2025 Clinical Practice Guidelines
Clinical practice guidelines are designed to guide decisions about diagnosing and treating specific health conditions. These guidelines are based on scientific evidence, medical literature reviews, or established authority. All recommendations are grounded in published guidelines and do not prioritize treatments based solely on cost.
These guidelines serve as a guide for clinical decision-making, but clinicians and patients must collaborate to create individualized treatment plans tailored to each patient's unique needs and circumstances.
Molina Healthcare regularly reviews and updates these guidelines as new clinical evidence emerges. After review and necessary modifications by the Quality Improvement and Health Equity Transformation Committee, providers are notified of any changes via fax and/or mail.
To request a copy of any guideline, please contact Molina Healthcare Provider Services.
The guidelines listed below were reviewed and adopted by the Molina Healthcare National Quality Improvement and Health Equity Transformation Committee, with approval dates indicated for 2023 and beyond. All guidelines undergo monthly reviews and receive annual approval unless otherwise noted.
It's important to note that clinical guidelines are not used by Molina to determine benefit coverage. Instead, they are educational tools to aid clinical decision-making and are not considered a standard of care. Physicians should adapt the guidelines based on their clinical judgment.
Acute Stress and Post-Traumatic Stress Disorder (PTSD)
Molina Healthcare has adopted the guideline for Acute Stress and Post-Traumatic Stress Disorder from the Department of Veterans Affairs & Department of Defense.
The Clinical Practice Guideline may be accessed HERE.
Published: June 2017
Revised: June 2023
Molina approved:January 2023, February 2024, January 2025
Anxiety/Panic Disorder
Molina Healthcare has adopted the guideline for Anxiety/Panic Disorder from the American Academy of Clinical Psychiatrists.
The Clinical Practice Guideline may be accessed HERE.
Published: February 2021
Revised: February 2024
Molina approved: January 2023, February 2024, January 2025
Asthma
Molina Healthcare has adopted the guideline for Diagnosis and Management of Asthma (EPR-3) from the National Institute of Health (NIH): National Heart, Lung, and Blood Institute (NHLBI).
The Clinical Practice Guideline may be accessed HERE.
Published: January 2007
Revised: February 2021
Molina approved: January 2023, February 2024, January 2025
Attention Deficit Hyperactivity Disorder (ADHD)
Molina Healthcare has adopted the guideline for Diagnosis, Evaluation, and Treatment of Attention-Deficit Hyperactivity Disorder in Children and Adolescents from the Journal of the American Academy of Pediatrics (AAP).
The Clinical Practice Guideline may be accessed HERE.
Published: November 2011
Revised: October 2019
Molina approved: January 2023, February 2024, January 2025
Autism
Molina Healthcare has adopted the guideline for Identification, Evaluation, and Management of Children with Autism Spectrum Disorder from The American Academy of Pediatrics.
The Clinical Practice Guideline may be accessed HERE.
Published: January 2020
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
Bipolar Disorder
Molina Healthcare has adopted the guideline for Bipolar Disorder from the Department of Veterans Affairs & Department of Defense.
The Clinical Practice Guideline may be accessed HERE.
Published: May 2023
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
Cancer
Molina Healthcare has adopted the guideline for Cancer from The National Comprehensive Cancer Network® (NCCN®).
The Clinical Practice Guideline may be accessed HERE.
Published: N/A
Revised: N/A
Molina approved: January 2025
Children with Special Health Care Needs
Molina Healthcare has adopted the guideline for Access to Services for Children and Youth with Special Health Care Needs from The American Academy of Pediatrics.
The Clinical Practice Guideline may be accessed HERE.
Published: June 2022
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
Chronic Kidney Disease
Molina Healthcare has adopted the guideline for Evaluation and Management of Chronic Kidney Disease Guideline from the National Kidney Foundation, Kidney Disease Outcome Quality Initiative (NKF KDOQI).
The Clinical Practice Guideline may be accessed HERE.
Published: March 2024
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
Chronic Obstructive Pulmonary Disease
Molina Healthcare has adopted the guideline for Global Strategy for Diagnosis, Management, and Prevention of COPD from the Global Initiative for Chronic Obstructive Lung Disease (GOLD).
The Clinical Practice Guideline may be accessed HERE.
Published: 2011
Revised: January 2025
Molina approved: January 2023, February 2024, January 2025
Depression
Molina Healthcare has adopted the guideline for VA/VOD Clinical Practice Guideline for the Management of Major Depressive Disorder from the Department of Veterans Affairs & Department of Defense.
The Clinical Practice Guideline may be accessed HERE.
Published: February 2022
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
Diabetes
Molina Healthcare has adopted the guideline for Diabetes from the American Diabetes Association (ADA).
The Clinical Practice Guideline may be accessed HERE.
