Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which health care services are provided to low-income individuals pursuant to a schedule of benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, pharmacist services are a benefit under the Medi-Cal program, subject to federal approval, and the rate of reimbursement for pharmacist services is 85% of the fee schedule for physician services, except for medication therapy management (MTM) pharmacist services. Existing law requires the department to implement an MTM reimbursement methodology relating to the dispensing of qualified specialty drugs by an eligible contracting pharmacy, which would be intended to supplement Medi-Cal payments to eligible pharmacies for MTM pharmacist services provided in conjunction with certain specialty drug therapy categories. This bill would additionally require the rate of reimbursement for advanced practice pharmacist services to be the same as the fee schedule for physician services, including MTM pharmacist services. The bill would require the department to implement an MTM reimbursement methodology relating to the use of drugs to ensure that Medi-Cal payments are only made to eligible advanced practice pharmacists or pharmacies for MTM pharmacist services provided in conjunction with certain specialty drug therapy categories. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or disability insurer that offers coverage for pharmacist services to pay or reimburse the cost of the service performed by a pharmacist at an in-network pharmacy or a pharmacist at an out-of-network pharmacy if the insurer has an out-of-network pharmacy benefit. Existing law authorizes this payment or reimbursement when specified conditions are met, including that the coverage otherwise provides reimbursement for identical services performed by other licensed health care providers. This bill would additionally require those health care service plans and disability insurers to pay or reimburse the cost of the service performed by an advanced practice pharmacist enrolled as a provider with the plan or insurer. The bill would authorize payment or reimbursement if the coverage otherwise provides reimbursement for similar services performed by other licensed health care providers, among other requirements. Because a willful violation of the bill's requirements relative to health care service plans would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law, the California Affordable Drug Manufacturing Act of 2020, requires the California Health and Human Services Agency (CHHSA) or its departments to enter into partnerships, in consultation with other state departments as necessary, to increase competition, lower prices, and address shortages in the market for generic prescription drugs, to reduce the cost of prescription drugs for public and private purchasers, taxpayers, and consumers, and to increase patient access to affordable drugs. For purposes of implementing these provisions, existing law authorizes CHHSA and its departments, including the Department of Health Care Access and Information, to enter into exclusive or nonexclusive contracts on a bid or negotiated bases. Existing law exempts these contracts entered into by CHHSA and its departments from the review or approval of any division of the Department of General Services as well as from provisions pertaining to bidding and awarding of state contracts. This bill would prohibit a state agency from awarding a contract, pursuant to the above provisions, on a noncompetitive basis for the purchase or acquisition of an opioid antagonist, as defined, with a contractor that has entered into a multistate settlement agreement for its role in contributing to the opioid epidemic. The bill would make a contract void and unenforceable for a violation of this provision and apply those provisions retroactively to contracts entered into before January 1, 2026.
