​​​Clinical Research & Medical Policy Branch​

One of the four branches within the Department of Health Care Services (DHCS), Benefits Division (BD) is the Clinical Research & Medical Policy Branch, which is responsible for researching, developing, implementing, and overseeing medical coverage and reimbursement policies for most health care services provided by Medi-Cal. ​¹

Overview

When BD is making determinations about medical coverage and reimbursement policy for Medi-Cal, BD's clinical consultants – in partnership with other clinical consultants throughout DHCS – conduct an independent analysis and consider a myriad of factors, including, but not limited to: coverage determinations from other payors, including other state Medicaid programs; coverage determinations for federal Medicare, commercial insurance, etc.; guidance from federal oversight/policy bodies such as the Federal Food and Drug Administration, etc.; and evidence-based, nationally recognized clinical practice guidelines, and consensus statements; and peer-reviewed literature and randomized, controlled clinical studies/trials. Ultimately, BD's clinical consultants must ensure that every device, test/procedure, service, and/or billing code added as a benefit under Medi-Cal meets appropriate “medical necessity" requirements and other threshold standards for coverage under a federal Medicaid program.

Pursuant to California Welfare and Institutions Code section 14059.5: (a) For individuals 21 years of age or older, a service is "medically necessary" or a "medical necessity" when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. (b)(1) For individuals under 21 years of age, a service is "medically necessary" or a "medical necessity" if the service meets the standards set forth in Section 1396d(r)(5) of Title 42 of the United States Code. As specified in Medi-Cal policy, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services are medically necessary or a medical necessity if they correct or ameliorate defects and physical and mental illnesses and conditions discovered through screening.

Medi-Cal Benefit Request Process

BD has created the Medi-Cal Benefit Request (MBR) (DHCS 8712), which must be completed by any external parties (e.g., providers, manufacturers, advocates, etc.) who are requesting BD's consideration for adding a particular device, test/procedure, service, and/or billing code as a Medi-Cal benefit. BD will not be able to accept an MBR for coverage policies or programs outside of our defined areas. If BD receives an MBR for this purpose, BD will redirect the MBR to the appropriate DHCS team for follow-up.

When submitting the MBR, the external party must fully address items #1-9 as outlined in the form and also ensure that any required supporting documentation or information is submitted. Please note that supporting documentation or information must either be submitted as a hyperlink and/or be attached as a separate file and submitted with the MBR Form via email to BD. Please note that failure to submit or fully complete the MBR along with any necessary supporting documentation or information may result in the MBR being returned and the request not being evaluated.

Depending on the nature of the coverage request, BD may need to consult with other DHCS divisions, which can increase the time needed to complete our review; however, on average, BD takes approximately one (1) month to complete its comprehensive analysis of the information provided on the MBR and conduct its own independent research before responding via email.²

Instructions for Submission:

• Completed MBRs and any supporting document or information must be submitted to BD electronically via email at dhcsmedicalpolicy@dhcs.ca.gov.
• Please note that the MBR and any supporting documentation submitted is subject to disclosure pursuant to the PRA (see Government Code section 6250 et seq.).
• As a result, BD recommends that requestors not submit any confidential or proprietary information.
• For more information on the PRA, please see DHCS' Public Records Act website. 
  

Resources

• Medi-Cal Benefit Request (MBR) (DHCS 8712)​​​
  

Contact Information

To contact the DHCS/BD's Clinical Research & Medical Policy Branch, please call us at (916) 345-8134  or email us at  dhcsmedicalpolicy@dhcs.ca.gov. You may also mail us at the following address:

¹ Please note that BD is not primarily responsible for developing coverage policy for family planning benefits and services (except for abortion services), specialty mental health (SMH) and substance use disorder (SUD)/Drug Medi- Cal Organized Delivery System (DMC-ODS) services provided through the county behavioral health delivery system, outpatient drugs, including physician administered drugs (PADs), blood factors, optometry, enteral nutrition, eyeglasses/fabrication, or medical supplies. Additionally, BD does not oversee coverage policy for the following specialty programs: California Children's Services (CCS) Program, Family Planning, Access, Care, and Treatment (FPACT) Program, Breast and Cervical Cancer Treatment Program (BCCTP), or Genetically Handicapped Persons Program (GHPP).​

² Additionally, please note that if the coverage request would require additional state and/or federal approvals for BD to implement (e.g., the particular device, test/procedure, or service does not fall under an existing benefits coverage category), BD may be unable to issue a final benefits coverage decision and you would be informed via email.