Published: January 2015
Revised: January 2025
Molina approved: January 2023, February 2024, January 2025
Heart Failure in Adults
Molina Healthcare has adopted the guideline for Management of Heart Failure from the American College of Cardiology (ACA).
The Clinical Practice Guideline may be accessed HERE.
Published: 2013
Revised: May 2022
Molina approved: January 2023, February 2024, January 2025
You may also visit the web site below for more information.
American College of Cardiology HERE.
Homelessness – Special Health Care Needs
Molina Healthcare has adopted the guideline for Adapting Your General Recommendations for the Care of Homeless Patients from the National Health Care for the Homeless Council.
The Clinical Practice Guideline may be accessed HERE.
Published: 2010
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
You may also visit the web site below for more information.
National Health Care for Homeless Council HERE.
HIV/AIDS
Molina Healthcare has adopted the guideline for Use of Antiretroviral Agents in Adults and Adolescents with HIV from the Department of Health and Human Services.
The Clinical Practice Guideline may be accessed HERE.
Published: April 2015
Revised: September 2024
Molina approved: September 2024, January 2025
Molina Healthcare has adopted the guideline for HIV/AIDS from the National Center for Biotechnology Information.
The Clinical Practice Guideline may be accessed HERE.
Published: January 2024
Revised: July 2024
Molina approved: September 2024, January 2025
You may also visit the web site below for more information.
Clinical Practice Guidelines for HIV/AIDS HERE.
Hypertension
Molina Healthcare has adopted the guideline for Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults from the American College of Cardiology.
The Clinical Practice Guideline may be accessed HERE.
Published: February 2014
Revised: May 2018
Molina approved: January 2023, February 2024, January 2025
Obesity and Weight Management
Molina Healthcare has adopted the guideline for Comprehensive Medical Care of Patients with Obesity from the American Association of Clinical Endocrinologists (AACE).
The Clinical Practice Guideline may be accessed HERE.
Published: July 2016
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
Molina Healthcare has adopted the guideline for Obesity and Weight Management from
The American Academy of Pediatrics (AAP)
The Journal of Obesity and Metabolic Syndrome
The National Institute of Health (NIH)
The American Psychological Association (APA)
The Clinical Practice Guidelines may be accessed below:
Preventing Obesity and Eating Disorders in Adolescents HERE.
Published: September 2016
Revised: June 2022
Molina approved: January 2025
Clinical Practice Guideline for Multicomponent Behavioral Treatment of Obesity and Overweight in Children and Adolescents HERE.
Published: March 2018
Revised: N/A
Molina approved: January 2025
Obesity in Adults: clinical practice guideline HERE.
Published: August 2020
Revised: N/A
Molina approved: January 2025
You may also visit the below websites for additional information on Obesity and Weight Management:
American Academy of Pediatrics (AAP) - HERE.
National Institute of Health (NIH) - HERE.
Opioid Management
Molina Healthcare has adopted the guideline for Use of Medications in the Treatment of Addiction Involving Opioids from the American Society of Addiction Medicine (ASAM).
The Clinical Practice Guideline may be accessedHERE.
Published: June 2015
Revised: January 2020
Molina approved: January 2023, February 2024, January 2025
Molina Healthcare has adopted the guideline CDC Guideline for Prescribing Opioids for Chronic Pain from the Centers for Disease Control and Prevention
The Clinical Practice Guideline may be accessed HERE.
Published: March 2016
Revised: November 2022
Molina approved: January 2023, February 2024, January 2025
Perinatal Care
Molina Healthcare has adopted the guideline for Perinatal Care from the American College of Obstetricians and Gynecologists.
The Clinical Practice Guideline may be accessed HERE.- Guidelines can be reviewed by ACOG members only using a secure password.
Published: July 2012
Revised: September 2017
Molina approved: January 2023, February 2024 , January 2025
Postpartum Care
Molina Healthcare has adopted the guideline for Postpartum Care from The American College of Obstetricians and Gynecologists.
The Clinical Practice Guideline may be accessed HERE.
Published: June 2016
Revised: May 2018
Molina approved: January 2025
Pregnancy Management
Molina Healthcare has adopted the guideline for Routine Prenatal and Postnatal Care from Michigan Quality Improvement Consortium.
The Clinical Practice Guideline may be accessed HERE.
Published: 2018
Revised: June 2022
Molina approved: January 2023, February 2024, January 2025
Schizophrenia
Molina Healthcare has adopted the guideline for Schizophrenia from the American Psychiatric Association.
The Clinical Practice Guideline may be accessed HERE.
Published: 2021
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
Sickle Cell Disease
Molina Healthcare has adopted the guideline for Management of Sickle Cell Disease from the National Heart, Lung, and Blood Institute (NHLBI).
The Clinical Practice Guideline may be accessed HERE.