Existing law establishes, under the Medi-Cal program, certain time and distance standards for specified Medi-Cal managed care covered services, consistent with federal regulations relating to network adequacy standards, to ensure that those services, including certain specialty care, are available and accessible to enrollees of Medi-Cal managed care plans in a timely manner. Existing law sets forth other timely access requirements for health care service plans and health insurers, including with regard to referrals to a specialist. Existing law establishes various health professions development programs, within the Department of Health Care Access and Information, for the promotion of education, training, and recruitment of health professionals to address workforce shortage and distribution needs. Existing law sets forth various provisions for the authorized use of telehealth in the delivery of health care services. This bill would, subject to an appropriation, require the California Health and Human Services Agency, in collaboration with the Department of Health Care Access and Information and the State Department of Health Care Services, to establish a demonstration project for a grant program. Under the bill, the grant program would be aimed at facilitating a telehealth and other virtual services specialty care network or networks that are designed to serve patients of safety-net providers consisting of qualifying providers, as defined. Under the bill, the purpose of the demonstration project would be to improve access to specialty care for Medi-Cal beneficiaries through development of a financially sustainable specialty care network or networks that are focused on serving the needs of the health care safety net. The bill would authorize the focus of the project to include increasing access to behavioral and maternal health services and additional specialties prioritized by the agency. The bill would state the intent of the Legislature that implementation of the demonstration project would facilitate compliance with any applicable network adequacy standards. The bill would require the agency to administer the grant program to award grant funds to one or more grantees based on an application process and by meeting specified conditions. The bill would require a grantee to use the funds to develop a network or networks by, among other things, providing health information technology and technical assistance to support both the specialists and any primary care provider care coordination, referral, or electronic consultations. The bill would require the agency to arrange an independent evaluation of the demonstration project. The bill would require the evaluation to examine the extent to which the project was successful in achieving certain objectives, including, among others, reducing structural barriers to access experienced by patients. The bill would require a grantee to report data and information to allow for monitoring and evaluation of the project. The bill would require the agency to ensure that lessons learned, recommendations, and best practices from the project are publicly disseminated to inform the development of a telehealth and specialty care network or networks to serve the needs of the health care safety net.
Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes the willful violation of its provisions a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or health insurance policy that provides coverage for outpatient prescription drugs to cover medically necessary prescription drugs. For a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2026, this bill would prohibit a health care service plan, health insurer, or pharmacy benefit manager from engaging in specified steering practices, including, among others, requiring an enrollee or insured to use a retail pharmacy for dispensing prescription oral medications, as specified, and imposing any requirements, conditions, or exclusions that discriminate against an in-network physician in connection with dispensing prescription oral medications. The bill would require a health care provider, physician's office, clinic, or infusion center to obtain consent from an enrollee or insured and disclose a good faith estimate of the enrollee's or insured's applicable cost-sharing amount before supplying or administering an injected or infused medication to an enrollee or insured, or sending an enrollee or insured to receive an injected or infused medication, if the setting or manner of administration is different than the setting or manner of administration for which the health care service plan, health insurer, or pharmacy benefit manager directed the enrollee or insured, as specified. Because a willful violation of these provisions relative to health care service plans would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law requires the State Department of Public Health to establish a program for the development, provision, and evaluation of genetic disease testing. Existing law establishes the continuously appropriated Genetic Disease Testing Fund (GDTF) , consisting of fees paid for newborn screening tests, and states the intent of the Legislature that all costs of the genetic disease testing program be fully supported by fees paid for newborn screening tests, which are deposited in the GDTF. Existing law also authorizes moneys in the GDTF to be used for the expansion of the Genetic Disease Branch Screening Information System to include cystic fibrosis, biotinidase, severe combined immunodeficiency (SCID) , adrenoleukodystrophy (ALD) , and any other disease that is detectable in blood samples, as specified, and exempts the expansion of contracts for this purpose from certain provisions of the Public Contract Code, the Government Code, and the State Administrative Manual, as specified. This bill would require the department to expand statewide screening of newborns to include screening for Duchenne muscular dystrophy as soon as possible, but no later than January 1, 2027. By expanding the purposes for which moneys from the GDTF may be expended, this bill would make an appropriation.
