous Transluminal Angioplasty (PTA)    (Effective: February 19, 2019)  (Implementation Date: February 19, 2019)  CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA.  What is covered: Percutaneous Transluminal Angioplasty (PTA) is covered in the below instances in order to improve blood flow through the diseased segment of a vessel in order to dilate lesions of peripheral, renal and coronary arteries.  Who is covered: The PTA is covered under the following conditions:  1. Treatment of Atherosclerotic Obstructive Lesions  2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) – Approved Category B Investigational Device Exemption (IDE) Clinical Trials  3. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies  4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 5. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials Click here for more detailed information on PTA coverage. 10. Transcatheter Aortic Valve Replacement (TAVR) (Effective: June 21, 2019) (Implementation Date: June 12, 2020) CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met. What is covered: Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. Who is covered: This service will be covered when the TAVR is used for the treatment of symptomatic aortic valve stenosis according to the FDA-approved indications and the following conditions are met: The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication The patient is under the care of a heart team, which consists of a cardiac surgeon, interventional cardiologist, and various Providers, nurses, and research personnel The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR The hospital where the TAVR is complete must have various qualifications and implemented programs The registry shall collect necessary data and have a written analysis plan to address various questions. This service will be covered when the TAVR is not expressly listed as an FDA-approved indication, but when performed within a clinical study and the following conditions are met: The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR The clinical research study must critically evaluate each patient's quality of life pre- and post-TAVR for a minimum of 1 year, but must also address other various questions The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. Click here for more information on NGS coverage. 11. Ambulatory Blood Pressure Monitoring (ABPM) (Effective: July 2, 2019) (Implementation Date: June 16, 2020) CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover Ambulatory Blood Pressure Monitoring (ABPM) when specific requirements are met. What is covered: Effective July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring (ABPM) when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the NCD Manual. Who is covered: This service will be covered when the Ambulatory Blood Pressure Monitoring (ABPM) is used for the diagnosis of hypertension when either there is suspected white coat or masked hypertension and the following conditions are met: The ABPM device must be: Capable of producing standardized plots of BP measurements for 24 hours with daytime and nighttime windows and normal BP bands demarcated; Provided to patients with oral and written instructions, and a test run in the physician’s office must be performed; and, Interpreted by the treating physician or treating non-physician practitioner. Coverage of other indications for ABPM is at the discretion of the Medicare Administrative Contractors. Click here for more information on ambulatory blood pressure monitoring coverage. 12. Acupuncture for Chronic Low Back Pain (cLBP) (Effective: January 21, 2020) (Implementation Date: October 5, 2020) CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. What is covered: Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP) for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the NCD Manual. Who is covered: This service will be covered only for beneficiaries diagnosed with chronic Lower Back Pain (cLBP) when the following conditions are met: For the purpose of this decision, cLBP is defined as: Lasting 12 weeks or longer; nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); not associated with surgery; and, not associated with pregnancy. An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Treatments must be discontinued if the patient is not improving or is regressing. All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare. Click here for more information on acupuncture for chronic low back pain coverage. 13. Vagus Nerve Stimulation (VNS) (Effective: February 15. 2020) (Implementation Date: July 22, 2020) CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. What is covered:  Effective February 15, 2020, CMS will cover FDA approved Vagus Nerve Stimulation (VNS) devices for treatment-resistant depression through Coverage with Evidence Development (CED) in a CMS approved clinical trial in addition to the coverage criteria outlined in the National Coverage Determination Manual. Who is covered: Beneficiaries participating in a CMS approved clinical study undergoing Vagus Nerve Stimulation (VNS) for treatment resistant depression and the following requirements are met: Treatment is furnished as part of a CMS approved trial through Coverage with Evidence Development (CED).Detailed clinical trial criteria can be found in section 160.18 of the National Coverage Determination Manual. The clinical study must address whether VNS treatment improves health outcomes for treatment resistant depression compared to a control group, by answering all research questions listed in 160.18 of the National Coverage Determination Manual. Patient Criteria:      The following criteria must be used to identify a beneficiary demonstrating treatment resistant depression: Beneficiary must be in a major depressive disorder episode for at least two years or have had at least four episodes, including the current episode. Patient’s depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose. The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. Patients must maintain a stable medication regimen for at least four weeks before device implantation. If patients with bipolar disorder are included, the condition must be carefully characterized. Patients must not have: Current or lifetime history of psychotic features in any MDE; Current or lifetime history of schizophrenia or schizoaffective disorder; Current or lifetime history of any other psychotic disorder; Current or lifetime history of rapid cycling bipolar disorder; Current secondary diagnosis of delirium, dementia, amnesia, or other cognitive disorder; Current suicidal intent; or, Treatment with another investigational device or investigational drugs. