Medi-Cal: pharmacist services: reporting.

Plain English Breakdown

The bill text does not specify the exact nature of corrective actions beyond enforcement and sanctions.

Medi-Cal: Pharmacist Services Reporting

This law requires Medi-Cal managed care plans to submit annual reports on pharmacist services and for the State Department of Health Care Services to compile these reports, take corrective action if needed, and update coverage guidelines.

What This Bill Does

• Requires each Medi-Cal managed care plan to submit an annual report about pharmacist services they provide that are within their jurisdiction and not covered by the FFS delivery system under the Medi-Cal Rx program.
• Directs the department to compile all submitted reports into a single consolidated report for lawmakers, including information on implementation, compliance, service access, claims processing, oversight, fiscal impact, and public health impact.
• Specifies that if managed care plans do not comply with pharmacist services-related provisions, the department can take corrective action, including enforcement actions and sanctions.
• Requires the department to issue guidance clarifying Medi-Cal managed care plan obligations to cover pharmacist services and update its model evidence of coverage to explicitly include coverage of pharmacist services.

Who It Names or Affects

• Medi-Cal managed care plans
• The State Department of Health Care Services

Terms To Know

Medi-Cal

A health insurance program for low-income people in California, funded by federal and state money.

Managed care plans

Health insurance companies that manage Medi-Cal services for the government.

Limits and Unknowns

• The bill does not specify what happens if managed care plans do not submit their reports.
• It is unclear how much money will be needed to implement these new reporting requirements.
• There are no details on how often or in what form the department can issue guidance.

Official Summary Text

AB 2565, as amended, Wallis.
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 2019 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.
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.
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.
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.

Current Bill Text

Download Bill PDF