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and achieve health goals. IEHP’s Health & Wellness Programs help Members learn how to manage their health and make healthy lifestyle changes. You can refer your IEHP Members to these programs anytime by logging into the Secure Provider Website and completing the Health Education Program Request Form. Health Resources Kids and Teens Managing Your Illness Pregnancy and Postpartum Senior Health Weight Management Health & Wellness Brochures and Handouts Inland Empire Health Plan (IEHP) offers many Wellness Programs that focus on the health and well-being of our Members. All of our programs are free, join us at our next session and learn ways to stay healthy.  Get information on important health topics through our health education brochures and handouts: Controlling Asthma (PDF) Diabetes. What's next? (PDF) Eat Healthy, Feel Better (PDF) Fever in Children (PDF) Flu Decision Guide (PDF) Flu Shot (PDF) High Blood Pressure (PDF) Immunizations - English (PDF) Immunizations - Spanish (PDF) Immunizations - Chinese (PDF) Immunizations - Vietnamese (PDF) PAP and HPV Tests: What to Expect (PDF) Diabetes Prevention Program (DPP) - Live the Life You Love Format: Online (small group) Duration: One year Ages: 18 years and over This online year-long lifestyle change program helps you make real changes that last.  During the first 6 months, you will meet weekly with a small online group to learn how to make healthy choices into your life. In the second 6 months, you will meet monthly to practice what you have learned. No person is alike, so the program will be tailored to meet your needs and honor your customs and values. You will also be paired with a health coach for one year to help you set your goals, such as how to: Eat healthier Add physical activity into your daily life Reduce stress Improve problem-solving and coping skills Studies have shown that those who finish the program can lose weight and prevent Type 2 Diabetes. Small changes can have big results! Let's start living the best version of you and living the life you love. Find out if you qualify! Click here to visit the Skinny Gene Project online, or Call Skinny Gene Project at (909) 922- 0022, Monday - Friday 8am – 5pm., or Email hello@skinnygeneproject.org For Providers DPP Rx Pad (PDF) Educational Resources 2021 Population Needs Assessment (PNA) Report IEHP’s Population Needs Assessment (PNA) identifies Member health status and behaviors, Member health education priorities, cultural/linguistics needs, health disparities, and gaps in service related to these issues. The findings of the PNA may help Providers better understand and serve our Members. For questions, please contact IEHP Health Education Department at healthed@iehp.org 2021 Population Needs Assessment (PNA) Report Loving Support Program IEHP supports and sponsors the Loving Support Program that is run by Riverside University Health System (RUHS). Loving Support is a program committed to helping mothers achieve their breastfeeding goals. This service offers help and support with the first days at home, return to work, support groups, and timely answers to challenges nursing mothers face. Members can directly contact the Loving Support 24/7 Helpline at 888-451-2499. No referral is necessary. English and Spanish-speaking certified lactation specialists and Internationally Board Certified Lactation Consultants (IBCLCs) are available 24 hours a day, 7 days a week to answer questions. Messages are recorded after hours and promptly addressed. Member Education Resources The following websites are good sources of easy-to-read patient information that can be downloaded, printed, or ordered. By clicking on these links, you will be leaving the IEHP website.  RESOURCE  DESCRIPTION Medline Plus A service of the US National Library of Medicine and the National Institutes of Health. Easy to read information and audio tutorials on many health topics in English and Spanish. Topics are available in multiple languages. Food and Drug Administration - Office of Women's Health Easy-to-read handouts in English, Spanish and other languages on nutrition, diabetes, depression, and other topics related to women’s health. Learning About Diabetes, Inc. Easy to read “Handouts and Visual Aids” in color on diabetes care and nutrition to help patients eat the right foods to control blood sugar. Weight Control Information Network An extensive list of health education materials about healthy weight and physical activity in English and Spanish. Materials can be printed or ordered. Health Information Translations Easy-to-read educational handouts on many health topics and in multiple languages.   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

will now be held at the following address: Dr. Bradley P. Gilbert Center for Learning & Innovation 9500 Cleveland Ave. Rancho Cucamonga, CA 91730 Click here to view the meeting room map. Any Member of the public may observe the scheduled proceedings by using the link listed below. Click here to join the virtual meeting. September 2023 Watch Video (YouTube) Agenda Board Report Under $200k Summary Report August 2023 Watch Video (YouTube) Agenda Board Report Under $200k Summary Report July 2023 Watch Video (YouTube) Agenda Board Report Under $200k Summary Report

