尊敬的 SFHP 會員:國會未能就2026財年的資金達成協議,聯邦政府於10月1日停擺。雖然我們尚不清楚停擺將持續多久,但SFHP將繼續正常運作。您仍然可以獲得所需的護理。我們致力於確保您獲得照護的途徑不受影響。如果您遇到任何問題,請聯絡 SFHP 客戶服務部,電話:1(415) 547-7800,或免費電話 1(800) 288-5555 (TTY 使用者可撥打 711)。我們的營業時間為週一至週五,8:00am 至 5:00pm。

1(415) 547-7800 聯絡我們

SFHP Medical Criteria

SFHP uses external criteria MCG care guidelines, State/Federal (Medi-Cal/CMS), and when available and, in limited circumstances, internally developed and approved criteria (available below). The public, including providers and members, may obtain the relevant UM criteria for specific medical procedures or conditions on request at no cost.

UM Criteria for EPSDT Private Duty Nursing

Gender Affirming Care

As of 4/1/25, medical necessity criteria and guidelines for gender affirming care authorizations are accessed directly from World Professional Association for Transgender Health’s (WPATH) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, Department of Health Care Services (DHCS) guides and California Health and Safety Code regulations.

Resources:

Long-Term Care Criteria

Decisions regarding the appropriate level of care are based on the definitions set forth in California regulations and DHCS Medi-Cal Manual of Criteria.

These guidelines are used to determine the medical necessity for continued placement in a long-term care facility. If care can be delivered at a lower acuity level, an alternative setting will be approved/ recommended. Classification categories include the following:

  • Subacute Care: The member requires subacute care, which is more intense than skilled nursing care but less intense than acute hospitalization. Members at this level of care either can be short term, where there is potential for the member eventually being transferred to a lower level of care; or long term, when there is no potential for improvement in their medical condition. Treatment Authorization Requests (TARs) for these members are authorized for time intervals based on the characteristics of the member’s medical condition.
  • Short Term Care: The member may need a short term stay for a skilled nursing care need or short term rehab services and expected to return to his/her previous living arrangement or alternate level of care.
  • Long Term Care: When a member is admitted for custodial care, the TAR submission may be approved for up to a twelve (12) month period. Member’s condition will be re-evaluated at six (6) -twelve (12) month increments, depending on the initial authorization period and plan of care.

Resources:

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