20250AB__256597AMD INTRODUCED 2026-02-20 AMENDED_ASSEMBLY 2026-03-19 AMENDED_ASSEMBLY 2026-04-23 2025 AB AMD Introduced by Assembly Member Wallis LEAD_AUTHOR ASSEMBLY Wallis

An act to add

Section 14132.967 to the Welfare and Institutions Code, relating to Medi-Cal. Medi-Cal Medi-Cal: pharmacist services: reporting. Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services through fee-for-service (FFS) or managed care delivery systems. The Medi-Cal program is in part governed by, and funded pursuant to, federal Medicaid program provisions. Under existing law, pharmacist services are a benefit under the Medi-Cal program, subject to federal approval, as specified.

Existing law authorizes the department to provide and administer Medi-Cal pharmacy services under a single statewide FFS delivery system, commonly known as the Medi-Cal Rx program. The department has implemented a transition of Medi-Cal pharmacy services, through Medi-Cal Rx, from managed care to FFS as a result of a executive order by the Governor.

This bill would require the department to require each Medi-Cal managed care plan to submit an annual report to the department containing information about pharmacist services that are within the jurisdiction of managed care plans and not within the jurisdiction of the FFS delivery system under the Medi-Cal Rx program.</xhtml:p><xhtml:p>The bill would require the department to compile the information and to submit an annual consolidated report to the appropriate policy and fiscal committees of the Legislature, as specified.

The bill would require the consolidated report to contain certain information relating to, among other things, implementation, compliance, service access, claims processing, oversight, and fiscal and public health impact.</xhtml:p><xhtml:p>If the department determines that a managed care plan has failed to comply with the pharmacist services-related provisions, the bill would require the department to take appropriate corrective action, including enforcement action and the imposition of sanctions, if a pattern of noncompliance is identified.</xhtml:p>"?> This bill would require the department to issue guidance clarifying Medi-Cal managed care plan obligations to cover pharmacist services, as specified.

The bill would require the department to update its model evidence of coverage to explicitly include coverage of pharmacist services. The bill would also require the department to take appropriate corrective action for failure to comply with existing provisions of law relating to Medi-Cal coverage of pharmacist services or the issued guidance. The bill would authorize the department to implement, interpret, or make specific these provisions by means of all-plan letters, plan letters, or other similar instructions, without taking any further regulatory action.

MAJORITY NO YES NO NO NO NO NO NO NO NO The people of the State of California do enact as follows:

SECTION

Section 14132.967 is added to the Welfare and Institutions Code , immediately preceding

Section 14132.968 , to read: 14132.967. (

a) The department shall issue guidance, including, but not limited to, an all-plan letter or similar instruction, clarifying Medi-Cal managed care plan obligations to cover pharmacist services pursuant to

Section 14132.968 and applicable state plan amendments. (

b) The guidance issued pursuant to subdivision (

a) shall include, at a minimum, all of the following:

(1) Requirements for coverage of pharmacist services consistent with

Section 14132.968 and applicable state plan amendments.

(2) Expectations for timely and appropriate reimbursement of pharmacist services.

(3) Requirements for managed care plans to ensure accountability for coverage of pharmacist services at the delegated entity level, including independent physician associations or other subcontractors, where applicable.

(4) Requirements that coverage of pharmacist services be clearly reflected in provider manuals, billing guidance, and claims processing systems. (

c) The department shall update its model evidence of coverage to explicitly include coverage of pharmacist services described in

Section 14132.968. (

d) If the department determines that a Medi-Cal managed care plan, or its delegated entity, has failed to comply with

Section 14132.968, applicable state plan amendments, or departmental guidance issued pursuant to this section, the department shall take appropriate corrective action pursuant to its existing authority, including enforcement actions and the imposition of sanctions, as appropriate. (

e) Notwithstanding

Chapter 3.5 (commencing with

Section 11340) of Part of Division of Title of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-plan letters, plan letters, or other similar instructions, without taking any further regulatory action. <caml:Num>SECTION 1.</caml:Num><caml:ActionLine action="IS_ADDED" xlink:href="urn:caml:codes:WIC:caml#xpointer(%2Fcaml%3ALawDoc%2Fcaml%3ACode%2F%2Fcaml%3ALawSection%5Bcaml%3ANum%3D'14132.967'%5D)" xlink:label="fractionType: LAW_SECTION" xlink:type="locator">Section 14132.967 is added to the <caml:DocName>Welfare and Institutions Code</caml:DocName>, <caml:Positioning>immediately preceding

Section 14132.968</caml:Positioning>, to read:</caml:ActionLine><caml:Fragment><caml:LawSection id="id_7084167F-5ABF-42AF-ADDC-EF79C2D11C22"><caml:Num>14132.967.</caml:Num><caml:LawSectionVersion id="id_FE359649-7198-4182-B59B-BB69230B432D"><caml:Content><xhtml:p>(a)<xhtml:span class="EnSpace"/>The department shall require each Medi-Cal managed care plan to submit an annual report to the department containing information about pharmacist services provided pursuant to

Section 14132.968 and that are within the jurisdiction of Medi-Cal managed care plans and not within the jurisdiction of the fee-for-service delivery system under the Medi-Cal Rx program.</xhtml:p><xhtml:p>(b)<xhtml:span class="EnSpace"/>The department shall compile the information submitted pursuant to subdivision (

a) and shall submit an annual consolidated report to the appropriate policy and fiscal committees of the Legislature, in accordance with

