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de and San Bernardino counties. Visit our Community Calendar to find upcoming partner events near you. How can you become a Community Partner with IEHP? Read about the Community Partner Network Meeting to learn more. Please contact our Community Outreach Team for help.  If your organization is interested in becoming an IEHP Community Partner, please sign up here.  How can I find resources in my community? ConnectIE is a new one-stop, interactive website that makes it easy to link people to community resources in the Inland Empire. Visit ConnectIE to find out more!  

ng appeals with problems related to your benefits and coverage. It also includes problems with payment. You are not responsible for Medicare costs except for Part D copays. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services)  To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision.  You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347.  You can fax us at: (909) 890-5877  You can to write us at: IEHP DualChoice P.O. Box 1800 Rancho Cucamonga, CA 91729-1800. How long does it take to get a coverage decision coverage decision for Part C services? It usually takes up to 14 calendar days after you asked. If we don’t give you our decision within 14 calendar days, you can appeal. Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 calendar more days. The letter will explain why more time is needed. Can I get a coverage decision faster for Part C services? Yes. If you need a response faster because of your health, you should ask us to make a “fast coverage decision.”  If we approve the request, we will notify you of our coverage decision coverage decision within 72 hours. However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. Asking for a fast coverage decision coverage decision: If you request a fast coverage decision coverage decision, start by calling or faxing our plan to ask us to cover the care you want.  You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. You can also have your doctor or your representative call us. Here are the rules for asking for a fast coverage decision coverage decision:  You must meet the following two requirements to get a fast coverage decision coverage decision:  You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.) You can get a fast coverage decision only if the standard 14 calendar day deadline could cause serious harm to your health or hurt your ability to function.  If your doctor says that you need a fast coverage decision, we will automatically give you one. If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision.  If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. We will also use the standard 14 calendar day deadline instead. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. The letter will also tell how you can file a “fast appeal” about our decision to give you a fast coverage decision instead of the fast coverage decision you requested. If the coverage decision is Yes, when will I get the service or item? You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. If the coverage decision is No, how will I find out?  If the answer is No, we will send you a letter telling you our reasons for saying No. If we say no, you have the right to ask us to change this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. Appeals What is an Appeal? An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagree with our decision, you can appeal. In most cases, you must start your appeal at Level 1. If you do not want to first appeal to the plan for a Medi-Cal service, in special cases you can ask for an Independent Medical Review. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. The Office of Ombudsman is not connected with us or with any insurance company or health plan. What is a Level 1 Appeal for Part C services? A Level 1 Appeal is the first appeal to our plan. We will review our coverage decision to see if it is correct. The reviewer will be someone who did not make the original coverage decision. When we complete the review, we will give you our decision in writing. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal.  Can someone else make the appeal for me for Part C services? Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. The form gives the other person permission to act for you. If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. How do I make a Level 1 Appeal for Part C services? To start your appeal, you, your doctor or other provider, or your representative must contact us. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY should call (800) 718-4347. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. You can ask us for a “standard appeal” or a “fast appeal.” If you are asking for a standard appeal or fast appeal, make your appeal in writing: IEHP DualChoice P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Fax: (909) 890-5748 You may also ask for an appeal by calling IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY should call (800) 718-4347. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. How much time do I have to make an appeal for Part C services? You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of a good reason are: you had a serious illness, or we gave you the wrong information about the deadline for requesting an appeal. Can I get a copy of my case file? Yes. Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). TTY (800) 718-4347. Can my doctor give you more information about my appeal for Part C services? Yes, you and your doctor may give us more information to support your appeal. How will the plan make the appeal decision?  We take a careful look at all of the information about your request for coverage of medical care. Then, we check to see if we were following all the rules when we said No to your request. The reviewer will be someone who did not make the original decision. If we need more information, we may ask you or your doctor for it.  When will I hear about a “standard” appeal decision for Part C services? We must give you our answer within 30 calendar days after we get your appeal. We will give you our decision sooner if your health condition requires us to. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter. If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. If we do not give you an answer within 30 calendar days or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. Please see below for more information.  If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal. If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. Please see below for more information. What happens if I ask for a fast appeal? If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal. We will give you our answer sooner if your health requires us to do so. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter. If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. If we do not give you an answer within 72 hours or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. Please see below for more information. If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal.  If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. Please see below for more information. Will my benefits continue during Level 1 appeals? If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. If you disagree with the action, you can file a Level 1 Appeal and ask that we continue your benefits for the service or item. You must make the request on or before the later of the following in order to continue your benefits: Within 10 days of the mailing date of our notice of action; or The intended effective date of the action. If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing. Level 2 Appeal If the plan says No at Level 1, what happens next? If we say no to part or all of your Level 1 Appeal, we will send you a letter. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete. If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. The letter will tell you how to do this. Information is also below. What is a Level 2 Appeal? A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan.   My problem is about a Medi-Cal service or item. How can I make a Level 2 Appeal? There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. 1)    Independent Medical Review You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). An IMR is available for any Medi-Cal covered service or item that is medical in nature. An IMR is a review of your case by doctors who are not part of our plan. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR. You can apply for an IMR if our plan: Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. Will not pay for emergency or urgent Medi-Cal services that you already received. Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal. You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue. In most cases, you must file an appeal with us before requesting an IMR. If you disagree with our decision, you can ask the DMHC Help Center for an IMR. If your treatment was denied because it was experimental or investigational, you do not have to take part in our appeal process before you apply for an IMR. If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHC’s attention. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. You must apply for an IMR within 6 months after we send you a written decision about your appeal. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. To ask for an IMR: Fill out the Independent Medical Review/Complaint Form available at: http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx or call the DMHC Help Center at (888) 466-2219. TDD users should call (877) 688-9891. If you have them, attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents. Fill out the Authorized Assistant Form if someone is helping you with your IMR. You can get the form at http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx Or call the DMHC Help Center at (888) 466-2219. TDD users should call (877) 688-9891. Mail or fax your forms and any attachments to:  Help Center Department of Managed Health Care 980 Ninth Street, Suite 500 Sacramento, CA 95814-2725 FAX: 916-255-5241 If you qualify for an IMR, the DMHC will review your case and send you a letter within 7 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. You should receive the IMR decision within 45 calendar days of the submission of the completed application. If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. You should receive the IMR decision within 7 calendar days of the submission of the completed application. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing.  If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. 2)    State Hearing You can ask for a State Hearing for Medi-Cal covered services and items. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing. In most cases you have 120 days to ask for a State Hearing after the “Your Hearing Rights” notice is mailed to you.  NOTE: If you ask for a State Hearing because we told you that a service you currently get will be changed or stopped, you have fewer days to submit your request if you want to keep getting that service while your State Hearing is pending. Read “Will my benefits continue during Level 2 appeals” in Chapter 9 of the Member Handbook for more information. There are two ways to ask for a State Hearing: You may complete the "Request for State Hearing" on the back of the notice of action. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. Then you may submit your request one of these ways: To the county welfare department at the address shown on the notice. To the California Department of Social Services: State Hearings Division P.O. Box 944243, Mail Station 9-17-37 Sacramento, California 94244-2430 To the State Hearings Division at fax number 916-651-5210 or 916-651-2789. You can call the California Department of Social Services at (800) 952-5253. TDD users should call (800) 952-8349. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. Will my benefits continue during Level 2 appeals? If your problem is about a service or item covered by Medicare, your benefits for that service or item will not continue during the Level 2 appeals process with the Independent Review Entity. If your problem is about a service or item covered by Medi-Cal and you ask for a State Fair Hearing, your Medi-Cal benefits for that service or item will continue until a hearing decision is made. You must ask for a hearing on or before the later of the following in order to continue your benefits: Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or The intended effective date of the action. If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made. How will I find out about the decision? If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision.  If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. We may stop any aid paid pending you are receiving.  If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision.  If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. You can still get a State Hearing. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IRE’s decision.  If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. This is called “upholding the decision.” It is also called “turning down your appeal.” If the decision is No for all or part of what I asked for, can I make another appeal? If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. You may also ask for judicial review of a State Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision.  If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing.  If your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The letter you get from the IRE will explain additional appeal rights you may have. Payment Problems We do not allow our network providers to bill you for covered services and items. This is true even if we pay the provider less than the provider charges for a covered service or item. You are never required to pay the balance of any bill. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. If you get a bill that is more than your copay for covered services and items, send the bill to us. You should not pay the bill yourself. We will contact the provider directly and take care of the problem. How do I ask the plan to pay me back for the plan’s share of medical services or items I paid for? Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items.  If you are asking to be paid back, you are asking for a coverage decision. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage. If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 60 calendar days after we get your request. Or, if you haven’t paid for the service or item yet, we will send the payment directly to the provider. When we send the payment, it’s the same as saying Yes to your request for a coverage decision. If the service or item is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item and explaining why. What if the plan says they will not pay? If you do not agree with our decision, you can make an appeal. Follow the appeals process. When you are following these instructions, please note: If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.  If we answer “no” to your appeal and the service or item is usually covered by Medicare, we will automatically send your case to the Independent Review Entity. We will notify you by letter if this happens. If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider within 30 calendar days. If the answer to your appeal is Yes at any stage of the appeals process after Level 2, we must send the payment you asked for to you or to the provider within 60 calendar days. If the IRE says No to your appeal, it means they agree with our decision not to approve your request. (This is called “upholding the decision.” It is also called “turning down your appeal.”) The letter you get will explain additional appeal rights you may have. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. If we answer “no” to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself (see above). IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. Information on this page is current as of October 01, 2022. H8894_DSNP_23_3241532_M

