Medi-Cal: pharmacist services: reporting., the official text

An act to add Section 14132.967 to the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL'S DIGEST

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 2019 executive order by the Governor.
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.

The people of the State of California do enact as follows:

SECTION 1.
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 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-plan letters, plan letters, or other similar instructions, without taking any further regulatory action.