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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
Awards and Recognitions
ence and access to care for the low-income working residents of the Inland Empire. These recognitions honor our steadfast commitment to improving access to quality, wellness-based healthcare services when and where members need it. NCQA Accreditation IEHP was the first Medicaid-only health plan in California to earn accreditation from the National Committee for Quality Assurance (NCQA) for its Medi-Cal health plan, in 2000. We have retained NCQA accreditation every year since. Innovation Awards from DHCS In November 2021, IEHP received the “Innovation Award - Runner Up 2021” for the Medi-Cal PCP Auto Assignment Redesign, which focused on directing Members to Providers with higher quality scores. In November 2020, IEHP was awarded the prestigious California Department of Healthcare Services (DHCS) Innovation Award. The award was based on IEHP’s groundbreaking work using location intelligence to reach high-risk members and providers in geographic areas affected by power outages, wildfires, and other natural disasters. This is the fourth time the health plan has received this honor. In 2018, IEHP received the Innovation Award from Department of Health Care Services (DHCS), for its Housing Initiative, which provides permanent supportive housing and intensive case management services to homeless, high utilizing Members. In October 2017 IEHP won a California Department of Health Care Services (DHCS) Innovation Award for improving the health of low-income members through a program that coordinates their complex physical and behavioral health care needs across the healthcare system in Riverside and San Bernardino counties. In 2015 IEHP won the first annual Innovation Award from DHCS for its Transitional Care Program, which strives to reduce emergency room usage and curtails the re-admission rates of members recently discharged from the hospital IEHP Receives the CORE Certification Seal In April 2022, IEHP received the CORE Certification Seal for the Eligibility & Benefits, Claim Status, and Payment & Remittance CAQH CORE Operating Rule Sets. As a CAQH CORE-certified entity, IEHP has demonstrated that they follow a set of national operating rules and standards which improve business processes in healthcare — going above and beyond what is federally required. The CORE Seal is widely recognized as the industry gold standard. IEHP Receives Rancho Cucamonga Fire District’s Business Partner of the Year Award In September 2021, IEHP was awarded Business Partner of the Year by the Rancho Cucamonga Fire District at the City’s Fire and Police Recognition. The distinguished award recognizes the health plan’s partnership with the City and County of San Bernardino to host an ongoing super vaccine clinic at the health plan’s headquarters. IEHP Receives Health Equity Award for Engaging Communication In 2020, IEHP received the Health Equity Award for their ability to engage and connect with members via text message during Governor Newsom’s social isolation order. The award was given by mPulse Mobile, a leader in conversational AI solutions for healthcare, during their annual Activate Awards. Click here to learn more. IEHP DualChoice Cal MediConnect Plan Earns Top Customer Satisfaction Score in the Nation The IEHP DualChoice Cal MediConnect Plan had the third-highest score in the country in the 2016 MMP CAHPS survey from the Centers for Medicare and Medicaid Services (CMS), which assesses the experiences patients have with their health plans. In 2016 there were 40 Medicare-Medicaid Plans (MMP) in the nation (called Cal MediConnect plans in California). Annual Excellence Award In 2016, IEHP received the Excellence Award from the Pharmacy Benefit Management Institute (PBMI) for its Pharmacy Pay for Performance Program, which leverages IEHP network pharmacies to offer clinical education to its members. Top Physician Satisfaction Doctors and other medical providers ranked IEHP at or above the 90th percentile in most areas on a 2016 satisfaction survey administered by an independent survey vendor. They ranked IEHP at the: 99th percentile for “IEHP Compared to All Other Health Plans” 98th percentile for “Overall Satisfaction with Call Center Staff” 98th percentile for “Overall Satisfaction with Financial Services” 97th percentile for “Recommend IEHP to Other Physicians’ Practices” IEHP Receives Workplace of the Year Award from Advisory Board in March 2018 Inland Empire Health Plan (IEHP) has been awarded the Advisory Board 2018 Workplace of the Year Award. The annual award recognizes hospitals and health systems nationwide that have outstanding levels of employee engagement. IEHP is one of only 20 organizations nationwide to receive the award. Favorite Employer IEHP was voted “Favorite Overall Company to Work For,” “Favorite Training Program” and “Favorite Workplace Culture” by Los Angeles News Group Readers in the 2014 Winning Workplaces survey. “Access to Caring” Award IEHP was recognized for making a difference in advancing health care access and availability to people with disabilities by the Western University of Health Sciences, in 2014. Energy Star Award for Superior Energy Performance IEHP’s corporate headquarters (“The Atrium”) in Rancho Cucamonga, Calif. earned the U.S. Environmental Protection Agency’s ENERGY STAR® certification for superior energy performance in 2017, demonstrating IEHP’s commitment to continued energy savings and environmental responsibility. “Gold Standard” Certification for Electronic Payments and Claims Processing In 2016 IEHP achieved Phase III certification for accurate and efficient electronic provider payments and claims reconciliation from the Council for Affordable Quality Healthcare (CAQH) and the Committee on Operating Rules for Information Exchange (CORE). The voluntary certification is widely viewed as the industry “gold standard” for provider payments and claims processing.