have problems getting a Part D drug or you want us to pay you back for a Part D drug. Your benefits as a member of our plan include coverage for many prescription drugs. Most of these drugs are “Part D drugs.” There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? Yes. Here are examples of coverage determination you can ask us to make about your Part D drugs.  You ask us to make an exception such as: Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary) Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get) You ask us if a drug is covered for you (for example, when your drug is on the plan’s Formulary but we require you to get approval from us before we will cover it for you). Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage determination. You ask us to pay for a prescription drug you already bought. This is asking for a coverage determination about payment. If you disagree with a coverage decision we have made, you can appeal our decision. What is an exception? An exception is permission to get coverage for a drug that is not normally on our List of Covered Drugs, or to use the drug without certain rules and limitations. If a drug is not on our List of Covered Drugs, or is not covered in the way you would like, you can ask us to make an “exception.” When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception. Here are examples of exceptions that you or your doctor or another prescriber can ask us to make:  Covering a Part D drug that is not on our List of Covered Drugs (Formulary). If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drug. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. Removing a restriction on our coverage. There are extra rules or restrictions that apply to certain drugs on our Formulary. The extra rules and restrictions on coverage for certain drugs include: Being required to use the generic version of a drug instead of the brand name drug. Getting plan approval before we will agree to cover the drug for you. (This is sometimes called “prior authorization.”) Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called “step therapy.”) Quantity limits. For some drugs, the plan limits the amount of the drug you can have. If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug. Important things to know about asking for exceptions Your doctor or other prescriber must give us a statement explaining the medical reasons for requesting an exception. Our decision about the exception will be faster if you include this information from your doctor or other prescriber when you ask for the exception. Typically, our Formulary includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. We will say Yes or No to your request for an exception. If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. If we say No to your request for an exception, you can ask for a review of our decision by making an appeal. Coverage Decision What to do Ask for the type of coverage decision you want. Call, write, or fax us to make your request. You, your representative, or your doctor (or other prescriber) can do this.   You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347. You can fax us at: (909) 890-5877  You can to write us at: IEHP DualChoice P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. You can also have a lawyer act on your behalf. You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. If you are requesting an exception, provide the “supporting statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception. We call this the “supporting statement.”  Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. Request for Medicare Prescription Drug Coverage Determination (PDF) These forms are also available on the CMS website: Medicare Prescription Drug Determination Request Form (for use by enrollees and providers) By clicking on this link, you will be leaving the IEHP DualChoice website. Deadlines for a “standard coverage decision” about a drug you have not yet received If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctor’s or prescriber’s supporting statement. We will give you our answer sooner if your health requires it. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review the decision. If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctor’s or prescriber’s supporting statement.  If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision. Deadlines for a “standard coverage decision” about payment for a drug you have already bought We must give you our answer within 14 calendar days after we get your request. If we do not meet this deadline, we will send your request to Level 2 of the appeals process. At level 2, an Independent Review Entity will review the decision. If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. This statement will also explain how you can appeal our decision. If your health requires it, ask us to give you a “fast coverage decision” We will use the “standard deadlines” unless we have agreed to use the “fast deadlines.” A standard coverage decision means we will give you an answer within 72 hours after we get your doctor’s statement. A fast coverage decision means we will give you an answer within 24 hours after we get your doctor’s statement. You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.) You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. If your doctor or other prescriber tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision, and the letter will tell you that. If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether you get a fast coverage decision. If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead. We will send you a letter telling you that. The letter will tell you how to make a complaint about our decision to give you a standard decision. You can file a “fast complaint” and get a response to your complaint within 24 hours. Deadlines for a “fast coverage decision” If we are using the fast deadlines, we must give you our answer within 24 hours. This means within 24 hours after we get your request. Or, if you are asking for an exception, 24 hours after we get your doctor’s or prescriber’s statement supporting your request. We will give you our answer sooner if your health requires us to. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an outside independent organization will review your request and our decision. If our answer is Yes to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctor’s or prescriber’s statement supporting your request. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision. Level 1 Appeal for Part D drugs To start your appeal, you, your doctor or other prescriber, or your representative must contact us. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am – 8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347. If you want a fast appeal, you may make your appeal in writing or you may call us. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal.  For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal. You can ask for a copy of the information in your appeal and add more information. You have the right to ask us for a copy of the information about your appeal.  If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. You may use the following form to submit an appeal: Coverage Determination Form (PDF) Can someone else make the appeal for me? Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. The form gives the other person permission to act for you. If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal.  Deadlines for a “standard appeal” If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. If you think your health requires it, you should ask for a “fast appeal.” If you are asking us to pay you back for a drug you already bought, we must give you our answer within 14 calendar days after we get your appeal. If we do not give you a decision within 7 calendar days, or 14 days if you asked us to pay you back for a drug you already bought, we will send your request to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review our decision. If your health requires it, ask for a “fast appeal” If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.” The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision.”  Our plan will review your appeal and give you our decision We take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said No to your request. We may contact you or your doctor or other prescriber to get more information. Deadlines for a “fast appeal” If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it. If we do not give you an answer within 72 hours, we will send your request to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review your appeal. If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. Level 2 Appeal for Part D drugs If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. If you want the Independent Review Organization to review your case, your appeal request must be in writing.   Ask within 60 days of the decision you are appealing. If you miss the deadline for a good reason, you may still appeal. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. When you make an appeal to the Independent Review Entity, we will send them your case file. You have the right to ask us for a copy of your case file. You have a right to give the Independent Review Entity other information to support your appeal. The Independent Review Entity is an independent organization that is hired by Medicare. It is not connected with this plan and it is not a government agency. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. The organization will send you a letter explaining its decision. If we uphold the denial after Redetermination, you have the right to request a Reconsideration. See form below: Reconsideration Form (PDF) Deadlines for a “fast appeal” at Level 2 If your health requires it, ask the Independent Review Entity for a “fast appeal.” If the review organization agrees to give you a “fast appeal,” it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 24 hours after we get the decision. Deadlines for “standard appeal” at Level 2 If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision.   If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision. What if the Independent Review Entity says No to your Level 2 Appeal? No means the Independent Review Entity agrees with our decision not to approve your request. This is called “upholding the decision.” It is also called “turning down your appeal.” If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. The Level 3 Appeal is handled by an administrative law judge. For more information see Chapter 9 of your IEHP DualChoice Member Handbook. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. Information on this page is current as of October 01, 2022. H8894_DSNP_23_3241532_M