Published: December 2014
Revised: January 2020
Molina approved: January 2023, February 2024, January 2025
You may also visit the below websites for additional information on Sickle Cell Disease:
American Society of Hematology - HERE.
Centers for Disease Control and Prevention - HERE.
Substance Use Disorder
Molina Healthcare has adopted the guideline for Detoxification and Substance Abuse Treatment from the Substance Abuse and Mental Health Services Administration (SAMHSA).
The Clinical Practice Guideline may be accessed HERE.
Published: October 2015
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
Suicide Prevention
Molina Healthcare has adopted the guideline for Assessment and Management of Patients at Risk for Suicide from the Department of Veterans Affairs & Department of Defense.
The Clinical Practice Guideline may be accessed HERE.
Published: May 2019
Revised: April 2024
Molina approved: January 2023, February 2024, July 2024, January 2025
Trauma-Informed Primary Care
Molina Healthcare has adopted the guideline for Fostering Resilience and Recovery: A Change Package for Advancing Trauma-Informed Primary Care from The National Council for Mental Wellbeing.
The Clinical Practice Guideline may be accessed HERE.
Published: November 2019
Revised: N/A
Molina approved: January 2023, February 2024, January 2025
Therapeutic Foster Care (TFC)
Molina Healthcare has adopted the guidelines below for Therapeutic Foster Care.
The Clinical Practice Guidelines are noted below:
Medical Necessity
1. Medical Necessity Criteria for Admission:
a. The recommended level of care determined using CALOCUS/ECSII shall be used to demonstrate sufficient necessity for admission to the indicated level of care without requiring
additional PA for a period of no less than 30 days,
b. The recommendation for TFC shall come through the CFT practice specified in AMPM Policy 580, i. An interim service plan coordinated through
Integrated Rapid Response can be used to establish this recommendation for admission, prior to the establishment of a full CFT.
c. An assessment, as outlined in AMPM Policy 320-O and AAC Title 9, Chapter 10, which indicates the member has been diagnosed with a behavioral
health condition and indicates symptoms and behaviors to be treated, and
d. Special consideration will be given to children with two or more of following:
i. Multiple out-of-home placements (foster homes, Behavioral Health Residential Facility (BHRF), Behavioral Health Inpatient Facility (BHIF), Residential Treatment Center (RTC), etc.),
ii. History of disruption from a foster home due to behaviors,
iii. One or more hospitalizations due to a behavioral health condition in the last year,
iv. Chronic pattern of suspensions from school, daycare, or day programming,
v. Adoption disruption or potential adoption disruption,
vi. Significant trauma history or trauma-related diagnosis,
vii. Placed or at-risk of placement in a congregate care setting,
viii. At-risk of placement disruption due to behaviors requiring a higher level of supervision,
ix. Identified as a potential victim of trafficking,
x. Criminal justice involvement,
xi. Co-occurring developmental disability, and
xii. At-risk of being removed from their home by Department of Child Safety (DCS) due to
behavioral concerns.
e. As a result of the diagnosed behavioral health condition, there is evidence that the member has a moderate functional impairment as indicated by the CALOCUS/ECSII score and/or other clinical indicators. This moderate functional and/or psychosocial impairment per the behavioral health
assessment and ISP, reviewed and signed by a BHP:
i. Has not improved or cannot be reasonably expected to improve in response to a less intensive level of care, or
ii. Could improve with appropriate community-based treatment but treatment is not available, therefore, warranting a more intensive level of care.
f. Does not require or meet clinical criteria for a higher level of care.
2. Criteria for Continued Stay:
a. An assessment which indicates the member has been diagnosed with a behavioral health condition and indicates symptoms and behaviors to be treated,
b. An expectation by the CFT that continued treatment at the TFC shall improve the member’s condition so that this type of service shall no longer be needed, and
c. The member continues to demonstrate moderate functional or psychosocial impairment as a result of a behavioral health condition.
3. Criteria for Discharge
a. The member demonstrates sufficient symptom or behavior relief as evidenced by completion of the TFC treatment goals,
b. The member’s functional capacity is improved, at minimum, as evidence by an improved CALOCUS/ECSII score and/or other clinical indicators of improved functioning,
c. The member can be safely cared for in a less restrictive level of care, as identified by the CFT,
d. The CFT has identified that appropriate services, providers, and support are available to meet the member’s current behavioral health needs at a less restrictive level of care,
e. There is no evidence to indicate that continued treatment in TFC would improve the member’s clinical outcome,
f. There is potential risk that continued stay in TFC may precipitate regression or decompensation of the member’s condition, or
g. A current assessment of the member’s symptoms, behaviors, and treatment needs by the CFT has established that continued care in TFC is no longer
adequate to provide for the member’s safety and treatment and therefore a higher level of care is necessary.