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.
COVID-19 - Resources
19. Below you will find resources and information on how to protect yourself and your loved ones during this time. 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. COVID-19: Home isolation tips If you or someone in your household has been diagnosed with COVID-19, there are necessary steps you can take to reduce the risk of it spreading to those you live with. COVID-19: What to do when you're sick IEHP Chief Medical Officer, Dr. Karen Hansberger, is here to discuss what you need to do if you find yourself sick from COVID-19. Face Mask Resources Proper use of face coverings (CDC) How to make a homemade mask How to make your own face mask (whether or not you know how to sew) Refer to the following resources for information on self isolation during COVID-19. Riverside County COVID-19 Self Isolation Recommendations For IEHP DualChoice Members A healthcare fraud alert has been issued in relation to COVID-19 complaints. Scammers are giving COVID-19 tests to Medicare Members in trade for personal details. They are reaching out to Medicare Members by sales calls, social media platforms, and door to door visits. The personal details taken may be used to falsely bill Federal health care programs and the COVID-19 test kits may cause harm to Members. If you suspect COVID-19 fraud, call IEHP right away at: Compliance Hotline: (866) 355-9038 Fax: (909) 477-8536 E-mail: firstname.lastname@example.org Mail: IEHP Compliance Officer P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Click here to report a compliance issue online. Refer to the following websites/resources for more information on coronavirus (COVID-19). Centers for Disease Control and Prevention (CDC) Riverside County Public Health San Bernardino Public Health State of California Coronavirus (COVID-19) Updates CA COVID-19 Rent Relief Portal California Workplace Rights Immigrant Eligibility for Public Programs during COVID-19 Protections for Housing and Utility Shutoff Order ConnectIE Below you will find resources and information on local food pantries in your area. Riverside County Pantries: A list of food pantries in Riverside County San Bernardino County Pantries: A list of food pantries in San Bernardino County Connect IE: A free website that provides community resources 24/7. It can connect you to housing services, job training's, food pantries and more. High Desert Food Distribution:The High Desert is hosting a food distribution on the last Thursday of every month.
Healthcare Scholarship Fund - About the Healthcare Scholarship Fund
p Fund is the health plan’s partnership with local academic institutions to help remove the barrier of debt for medical students and develop a growing workforce for healthcare professionals to care for the Inland Empire’s growing Medi-Cal population. Why is the Healthcare Scholarship Fund needed? According to the California Healthcare Foundation, the Inland Empire has one of the lowest ratios of Primary Care Physicians (PCPs) and specialty physicians per 100,000 people in California. In addition, the Inland Empire lacks adequate Specialty and Behavioral Health practitioner capacity to serve the current growing population. With the average cost of a four-year medical degree standing firm at $276,800, pursuing a career in the medical field is out of reach for more and more each year. The HSF will aid students by helping to remove the financial burden of medical school that often restricts the choices of many aspiring healthcare professionals and allow recipients to immediately pursue careers in healthcare. I am a student and am interested in becoming a Doctor, what should I do? Students interested in the IEHP Healthcare Scholarship Fund are encouraged to contact the academic institutions below for more information on how apply. While each institution may have differing eligibility requirements, all Healthcare Scholarship Fund scholarships require students commit to practicing in the Inland Empire for 5 years after graduation. Participating schools and programs include: Loma Linda University Medical School University of California Riverside California University of Science and Medicine
Medi-Cal Behavioral Health Treatment
ed benefit solely for Members Diagnosed with Autism Spectrum Disorder. The coverage criteria have been expanded to include IEHP Members who meet ALL the below: Under 21 years of age Have a recommendation from a licensed physician and surgeon or a licensed psychologist that evidence based BHT services are medically necessary. Be medically stable Not need 24-hour medical/nursing monitoring or procedures provided in a hospital or intermediate care facility for persons with intellectual disabilities. Behavioral Health Treatment (BHT) is the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the direct observation, measurement and functional analysis of the relations between environment and behavior. BHT services teach skills using behavioral observation and reinforcement, or through prompting to teach each step of targeted behavior. BHT services are based on reliable evidence and are not experimental. Treatment may or may not include Applied Behavioral Analysis (ABA). BHT is medically necessary after the Provider has completed a comprehensive developmental surveillance and screening, and have recommended BHT services is clinically warranted to treat persistent developmentally inappropriate behavior and/or diagnoses that may be able to be corrected or ameliorated with BHT services. Aberrant behaviors include but are not limited to self-injury, aggression, and deficits in language skills, daily living skills, and social skills. PCPs will continue to referral a Member directly to IEHP Behavioral Health for any BHT services and/or diagnostic needs regardless of IPA. If you have any questions or ask your PCP for screening, diagnosis and treatment, you can call IEHP Member Services at 1-800-440-IEHP (4347), Monday–Friday, 7am–7pm, and Saturday–Sunday, 8am–5pm. TTY users should call 1-800-718-4347. Cost to Member There is no cost to the Member for these services. Visit IEHP's Mental Health page for general mental health information.