cond year in a row, ranking 14th on the list. The Rancho Cucamonga-based, not-for-profit health organization joins other national companies on the list like Humana, Cleveland Clinic and Elevance Health. This is the third time IEHP has been recognized in 2023 for effective practices to ensure its team members and providers work in a positive, uplifting environment with personal and career growth benefits available year-round. In June, IEHP was designated a Great Place To Work™; then in July, PEOPLE named the organization one of its 100 Companies That Care©, ranking in at No. 87. “We are incredibly proud to be recognized again as one of the country’s best workplaces in health care,” said Jarrod McNaughton, IEHP’s chief executive officer. “This achievement reflects our organization’s strong team culture and deep commitment to serving our community and one another.” IEHP’s Chief People Officer Supriya Sood agreed. “Our entire team is a vital component in the work we do to support our nearly 1.7 million IEHP members living and working in both San Bernardino and Riverside counties,” she said. “From cultivating a strong culture of communication and recognition to offering employees a myriad of growth opportunities, IEHP strives to be the prime example of how to shape a positive workplace environment in one of the fastest growing areas in the state.” The Best Workplaces in Health Care list is highly competitive. Great Place To Work, the global authority on workplace culture, determines its list using its proprietary For All™ Methodology to evaluate and certify thousands of organizations in America’s largest ongoing annual workforce study, based on over 1.3 million survey responses and data from companies representing more than 7.5 million employees this year alone. Survey responses reflect a comprehensive picture of the workplace experience. Honorees were selected based on their ability to offer positive outcomes for employees regardless of job role, race, gender, sexual orientation, work status or other demographic identifier. According to IEHP employees surveyed: 92% said IEHP is a great place to work compared to 57% of employees at a typical U.S.-based company. 96% say they felt good about the ways IEHP contributes to the community. 95% said IEHP has special and unique benefits and believed the company made them feel welcome upon employment. 94% said IEHP’s facilities contribute to a good working environment, and they are proud to tell others they work for the organization. “Congratulations to the Best Workplaces in Health Care,” said Michael C. Bush, CEO of Great Place To Work. “These companies know that it isn’t the industry but the company that determines the employee experience. By putting people first, they are reaping the rewards: lower labor costs, higher standards of care, and happier employees.” “Fortune congratulates the Best Workplaces in Health Care,” added Fortune Editor-in-Chief Alyson Shontell. “Creating a vibrant workplace culture that draws the best talent in health care is vital for the success of leaders in this highly competitive industry. It is also what’s needed to ignite the innovation and deliver best-in-class performance.”