c9; border: none; color: white !important; padding: 15px 32px; margin: 25px 0; 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. Please view our video to learn more on how vaccines build immunity. 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

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

ne year Ages: 18 years and over This online year-long lifestyle change program helps you make real changes that last.  During the first 6 months, you will meet weekly with a small online group to learn how to make healthy choices into your life. In the second 6 months, you will meet monthly to practice what you have learned. No person is alike, so the program will be tailored to meet your needs and honor your customs and values. You will also be paired with a health coach for one year to help you set your goals, such as how to: Eat healthier Add physical activity into your daily life Reduce stress Improve problem-solving and coping skills Studies have shown that those who finish the program can lose weight and prevent Type 2 Diabetes. Small changes can have big results! Let's start living the best version of you and living the life you love.  Find out if you qualify! Click here to visit the Skinny Gene Project online, or Text “DPP” to 313131, or Call Skinny Gene Project at (909) 922- 0022, Monday - Friday 8am – 5pm., or Email hello@skinnygeneproject.org Click on the video below to learn more about this program. 

provider, and receive treatment for COVID-19 – all in one place at a Test to Treat site.  If you have a medical condition which makes you more likely to get very sick from COVID-19, you may be eligible to receive treatments.  Adults and Children over the age of 12 can receive treatments, but treatment must be started as soon as possible and within 5 days of symptom onset. Click here for more information on the COVID-19 Test to Treat Program.  Walgreens Test to Treat Program  Select Walgreens pharmacies are now dispensing oral antivirals for the treatment of COVID-19.  Eligible members must have a valid prescription from their healthcare provider. Walgreens offers a variety of delivery options, like same day or free 2-day delivery. Most prescriptions are eligible for Same Day Delivery.  Click here for more information. FREE at-home COVID-19 tests Every home in the U.S. is eligible to order one free COVID-19 test kit, which includes four at-home tests. The tests are completely free. Click here to order your free at-home tests from USPS.  Effective 2/1/22, Medi-Cal Members can receive at-home COVID-19 tests from a Medi-Cal enrolled pharmacy. California Department of Health Care Services (DHCS) will cover up to 8 test kits per month per member. For information on which test kits are covered or if you need assistance with a prescription, please ask your Doctor or your Pharmacist. Medi-Cal Members will be reimbursed for at-home test kits purchased between March 11, 2021, and January 31, 2022, by DHCS the cost (with a receipt) using the process outlined here. San Bernardino County-facilitated testing sites will offer free at-home COVID-19 tests kits to people who live, work, or attend school in San Bernardino County (proof of residency or employment required). Click here to find a list of county-facilitated testing sites. Testing IEHP covers provider-ordered tests, regardless of whether it’s PCR, rapid, at-home, etc. If your doctor orders the test for you, IEHP will cover the cost of the test. Your provider is required to bill IEHP directly for these tests.  IEHP does NOT reimburse Members who choose to pay for COVID tests that are not ordered by a provider.  For information on COVID-19 testing sites in Riverside County, please visit the Riverside County Public Health website. For information on COVID-19 testing sites in San Bernardino County, please visit the San Bernardino County COVID Testing Sites.

