Internal Benefit Review Committee (IBRC)

New York's Medicaid program provides comprehensive health coverage to approximately one-third of New Yorkers. New York State Law enables Medicaid to consider medically necessary new technology and health services and make determinations on whether to include them in the New York State Medicaid Plan. Most of these are reviewed by an internal Medicaid benefit review committee. The Internal Benefit Review Committee typically meets once a month and brings together Department of Health Medicaid program staff with a wide variety of expertise.

Meetings are internal to the Department and uses a thorough review of the scientific evidence, clinical information, relevant policies, and professional experience to guide decisions. The review considers United States Food and Drug Administration (FDA) approval or clearance status, United States Food and Drug Administration indications, support in published clinical guidelines, evaluations by high-quality independent clinical studies, assessments by well-established evidence-based review organizations (e.g., Hayes Rating System and National Institute for Health and Care Excellence-NICE), population demographics in New York State, network adequacy to provide the service, available alternatives, risk of adverse effects, fiscal implications, among other factors when deciding whether to include a benefit for coverage.

The New York State Department of Health decision to provide a benefit to Medicaid members are made independent of Medicare coverage decisions.

IBRC Procedures

New York State Medicaid generally does not cover:

• Services assigned temporary Current Procedural Terminology (CPT) codes
• Experimental and investigational services
• Cosmetic procedures
• Services that are not medically necessary

Pharmaceuticals are reviewed separately by the Drug Utilization Review (DUR) Board.

New Technologies or services that would represent a "material" change to the New York State Medicaid program are reviewed through the Evidence Based Benefit Review Advisory Committee (EBBRAC).

Please note: "Medically Necessary" means health care and services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap. For children and youth, medically necessary means health care and services that are necessary to promote normal growth and development and prevent, diagnose, treat, ameliorate or palliate the effects of a physical, mental, behavioral, genetic, or congenital condition, injury or disability.

IBRC Review Request

All service requests must be submitted using the designated IBRC Review Request Form. Upon submission, requests are placed in the review queue and evaluated through a multi-step process involving comprehensive research and committee review of the proposed technology or health service. The duration of the review may vary, as no standardized timeframe exists for issuing a final coverage determination. The submitter will be notified when the Committee makes a coverage decision. A new technology, health service or other benefit may be considered at the New York State Department of Health's discretion.

Submission of an IBRC Review Request Form does not guarantee service coverage. The Department, in its discretion, may request additional information to evaluate a technology or health service, or may deem a service ineligible for review.

Contact
(518) 473-2160
EBBRAC@health.ny.gov