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's requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law also provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services through, among other things, managed care plans licensed under the act that contract with the State Department of Health Care Services.
Existing law sets forth specified coverage requirements for health care service plan contracts and health insurance policies. Existing law generally authorizes a health care service plan or health insurer to use utilization controls to approve, modify, delay, or deny requests for health care services based on medical necessity. Existing law requires health care service plans and health insurers, as specified, within 6 months after the relevant department issues specified guidance, or no later than March 1, 2025, to require all of their staff who are in direct contact with enrollees or insureds in the delivery of care or enrollee or insured services to complete evidence-based cultural competency training for the purpose of providing trans-inclusive health care for individuals who identify as transgender, gender diverse, or intersex.
This bill would require a health care service plan contract, including a Medi-Cal managed care plan contract, or health insurance policy issued, amended, renewed, or delivered on or after January 1, 2026, to cover up to a 12-month supply of a United States Food and Drug Administration (FDA) -approved prescription hormone therapy, and the necessary supplies for self-administration, that is prescribed by a network provider within their scope of practice and dispensed at one time, as specified. The bill would prohibit a plan or insurer from imposing utilization controls or other forms of medical management limiting the supply of this hormone therapy to an amount that is less than a 12-month supply, but would not prohibit a contract or policy from limiting refills that may be obtained in the last quarter of the plan or policy year if a 12-month supply of the prescription hormone therapy has already been dispensed during that year. The bill would require the State Department of Health Care Services to seek federal approval, if necessary, and to issue all-plan letters or similar instructions to implement these provisions for Medi-Cal managed care plans.
This bill would prohibit a subscriber, enrollee, policyholder, or insured from being excluded from enrollment or participation in, being denied the benefits of, or being subjected to discrimination by, any health care service plan or health insurer licensed in this state, on the basis of race, color, national origin, age, disability, or sex. The bill would define discrimination on the basis of sex for those purposes to include, among other things, sex characteristics, including intersex traits, pregnancy, and gender identity. The bill would prohibit a health care service plan or health insurer from taking specified actions relating to providing access to health programs and activities, including, but not limited to, denying or limiting health care services to an individual based upon the individual's sex assigned at birth, gender identity, or gender otherwise recorded. The bill would prohibit a health care service plan or health insurer, in specified circumstances, from taking various actions, including, but not limited to, denying, canceling, limiting, or refusing to issue or renew health care service plan enrollment, health insurance coverage, or other health-related coverage, or denying or limiting coverage of a claim, or imposing additional cost sharing or other limitations or restrictions on coverage, on the basis of race, color, national origin, sex, age, or disability, as specified. Because a violation of the bill's requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
Existing law requires a pharmacist to dispense, at a patient's request, up to a 12-month supply of an FDA-approved, self-administered hormonal contraceptive pursuant to a valid prescription that specifies an initial quantity followed by periodic refills.
This bill would additionally require a pharmacist to dispense, at a patient's request, up to a 12-month supply of an FDA-approved, prescription hormone therapy pursuant to a valid prescription that specifies an initial quantity followed by periodic refills, unless an exception is met.
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.

Statutes affected:
06/23/25 - Amended Assembly: 4064.5 BPC, 4064.5 BPC, 14000.01 WIC, 14000.01 WIC