our child stay healthy. During the well-care visit, the Doctor will complete a physical exam, and make sure you or your child are up to date on all shots. Please call your Doctor today and set up a well-care visit to get needed shots, screenings or exams. What do you need to do? Get a well-care visit with your or your child’s Doctor by 12/15/23.* The Doctor will send proof of the visit to IEHP. Once IEHP receives proof of the visit, a reward certificate will be mailed.** Choose your gift card from the list of major companies online, over the phone or by mail, and your $25 gift card will be mailed to you.*** Questions? 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.   *Member must be eligible with IEHP on the day of the exam and at the time of gift card distribution. **Reward certificate may be mailed up to two weeks after IEHP receives proof of your exam. ***After choosing your gift card, please allow two to three weeks for delivery. Note: Gift card cannot be used to purchase alcohol, tobacco or firearms.                                                                

s with your retinas over time. Your retinas are parts of your eyes that help you see. Over a long period of time, blood sugar levels can damage blood vessels in your retinas, leading to retinopathy. This can cause symptoms like swelling, blurred vision or vision loss. Even if you have no symptoms, it’s still a good idea to get a full eye exam to screen for that is not normal. What do you need to do? If you don’t have an IEHP Eye Doctor yet, visit our Provider Search Tool (select Vision Services) to find one near you. Make an appointment with your IEHP Eye Doctor and get a dilated or retinal eye exam by 12/15/2023. The IEHP Eye Doctor will send proof of your exam to IEHP.* Once IEHP gets proof of your exam, we will mail you a reward certificate.** Choose your gift card from the list of major companies online, over the phone or by mail, and your $25 gift card will be mailed to you.** Questions? 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.   *You must be eligible with IEHP on the day of your exam or service and at the time the gift card is sent. **Reward may be mailed up to two weeks after IEHP receives proof of your exam. ***After choosing your gift card, please allow two to three weeks for delivery. Note: Gift card cannot be used to purchase alcohol, tobacco or firearms.

Answers What can happen if I take a few medicines at the same time? When you take two or more medicines, they will likely mix well. On certain occasions, you might have what’s called a “drug-to-drug interaction.” This means that some medicines you take together may cause an adverse reaction in your body. For example, a “drug-to-drug” interaction could: make your medicines not work as well (weaken them) make one or more of the medicines too strong and cause unwanted side effects, which could be deadly TIP: Talk to your Pharmacist about all medicines you take and ask if they mix well together. What are some reasons that I might have a harmful effect from taking one or more medicines at the same time? These reasons might include: dose may be too high interaction with other drugs Note: Everyone can react differently – based on age, weight, gender, etc. TIP: To avoid problems when taking two or more medicines together, tell your health care Provider and Pharmacist about all the medicines (and other remedies) you are taking.    How do I know if I’m taking the right medicine – at the right dose, at the right time to control my symptoms? Any medicine taken the wrong way might put your health at risk.  A drug maker has to show research data to the FDA to get each medicine approved. This research could be about: how the medicine works why it is safe to take (or not) what dose works best with the fewest side effects Could a medicine taken at a high dose be harmful? Yes. That is why your Pharmacist checks your medicines to make sure you are on the right dose. Don’t forget to ask your Doctor or Pharmacist any questions about your medicine.  Taking higher than recommended doses of certain over-the-counter (OTC) and prescription medicines – including abuse or misuse of the medicines – can cause serious health problems. It could even lead to death. Also, a dose that is safe for you may not be safe for someone else.     Who most often needs to have their medicine dose changed and why? Certain people need to have their dose changed, so that they don’t take too much (called “overdosing”). These include the elderly, children, and women who are pregnant or mothers who are breastfeeding, and people with chronic health conditions.  Always ask your Pharmacist if the medicines are safe for you to take at the prescribed doses. Don’t share your medicines with friends or family.    What are “duplicate drug therapies”? Why do I need to know about this? You might have different Doctors who have prescribed medicines that work in the same way for you. When medicines have similar active ingredients, they could be:  the same medicine with different names (for example, one could have a brand name and the other might have a generic name), or  two medicines of similar nature TIP: Be cautious about taking the same medicine twice – as you could have two bottles of the same medicine! TIP: It’s important for you to keep a full list of each medicine, vitamin and herbal remedy you are taking. Please show this list to your Pharmacist or your Doctor. The list helps your health care Provider check for any unwanted effects between drugs and check that the two or more medicines work well for you or not. What happens if my medicine is recalled? A recall may be issued if a medication is: A health hazard: If there is some health risk associated with the medication.  Mislabeled or packaged poorly: If there is a problem with the dosing tool provided with the drug.  Poorly manufactured: If there are defects related to poor quality, impurities, and incorrectly potency of the drug from the manufacturer.  Please click here to view an up-to-date list of drug recall notifications. Why are some medicines “high risk” for the elderly?  Some medicines can be too strong for a certain group of people and are considered “high risk” for them. This special group may include older people, pregnant women or mothers who are breastfeeding, children, and people with other medical conditions affecting their kidney or liver. For example, certain medicines prescribed for memory issues may have a side-effect that causes dizziness in some seniors who are at “high risk” for falling. In that case, an alternative medicine (or no medicine) for this condition would be better.   Where can I find details about medicines that might be harmful for older people? If you are over 65 years old, ask your Doctor or Pharmacist if the medicines you are taking may not be right for you.  Please see the short list below of the most common medicines prescribed that may be harmful for older people.  Older adults (age 65+): Check with your Doctor first before taking these medicines: Medicine or Medicine Class   Potential Risks Sliding scale insulin May make your blood sugar level too low – without improving the condition Glyburide  May cause a long period of excessively low blood sugar Muscle relaxants  May be poorly tolerated Barbiturates May increase risk of dependence and overdose Benzodiazepines (alprazolam, temazepam, lorazepam) May increase risk of falls and fractures To learn more, visit: https://www.pharmacytoday.org/article/S1042-0991(19)31235-6/fulltext Pharmacy Benefits: Medi-Cal Members IEHP Dual Choice Cal MediConnect Members

