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:

• WPATH Standards of Care 8
• DHCS Transgender and Gender Diverse Services Manual
• DHCS All Plan Letter 20-018 Ensuring Access to Transgender Services
• California Code, Health and Safety Code – HSC § 1374.551 Fertility Preservation (for Healthy Workers only)

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:

• Title 22, California Code of Regulations (CCR) Sections 51118, 51120, 51120.5, 51121, 51124, 51124.5, and 51124.6, and the criteria for admission set forth in Sections 51335, 51118, 51120, 51335.5, 51334, 51335.6, and referenced sections of 51003 (e)
• Welfare and Institutions Code (W&I) section 14132.25
• DHCS Medi-Cal Manual of Criteria