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. Nationally Non-Covered Indications VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. All other indications of VNS for the treatment of depression are nationally non-covered. Patients implanted with a VNS device for TRD may receive a VNS device replacement if it is required due to the end of battery life, or any other device-related malfunction. Click here for more information on Vagus Nerve Stimulation.  14. Chimeric Antigen Receptor (CAR) T-cell Therapy (Effective: August 7, 2019) (Implementation Date: September 20, 2021) CMS has updated Section 110.24 of the Medicare National Coverage Determinations Manual to include coverage of chimeric antigen receptor (CAR) T-cell therapy when specific requirements are met. What is covered: Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administration’s (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met. Who is covered: Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one least one chimeric antigen receptor CAR, when all the following requirements are met: Autologous treatment is for cancer with T-cells expressing at least one chimeric antigen receptor (CAR); and Treatment is administered at a healthcare facility enrolled in the FDA’s REMS; and The therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia. Non-Covered Use: The use of non-FDA-approved autologous T-cell expressing at least one CAR is non-covered or when the coverage requirements are not met. Click here for more information on chimeric antigen receptor (CAR) T-cell therapy coverage.  15. Screening for Colorectal Cancer (CRC)-Blood-Based Biomarker Tests (Effective: January 19, 2021)  (Implementation Date: October 4, 2021)  What is covered: Effective January 19, 2021, CMS has determined that blood-based biomarker tests are an appropriate colorectal cancer screening test, once every 3 years for Medicare beneficiaries when certain requirements are met.  Who is covered: Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met: The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory The Patient is:  age 50-85 years, and, asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and, average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer) The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and Proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), based on the pivotal studies included in the FDA labeling. What is not covered: All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. This includes: All screening sDNA tests, effective April 28, 2008, through October 8, 2014. Effective for dates of service on or after October 9, 2014, all other screening sDNA tests not otherwise specified above remain nationally non-covered. Screening computed tomographic colonography (CTC), effective May 12, 2009. Click here for more information on NGS coverage. 16. Ventricular Assist Devices (VADs) (Effective: December 1, 2020) (Implementation Date: July 27, 2021) What is covered: Effective for dates of service on or after December 1, 2020, CMS has updated section 20.9.1 of the National Coverage Determination Manual to cover ventricular assist devices (VADs) when received at facilities credentialed by a CMS approved organization and when specific requirements are met. Who is covered: Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR They receive a left ventricular device (LVADs) if the device is FDA approved for short- or long-term use for mechanical circulatory support for beneficiaries with heart failure who meet the following requirements: Have New York Heart Association (NYHA) Class IV heart failure; and Have a left ventricular ejection fraction (LVEF) ≤ 25%; and Are inotrope dependent OR have a Cardiac Index (CI) < 2.2 L/min/m2, while not on inotropes, and meet one of the following: Are on optimal medical management, based on current heart failure practice guidelines for at least 45 out of the last 60 days and are failing to respond; or Have advanced heart failure for at least 14 days and are dependent on an intra‐aortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days. Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. Facilities must be credentialed by a CMS approved organization. Non-Covered Use: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. Click here for more information on Ventricular Assist Devices (VADs) coverage. 17. Blood-Derived Products for Chronic, Non-Healing Wounds (Effective: April 13, 2021) (Implementation Date: February 14, 2022) What is covered: Effective for dates of service on or after April 13, 2021, CMS has updated section 270.3 of the National Coverage Determination Manual to cover Autologous (obtained from the same person) Platelet-Rich Plasma (PRP) when specific requirements are met. Who is covered: Beneficiaries receiving treatment for chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by a device cleared by the Food and Drug Administration (FDA) for the management of exuding (bleeding, oozing, seeping, etc.) wounds affecting the skin. Non-Covered Use: The following uses are considered non-covered: Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and, Becaplermin, a non-autologous growth factor for chronic, non-healing, subcutaneous (beneath the skin) wounds, and, Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. Other: Coverage for the treatment beyond 20 weeks, or for all other chronic non-healing wounds will be determined by the local Medicare Administrative Contractors ( Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. 18. Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation (Effective: January 19, 2021) (Implementation Date: October 8, 2021) What is covered: Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. Who is covered: Beneficiaries receiving treatment for Transcatheter Edge-to-Edge Repair (TEER) when either of the following are met: For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met: Treatment is a Food and Drug Administration (FDA) approved indication, The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. The beneficiary is under pre- or post-operative care of a heart team meeting the following: Cardiac Surgeon meeting the requirements listed in the determination. Interventional Cardiologist meeting the requirements listed in the determination. Interventional echocardiographer meeting the requirements listed in the determination. Heart failure cardiologist with experience treating patients with advanced heart failure. Providers from other groups including patient practitioners, nurses, research personnel, and administrators. Patient must be evaluated for suitability for repair and must documented and made available to the Heart team members meeting the requirements of this determination. The procedure must be performed by an interventional cardiologist or cardiac surgeon.< An interventional echocardiographer must perform transesophageal echocardiography during the procedure. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.> Mitral valve TEERs are covered for other uses not listed as an FDA-approved indication when performed in a clinical study and the following requirements are met: The procedure must be performed by an interventional cardiologist or cardiac surgeon. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.> All physicians participating in the procedure must have device-specific training by the manufacturer of the device. The clinical research must evaluate the required twelve questions in this determination. The clinical research must evaluate the patient’s quality of life pre and post for a minimum of one year and answer at least one of the questions in this determination section. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. Submit the required study information to CMS for approval. Non-Covered Use: The following uses are considered non-covered: Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. Treatment for patients with untreated severe aortic stenosis. Other: This determination will expire ten years after the effective date if a reconsideration is not made during this time.  Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . 19. Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer- Manual Update Only  (Effective: December 15, 2017) (Implementation Date: January 17, 2022)  Effective for dates of service on or after December 15, 2017, CMS has updated section 220.6.19 of the National Coverage Determination Manual clarifying there are no nationally covered indications for Positron Emission Tomography NaF-18 (NaF-18 PET). Non-Covered Use: Positron Emission Tomography NaF-18 (NaF-18 PET) services to identify bone metastases of cancer provided on or after December 15, 2017, are nationally non-covered. Other Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. Information on the page is current as of December 28, 2021 H5355_CMC_22_2746205 Accepted 20. Home Use of Oxygen  (Effective: September 27, 2021) (Implementation Date: January 3, 2023) What is covered: Effective September 27, 2021, CMS has updated section 240.2 of the National Coverage Determination Manual to cover oxygen therapy and oxygen equipment for in home use of both acute and chronic conditions, short- or long- term, when a patient exhibits hypoxemia. CMS has updated section 240.2 of the National Coverage Determination Manual to amend the period of initial coverage for patients in section D of NCD 240.2 from 120 days to 90 days, to align with the 90-day statutory time period Who is covered: Beneficiaries who exhibit hypoxemia (low oxygen in your blood) when ALL (A, B, and C) of the following are met:   A. Hypoxemia is based on results of a clinical test ordered and evaluated by a patient’s treating practitioner meeting either of the following: a. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. i. PO2 measurements can be obtained via the ear or by pulse oximetry. ii. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. b. A clinical test providing the measurement of arterial blood gas. i. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. B. The clinical test must be performed at the time of need: a. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patient’s condition. i. For inpatient hospital patient’s, the time of need is within 2 days of discharge. ii. For patient’s whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy. C. Beneficiary’s diagnosis meets one of the following defined groups below: a. Group I: i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or; ii. Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation at or below 88% when tested during sleep for patients that demonstrate an arterial PO2 at or above 56 mmHg, or iii. Arterial oxygen saturation at or above 89% when awake;or greater than normal decrease in oxygen level while sleeping represented by a decrease in arterial PO2 more than 10 mmHg or a decrease in arterial oxygen saturation more than 5%. a. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. 2. During these events, oxygen during sleep is the only type of unit that will be covered. 