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: July 31, 2023) (Implementation Date: July 31, 2023) 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) with either: An episode of VT (spontaneous or induced by an electrophysiology (EP) study, not associated with myocardial infraction (MI) (heart attack) and not due to a short term or reversible cause. An episode of cardiac arrest due to VF, not due to a short term or reversible cause. Prior MI and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to 0.03 and do not meet the indications not covered below. 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% and do not meet the indications not covered below. Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest due to VT or sustained VT, and have NYHA Class II or II heart failure, LVEF less than or equal to 35%, and utilization of optimal medical therapy for at a minimum of three (3) months. Patients must not meet the indications below for this indication.  Documented, familial (family history) or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy (thickening muscle of the heart). Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction For patients identified in bullet points 2 through 5, a formal shared decision-making encounter must occur prior to the initial implantation per the NCD. Who is not covered: ICDs will not be covered for patient indications: For patients meeting the indications in bullet points 2 through 4, patient must not have any of the indications listed in the NCD that would make their treatment non-covered. 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 screenings DNA 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: July 31, 2023) (Implementation Date: July 31, 2023) 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) (a type of heart valve disease) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization (treatment to help correct heart rhythm problems) 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 the care of a heart team meeting the requirements listed in this coverage determination.   Patient must be evaluated for suitability for repair and must be documented and made available to the other heart team members meeting the requirements of this determination. For patients with functional MR, the cardiologist must document the persistent symptoms in accordance with this coverage determination. The procedure must be performed by an interventional cardiologist or cardiac surgeon from the heart team in accordance with the requirements in this coverage determination. 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 coverage 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 requirements listed in this coverage determination are met.   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). 24. Colorectal Cancer Screening Tests (Effective: January 1, 2023) (Implementation Date: February 27, 2023) What is covered: Effective on January 1, 2023, CMS has updated section 210.3 of the NCD Manual that provides coverage for colorectal cancer (CRC) screening tests under Medicare Part B. Who is covered: Beneficiaries that are at least 45 years of age or older can be screened for the following tests when all Medicare criteria found in this national coverage determination is met: Fecal Occult Blood Tests (gFOBT) once every 12 months The Cologuard™ – Multi-target Stool DNA (sDNA) Test once every 3 years Blood-based Biomarker Tests once every 3 years Non-Covered Use: All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. Noncoverage specifically includes the following: All screenings DNA 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 Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. 25. Cochlear Implantation (Effective: September 26, 2022) (Implementation Date: March 24, 2023) What is covered: Effective on September 26, 2022, CMS has updated section 50.3 of the National Coverage Determination (NCD) Manual that expands coverage on cochlear implants for the treatment of bilateral pre- or post- linguistic, sensorineural, moderate-to-profound hearing loss when the individual demonstrates limited benefit from amplification under Medicare Part B. Who is covered: Beneficiaries that demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence recognition. The following criteria must also be met as described in the NCD: Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit Cognitive ability to use hearing clues and a willingness to undergo an extended program of rehabilitation Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the hearing nerve and acoustic areas of the central nervous system No indicated risks to surgery that are determined harmful or inadvisable The device must be used in accordance with Food and Drug Administration (FDA) approved labeling Non-Covered Use: Beneficiaries not meeting all the criteria for cochlear implants are deemed not eligible for Medicare coverage except for FDA-approved clinical trials as described in the NCD. Click here for more information on Cochlear Implantation. 26. Histocompatibility Testing (Effective: July 31, 2023) (Implementation Date: July 31, 2023) What is covered: Effective on July 31, 2023, CMS has issued section 190.1 of the National Coverage Determination (NCD) Manual that provides coverage for histocompatibility testing (compatibility between the tissues of different individuals).  The test matches or types the human leucocyte antigen (HLA), a type of marker on cells in your body. Who is covered: The test is considered safe and effective when performed on beneficiaries who meet one of the following criteria: In preparation for a kidney transplant. In preparation for bone marrow transplantation. In preparation for blood platelet transfusions (particularly where multiple infusions are involved). Members that are suspected of having ankylosing spondylitis, a type of arthritis that causes inflammation in the joints and ligaments of the spine. Histocompatibility testing is covered when it is considered reasonable and necessary for beneficiaries that meets one of the first three bullet items listed above.  The test would also be covered for ankylosing spondylitis in cases where other methods of diagnosis would not be appropriate or yield inconclusive findings. Non-Covered Use: Indications that do not meet the coverage requirements listed above. Click here for more information on Histocompatibility Testing. 27. Power Seat Elevation Equipment on Power Wheelchairs (Effective: May 16, 2023) (Implementation Date: September 4, 2023) What is covered: Effective on September 4, 2023, CMS has issued section 280.16 of the National Coverage Determination (NCD) Manual that provides coverage for power seat elevation equipment on certain power wheelchairs. Who is covered: Effective for services performed on or after May 16, 2023, beneficiaries that have undergone a specialty evaluation that confirms their ability to safely operate the seat elevation equipment in the home. The evaluation must be performed by a licensed/certified medical professional such as a Physical Therapist (PT), Occupational Therapist (OT), or other practitioner, who has specific training and experience in rehabilitation wheelchair evaluations. One of the following conditions must also apply: The beneficiary can perform weight bearing transfers to/from the power wheelchair while in the home, using either their upper limbs during a non-level (uneven) sitting transfer and/or their lower limbs during a sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive equipment (e.g. sliding board, cane, crutch, walker, etc.). The beneficiary requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power wheelchair while in the home.  Note: Transfers may be accomplished with or without a floor or mounted lift. The beneficiary is able to reach from the power wheelchair to complete one or more mobility related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary locations within the home. This may be accomplished with or without caregiver assistance and/or the use of assistive equipment. Non-Covered Use: Requests that do meet the coverage requirements described above. Click here for more information on Power Seat Elevation Equipment on Power Wheelchairs. Information on the page is current as of September 1, 2023 H8894_DSNP_23_4377179_M Accepted