amily of viruses that cause smallpox. Is monkeypox very dangerous?  The Centers for Disease Control and Prevention (CDC) stated that most of those infected recover from monkeypox in two to four weeks. Those who caught the virus said the rash (that looks like pimples or blisters) can be painful.    Those with weakened immune systems, children under age 8, people who are pregnant or breastfeeding, and those with a history of eczema may be more likely to get seriously ill or pass away.  What are the symptoms? The most common symptoms are:  Fever and headache Muscle aches and backache Swollen lymph nodes Exhaustion and chills Sore throat, stuffy nose or cough Rash (i.e., pimples or blisters that show up on the face, inside the mouth and on other body parts) If you have monkeypox symptoms, please call your Doctor’s office. How does monkeypox spread? It is spread through direct contact with someone who has an infected rash, scabs or body fluids. It could also spread through face-to-face contact. Or it can be spread by touching items that had been touched by those with the infection. People who don’t have monkeypox symptoms can’t spread this virus to others. How can I protect myself and my family? Take these precautions:  Avoid skin-to-skin contact with those who have a rash that looks like monkeypox. This rash can look like small blisters or pimples and may be itchy or painful. Avoid contact with surfaces or materials that a person with monkeypox has used or touched. Wash your hands with soap and water for 20 seconds often or use an alcohol-based hand sanitizer. Is there a monkey pox vaccine? JYNNEOS is a 2-dose vaccine developed to protect against monkeypox. The second dose should be given 4 weeks after the first dose. Consult with your health care provider if you are at high risk of exposure or if you were in contact with a person who has monkeypox within the last 2 weeks.  Antiviral drugs used for treatment of smallpox may be considered some instances to treat monkeypox viral infections. Consult with your health care provider for more information.  Who should get this vaccine? The Centers for Disease Control and Prevention (CDC) recommends it for those who have been in close contact with those with monkeypox. While anyone exposed to this monkeypox can become infected, 98% of current infections have been found in men who have sex with men. Talk with your Doctor if you believe you have been exposed to monkeypox. If you have monkeypox symptoms, please call your Doctor’s office. Click here to learn more.  What are the side effects of the vaccine? The most common side effects are pain, redness, and itching at the spot where the vaccine is given. You may also experience fever, headache, tiredness, nausea, chills, and muscle aches; however, these are signs that the vaccine is working, not getting sick. These side effects may last for several weeks. Is the vaccine safe? The vaccine is safe to get. However, you should not get the vaccine if you have a severe allergic reaction (anaphylaxis) after getting your first dose of the JYNNEOS vaccine. Make sure to let your health care provider know if you have a severe allergic reaction from any vaccinations. Do I have to pay for the vaccine? Monkeypox vaccines are FREE. Your health care provider must give you the vaccine regardless of your ability to pay the administration fee.   

treach program for our providers and pharmacies. We perform phone and one-on-one outreaches with physicians, nurse practitioners, physician assistants, and pharmacy staff. Our goal is to transform the prescriber and pharmacy practice and enhance the provider, pharmacist and member experience. Clinical Drug Education Clinical Drug Education provides materials that focus on a specific drug, drug class, and/or disease state. These materials contain pharmacological and clinical practice information to assist providers and pharmacies in their practice. As new drug information is available, it is important to stay up to date on clinical research findings to assist with member care and medication-use decisions.   Practice Development Practice development education provides materials that focus on enhancing provider and member experience. The materials contain guidance on Formulary Utilization and PA submissions as well as insights regarding electronic prescribing and electronic health records. It is our commitment to provider practice optimization tools and resources to enhance member care.   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader.  By clicking on this link, you will be leaving the IEHP website. Biosimilars A growing trend in healthcare is the use of biosimilar drugs. The following information will assist you and your practice on prescribing biosimilars. What is a Biosimilar? (PDF) Biosimilars: Are They the Same Quality? (PDF) Biological Product Definitions (PDF) Prescribing Biosimilar Products (PDF) Prescribing Interchangeable Products (PDF) Opioid and Chronic Pain Management In collaboration with Riverside University Health System (RUHS) and Centers for Disease Control and Prevention (CDC), IEHP would like to provide the following information to assist you and your practice on prescribing opioids for chronic pain management. CURES CURES FAQ (PDF) CURES 2.0 User Guide (PDF) CURES tips and tricks (PDF) Naloxone Naxolone Drug facts (PDF) Naxolone instructions for use (PDF) First Responder Naxolone administration fact sheet (PDF) Opioid Prescribing Guidelines Medication Assisted Treatment (MAT) and Opioid Treatment Program (OTP) FAQ (PDF) CDC Guideline Infographic (PDF) CDC Guidelines Factsheet (PDF) TurnTheTide Pocket Guide for Prescribing Opioids for Chronic Pain (PDF) CDC Guideline at a Glance  Opioid Tapering Clinical Pocket Guide to Tapering (PDF) Tapering Resource-AAFP (PDF) Opioid Tapering Resource pack (PDF) Pharmacy Medication Assisted Treatment (MAT) for Substance Abuse (PDF) Urine Drug Testing CDC Clinical Practice Guideline for Prescribing Opioids for Pain UDT for monitoring opioid therapy-AAFP (PDF) X-Waiver  X-Waiver resources Removal of DATA Waiver (X-Waiver) Requirement https://www.samhsa.gov/medications-substance-use-disorders/removal-data-waiver-requirement All prescriptions for buprenorphine will now only require a standard DEA registration number. For additional information on the removal of the DATA-Waiver requirement, see the Removal of DATA Waiver (X-Waiver) Requirement. Practice Optimization   Electronic Prescribing (e-Rx) Electronic prescribing is a growing standard in the healthcare industry. Most electronic health record systems offer electronic prescription capabilities. The information below will provide insight to the practice of e-prescribing. Benefits of e-Rx brochure (PDF) Formulary Utilization The IEHP Formulary offers a variety of drugs based on safety and efficacy for any condition. The information below will help you find out how to access and interpret the formulary Medicare FAQ (PDF) The process of submitting a prior authorization may be cumbersome for your practice. The information below will help you understand this process and assist with receiving a proper decision in a timely manner.   For any questions regarding Pharmacy Academic Detailing Training please contact: PharmacyAcademicDetailing@iehp.org     You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website. Information on this page is current as of January 1. 2022  