3. Portable oxygen would not be covered. iv. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise, 1. For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day. 2. During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air. b. Group II: i. Patients demonstrating arterial PO2 between 56-59 mm Hg, or who’s arterial blood oxygen saturation is 89%, with any of the following condition: 1. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or, 2. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or, 3. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patient’s age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity. Non-Covered Use: The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Angina pectoris (chest pain) in the absence of hypoxemia; or, Breathlessness without cor pulmonale or evidence of hypoxemia; or, Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or, Terminal illnesses, unless it affects the patient’s ability to breathe. Other: The MAC may determine necessary coverage for in home oxygen therapy for patient’s that do not meet the criteria described above. Initial coverage for patient’s experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioner’s prescription. Oxygen therapy can be renewed by the MAC if deemed medically necessary. The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system. For more information on Home Use of Oxygen coverage click here. 21. 180.1 - Medical Nutrition Therapy (MNT) (Effective: January 1, 2022) (Implementation Date: July 5, 2022) What is covered: Effective for dates of service on or after January 1, 2022, CMS has updated section 180.1 of the National Coverage Determination Manual to cover three hours of administration during one year of Medical Nutrition Therapy (MNT) in patients with a diagnosis of renal disease or diabetes, as defined in 42 CFR 410.130. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. Medicare will cover both MNT and Diabetes Outpatient Self-Management Training (DSMT) during initial and subsequent years, if the physician determines treatment is medically necessary and as long as DSMT and MNT are not provided on the same date. Dieticians and Nutritionist will determine how many units will be administered per day and must meet the requirements of this NCD as well at 42 CFR 410.130 – 410.134. Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients’ medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care. Who is covered: Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. For more information on Medical Nutrition Therapy (MNT) coverage click here. 22.  Reconsideration – Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (Effective: February 10, 2022) (Implementation Date: October 3, 2022)  What is covered: Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met.  Prior to the beneficiary’s first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. Who is covered: Members must meet all of the following eligibility criteria:  50– 77 years old; Asymptomatic (no signs or symptoms of lung cancer); Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes); Current smoker or one who has quit smoking within the last 15 years; Receive an order for lung cancer screening with LDCT. Click here for more information on LDCT coverage.  23. (Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (AD))  (Effective: April 7, 2022) (Implementation Date: December 12, 2022)  What is covered: Effective on April 7, 2022, CMS has updated section 200.3 of the National Coverage Determination (NCD) Manual to cover Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for treatment of Alzheimer’s Disease (AD) when the coverage criteria below is met.  Who is covered: Beneficiaries with Alzheimer’s Disease (AD) may be covered for treatment when the following conditions (A or B) are met:  The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. The treatment is considered reasonably likely to predict a clinical benefit and is administrated in a randomized controlled trial under an investigational new drug application. The treatment is based upon efficacy from a direct measure of clinical benefit in CMS-approved prospective comparative studies. Study data for CMS-approved prospective comparative studies may be collected in a registry. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. CMS-approved studies of a monoclonal antibody directed against amyloid approved by the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit must address all of the questions included in section B.4 of this National Coverage Determination. CMS approved studies must also adhere to the standards of scientific integrity that have been identified in section 5 of this NCD by the Agency for Healthcare Research and Quality (AHRQ). Click here for more information on study design and rationale requirements. Non-Covered Use: Monoclonal antibodies directed against amyloid for the treatment of AD provided outside of an FDA-approved randomized controlled trial, CMS-approved studies, or studies supported by the NIH. Other: N/A. Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (AD). Information on the page is current as of December 1, 2022 H8894_DSNP_22_3617111_M Accepted

Enroll with IEHP DualChoice