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website. Medicare: For IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan - Formulary and Criteria information, please click here IEHP DualChoice (HMO D-SNP). Medicaid: On January 7, 2019, Governor Gavin Newsom issued Executive Order N-01-19 (EO-N-01-19) for achieving cost-savings for drug purchases made by the state. A key component of EO N-01-19 requires the Department of Health Care Services (DHCS) transition all Medi-Cal pharmacy services from managed care (MC) to fee for service (FFS). Click here to go to the “DHCS Medi-Cal Rx” page on IEHP website Click here to go to “Medi-Cal Rx: Transition” page on DHCS website Updated April 7, 2021, this document describes DHCS’ multi-faceted pharmacy transition policy, inclusive of “grandfathering” previously approved PAs from managed care and fee-for-service, as well as a 180-day period with no PA requirements for existing prescriptions, to help support the Medi-Cal Rx transition. During this transition period, Magellan will provide system messaging, reporting and outreach to provide for a smooth transition to Medi-Cal Rx. Click here to view “Medi-Cal Rx Pharmacy Transition Policy” from DHCS website To view Drug Criteria Referenced in Summary Table - Click Links Below: Clinical Practice Guidelines - CPGs Drug Prior Authorization Criteria HP Acthar (repository corticotropin injection) (PDF) Nucala (PDF) Synagis (PDF) Xolair (omalizumab) (PDF)  Zynteglo (PDF) Drug Class Prior Authorization Criteria Erythropoiesis Stimulating Agents (PDF) Growth Hormones (PDF) Immuno Globulins (PDF) Pharmacy Policies Discharge Policy (PDF) Drug Trial and Failure (PDF) High Daily Morphine Milligram Equivalent (PDF) IEHP Drug Prior Authorization Policy (PDF) Intradialytic Parenteral Nutrition (IDPN) Policy (PDF) Non-Formulary Drug (PDF) Non-Sterile Compounded Medication (PDF) Off-Label Indication Policy (PDF) Pharmacy Drug Management Program for Pain (PDF) Quantity Limit Policy (PDF) Information on this page is current as of September 08, 2023.

most appropriate, high quality and cost-effective drug therapies.   The Inland Empire Health Plan Pharmacy and Therapeutics (P & T) Subcommittee develops and monitors the Formulary. The P & T is composed of the IEHP Chief Medical Officer, Medical Directors, Director of Pharmaceutical Services, physicians from various medical specialties, local communities, and clinical pharmacists. This panel reviews the medications in all therapeutic categories based on safety, clinical efficacy, and cost-effectiveness and selects the most appropriate drugs in each class.   Formulary development and maintenance is a dynamic process. The IEHP P & T Subcommittee is responsible for developing, managing, updating and administering the Formulary. The Subcommittee also ensures that the IEHP Formulary remains responsive to the needs of our members and providers.   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website.   IEHP Medi-Cal Formulary Items: DHCS Noncapitated Physician Administered Drugs (PADs) Medi-Cal Medical Benefit PA (PDF) Medi-Cal Medical Benefit Formulary (PDF) Referral Form for Medi-Cal Benefit (PDF) Exceptions to criteria or requests for coverage of drugs not on the Medi-Cal Drug Benefit Formulary may be submitted by prescribers on the Referral Form for Medi-Cal Benefit. Starting January 1, 2022, all IEHP Medi-Cal pharmacy services will be transitioned from managed care (MC) to fee for service (FFS). The Medi-Cal pharmacy benefits and services administered by the Department of Health Care Services (DHCS) will be identified collectively as "Medi-Cal Rx." Magellan Medicaid Administration, Inc. (MMA) will assume operations for Medi-Cal Rx on behalf of DHCS. For further information on Medi-Cal Rx, please visit: https://www.iehp.org/en/providers/pharmacy-services?target=medi-cal-rx For more information on the Medi-Cal Rx Covered Drug List (CDL), please visit: https://medi-calrx.dhcs.ca.gov/home/cdl   IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan Items: IEHP DualChoice (HMO D-SNP) Formulary Book (PDF) Grievance Coverage Determination and Appeals Process IEHP DualChoice (HMO D-SNP) Formulary Search Tool        E-prescribing Tips (PDF)   Information on this page is current as of September 8, 2023