CA 92324 (909) 580-1000 (909) 580-6308 Barstow Community Hospital 820 E Mountain View Barstow, CA 92311 (760) 256-1761 (760) 957-3397 Bear Valley Community Healthcare District 41870 Garstin Drive Big Bear Lake, CA 92315 (909) 866-6501 (909) 878-8282 Chino Valley Medical Center 5451 Walnut Ave. Chino, CA 91710 (909) 464-8600 (909) 464-8882 Colorado River Medical Center 1401 Baily Ave. Needles, Ca. 92363 (909) 326-7100 (909) 326-7292 Community Hospital of San Bernardino 1805 Medical Center Dr #201 San Bernardino, CA 92411 (909) 887-6333 (909) 806-1044 Corona Regional Medical Center 800 S Main St. Corona, CA 92882 (951) 737-4343 (951) 736-6310 Desert Regional Medical Center 1150 N Indian Canyon Dr. Palm Springs, CA 92262 (760) 323-6511 (760) 323-6330 Desert Valley Hospital 16850 Bear Valley Rd. Victorville, CA 92395 (760) 241-8000 (760) 951-2034 Eisenhower Medical Center 39800 Bob Hope Dr. Rancho Mirage, CA 92270 (760) 340-3911 (760) 773-1532 Hemet Global Medical Center 1117 E Devonshire Ave. Hemet, CA 92543 (951) 652-2811 (951) 765-4745 Hi-Desert Medical Center 6601 White Feather Rd. Joshua Tree, CA 92252 (760) 366-3711 (760) 365-9309 Inland Valley Regional Medical Center 36485 Inland Valley Dr., Wildomar, CA 92595 (951) 677-1111 (951) 698-7721 John F. Kennedy Memorial Hospital 47111 Monroe St. Indio, CA 92201 (760) 347-6191 (760) 775-8014 Loma Linda University Children's Hospital 11234 Anderson St. Loma Linda, CA 92354 (909) 558-8000 (909) 558-3278 Loma Linda University Medical Center 11234 Anderson St. Loma Linda, CA 92354 (909) 651-1702 (909) 478-3202 Loma Linda University Medical Center - Murrieta 28062 Baxter Rd. Murrieta, CA 92563 (951) 290-4000 (951) 290-4092 Menifee Global Medical Center 28400 McCall Blvd. Sun City, CA 92585 (951) 679-8888 (951) 766-6470 Montclair Hospital Medical Center 5000 San Bernardino St. Montclair, CA 91763 (909) 625-5411 (909) 626-4777 Mountains Community Hospital 29101 Hospital Rd. Lake Arrowhead, CA 92352 (909) 336-3651 (909) 336-4730 Palo Verde Hospital 250 N 1st St. Blythe, Ca 92225 (760) 922-4115 (760) 921-5263 Parkview Community Hospital Medical Center 3865 Jackson St. Riverside, CA 92503 (951) 688-2211 (951) 352-5363 Pomona Valley Hospital Medical Center 1798 N. Garey Ave. Pomona, CA 91767 (909) 865-9500 (909) 865-2104 Rancho Springs Medical Center 25500 Medical Center Dr. Murrieta, CA 92562 (951) 696-6000 (619) 627-5949 Redlands Community Hospital 350 Terracina Blvd. Redlands, CA 92373 (909) 335-5500 (909) 335-6497 Riverside Community Hospital 4445 Magnolia Ave. Riverside, CA 92501 (951) 788-3000 (951) 788-3201 Riverside University Health Care System 26520 Cactus Ave. Moreno Valley, CA 92555 (951) 486-4000 (951) 486-4475 San Antonio Regional Hospital 999 San Bernardino Rd. Upland, CA 91786 (909) 985-2811 (909) 920-6357 San Gorgonio Memorial Hospital 600 N Highland Springs Ave., Banning, CA 92220 (951) 845-1121 (951) 845-2836 St. Bernardine Medical Center 2101 N Waterman Ave., San Bernardino, CA 92404 (909) 883-8711 (909) 881-4337 St. Mary Medical Center 18300 US Highway 18 Apple Valley, CA 92307-2206 (760) 242-2311 (760) 946-8714 Temecula Valley Hospital 31700 Temecula Pkwy Temecula, CA 92592 (951) 331-2200 (951) 331-2211 Victor Valley Global Medical Center 15248 Eleventh St. Victorville, CA 92395 (760) 245-8691 (760) 245-6996

re District at the City’s Fire and Police Recognition Celebration on September 9. 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. Located in Rancho Cucamonga, IEHP’s 400,000-square-foot headquarter building (known as the Atrium) was transformed into a super vaccination site in February 2021 where more than 36,900 COVID-19 vaccines have been administered to date. “We are incredibly humbled to receive this recognition from the Rancho Cucamonga Fire District,” said Jarrod McNaughton, IEHP Chief Executive Officer. “Hosting the vaccine clinic is very important to us. As a health plan, a partner of the city and county, we knew we needed to do our part to make these vaccines accessible.” Rancho Cucamonga Fire District’s Business Partner of the Year is traditionally awarded to a community business who assists the district as a problem solver. “This award is our humble way of expressing our gratitude for the partnership in this historic effort. We thank IEHP for opening their doors and making a difference in thousands of lives within our community during these unprecedented times,” said Ivan Rojer, Rancho Cucamonga Fire District’s Fire Chief. IEHP has been a Rancho Cucamonga Business Partner since relocating from San Bernardino in 2013. Prior to March 2020, IEHP’s ENERGY STAR® certified Atrium building supported more than 2,400 Team Members (IEHP employees), who have temporarily transitioned to full-time work-from-home schedules during the pandemic. “In addition to addressing the needs of our Members and residents throughout the Inland Empire, it means so much to us that we were able to open our building to provide more access for our friends and neighbors in Rancho Cucamonga as well,” said Dr. Takashi Wada, IEHP Chief Medical Officer. “We are incredibly grateful for the recognition and the ongoing support pouring into the vaccine clinic. And we look forward to continuing our partnerships to help increase vaccine rates in our region.” The clinic is located at 10801 Sixth Street in Rancho Cucamonga and is scheduled to run for the rest of the year. Appointments and walk-ins can be accommodated. Appointments can be made at SBCovid19.com/vaccine.

