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<ns0:Id>20250AB__256598AMD</ns0:Id>
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<ns0:ActionText>INTRODUCED</ns0:ActionText>
<ns0:ActionDate>2026-02-20</ns0:ActionDate>
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<ns0:ActionDate>2026-03-19</ns0:ActionDate>
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<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Assembly Member Wallis</ns0:AuthorText>
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<ns0:Name>Wallis</ns0:Name>
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<ns0:Title> An act to add Section 14132.967 to the Welfare and Institutions Code, relating to Medi-Cal.</ns0:Title>
<ns0:RelatingClause>Medi-Cal</ns0:RelatingClause>
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<ns0:Subject>Medi-Cal: pharmacist services: reporting.</ns0:Subject>
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<html:p>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.</html:p>
<html:p>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 2019 executive order by the Governor.</html:p>
<html:p>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.</html:p>
<html: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.</html:p>
<html: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.</html:p>
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<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
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<ns0:Num>SECTION 1.</ns0:Num>
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Section 14132.967 is added to the
<ns0:DocName>Welfare and Institutions Code</ns0:DocName>
,
<ns0:Positioning>immediately preceding Section 14132.968</ns0:Positioning>
, to read:
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(a)
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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.
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(b)
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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 9795 of the Government Code, no later than March 1 of each year. The deadline for the initial consolidated report shall be March 1, 2028.
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(c)
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The consolidated report described in subdivision (b) shall contain all of the following information:
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(1)
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Implementation and compliance, including all of the following:
</html:p>
<html:p>
(A)
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The extent to which the department has implemented Section 14132.968, including identification of any remaining implementation barriers or delays.
</html:p>
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(B)
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The department’s compliance with State Plan Amendments 18-0039, 19-0017, and 20-0036.
</html:p>
<html:p>
(C)
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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.
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<html:p>
(2)
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Access to
pharmacist services, including both of the following:
</html:p>
<html:p>
(A)
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The uniformity of beneficiary access to pharmacist services statewide, including utilization data by service type.
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(B)
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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.
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(3)
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(A)
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Claims payment and processing, including all of the following:
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<html:p>
(i)
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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.
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<html:p>
(ii)
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The primary reasons for claim denials, categorized and quantified.
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<html:p>
(iii)
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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.
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<html:p>
(iv)
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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.
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<html:p>
(v)
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Whether pharmacist services described in subdivision (a) are included in the managed care plan’s provider manuals, billing guidance, and encounter reporting systems.
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(vi)
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The average and median number of days from claim submission to payment or denial, disaggregated by service type
and managed care plan.
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<html:p>
(B)
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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.
</html:p>
<html:p>
(4)
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Oversight and enforcement, including all of the following:
</html:p>
<html:p>
(A)
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The methods used by the department to monitor managed care plan compliance with Section 14132.968.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Any corrective actions taken by the department pursuant to its existing authority, including the type of action and outcome.
</html:p>
<html:p>
(C)
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The number of provider complaints received by the department relating to pharmacist services, categorized by issue type
and resolution status.
</html:p>
<html:p>
(5)
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Fiscal and public health impact, including both of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
The estimated fiscal and public health impacts of underutilization of pharmacist services under the Medi-Cal program.
</html:p>
<html:p>
(B)
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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.
</html:p>
<html:p>
(d)
<html: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.
</html:p>
<html:p>
(e)
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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.
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<html:p>
(f)
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Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 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.
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