padding-left: 2em; padding-bottom: 0.6em; padding-top: 0.6em; margin-top: 1em; margin-bottom: 1.75em; border-radius: 8px; font-weight: bold; font-size: 1.25rem; } /** BEGIN MOBILE STYLES - Screens less than 769px **/ @media only screen and (max-width: 769px) { .dsnp-cta-btn{ background: #005bab !important; color: white; padding-right: 1em; padding-left: 1em; padding-bottom: 0.6em; padding-top: 0.6em; margin-top: 1em; margin-bottom: 1.75em; border-radius: 8px; font-weight: bold; font-size: 0.9rem; } Trust your heart when it comes to your health-enroll with IEHP DualChoice (HMO D-SNP) If you have both Medi-Cal and Medicare, you may be eligible to enroll in the IEHP DualChoice (HMO D-SNP) plan. Our IEHP DualChoice plan helps you get the care you need to achieve your best possible health. Get covered benefits for $0 including: Doctor visits such as routine checkups and sick visits Prescriptions from the IEHP DualChoice formulary Hospital care such as emergency room and urgently needed servicesAre currently eligible for Medi-Cal, and  Specialist case PLUS extra benefits like: Vision care: $350 limit every two years for contact lenses and eyeglasses (frames and lenses) Utilities allowance of $40 for covered utilities. You must qualify for this benefit. Who is eligible for IEHP DualChoice (HMO D-SNP)? IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). Included Population: With mandatory enrollment for Medi-Cal benefits, including Long-Term Services and Supports (LTSS) benefits and Medicare benefits. You are eligible for our Plan as long as you: Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it.), and Are age 21 and older at the time of enrollment, and  Have both Medicare Part A and Medicare Part B, and Are currently eligible for Medi-Cal, and Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. This is known as “Exclusively Aligned Enrollment”, and Are a United States citizen or are lawfully present in the United States Enroll for IEHP DualChoice Plan Today! For questions or to enroll over the phone, please call the IEHP DualChoice Medicare Team at 1-800-741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347. IEHP DualChoice Enrollment Form IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. Information on this page is current as of October 01, 2022. H8894_DSNP_23_3241532_M Pending Accepted

Testimonials - Gayani DeSilva

ted States are living with some form of behavioral health issue.  In fact, according to the National Alliance on Mental Illness, 50 percent of lifetime mental health illnesses begin by age 14. Yet unlike diabetes or cancer, most people don’t feel comfortable talking about their behavioral health concerns with their Doctor.  Dr. Gayani DeSilva is hopeful that will change sooner rather than later.  “Physical health and mental health affect the whole person, so it’s important that both are considered when we look at how to improve quality and awareness,” said Dr. DeSilva, a psychiatrist and the medical director of Behavioral Health at IEHP.  Before joining the health plan in 2019, Dr. DeSilva treated IEHP Members in a variety of settings and even then she realized IEHP was different in terms of its coordination of behavioral health care. She saw that IEHP patients were more educated about how to access their services and were more confident that they would get the treatment they needed.  Now, as an IEHP Team Member, Dr. DeSilva knows why.  “The team is very conscientious and aware of what our Members need. We don’t just want to meet the expectations of our Members, but exceed them,” she said. Dr. DeSilva said her role as medical director isn’t just to provide clinical leadership for the department. She also wants to facilitate the ongoing integration between Utilization Management, Behavioral Health and Care Coordination even more. Removing barriers and improving access to care is another top priority, she said. That’s the goal behind a new program that will offer home-based behavioral health services to IEHP Members who are unable to go outside of their house for treatment.  “We’re always thinking of how to do things better in order to meet the needs of our Members,” she said.   

Leadership Team - Takashi Wada, MD, MPH

021. He is responsible for providing clinical and strategic leadership through accountable, collaborative processes to improve the quality-of-care delivery as evidenced by improved external quality metrics. Dr. Wada leads and drives innovative solutions for program development and implementation to improve access, satisfaction and care outcomes that are sustainable and scalable.  Dr. Wada joined IEHP in 2019 as Vice President of Population Health. In this capacity, he oversaw the internal departments of Behavioral Health & Care Management, Community & Family Health, Health Education, and Practice Transformation. He also played a key role in various statewide and regional population health initiatives.   Prior to his role at IEHP, Dr. Wada served as Chief Medical Officer/ Deputy Chief Medical Officer for CenCal Health and Director/Health Officer for Santa Barbara County’s Health Department.  Dr. Wada holds an undergraduate degree in biomedical sciences from University of California, Riverside and a master’s degree in public health from University of California, Los Angeles (UCLA). After receiving his medical degree at UCLA, he completed his graduate medical education at Kaiser Permanente Los Angeles Medical Center.

Leadership Team - Michelle Rai, MS

2020. She oversees IEHP’s communications and marketing programs and guides the development of long-term communication and marketing strategies. In addition, Ms. Rai oversees the strategic execution of IEHP’s community relations, media relations, internal communications, digital and social media. Ms. Rai has over 20 years of experience in public relations, communications, marketing, and media relations. Prior to joining IEHP, Ms. Rai served as Chair of the Communication Department at Pacific Union College in Napa Valley, Calif. Before her role as Chair, Ms. Rai acted as the College’s Public Relations Director and Public Information Officer. Ms. Rai holds a master’s degree in integrated marketing communications from Golden Gate University. She earned bachelor’s degrees in journalism and communications from Pacific Union College, where she received the prestigious Educator of the Year award in 2016. Ms. Rai’s leadership enables IEHP to increase its brand reach and social media presence, while enhancing perception of the organization and strengthening its place as an industry thought leader.