er place for all?  Inland Empire Health Plan (IEHP) is currently collecting nominations for its 2023 Living the Mission Awards, which will be announced next spring. Nominations can be made until Feb. 15, 2023, by visiting LivingTheMissionAwards.IEHP.org. Categories for the awards include Creativity and Innovation, Vibrant Health, Optimal Care and Inspire.   The Creativity and Innovation Award will honor a provider, entity or community partner that exemplifies the courage to “break the mold” in pursuit of innovative ways to address health concerns for Inland Empire residents. IEHP’s Vibrant Health Award will recognize a provider, entity or community partner that exemplifies engagement with the well-being and joyful life of residents in the Inland Empire.  The health plan’s Optimal Care Award will celebrate a provider or entity that exemplifies world-class care and outcomes in preventive care, chronic care or hospital care. In addition, the Inspire Award will acknowledge a provider, an entity or community partner that exemplifies IEHP’s mission, “We heal and inspire the human spirit.” Earlier this year, Community Action Partnership of San Bernardino County (CAPSB) and SAC Health System earned IEHP’s first Living the Mission Awards. This recognition highlighted CAPSB’s dedication to eliminate effects of poverty and SAC Health System’s tireless support and service to residents in both Riverside and San Bernardino counties. “The work we do each and every day to fulfill our mission to heal and inspire the human spirit is made possible through the innovative and courageous contributions of our providers and partners,” said IEHP Chief Executive Officer Jarrod McNaughton. “We look forward to honoring these groups and continuing our collaborative work to make the Inland Empire a healthier place for all.”   Awards will be announced at IEHP’s annual Mission Conference scheduled for May 5, 2023.  To learn more, visit missionconference.iehp.org.     

h Diversity Awareness and National Disability Employment Awareness Month. SNC is a mobile coffee shop in Ontario, California, that provides work opportunities to adults with intellectual and developmental disabilities. Nearly 95% of the staff at SNC identify as persons with disabilities. “This is the first time IEHP has partnered with SNC, but it will not be the last,” said Marisol Pilotin, IEHP Community Health Representative. “Every October, our Independent Living and Diversity Services teams organize informational workshops and trainings for our Team Members that highlight the importance of equity and inclusion. SNC is an incredible model of that, and the positive impacts on both their extraordinary employees and the community are undeniable.” The partnership includes the purchase and distribution of SNC coffee vouchers for IEHP Team Members (employees) who participate in various trainings and events throughout the month. Employees from SNC will also join the health plan as guest speakers at a virtual workshop titled, Social Inclusion for People with Disabilities. "Partnering with IEHP during Diversity Awareness Month helps us fulfill our mission of raising awareness and empowering individuals with special needs and/or mental illnesses,” said Mia Humphreys, SNC Administrative Director. “Special Needz Coffee and IEHP share the common goal of promoting acceptance of everyone's differences, whether they are based on racial, cultural, religious, or political beliefs, and, most importantly, their mental or physical abilities. We are both working toward providing individuals with special needs an equal opportunity to work at organizations that promote diversity and inclusivity.” SNC’s mobile coffee shop sets up in Ontario at 2920 Inland Empire Blvd. Suite 108 (in the parking lot near the freeway). The shop is open to the public from 7:30 a.m. to 3:30 p.m. Monday through Friday, and from 9 a.m. to 1 p.m. on Saturday. “We’re really looking forward to continuing our partnership with SNC beyond this month’s celebration,” said Jose Solorzano, IEHP Community Health Representative. “Diversity should be celebrated every day, and we really appreciate that SNC reminds adults with disabilities that, through challenges and differences, they are able to make a positive impact in this world.” To learn more about SNC, visit specialneedzcoffee.com.

le with disabilities in the Inland Empire (I.E.). After applying and participating in the California Department of Health Care Services Physical Accessibility Review Survey (PARS), providers were selected by Inland Empire Health Plan (IEHP) and scheduled for table distribution by the fall. Receiving clinic locations include: Palm Desert, Corona, Hemet, Pomona, Rancho Cucamonga, and Indio with clinic types ranging from Adult Day Care Centers, OB/GYN clinics to Urgent Care Centers.  Studies indicate fewer than 10% of Primary Care Clinics in California reported having accessible exam tables, despite one in seven adults having a disability. “Being able to comfortably visit and be examined by your physician is critical to receiving optimal and complete care,” said Carmen Ramirez, IEHP’s disability program manager. “These exam tables provide patients with mobility challenges an opportunity to connect with their physician—with dignity.” The UpScale accessible exam tables, created by Medical Accessibility LLC, are ADA Compliant and ergonomically designed to enable a full-body exam with both height and weight measurements, important in-office visit elements that are often difficult for persons with disabilities.  “As an Internal Medicine-based clinic, our providers see some of the sickest patients with co-morbidities that challenge many of them in their fullest potential and quality of life,” said Denise E. Grant, ARMC Clinic Operations Supervisor. “Having an accessible exam table in our practice will allow us to better serve our patients who are challenged with obesity, are a fall risk, and/or have conditions that prevent them from standing on a regular scale. It would allow us to provide accessibility that enhances not only quality of care impacting the health of our patients but also contributing to our care team’s ability to collect key population health metrics.” To further support health equity and the need for accessible, comprehensive exams for residents with disabilities, IEHP also plans to provide comprehensive feedback based on each provider’s PARS response and conduct Culture Competency Trainings for providers who receive accessible exam tables.  The health plan will conduct accessible table distributions annually to increase the number of I.E. clinics that can offer accessible exams, increase access for residents with disabilities, and increase opportunities for better health outcomes. “Everyone is entitled to a safe and comprehensive medical exam,” said Dr. Takashi Wada, IEHP interim chief medical officer. “These exam tables and the pledge to continue this effort make that a reality for so many in our communities.  They also serve as an active reminder of the importance of health care equity and meeting our neighbors where they are to deliver optimal and vibrant care that benefits them as individuals.”  