OS June 30, 2022, payments will run out through June 2023. The Proposition 56 VBP Program provided direct payments incentivizing Providers to meet specific measures aimed at delivering key quality healthcare services that improve the quality of care to Medi-Cal beneficiaries. Targeted areas were behavioral health integration, chronic disease management, prenatal/post-partum care and early childhood prevention. For more information about the VBP Program, please visit the DHCS website at https://www.dhcs.ca.gov/provgovpart/Pages/VBP_Measures_19.aspx. By clicking on this link, you will be leaving the IEHP website.  Value Based Payments Program Guide Value Based Payments (VBP) Program Guide (PDF) - Published: August 23, 2023 Value Based Payments Dispute Forms Value Based Payments Program - Paid Claims Dispute Request (PDF) Published: January 19, 2022 Value Based Payments Program - Encounter Dispute Request (PDF) Published: January 19, 2022 Please e-mail completed forms to ValueBasedPaymentsProgram@iehp.org At-Risk Condition Codes The At-Risk Condition Codes list includes diagnosis codes to identify Serious Mental Illness, Substance Use Disorder or Homelessness Conditions for the VBP Program. These conditions qualify Providers for an additional payment amount for VBP services. Please refer to page 4 of the VBP Program Guide for additional details. At-Risk Condition Codes (PDF) Published: March 25, 2020 You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

d range of topics for all types of Providers with questions regarding billing requirements and claims processing guidelines. Resources are not limited to webinars, computer based training, and webinars. Providers also have direct access to their Regional Representative and the Small Provider Billing Unit (SPBU) through this link (By clicking on this link, you will be leaving the IEHP website) https://learn.medi-cal.ca.gov/. Medi-Cal Rates and Codes By clicking on these links, you will be leaving the IEHP website. Medi-Cal Rates The file lists the maximum reimbursement rates payable by the Medi-Cal program for covered procedures described in the HCPCS and CPT-4 coding system. Resource: website CPT Codes This website is aimed at providing information to Providers on Medicare's National CCI edits, but will not address specific CCI edits. Resource: website Alpha-Numeric HCPCS Files These files contain the Level II alpha-numeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage, and pricing data. Resource: website ZIP code To Carrier Locality File This file is primarily intended for use by ambulance suppliers to map ZIP Codes to CMS carriers and localities. This file will also map ZIP Codes to their State and can determine whether the ZIP Code has a rural designation as determined by CMS. Resource: website Medicare Physician Fee Schedule Information on services covered by the Medicare Physician Fee Schedule (MPFS). Resource: website IEHP Fee Schedule IEHP Fee Schedule - December 08, 2020 (PDF) Provider Dispute Resolution Process For more information about the Provider dispute resolution process for contracted and non-contracted Providers, click here Other Health Coverage (OHC) Coordination of Benefits with Other Health Coverage (OHC) (PDF) Frequently Asked Questions (FAQs) - OHC (PDF)

n programs, and important reminders to help you live a better life. The Pulse: this newsletter is for adults and families with children and who have Medi-Cal with IEHP. Health Spotlight: this newsletter is for IEHP Members with both Medi-Cal and Medicare (CMC).  AccessAbility: this newsletter is for seniors and people with disabilities who have Medi-Cal with IEHP. 