Community Supports - Flexible Care Choices: Community Supports
e options. These may be offered (instead of state plan-covered services) to qualified Members at medium to high levels of risk. Community Supports can help you remain healthy, reduce complications from illnesses, and avoid unnecessary stays in the hospital, nursing facilities, and emergency departments You may find that Community Supports with IEHP can help during a transition in housing or care. If you need help managing your health, IEHP’s Community Supports might be the right choice. When you need extra care IEHP’s Community Supports are open to any Medi-Cal or IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) Member who needs supportive care. Community Supports may nurture your whole health—to care for your body and mind. Members who could benefit from Community Supports may be: Facing times without housing Struggling to get food for their loved ones Having asthma issues and need changes to their living space How your Care Team can help you If you can be helped by Community Supports, you may get a care team that can assist in identifying your needs. Then, they will coordinate no-cost services. This includes finding resources for housing, care after leaving the hospital, and dealing with asthma at home. Who may be on your care team: Nurse Care Manager Behavioral Health Care Manager Care Coordinator Community Health Worker Support when you need it Your care team can assist you by phone or in person, and they can even meet you at your location. You are not alone with IEHP’s Community Supports. What community supports are offered? Asthma Remediation: Environmental Asthma Trigger Remediations are physical modifications to a home environment that are necessary to ensure the health, welfare, and safety of the individual, or enable the individual to function in the home and without which acute asthma episodes could result in the need for emergency services and hospitalization. Community Transition Services/Nursing Facility Transition to a Home: Assist members to live in the community and avoid further institutionalization.These services are non-recurring set-up expenses for individuals who are transitioning from a licensed facility to a living arrangement in a private residence where the person is directly responsible for his or her own living expenses. Environmental Accessibility Adaptations (Home Modifications): Environmental Accessibility Adaptations (EAAs also known as Home Modifications) are physical adaptations to a home that are necessary to ensure the health, welfare, and safety of the individual, or enable the individual to function with greater independence in the home: without which the Member would require institutionalization. Housing Deposits: Housing Deposits assist with identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a person to establish a basic household that do not constitute room and board. Housing Tenancy & Sustaining Services: This service provides tenancy and sustaining services, with a goal of maintaining safe and stable tenancy once housing is secured. Housing Transition Navigation Services: Housing transition services assist Members with obtaining housing. Medically Supportive Food/Meals/Medically Tailored Meals: Malnutrition and poor nutrition can lead to devastating health outcomes, higher utilization, and increased costs, particularly among Members with chronic conditions. Meals help individuals achieve their nutrition goals at critical times to help them regain and maintain their health. Results include improved Member health outcomes, lower hospital readmission rates, a well-maintained nutritional health status, and increased Member satisfaction. Nursing Facility Transition/Diversion to Assisted Living Facilities: Nursing Facility Transition/Diversion services assist individuals to live in the community and/or avoid institutionalization when possible. The goal is to both facilitate nursing facility transition back into a home-like, community setting and/or prevent skilled nursing admissions for Members with an imminent need for nursing facility level of care (LOC). Individuals have a choice of residing in an assisted living setting as an alternative to long-term placement in a nursing facility when they meet eligibility requirements. Recuperative Care (Medical Respite): Recuperative care, also referred to as medical respite care, is short-term residential care for individuals who no longer require hospitalization, but still need to heal from an injury or illness (including behavioral health conditions) and whose condition would be exacerbated by an unstable living environment. An extended stay in a recovery care setting allows individuals to continue their recovery and receive post-discharge treatment while obtaining access to primary care, behavioral health services, case management and other supportive social services, such as transportation, food, and housing. Short-Term Post-Hospitalization Housing: Short-Term Post-Hospitalization housing provides Members who do not have a residence and who have high medical or behavioral health needs with the opportunity to continue their medical/psychiatric/substance use disorder recovery immediately after exiting an inpatient hospital (either acute or psychiatric or Chemical Dependency and Recovery hospital), residential substance use disorder treatment or recovery facility, residential mental health treatment facility, correctional facility, nursing facility, or recuperative care and avoid further utilization of State plan services. Sobering Centers: Sobering centers are alternative destinations for individuals who are found to be publicly intoxicated (due to alcohol and/or other drugs) and would otherwise be transported to the emergency department or jail. Sobering centers provide these individuals, primarily those who are homeless or those with unstable living situations, with a safe, supportive environment to become sober. To learn more about Community Supports, call IEHP Member Services at 1-800-440-IEHP (4347), Monday–Friday, 7am–7pm, and Saturday–Sunday, 8am–5pm. TTY users should call 1-800-718-4347.
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.”