Special Programs - Independent Living and Diversity Resources

A resource for health providers, IPAs and others interested in the Americans with Disabilities Act, California law as it related to accessibility and Universal Design. In partnership with our Provider Network, IEHP strives to break down barriers to medical care and promote health and wellness for Members with disabilities. With accessibility issues often cited as an obstacle to care, we publish this site to help all stakeholders in the health care system understand the barriers and in some cases the solutions. We invite you to browse these topics: Information on the Americans with Disabilities Act (ADA) Accessibility of Doctor's offices, clinics, and other health care providers is essential in providing medical care to people with Disabilities. Find out more by following the link to the ADA's Access Guide (PDF). The Federal Americans with Disabilities Act (ADA) of 1990 prohibits discrimination on the basis of disability and sets national standards for accessibility. Each page in this section gives you a summary of ADA related documents and a link to the actual Federal resource.  By clicking on this link, you will be leaving the IEHP website. View the full text of the law at the ADA Website.  Enforcement Lawsuits for ADA Violations U.S. Department of Justice (DOJ) 1994 Status reports, briefs, and settlement information will help you stay up-to-date on precedent-setting ADA litigation. Unsuccessful negotiations or mediation may lead to federal lawsuits. Courts can order compensatory damages, back pay, or civil penalties up to $55,000 for the first violation and $110,000 for any subsequent one.  Read more about DOJ Litigation Alternative to Litigation U.S. Department of Justice (DOJ) Mediation Program Established: 1994 Mediation, which is confidential and voluntary, can resolve some ADA disputes quickly and satisfactorily – without the expense and delay of formal investigation and litigation.  Read more about DOJ Mediation Facts and Information Diagnosing & Treating Members with Auditory Disability Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings U.S. Department of Justice (DOJ) Disability Rights Section, Civil Rights Division Published 2003 Interactive doctor-patient discussions with individuals who are deaf or hard-of-hearing may require an interpreter to ensure proper diagnosis and treatment. DOJ’s brief outlines the types of interpreter services including sign language, oral interpretation, cued speech, and Computer Assisted Real-time Transcription (CART). Read the Full Article: HTM PDF Phone Calls & Auditory/Speech Disabilities Phone Calls & Auditory/Speech Disabilities - Technology Breaks Communication Barriers Created by IEHP, 2006 Learn about FREE options for effective telephone communication with individuals who have auditory and/or speech disabilities: National Telecommunication Relay Service (TRS) – two-way translation between individuals using a TTY and a standard telephone Speech-to-Speech (STS) Relay Service – assistance for individuals with speech disabilities by repeating their message verbatim. Read the Full Article  Fact Sheet - PDF Fact Sheet - TXT Dispelling ADA Myths Just the Facts on the ADA Adapted from 1995 DOJ fact sheet IEHP, 2006 Get the facts on common ADA misconceptions. ADA Myths & Facts  PDF Text Accessibility Pays Off at Tax Time Tax Incentives for ADA Compliance Take advantage tax incentives that help eligible businesses comply with the Americans with Disabilities Act.  The Federal and California state governments offer Tax Credits and/or Deductions for improving accessibility and/or employing persons with disabilities. Attorney General’s ADA Tax Incentives Packet Your practice/health care facility may be eligible for tax credits and/or deductions to help offset the costs of improving accessibility for patients and employees with disabilities. The Attorney General’s packet includes a fact sheet and Internal Revenue Service (IRS) form and instructions. Download IEHP's Fact Sheet PDF Text  Download the Attorney General's information packet: Website Legal Obligations Standards for Accessible Design ADA Accessibility Guidelines U.S. Department of Justice (DOJ) 1991 The ADA Accessibility Guidelines (ADAAG) include stringent criteria for health care Providers as well as additional requirements based on building use (special application 6 – Medical Care Facilities). The Standards for Accessible Design apply to the architecture and construction of new buildings/facilities as well as alterations to existing structures. Download the Standards Standards - PDF Standards - HTM Download Special Application 6 (Health Care Facilities) Access to Medical Care for Individuals with Mobility Disabilities (PDF) Access to Medical Care for Individuals with Mobility Disabilities (HTM) Removing Existing Barriers Checklist for Readily Achievable Barrier Removal Adaptive Environments Center, Inc. and Barrier Free Environments, Inc. 1995 Identify accessibility problems and solutions for eliminating physical/architectural and communication barriers. Use this informal checklist as a guide to meet your obligations under the ADA (for existing facilities only, not new construction or alterations). Download the checklist for readily achievable barrier removal Checklist - PDF Checklist - HTM ADA Regulations for Health Care Providers Nondiscrimination on the Basis of Disability U.S. Department of Justice (DOJ) 1991 Federal regulations for accessibility at Health care facilities include standards for the architecture of buildings, alterations, and new construction (ADA, Title III).  