rence on May 6. Held at its company headquarters in Rancho Cucamonga, the conference featured educational and networking opportunities and a keynote presentation from New York Times best-selling author and Reality-Based Leadership CEO Cy Wakeman.  The Mission Conference was first held in 2019 but took a hiatus during the COVID-19 pandemic. “The gatherings may have been paused, but the work certainly was not,” said IEHP CEO Jarrod McNaughton. “It was important for us as health care leaders to come back together to reflect on the challenges and successes of the past two years, strengthen our connections, claim our collective courage, and find opportunities to better meet the needs of those we serve in the Inland Empire.” Like the inaugural event, this year’s conference brought together health care CEOs, hospital board members and other industry leaders from across the state to share in collectively preparing for the future in a post-pandemic world.  This year’s event also honored the very first recipients of IEHP’s Living the Mission INSPIRE Award, which honors providers, community organizations and partners for their commitment to the health plan’s mission to “heal and inspire the human spirit.” This year awards recognized Community Action Partnership of San Bernardino County for their dedication to eliminating effects of poverty and SAC Health System for its tireless support and service to residents in both Riverside and San Bernardino counties. Sharing her insight on what the pandemic can teach us about post-traumatic growth, Wakeman highlighted how experiences of the past year can be leveraged to build sustainable resilience and reduce burnout and exhaustion. “If you’re in health care, you need to do two things. You need to love people up and call people up. Remind people that what we do here is sacred,” Wakeman shared with conference attendees.  “What makes the IEHP Mission Conference unique is its ability to celebrate courage and truly inspire the future of health and wellness in the Inland Empire,” said IEHP Governing Board Chair and San Bernardino County Third District Supervisor Dawn Rowe. “Putting all of that under one roof cultivates a type of collaboration that will sculpt and define Inland Empire Public Health Systems for generations.” To learn more about how IEHP is charting a collaborative path forward, visit iehp.org or follow IEHP on social media.   

eve Morgan Leopard of the Year award, University of La Verne’s (ULV) most prestigious alumni recognition.  “We consider this our Lifetime Achievement award, given to an alumnx who not only has achieved extraordinary career success, but maybe more importantly, has also greatly impacted and improved lives in their community,” shared University of La Verne President Dr. Devorah Lieberman. Selected by a committee comprised of leaders from ULV’s Alumni Advisory Board, the Office of Alumni Engagement and University Administration, recipients of the award are alumni who demonstrate a deep-seated commitment to their community and support the university with their time, talent and resources.  “Jarrod has been a transformational partner with us over the past several years in the creation of our new College of Health and Community Well-Being,” added Lieberman. “His intimate knowledge of the health care needs of the Inland Empire and his personal passion to help guide our students – many of them first-generation college graduates, like himself – into productive, worthwhile career paths was a visionary contribution to help guide our planning. As our programs grow and our students succeed, we will forever credit his foresight and support in helping form this college.” McNaughton, who earned a Master of Business Administration at ULV, has remained engaged with the university since graduation, serving students through guest lectures, commencement speeches and more.  “Maintaining a strong connection with your alma mater is an important part in supporting the next generation, especially those living in the Inland Empire,” said McNaughton. “I am incredibly humbled by this recognition and look forward to my continued collaboration with ULV in bridging gaps for current and future students.”  

t’s why the California Department of Healthcare Services (DHCS) initiated a series of Listening Sessions throughout the state, with the most recent event held at the headquarters of Inland Empire Health Plan (IEHP) in Rancho Cucamonga on Jan. 27.  The roundtable discussion focused on how the CalAIM state policy is being implemented in the Inland Empire and outlined improvement opportunities with DHCS Director Michelle Baass, Chief Deputy Director of Health Care Programs Jacey Cooper, Deputy Director Susan Philip, Assistant Director Tracy Arnold, and Health Program Specialist Brian Hansen. “Health is no longer just about a doctor’s office, a hospital or clinic. It’s about public health, behavioral health; things that are really going to influence a person’s life,” said Baass, who acknowledged the need and appreciation for the wide variety of care partners in attendance.  The group of DHCS representatives were met by IEHP leadership and nearly 70 Inland Empire partners including Molina Health Care and Kaiser Permanente to discuss priority issues, best practices and the experience of Medi-Cal programs for beneficiaries in our counties.  “I’m grateful to be sitting at the table, not only with our hospital folks, [but] along with housing and workforce solutions,” said Sayori Baldwin, Riverside County’s assistant executive officer of human services, who shared her team’s experience with child welfare and her colleague’s struggle to maximize and leverage funding for child welfare patients who have complex needs.  This meeting was the second in a larger series supporting DHCS’s ongoing effort to actively meet with and learn from various partners about the state’s Medi-Cal program.  “This discussion was a great opportunity to share details about the work being done, where the gaps lie and how DHCS can help us deliver quality and equitable care to the communities we serve,” said Jarrod McNaughton, IEHP’s chief executive officer. “We appreciated the time and really look forward to continued collaboration and the inspired action to come out of these conversations.” Top row, from left: Brian Hansen, DHCS health program specialist; Michelle Baass, DHCS director; Jacey Cooper, DHCS chief deputy director of health care programs; Jennifer Cruikshank, Riverside University Health System chief executive officer; William Gilbert, Arrowhead Regional Medical Center chief executive officer. Bottom row, from left: Jarrod McNaughton, IEHP chief executive officer; Amanda Flaum, Kaiser Foundation Health Plan, Inc. vice president; Susan Philip, DHCS deputy director; Tracy Arnold, DHCS assistant director.