Ang isa sa apat na sangay sa loob ng Department of Health Care Services (DHCS), Benefits Division (BD) ay ang Clinical Research & Medical Policy Branch, na responsable sa pagsasaliksik, pagbuo, pagpapatupad, at pangangasiwa sa mga patakaran sa pagsakop sa medikal at pagbabayad para sa karamihan ng mga serbisyo sa pangangalagang pangkalusugan na ibinibigay ng Medi-Cal.​​  

Pangkalahatang-ideya​​ 

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.​​ 

Proseso ng Paghiling ng Benepisyo ng Medi-Cal​​ 

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.​​ 

Kapag nagsusumite ng MBR, dapat na ganap na tugunan ng panlabas na partido ang mga item #1-9 gaya ng nakabalangkas sa form at tiyakin din na ang anumang kinakailangang pansuportang dokumentasyon o impormasyon ay isinumite. Pakitandaan na ang pagsuporta sa dokumentasyon o impormasyon ay dapat isumite bilang hyperlink at/o ilakip bilang hiwalay na file at isumite kasama ang MBR Form sa pamamagitan ng email sa BD. Pakitandaan na ang hindi pagsumite o ganap na pagkumpleto ng MBR kasama ang anumang kinakailangang pansuportang dokumentasyon o impormasyon ay maaaring magresulta sa pagbabalik ng MBR at hindi nasusuri ang kahilingan.​​ 

Depende sa uri ng kahilingan sa saklaw, maaaring kailanganin ng BD na kumunsulta sa iba pang mga dibisyon ng DHCS, na maaaring magpataas ng oras na kailangan upang makumpleto ang aming pagsusuri; gayunpaman, sa karaniwan, ang BD ay tumatagal ng humigit-kumulang isang (1) buwan upang makumpleto ang komprehensibong pagsusuri nito sa impormasyong ibinigay sa MBR at magsagawa ng sarili nitong independiyenteng pananaliksik bago tumugon sa pamamagitan ng email.​​ 

Mga tagubilin para sa pagsusumite:​​ 

• Ang mga nakumpletong MBR at anumang sumusuportang dokumento o impormasyon ay dapat isumite sa BD sa elektronikong paraan sa pamamagitan ng email sa dhcsmedicalpolicy@dhcs.ca.gov.​​ 

• Pakitandaan na ang MBR at anumang pansuportang dokumentasyong isinumite ay napapailalim sa pagsisiwalat alinsunod sa PRA (tingnan ang Government Code section 6250 et seq.).​​ 
• Bilang resulta, inirerekomenda ng BD na huwag magsumite ang mga humihiling ng anumang kumpidensyal o pagmamay-ari na impormasyon.​​ 
• For more information on the PRA, please see DHCS’ Public Records Act website.​​  

Mga mapagkukunan​​ 

• Medi-Cal Benefit Request (MBR) (DHCS 8712)​​ 
• Med-Cal Benefit Request (MBR) Biomarker Pharmacogenetic Testing (DHCS 7106)​​ 

Impormasyon sa Pakikipag-ugnayan​​ 

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:​​ 

Department of Health Care Services-Benefits Division​​ 

Attn: Clinical Research at Medical Policy Branch​​ 

MS 4601​​ 

PO Kahon 997417​​ 

Sacramento, CA 95899-7417​​ 

Mga Tala​​ 

• 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).​​ 
• Dagdag pa rito, pakitandaan na kung ang kahilingan sa pagsaklaw ay mangangailangan ng mga karagdagang pag-apruba ng estado at/o pederal para ipatupad ng BD (hal., ang partikular na device, pagsubok/pamamaraan, o serbisyo ay hindi nasa ilalim ng kasalukuyang kategorya ng saklaw ng mga benepisyo), maaaring hindi makapagbigay ang BD ng panghuling desisyon sa pagsakop sa mga benepisyo at sasabihin sa iyo sa pamamagitan ng email.​​