CHA News Article

Report Examines Medicaid’s Coverage Determination Policies

The California HealthCare Foundation has released a report that reviews how Medicaid and other large public health insurance programs in the U.S. and abroad determine coverage for specific treatments such as procedures, therapies, technologies and devices. Included in the report are behavior change interventions and emerging technologies, because Medicaid — the largest U.S. purchaser of health services — plays a substantial role in whether millions of Americans can get new health care interventions. The report also highlights themes from research and interviews with select state Medicaid agencies, and discusses policies and procedures for achieving greater rigor and transparency in the decision-making process.

The report concludes that state Medicaid programs, including California’s Medi-Cal, should consider the following core features for their coverage determination policies:

  • A defined process by which third parties may initiate a coverage review;
  • A systematic approach to securing and evaluating evidence of the effectiveness and value of a new intervention;
  • A systematic evaluation of high-cost, high-utilization services; and
  • A defined standard by which the state will determine whether to cover the intervention.

The full report is available on the CHCF website.