Latest News - Dr. Takashi Wada Named IEHP Chief Medical Officer
a will oversee IEHP’s Health Services department and collaboratively lead the implementation of initiatives such as CalAIM, Home and Community-Based Services, the organization’s Strategic Plan, and more. In addition, Dr. Wada will provide clinical and strategic leadership through accountable processes to improve the quality-of-care delivery with improved external quality metrics. “With innovative healthcare initiatives rolling out at state and federal levels, I’m eager to lead and support our team’s work, so that we may contribute in new and meaningful ways that will positively impact the wellness of our own members and communities,” he said. 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 received 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). He completed his medical degree from UCLA and his graduate medical education at Kaiser Permanente Los Angeles Medical Center. “Dr. Wada truly has a passion for this work,” said IEHP Chief Executive Officer Jarrod McNaughton. “I couldn’t be more thrilled that he is joining our Executive Team. We are absolutely looking forward to working with Dr. Wada in his new role and continuing our mission to heal and inspire the human spirit.”
Latest News - From Medi-Cal to Med School: An IEHP Member’s Quest to Serve the Inland Empire
hild would be paying her medical school bills today. And yet, that’s exactly what Inland Empire Health Plan (IEHP) has done for the past two years—and counting. IEHP awarded Hough with their innovative Healthcare Scholarship Fund award in 2020, bringing Hough’s journey from Medi-Cal member to medical school student to fruition. A Victorville native and now third-year medical student at California University of Science and Medicine (CUSM), Hough was one of 50 students to receive the inaugural award from IEHP. The health plan has sustained the program with annual scholarship awards ranging from full to partial tuition at three medical schools: CUSM, Loma Linda University and University of California, Riverside. “This scholarship means the world to me,” said Hough. “Growing up in a family who struggled financially, the dream of being able to go to medical school seemed so farfetched for so long.” IEHP created the scholarship fund to help address the provider shortage in Riverside and San Bernardino counties. “By supporting local medical students, we are able to secure their service to the Inland Empire after graduation and create a pipeline of health care professionals who are committed to serving our communities with compassion and empathy,” said Jarrod McNaughton, IEHP Chief Executive Officer. Hough discovered her passion for medicine while taking human science classes at California State University Fullerton and spending countless hours volunteering at Children’s Health Orange County. Encouraged by these experiences and several physician mentors, she decided to pursue a career as a doctor. Hough intentionally applied to only local schools so she could remain connected to her Inland Empire roots. “Most people apply very broadly—to as many schools as they want,” Hough said. “But I felt it was really important to be in this area, so I only applied to three medical schools. It was very risky, but it worked out.” Hough remembers not having much guidance or role models related to her dream of medicine growing up, so becoming a doctor didn’t seem possible. “When I got that acceptance letter,” she said, “it was really a moment of shock.” Through the medical school admissions process, Hough learned about IEHP’s Healthcare Scholarship Fund and its goal to support local students who wished to remain in the Inland Empire. Hough remembered IEHP was the health plan she had as a child and appreciated how they promoted a mission she resonated with. She applied and earned a four-year award. “After receiving the scholarship, a huge weight was lifted off of my shoulders,” said Hough. “Thank you so much IEHP, from the bottom of my heart. I don’t think words could ever explain how grateful I am.” The cost for medical school in California has been on an upward trend since 2013, increasing about $1,500 annually and currently averaging a total of $218,792. This puts the dream of being a physician even further out of reach for many IE students, and deeply impacts the ongoing provider shortage in the region. “Bridging the gap between aspiring IE medical professionals and local medical schools to serve the region’s most vulnerable populations is what this scholarship program was designed to do,” said McNaughton. “We are absolutely elated to support Jordan and our HSF award recipients on their path to becoming physicians and are especially eager to connect their desire and ability to provide optimal care and vibrant health to the communities they love so very much.” The health plan will be hosting networking and supportive events for medical students throughout their medical school journey, including a dinner at IEHP headquarters on May 3. To learn more about IEHP’s Healthcare Scholarship Fund, visit iehp.org.