DOJ article - PDF DOJ article - HTM Basic ADA Requirements for Health Care Providers ADA Title III Highlights U.S. Department of Justice (DOJ) Disability Rights Section, Civil Rights Division Published 1990 This functional outline of the ADA’s Title III (section covering health care providers) helps you become familiar with key requirements that impact you and your patients. DOJ’s overview provides details in bullet format for quick reference. See the Full DOJ Article Practical Guidance for ADA Compliance Title III Technical Assistance Manual  U.S. Department of Justice (DOJ) 1993 and 1994 This manual (with supplement) outlines ADA requirements for businesses to ensure access to goods, services, and facilities. The reader-friendly format offers: Lay terms and practical examples (limited legalese) Focused, systematic description of requirements Questions/answers and illustrations  Read the full Manual Read the Supplement Technical Assistance DOJ ADA Information and Technical Assistance on the Americans with Disabilities Act  The official ADA website of the U.S. Department of Justice (DOJ) offers the most up-to-date information and practical guidance on design, construction, and operation:  Regulations and standards impacting Providers and Members  Accessibility and reasonable accommodations guidelines  Solutions for ensuring access within your budget  Tax credits and incentives  Technical assistance and materials/publications Visit DOJ's ADA Homepage Avoid Costly Building Mistakes Common ADA Errors and Omissions in New Construction and Alterations  U.S. Department of Justice (DOJ) Disability Rights Section, Civil Rights Division Published 1997 Incorporating ADA Standards into initial building/alteration plans helps ensure patient safety as well as cost-effectiveness. Review some of the most common accessibility errors/omissions identified through DOJ’s ongoing enforcement efforts. Following each error/omission, you’ll find an explanation of its significance and reference to the appropriate requirement under the ADA Standards for Accessible Design.   Online ADA Course Reaching Out to Customers with Disabilities U.S. Department of Justice (DOJ) with Representatives of Business and Disability Communities 2005 Learn about ADA compliance in an online course with 10 short lessons. Policies, Practices, and Procedures Communicating with Customers Who Have Disabilities New Buildings, Additions, and Remodeling Removing Barriers in Buildings That Are Not Being Remodeled Providing Access When Removing Barriers Is Not Readily Achievable Maintaining Accessibility Transporting Customers ADA Compliance Costs and Tax Incentives Enforcement of the ADA Information Sources Take the ADA online course Pacific Region ADA Technical Assistance Disability Business Technical Assistance Center (DBTAC) Region IX  National Institute on Disability and Rehabilitation Research U.S. Department of Education 1995 Get information on your compliance obligations, problem-solving assistance, and referrals from ADA experts – without the high cost of a consultant. The 10 regional ADA & IT Technical Assistance Centers serve strictly as educational entities to help you understand your rights and responsibilities and have no enforcement or advocacy responsibilities. Federal Region IX, Pacific, serves: Arizona, California, Hawaii, Nevada, and the Pacific Basin. Visit Pacific ADA Center Visit DBTAC Homepage Visit NIDRR Community Based Adult Services (CBAS) Reminder: Community-Based Adult Center (PDF) SPD Awareness Training  By clicking on these links, you may be leaving the IEHP website. By making your facilities accessible you convey a sense of welcome for people with disabilities. Most of all, you comply with the requirements set by the Americans with Disabilities Act (ADA) of 1990. This is a civil rights law that prohibits discrimination against persons with disabilities on the basis of their disability in programs and services that receive federal financial assistance. Please see the resources below for more detailed information. Office Accessibility How to Make Your Medical Office More Accessible (PDF) Guidebook: How to Safely Transfer Patients with Disabilities to an Exam Table (PDF) Video #1: How to Safely Transfer Patients with Disabilities to an Exam Table Video #2: Using an Accessible Scale to Weigh Patients with Disabilities Accessibility Checklist (PDF) Community Resources Community Resources Guide (PDF) Disability Competency and Sensitive Training Disability Etiquette Guide (PDF) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Helpful Information and Resources - Medical and Government Links