Existing law establishes the licensure and regulation of health facilities by the State Department of Public Health, including, among others, general acute care hospitals. A violation of these provisions is a crime. Under existing law, a general acute care hospital is required to provide certain basic services, including medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services. Existing law authorizes a general acute care hospital to provide various special or supplemental services if certain conditions are met. Existing regulations define a supplemental service as an organized inpatient or outpatient service that is not required to be provided by law or regulation. This bill would, beginning ____, include perinatal services as a basic service. The bill would require, on or before ____, the department to establish a process to approve or deny a "perinatal service compliance plan" to meet the requirement to provide perinatal services. The bill would require, on or before ____, any general acute care hospital that does not provide perinatal services to submit a "perinatal service compliance plan to the department, with specified information. By expanding the scope of a crime, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law grants the sole authority in state government to the State Department of Health Care Services to certify alcohol or other drug programs and to license adult alcohol or other drug recovery or treatment facilities. Existing law requires the department to adopt the American Society of Addiction Medicine (ASAM) treatment criteria, or an equivalent evidence-based standard, as the minimum standard of care for licensed facilities and requires a licensee to maintain those standards with respect to the level of care to be provided by the licensee. This bill would similarly require the department to adopt the ASAM treatment criteria, or an equivalent evidence-based standard, as the minimum standard of care for alcohol or other drug programs certified by the department. The bill would also require certified programs to maintain those standards with respect to the level of care to be provided by the certified program. The bill would authorize the department to implement these provisions by means of plan or provider bulletins or similar instructions until regulations are adopted and would require that regulations be adopted by January 1, 2027.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of disability insurers by the Department of Insurance. Existing law generally authorizes a health care service plan or disability insurer to use prior authorization and other utilization review or utilization management functions, under which a licensed physician or a licensed health care professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity. This bill, upon communication of a decision by a health care service plan or health insurer delaying, denying, or modifying a health care service based in whole or in part on medical necessity, would authorize a provider to request review of the decision by a licensed physician, or a licensed health care professional under specified circumstances, who is competent to evaluate the specific clinical issues involved in the health care service being requested, and is of the same or similar specialty as the requesting provider. The bill would authorize a licensed health care professional to be the reviewer if the provider requesting peer-to-peer review is not a physician. The bill, notwithstanding any other law, would require these reviews to occur within 2 business days, or if an enrollee or insured faces an imminent and serious threat to their health, within a timely fashion appropriate for the nature of the enrollee's or insured's condition, as specified. If a health care service plan or health insurer fails to meet those timelines, the bill would deem the request for the health care service as approved and supersede any prior delay, denial, or modification. Because a violation of these provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law, the Nursing Practice Act, establishes the Board of Registered Nursing to license and regulate the practice of nursing. The act prohibits a person from engaging in the practice of nursing without an active license but authorizes a student to render nursing services incidental to the student's course of study, as specified. This bill would additionally authorize a student to render nursing services if the student is a resident of the state and enrolled in a prelicensure distance education nursing program based at an out-of-state private postsecondary educational institution, as defined, for the purpose of gaining clinical experience in a clinical setting that meets certain criteria, including that the program is accredited by a programmatic accreditation entity recognized by the United States Department of Education and that the program maintains minimum faculty to student ratios required of board-approved programs for inperson clinical experiences. The bill would require the student to be supervised in person by a registered nurse licensed by the board while rendering nursing services. The bill would prohibit a clinical agency or facility from offering clinical experience placements to an out-of-state private postsecondary educational institution if the placements are needed to fulfill the clinical experience requirements of in-state students enrolled in a board-approved nursing program.
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. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law, subject to any necessary federal approvals, sets forth various Medi-Cal provisions relating to complex rehabilitation technology (CRT) , which is a form of durable medical equipment, including, but not limited to, complex rehabilitation manual and power wheelchairs. Existing law requires a CRT provider to comply with certain standards, including with regard to CRT repairs. Existing law authorizes the department to adopt any utilization controls for CRT, as appropriate. This bill would prohibit the department from requiring prior authorization for the repair of a CRT-powered wheelchair if the cost of the repair does not exceed $1,250. Under the bill, a treatment authorization request for repair or replacement of a CRT-powered wheelchair would not require an individual prescription or documentation of medical necessity from the treating practitioner if the CRT-powered wheelchair has already been approved for use by the patient. For repair of a CRT-powered wheelchair, the bill would require the supplier to document and maintain records of the items being repaired, the reason for the repair, and the labor details, as specified, with the information being subject to a postpayment audit by the department. The bill would set forth other recording requirements for the supplier.