Latest News - IEHP Welcomes Lorena Rodriguez Chandler as first Chief Health Equity Officer
h plan as its first chief health equity officer. In this role, Chandler will serve the Inland Empire by further developing and implementing policies, procedures and programs aimed at improving health equity. This will include using race/ethnicity, language, gender identity/sexual orientation, and geographic data to identify disparities in access to care and health outcomes. IEHP will then work with community partners to improve the provision of culturally appropriate services and develop new initiatives to address these disparities. “Lorena has a heart for the communities we serve and is deeply committed to ensuring access to optimal care and vibrant health for everyone in the Inland Empire,” said Dr. Takashi Wada, IEHP’s chief medical officer. “We look forward to working with Lorena and learning from the vast experience she brings to IEHP.” Chandler joins IEHP with a strong background in Medicaid, Medicare, non-profit and government sponsored health programs. Prior to IEHP, she served as Blue Shield of California’s director of Medicare Growth Strategy and associate vice president of Strategic Planning and Performance and was responsible for the development of a Medicare Advantage Plan for Latino Seniors in Los Angeles County. She was also a lead in the integration of Care 1st Health Plan Medi-Cal line of business into Blue Shield of CA, giving her a broad and deep knowledge of health plan operations. In addition, Chandler brings experience from her work with Molina Healthcare Inc. as an associate vice president of Business Process Improvement and Member Engagement and LA Care Health Plan, where she worked closely with Latino and African American communities to launch and develop their inaugural community resource centers and programs. She has also worked for the country’s largest Hispanic civil rights organization, Unidos US, as their director for the Center for Latino Community Health, leading and evaluating their community health worker programs, and as a senior project manager for United Healthcare where she developed their Latino Health Solutions Initiative. Chandler graduated from California State University, Long Beach with a Bachelor of Science degree in Health Care Administration and the University of California, Los Angeles, where she earned a master’s in Public Health with an emphasis in Community Health Sciences. “Lorena’s experience and passion for health equity will help IEHP excel in its mission and will truly make the Inland Empire a healthier place for all,” said Jarrod McNaughton, IEHP chief executive officer.
Governing Board - Andrew Williams
Special Programs - Community Supports
e alternatives that MCPs may offer in place of services or settings covered under the California Medicaid State Plan. Beginning January 1, 2022, IEHP will be offering 11 of the 14 DHCS Preapproved Community Supports services. Please click on the service for additional details. Asthma Remediation Environmental Asthma Trigger Remediations are physical modifications to a home environment that are necessary to ensure the health, welfare, and safety of the individual, or enable the individual to function in the home and without which acute asthma episodes could result in the need for emergency services and hospitalization. Community Transition Services/Nursing Facility Transition to a Home Assist members to live in the community and avoid further institutionalization. These services are non-recurring set-up expenses for individuals who are transitioning from a licensed facility to a living arrangement in a private residence where the person is directly responsible for his or her own living expenses. Environmental Accessibility Adaptations (Home Modifications) Environmental Accessibility Adaptations (EAAs also known as Home Modifications) are physical adaptations to a home that are necessary to ensure the health, welfare, and safety of the individual, or enable the individual to function with greater independence in the home: without which the Member would require institutionalization. Housing Deposits Housing Deposits assist with identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a person to establish a basic household that do not constitute room and board. Housing Tenancy & Sustaining Services This service provides tenancy and sustaining services, with a goal of maintaining safe and stable tenancy once housing is secured. Housing Transition Navigation Services Housing transition services assist Members with obtaining housing. Medically Supportive Food/Meals/Medically Tailored Meals Malnutrition and poor nutrition can lead to devastating health outcomes, higher utilization, and increased costs, particularly among Members with chronic conditions. Meals help individuals achieve their nutrition goals at critical times to help them regain and maintain their health. Results include improved Member health outcomes, lower hospital readmission rates, a well-maintained nutritional health status, and increased Member satisfaction. Nursing Facility Transition/Diversion to Assisted Living Facilities Nursing Facility Transition/Diversion services assist individuals to live in the community and/or avoid institutionalization when possible. The goal is to both facilitate nursing facility transition back into a home-like, community setting and/or prevent skilled nursing admissions for Members with an imminent need for nursing facility level of care (LOC). Individuals have a choice of residing in an assisted living setting as an alternative to long-term placement in a nursing facility when they meet eligibility requirements. Recuperative Care (Medical Respite) Recuperative care, also referred to as medical respite care, is short-term residential care for individuals who no longer require hospitalization, but still need to heal from an injury or illness (including behavioral health conditions) and whose condition would be exacerbated by an unstable living environment. An extended stay in a recovery care setting allows individuals to continue their recovery and receive post-discharge treatment while obtaining access to primary care, behavioral health services, case management and other supportive social services, such as transportation, food, and housing. Short-Term Post-Hospitalization Housing Short-Term Post-Hospitalization housing provides Members who do not have a residence and who have high medical or behavioral health needs with the opportunity to continue their medical/psychiatric/substance use disorder recovery immediately after exiting an inpatient hospital (either acute or psychiatric or Chemical Dependency and Recovery hospital), residential substance use disorder treatment or recovery facility, residential mental health treatment facility, correctional facility, nursing facility, or recuperative care and avoid further utilization of State plan services. Sobering Centers (Riverside County) Sobering centers are alternative destinations for individuals who are found to be publicly intoxicated (due to alcohol and/or other drugs) and would otherwise be transported to the emergency department or jail. Sobering centers provide these individuals, primarily those who are homeless or those with unstable living situations, with a safe, supportive environment to become sober. IEHP Direct and Delegated Providers can submit referrals for Community Supports via the Provider Portal. For questions on how to submit a referral or more information relating to the above services, Providers can call the Provider Call Center at (909) 890-2054 or (866) 223-4347. Please continue to direct IEHP Members needing additional information on Community Supports Services to IEHP Member Services at (800) 440-4347, Monday - Friday, 8am - 5pm. TTY users should call (800) 718-4347. If you have programmatic questions, please email DGCommunitySupportTeam@iehp.org Community Supports Provider Brochure - English (PDF) | Spanish (PDF) | Chinese (PDF) | Vietnamese (PDF) Community Supports FAQs (PDF) Medi-Cal Community Supports or In Lieu of Services (ILOS) Policy 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.