alth information. All the links will open in a new window and you will leave the IEHP website. Medical Links Medscape: free medical news, journal articles, and more. Yahoo! Health: medical dictionary, disease symptoms, and treatments. KidsHealth: animations, games, and articles for parents, teens, and kids. First 5 San Bernardino: statewide initiative to improve the early development of children. First 5 Riverside: statewide initiative to improve the early development of children. Text4Baby: get FREE messages each week on your cell phone to help you through your pregnancy and your baby's first year. Government Links San Bernardino County Department of Public Health: get information on WIC, child car seat safety and more. Riverside County Department of Public Health: get information on injury prevention, WIC, HIV, family health and more. PubMed: life science journals from the United States National Library of Medicine. Healthy Finder: 1600 health-related topics. NCQA (National Committee for Quality Assurance): reports on the quality of care delivered by managed care plans. NIH (National Institutes of Health): get health information, clinical trials, research, and more. CDC (Centers for Disease Control and Prevention): get information on healthy living, disease, Zika virus, emergencies, workplace safety, and environmental health. Quality of Care Report Card: get quality ratings of health plans. California Department of Managed Health Care  California Department of Health Care Services  

Medi-Cal Dental Coverage Insurance Information - Medi-Cal Dental Coverage Insurance Information

ms can start in our mouths, that's why Medi-Cal dental coverage is so vital to California residents. Medi-Cal is the name for the California Medi-Cal Assistance Program, the regions Medicaid program. Medi-Cal provides health and medical dental insurance coverage for qualified families and individuals in California. Does Medi-Cal Cover Dental? Yes, Medi-Cal covers a wide range of dental services through their Medi-Cal Dental Program. This benefit is included with your Medi-Cal coverage at little to no cost to you. To access Medi-Cal's dental services, you can visit a Medi-Cal dental provider. They will let you know what the best form of treatment is under your Medi-Cal dental coverage. If you have any questions or need help finding a Medi-Cal dental provider, call the Medi-Cal Dental Customer Service Line at 1-800-322-6384, or visit www.smilecalifornia.org. What Does Medi-Cal Cover for Dental? Medi-Cal dental coverage includes the following: Diagnostic and preventive dental hygiene (e.g., examinations, x-rays, and teeth cleanings) Emergency services for pain control Tooth extractions Fillings Root canal treatments (anterior/posterior) Crowns (prefabricated/laboratory) Scaling and root planing Periodontal maintenance Complete and partial dentures; and Orthodontics for kids who qualify Does Medi-Cal cover root canals? Yes, Medi-Cal dental will cover both anterior and posterior root canals. Does Medi-Cal cover braces? Orthodontics are only covered for kids who qualify for this type of specialist treatment under Medi-Cal's dental services. Why You Need Dental Insurance It is a fact that your mouth can give a clear sign of your overall health. This is because dental health and hygiene link to other areas of the body, including the heart. It is vital to visit the dentist on a regular basis, to make sure your oral health is not causing you any problems. That said, dental work can be costly. Even more costly as we get older, and our teeth and gums start to weaken. Medi-Cal dental helps all Medi-Cal members save money on preventative and restorative dental work. Here are some reasons why dental health insurance is so important: Insurance pays for expensive dental care. For some people, dental care means two visits a year for checkups and teeth cleaning. For others, it means thousands of dollars in restorative surgery bills. Whether you brush your teeth three times a day or not, dental problems can come without notice. To prevent paying expensive dental bills apply for Medi-Cal coverage and visit a Medi-Cal registered dentist. Medi-Cal will pay some or all of the costs of your dental procedures. Keep great oral health and hygiene. The best way to save money on dental health bills (besides applying for Medi-Cal coverage) is to keep up to date on the overall health of your mouth. Regular dental checkups will help to make sure that your oral health is checked. Medi-Cal dental will cover *routine checkups. Give your kids a head start. According to the Pew Center on the States, about 20% of a child's healthcare expenses come from dental costs. Tooth decay is one of the most common and preventable childhood diseases. It's five times more common than asthma and seven times more prevalent than fever in U.S kids. Twenty percent of kids 0-5 do not get yearly dental checkups. Kids with oral health problems have a hard time learning in school. The U.S Department of Health and Human Services estimates that kids lose over 51 million school hours per year due to dental issues. How to Apply for Medi-Cal Dental Coverage If you have Medi-Cal, you will be able to use your dental benefits at any Medi-Cal Dental provider in California. All you need to do is make an appointment and show your Medi-Cal card when you visit the dentist. To apply to Medi-Cal, call our professional Enrollment Advisors at (866) 294-4347, Monday – Friday, 8am – 5pm. TTY users should call (800) 720-4347. You can also call Health Care Options at 1-800-430-4263 or visit www.healthcareoptions.dhcs.ca.gov. TTY users should call 1-800-430-7077. At IEHP, we are happy to answer any questions you may have regarding Medi-Cal dental coverage. We can also help you apply for Medi-Cal online.  *For more information on guidelines and coverage for Medi-Cal Dental age groups, please visit the covered services section on the Smile California website.