Section of the Government Code, no later than March of each year. The deadline for the initial consolidated report shall be March 1, 2028.</xhtml:p><xhtml:p>(c)<xhtml:span class="EnSpace"/>The consolidated report described in subdivision (

b) shall contain all of the following information:</xhtml:p><xhtml:p>(1)<xhtml:span class="EnSpace"/>Implementation and compliance, including all of the following:</xhtml:p><xhtml:p>(A)<xhtml:span class="EnSpace"/>The extent to which the department has implemented

Section 14132.968, including identification of any remaining implementation barriers or delays.</xhtml:p><xhtml:p>(B)<xhtml:span class="EnSpace"/>The department’s compliance with State Plan Amendments 18-0039, 19-0017, and 20-0036.</xhtml:p><xhtml:p>(C)<xhtml:span class="EnSpace"/>Whether Medi-Cal managed care plans are complying with departmental guidance relating to pharmacist services, as described in subdivision (a), including any identified instances of noncompliance.</xhtml:p><xhtml:p>(2)<xhtml:span class="EnSpace"/>Access to pharmacist services, including both of the following:</xhtml:p><xhtml:p>(A)<xhtml:span class="EnSpace"/>The uniformity of beneficiary access to pharmacist services statewide, including utilization data by service type.</xhtml:p><xhtml:p>(B)<xhtml:span class="EnSpace"/>Identification of disparities in access by county, region, or underserved area, including rural, urban, and frontier communities, with data disaggregated by geography, beneficiary demographics, and managed care plan, to the extent feasible.</xhtml:p><xhtml:p>(3)<xhtml:span class="EnSpace"/>(A)<xhtml:span class="EnSpace"/>Claims payment and processing, including all of the following:</xhtml:p><xhtml:p>(i)<xhtml:span class="EnSpace"/>The total number of claims submitted for pharmacist services, as described in subdivision (a), disaggregated by service type, and the number of claims paid, denied, or pending.</xhtml:p><xhtml:p>(ii)<xhtml:span class="EnSpace"/>The primary reasons for claim denials, categorized and quantified.</xhtml:p><xhtml:p>(iii)<xhtml:span class="EnSpace"/>Identification of any criteria used by the department or a managed care plan for payment or denial that are inconsistent with

Section 14132.968 or with the applicable State Plan Amendments.</xhtml:p><xhtml:p>(iv)<xhtml:span class="EnSpace"/>The reimbursement rates for each pharmacist service, as described in subdivision (a), as paid by a managed care plan, including identification of any variation by plan or delegated entity.</xhtml:p><xhtml:p>(v)<xhtml:span class="EnSpace"/>Whether pharmacist services described in subdivision (

a) are included in the managed care plan’s provider manuals, billing guidance, and encounter reporting systems.</xhtml:p><xhtml:p>(vi)<xhtml:span class="EnSpace"/>The average and median number of days from claim submission to payment or denial, disaggregated by service type and managed care plan.</xhtml:p><xhtml:p>(B)<xhtml:span class="EnSpace"/>For purposes of this section, reporting requirements shall include data from any delegated entity, independent physician association, or subcontractor responsible for claims processing, credentialing, or utilization management of pharmacist services.</xhtml:p><xhtml:p>(4)<xhtml:span class="EnSpace"/>Oversight and enforcement, including all of the following:</xhtml:p><xhtml:p>(A)<xhtml:span class="EnSpace"/>The methods used by the department to monitor managed care plan compliance with

Section 14132.968.</xhtml:p><xhtml:p>(B)<xhtml:span class="EnSpace"/>Any corrective actions taken by the department pursuant to its existing authority, including the type of action and outcome.</xhtml:p><xhtml:p>(C)<xhtml:span class="EnSpace"/>The number of provider complaints received by the department relating to pharmacist services, categorized by issue type and resolution status.</xhtml:p><xhtml:p>(5)<xhtml:span class="EnSpace"/>Fiscal and public health impact, including both of the following:</xhtml:p><xhtml:p>(A)<xhtml:span class="EnSpace"/>The estimated fiscal and public health impacts of underutilization of pharmacist services under the Medi-Cal program.</xhtml:p><xhtml:p>(B)<xhtml:span class="EnSpace"/>Estimated cost savings forgone by the state resulting from underutilization of pharmacist services, including, but not limited to, tobacco cessation, hypertension management, contraception, immunizations, and other pharmacist-delivered services.</xhtml:p><xhtml:p>(d)<xhtml:span class="EnSpace"/>The consolidated report described in subdivision (

b) shall be made publicly available and shall include only aggregated, deidentified data, as necessary to comply with state and federal privacy requirements.</xhtml:p><xhtml:p>(e)<xhtml:span class="EnSpace"/>If the department determines that a Medi-Cal managed care plan has failed to comply with

Section 14132.968, applicable State Plan Amendments, applicable departmental guidance, or this section, the department shall take appropriate corrective action, including enforcement action and the imposition of sanctions pursuant to

Section 14197.7 or any other applicable provisions, if a pattern of noncompliance is identified.</xhtml:p><xhtml:p>(f)<xhtml:span class="EnSpace"/>Notwithstanding

Chapter 3.5 (commencing with

Section 11340) of Part of Division of Title of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of all-county letters, plan letters, or other similar instructions, without taking any further regulatory action.</xhtml:p></caml:Content></caml:LawSectionVersion></caml:LawSection></caml:Fragment></caml:BillSection>"?>