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 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: 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). 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. Information on the page is current as of March 2, 2023 H8894_DSNP_23_3879734_M Accepted
Plan Updates - Coronavirus (COVID-19) Advisory
Control and Prevention (CDC) is responding to an outbreak of respiratory disease caused by a novel (new) coronavirus that was first detected in China and which has now been detected in almost 70 locations internationally, including in the United States. The virus has been named "SARS-CoV-2" and the disease it causes has been named "coronavirus disease 2019" (abbreviated "COVID-19"). IEHP will continually update you on the latest recommendations, news, and resources on COVID-19 as it becomes available. COVID-19 Therapeutics Available for Members In an effort to provide the most up-to-date treatments against COVID-19, IEHP continues to maintain a list of providers, including but not limited to infusion clinics, ancillary, hospital and non-hospital based infusion centers offering COVID-19 infusion therapy treatment. Under all Member coverage, outpatient COVID therapeutics will be offered immediately after a Member is determined to be clinically eligible under and Emergency Use Authorization (EUA). List of Infusion Sites COVID-19 Infusion Treatments by Organization (PDF) Test-To-Treat COVID-19 Vaccine Reimbursement for Medi-Cal Providers DHCS has carved out the COVID-19 vaccine from Medi-Cal managed care health plans and will reimburse providers under the Fee-for-Service (FFS) delivery system for both medical and pharmacy claims. Medi-Cal will reimburse the associated COVID-19 vaccine administration fee at the allowable Medicare rate for all claims (medical, outpatient, and pharmacy), based on the number of required doses for all Medi-Cal beneficiaries. For further information: June 13, 2022 - DHCS COVID-19 Vaccine Administration Provider FAQs 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. FIND A TESTING AND VACCINATION SITE NEAR YOU TODAY! RIVERSIDE Riverside County Public Health COVID Testing Site Vaccine Information Vaccine Locations & Registration Registrations encouraged but not required for: The CDC recommends everyone ages 6 months and older get vaccinated against COVID-19 as well as a booster for everyone 5 years and older, if eligible. For more information, visit the Riverside Country Vaccine webpage. Teenagers 5 to 17 years old must register for a vaccination clinic that offers the Pfizer vaccine and be accompanied by a parent/legal guardian or present a signed written consent from a parent/legal guardian and be accompanied by an adult. Pfizer Minor Consent Form (PDF) | Spanish The Moderna and Johnson & Johnson vaccines can only be given to individuals age 18 years and older. Johnson & Johnson Fact Sheet (PDF) | Spanish - Published April 26, 2021 SAN BERNARDINO San Bernardino County Public Health COVID Testing Site Vaccine Locations & Registration Additional Dose and Boosters Information COVID-19 Vaccine Consent Form (PDF) | Spanish The CDC recommends everyone ages 6 months and older get vaccinated against COVID-19 as well as a booster for everyone 5 years and older, if eligible. For more information, visit the San Bernardino County Pediatric COVID-19 Vaccination web page Walk-ins are now available at County-operated vaccination sites. Walk-in individuals will not need to bring any additional information to the site, however be prepared to register on site, which will include answering health screening questions. Walk-ins may experience longer wait times and availability may vary based on site demand. Centers for Disease Control and Prevention (CDC) Clinical Care Guidance Vaccines Vaccination Plans January 10, 2022 - Continued Coverage of COVID-19 Diagnostic Testing (PDF) CalVax CalVax is a state-wide centralized system for health care Providers enrolled or interested in participating in the California COVID-19 Vaccination Program, developed by the California Department of Public Health (CDPH). The new CalVax platform will provide a system to manage vaccine enrollment, ordering, inventory, administration, reporting and data analytics. Training materials such as job aids, videos, and recorded demos will be available to support all system users as they navigate through the new CalVax platform (mycavax.cdph.ca.gov). CA Notify • CA Notify Flyer in English (PDF) and Spanish(PDF) • CA Notify Shareable Tools for web and social media • CA Notify Website Financial Assistance Resources Riverside County Medical Association - COVID-19 Financial Toolkit for Medical Practice U.S. Department of Health & Human Services (HHS) CARES Provider Relief Fund Learn more about the Provider Relief Fund (PRF) Provider Relief Fund (PRF) Portal U.S. Small Business Administration. Borrowers may be eligible for Paycheck Protection Program (PPP) loan forgiveness. See if you're eligible here. Guidance Regarding Monoclonal Antibody Treatment for COVID-19 Even with decreasing cases and hospitalizations, those with high-risk conditions who have tested positive for COVID-19 are encouraged to get monoclonal antibody treatment at Riverside University Health System (RUHS) – Medical Center. In January, the U.S. Food and Drug Administration (FDA) limited the use of certain monoclonal antibody therapies that were ineffective against the omicron variant. In response, RUHS – Medical Center is administering sotrovimab, an IV infusion shown to be effective against omicron and other variants. January 14, 2022 - RUHS-Medical Center Offers Monoclonal Antibodies Treatment Quest Diagnostic For more information, please visit Quest Diagnostics FAQs COVID-19 Specimen Collection Instructions (Watch Video Here) Fact Sheet for Healthcare Providers for COVID-19 Testing (View PDF Here) LabCorp For more information, please visit LabCorp's COVID-19 page. Which COVID-19 Test is Right For You? COVID-19 FAQs If you do not have the ability to collect specimens for COVID-19, please refer to your County Public Health resources for guidance on directing Members for testing. Telehealth IEHP is strongly encouraging the utilization of telehealth for visits that can be conducted over the phone or via other audiovisual telecommunications. IEHP has published a telehealth FAQ which is available here: Telehealth Services Due to Limiting Exposure to COVID-19 (PDF)- October 17, 2022 Remember: IEHP Provider Telehealth Information (PDF) IEHP expects that Providers will offer telehealth services and support to their Members during their published business hours. Existing authorizations are valid and do not need to be changed even if services are being provided via telehealth You can request a POS 02 or POS 10 on your authorization however if you do not, you can still utilize the authorization for telehealth services even if a different POS was approved. When billing the claim for the service, you will utilize a POS 02 or POS 10. ONLY Services that are deemed clinically appropriate to provide via telehealth should be provided via telehealth. If there are treatments, exams, procedures or other services that cannot be provided via telehealth, those are not eligible to be provided via telehealth. Provider Resources for Combatting COVID-19 Fatigue ACEs Aware - Support for those on the front lines as California addresses stress and anxiety related to COVID-19 Department of Health Care Services (DHCS) and California Department of Public Health (CDPH) COVID 19 Response Department of Health Care Services (DHCS) California Department of Public Health (CDPH) The California Department of HealthCare Services (DHCS) has published a COVID-19 response page with guidance for Providers and Partners, Home and Community Based Services and Behavioral Health. Found Here: DHCS COVID‑19 Response | DHCS COVID-19 Medi-Cal FAQs The California Department of Public Health (CDPH) also has a page with new guidance documents and additional resources and news releases. Found Here: CDHP COVID-19 Updates Centers for Medicare & Medicaid Services (CMS) CMS Health Care Provider Toolkit - Help link to COVID-19 related questions San Bernardino Medical Society The San Bernardino County Medical Society promotes the science and art of medicine, the care and well-being of patients, the protection of the public health and to promote the betterment of the medical profession. The latest news, research and developments on the COVID-19 outbreak for physicians can be found here: SBCMS COVID-19. January 07, 2021 - COVID-19 Vaccines For All Practicing Physicians and Staff – San Bernardino County (PDF) 2-1-1 San Bernardino County Resource & Information Guide 2-1-1 San Bernardino County has curated a COVID-19 Resource & Information Guide and will update this page regularly as the situation changes. For more information, please click here. Correspondences May 2, 2022 - Webinar - IWIN COVID and the Community April 13, 2022 - COVID-19 “Test to Treat” Initiative April 8, 2022 - 2nd Round of Free At-Home COVID-19 Test Kits Available February 23, 2022 - COVID-19 Oral Antiviral Drugs – Coverage and Dispensing Pharmacies January 28, 2022 - Free OTC COVID-19 Antigen Kits Available January 26, 2022 - Free At-Home COVID-19 Tests Available by Request January 5, 2022 - Extending SNF COVID-19 Per Diem Rate December 22, 2021 - COVID-19 Vaccine Billing for Medicare Advantage Enrollees Effective DOS January 1, 2022 December 16, 2021- COVID-19 Vaccine Incentive Program – Program Guide December 16, 2021 - REMINDER: COVID Vaccine Enrollment Survey - Your Response is Requested December 10, 2021 - REMINDER: COVID Vaccine Enrollment Survey - Your Response is Requested December 10, 2021 - COVID-19 Vaccine Billing for Medicare Advantage Enrollees December 3, 2021- COVID-19 Vaccine Enrollment Survey December 1, 2021- CDC Encourages COVID Booster Due to Omicron Variant November 17, 2021- UPDATE! COVID-19 Vaccine FQHC, RHC and IHF Incentive Program November 9, 2021- Three Upcoming Webinars on Building COVID-19 Vaccine Trust October 22, 2021- 2021 COVID-19 Vaccination Member Incentive October 22, 2021- NEW!!! COVID-19 Vaccine FQHC and RHC Incentive Program October 19, 2021- COVID-19 Treatment – RUHS Monoclonal Antibody Treatment Center October 12, 2021- Reminder - NEW COVID-19 Vaccine PCP Incentive Program - Kickoff Meeting October 6, 2021- NEW COVID-19 Vaccine PCP Incentive Program- Kickoff Meetings October 4, 2021- New COVID-19 Vaccine PCP Incentive Program September 8, 2021- CDPH Webinar: How to Have Crucial Conversations About COVID-19 Vaccines – Thursday, September 9th August 18, 2021 - Riverside County Public Townhall on COVID-19 Vaccines For additional resources regarding COVID-19, please visit: Centers for Disease Control and Prevention (CDC) Riverside County Public Health San Bernardino Public Health You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Latest News - Meet Leslie: Finding hope in life’s uncertainties