e. IEHP has created UM Subcommittee Approved Authorization Guidelines to serve as one of the sets of criteria for medical necessity decisions. Our goal in creating this page is to provide you with easily accessible electronic versions of IEHP’s UM guidelines. IEHP utilizes a variety of sources in developing our UM guidelines which include: Medicare and Medi-Cal’s coverage policy statements Evidence in the peer-reviewed published medical literature Technology assessments and structured evidence reviews Evidence-based consensus statements Expert opinions of healthcare Providers Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies. IEHP is also licensed to use MCG Guidelines, Apollo Medical Review Criteria, and InterQual to guide in utilization management decisions. Since medical technology is constantly evolving, our clinical guidelines are subject to change without prior notification. Additional UM Subcommittee Guidelines may be developed as needed or may be withdrawn from use. Please note that benefits may vary based on Member’s line of business; therefore, certain services discussed in the UM Subcommittee Guidelines may not be a covered benefit. Table of Contents (PDF) Providers may obtain information about criteria, either in general or relating to specific UM decisions, from IEHP upon request by contacting the IEHP UM Department. Please contact the IEHP Provider Relations Team at (909) 890-2054 to be connected to the UM Department.  Behavioral Health Behavioral Health Treatment (BHT) Criteria (PDF) Criteria for Multidisciplinary Diagnostic Treatment (PDF) Community Supports Services Community Transition Services Nursing Facility Transition to a Home (PDF) Nursing Facility Transition-Diversion to Assisted Living (PDF) Housing Deposits (PDF) Housing Transition Navigation Services (PDF) Housing Tenancy and Sustaining Services (PDF) Asthma Remediation (PDF) Environmental Accessibility Adaptations (Home Modifications) (PDF) Medically Tailored Meals (PDF) Sobering Centers (PDF) Recuperative Care (PDF) Short-Term Post-Hospitalization Housing (PDF) Day Habilitation Programs (PDF) Respite Services (PDF) Personal Care and Homemaker Services (PDF) Diagnostic Testing Elastography (PDF) Inflammatory Bowel Disease Serology (PDF) Vestibular Autorotation Test (PDF) Gynecology and Obstetrics Fetal Non-Stress Testing (PDF) Neurology Bone Marrow Transplant in Treatment of Multiple Sclerosis (PDF) Pain Management Referrals to Pain Management Specialist (PDF) Pharmacy Biosimilar Products (PDF) CAR-T Therapy (PDF) Surgical Procedures Adolescent Bariatric Consultation and Surgery (PDF) Natural Orifice Transluminal Endoscopic Surgery (PDF) Other Allocation of Limited Critical Care Resources During a Public Health Emergency (PDF) Complementary and Alternative Medicine or Holistic Therapies (PDF) Congregate Living Health Facilities (PDF) Criteria for Custodial Care: Medi-Cal (PDF) Enhanced Care Management (PDF) Hair Removal Guideline (PDF) My Path (A Palliative Care Approach) (PDF) Tertiary Care Center Referral Requests (PDF) Transitional Care Medicine (PDF) Transportation Criteria (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.

r diabetes can be changed, the four main self-care behaviors to manage your diabetes and how SMART goals can help you take control.  Click here to register for this Webex class   Session Number:  26317554121 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

participants will learn what they can do to have a healthy pregnancy and some of the common discomforts that come with pregnancy. Click here to register for this in-person class Location IEHP Community Resource Center (San Bernardino) 805 W 2nd St San Bernardino, CA 92410

l understand how the heart works and lifestyle changes for a healthy heart. We will also be discussing early signs of a heart attack and how to prevent a heart attack.  Click here to register for this Webex class   Session Number:  26310238435 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

rn how to eat healthy on a budget, how to make healthy selections when dining out, and it also reviews the importance of physical activity. Click here to register for this WebEx class   Session Number: 26348782006 Download Webex for Apple users Download Webex for Android users Download Webex for PC users  

Topic: Healthy Communication – Learn how to communicate your needs clearly to your doctor or your support network. Click here to join register for this WebEx class   Session Number:  26329992976 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

s focuses on some things you can do to  prepare for your labor and birth.  Click here to register for this in-person class Location IEHP Community Resource Center (Riverside) 3590 Tyler St Riverside, CA 92503

hat happens in the lungs when asthma symptoms start, learn about asthma triggers, and how to avoid asthma attacks. Click here to register for this in-person class Location IEHP Community Resource Center (Victorville) 12353 Mariposa Rd Suites C-2 & C-3 Victorville, CA 92395  

yone. Who will decide your medical care when you can’t? Do your loved ones know how to decide for you? This class will help you answer these two questions. We will also show you where you can get a form called an Advance Directive, how to fill it out, and why we should have one. We plan for birthday parties and weddings, why not plan for our future medical care?  Click here to register for this in-person class Location Mead Valley Family Resource Center 21091 Rider Street. Perris, CA 92570      

diabetes can be changed, the four main self-care behaviors to manage your diabetes and how SMART goals can help you take control.  Click here to register for this Webex class   Session Number: 26349120697 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

yone. Who will decide your medical care when you can’t? Do your loved ones know how to decide for you? This class will help you answer these two questions. We will also show you where you can get a form called an Advance Directive, how to fill it out, and why we should have one. We plan for birthday parties and weddings, why not plan for our future medical care?  Click here to register for this in-person class Location Mead Valley Family Resource Center 21091 Rider Street. Perris, CA 92570