臨床研究 & 醫療政策科
醫療保健服務部（DHCS）的四個分支部之一，福利部（BD）是臨床研究 & 醫療政策科，負責研究、制定、實施和監督 Medi-Cal 提供的大多數醫療保健服務的醫療保障和退款政策。
概述
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.
醫療保障申請流程
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.
提交 MBR 時，外部方必須完整處理表格中所述的 #1 -9 項，並確保提交任何必要的證明文件或信息。 請注意，證明文件或資料必須以超連結形式提交及/或作為單獨的檔案附加，並與 MBR 表格一起透過電子郵件遞交給 BD。請注意，無法提交或完全填寫 MBR 以及任何必要的支持文件或信息，可能會導致 MBR 被退回並且請求不被評估。
根據保障要求的性質，BD 可能需要諮詢其他 DHCS 部門，這可能會增加完成審查所需的時間；然而，BD 平均需要大約一（1）個月來完成 MBR 上提供的信息的全面分析，並進行自己的獨立研究，然後再通過電子郵件回覆。
提交說明：
- 請注意，提交的 MBR 和任何提交的證明文件均須根據《法例》披露（見政府守則第 6250 條及以下條）。)。
- 因此，BD 建議要求人不要提交任何機密或專有資料。
- For more information on the PRA, please see DHCS’ Public Records Act website.
資源
聯絡資訊
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:
衛生保健服務部-福利組
主任：臨床研究 & 醫療政策科
小姐 4601
郵政編碼 箱子九九七四十七
加利福尼亞州薩克拉門托 99-7417
注意事項
- 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).
- 此外，請注意，如果保障要求需要 BD 進行額外的州和/或聯邦批准（例如，特定的設備、測試/程序或服務不屬於現有福利保障類別），BD 可能無法發出最終保障保障決定，並將通過電子郵件通知您。