changed. But after a tragic accident in October 2021, much of Leslie’s life will never be the same again. “I was on my way to LA, and I stopped because there was an accident in my lane,” said Leslie from her Jurupa Valley home. “I had gotten out and evidently, somebody got inpatient and went around us and … took me for a little drag down the road.” The car that hit Leslie ended up on top of her, causing severe injuries to her lower body. Throughout the entire ordeal, a police officer on the scene stayed with Leslie – even lying on the pavement with her – until the vehicle was removed and she was transported to a hospital. When Leslie woke up after an emergency eight-hour surgery, she discovered the devasting results of that fateful day. “I just lifted the sheets and went, ‘Oh, I have no legs,’” said the Inland Empire Health Plan (IEHP) member. ‘TRIAL AND ERROR’ Once Leslie was discharged from the hospital, some immediate needs became apparent quite quickly, including: Learning to operate an electric wheelchair Fitting through narrow doorways at home Using the bathroom safely It was a time of uncertainty and worry for Leslie and her husband, Robert. “I was scared, I didn’t know what to do – I didn’t know what I was supposed to do,” said Robert B., wiping away tears at the memory of those first days as his wife’s primary caregiver. “I didn’t know about having this house ready … how do I feed her, how do I bathe her? “… You don’t know. It’s just all trial and error.” As they navigated their new world, the couple had to find ways to adapt to a completely different lifestyle. “Because you can’t just go out and get in my truck and go do something,” said Leslie, a cowgirl who grew up on a ranch, routinely riding horses. She still proudly wears a Texas-shaped gold charm Texas around her neck. Leslie also used to raise chickens and sell their eggs to neighbors, but she can’t maneuver her wheelchair in the coop. And Robert gave up his truck driver job to be available for his wife. He has now taken over the chicken coop duties as well as laundry tasks since the couple’s washer and dryer are in their home’s basement. FINDING HOPE Leslie and Robert soon learned – thanks to the community partnership among Inland Housing Solutions (IHS), CalAIM and IEHP – help was available. In August 2022, Leslie and Robert received an authorization from IEHP for the CalAIM Community Supports Home Modifications (Environmental Accessibility Adaptations), which started the remodel process. With this program, individuals receive access to specialized care – whether that means changes to the inside or outside of their homes – ensuring the best quality of life. “We were doing so much on our own because we didn’t know what to ask for, who to ask for help – and that all kind of just started falling into place when Ron (Estrada of IHS) found us and he stepped up,” said Leslie. In many ways, Leslie and Robert simply needed their same home to function differently, but with things most people take for granted in their own homes. “They need those accessibility renovations to be able to use their space the way they used to,” said Kate Nazareno, director of client services at IHS. The renovations, which were completed for free in November 2022, focused on the couple’s only bathroom and included: Widening/adjusting doors Installing grab bars Modifying flooring to tile for electric wheelchair access Repositioning/rewiring of electrical outlets and switches Adding a wheelchair-accessible vanity, medicine cabinet and towel bars The vanity may be Leslie’s favorite update. “So I can blow dry my hair, put my make-up on and all that girly stuff,” she said. According to Robert, the modifications to their bathroom represent something much bigger for his wife than just the actual construction work. “She wants to be as independent as she can and having that bathroom finished in there was a huge burden taken off of us – big,” he said. And that’s exactly what this kind of multi-agency collaborative effort intends to do: help Inland Empire residents experiencing life-changing circumstances. “Through this program with CalAIM and IEHP, we are able to provide the home modifications and other services to help people like Robert and Leslie return to their homes, recover and be healthy and stable in their homes,” Nazareno said. For Leslie and Robert, receiving the accessibility modifications with no out-of-pocket costs is a welcomed positive change. “When things like that happen, it gives you hope that hey, it’s gonna get better,” Robert said. Leslie agreed. “That remodel has been a God’s gift – it’s made a big difference,” she added. See an inspiring video about Leslie and Robert.
Provider Resources - Utilization Management Criteria
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) 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 Pain Management - Centers of Excellence (COE) (PDF) 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) Transgender Services (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.