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26-156 Provider Communications Posted Online and Operations Manual Updates for January 2026

Date: 02/06/26

Access the Provider Library for the latest operational and Plan updates and changes to better service your patients

The tables below outline provider communications posted online and operations manual changes made in January 2026.

Communications posted online: Includes the posting date, material number and title, type of notice, applicable audience and lines of business, and a summary of the communication.
Provider operations manual changes (for physicians and practitioners, participating physician groups (PPGs), hospitals, and ancillary providers): Includes the effective date of the change, document name (and path to section where document is located), audience, affected lines of business and URLs, and a summary of the change.

Communications posted online in January 2026

Date, number and title	Type of notice	Audience	Lines of business¹	Summary
1/2/26 26-019m, Medication Trend Updates and Drug List/Formulary Changes – 1st Quarter 2026	Contractual	Physicians/ Practitioners PPGs	IFP (Ambetter HMO/PPO) Employer Group (HMO/POS, PPO) Medi-Cal (all counties) Molina	Discover changes for the formulary and any new medication safety issues to be aware of for the 1st quarter of 2026.
1/5/26 26-001m, Site of Care Optimization for Therapeutic Infusions (SCOTI) – 1st Quarter 2026	Contractual	Physicians/ Practitioners PPGs Hospitals Ancillary Behavioral Health	IFP (Ambetter HMO/PPO) Employer Group (HMO/POS, PPO)	Learn about new options for therapeutic infusion care, including home and alternative sites, available to your eligible patients through Coram® CVS Specialty™ Infusion Services starting 1/1/26.
1/21/26 26-063m, Essential Resources for Medi-Cal Providers	News & Announcements	Physicians/ Practitioners PPGs Hospitals Ancillary ECM CS Behavioral Health	Medi-Cal (all counties) Molina	Medi-Cal provider materials have been updated and are available on the New Providers Onboarding Materials.
1/23/26 26-058m (PDF), Updates to Clinical Policies – December 2025	Contractual	Physicians/ Practitioners PPGs Behavioral Health	IFP (Ambetter HMO/PPO) Employer Group (HMO/POS, PPO) Medi-Cal (all counties) Molina	Review changes to medical policies for procedures and services for December 2025. Medical policies are available online at Medical policies. Medical policies offer guidelines for determining medical necessity for certain procedures, equipment and services. As a reminder, all services must be medically necessary, and member benefits, legal and regulatory mandates take precedence over content of medical policies and must be applied first.

¹Medi-Cal (all counties) indicates that the communication applies to Medi-Cal Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.

Provider operations manual changes in January 2026

Effective Date	*Document name (and path)*	Audience²	Lines of business and Link	Summary
1/1/26	Sensitive Services (under Benefits > Access to Sensitive Services)	All	Medi-Cal	Added “HIV test result disclosure” section, which clarifies how HIV test results can be disclosed for Medi-Cal patients and the type of patient authorization required. These changes are driven by Senate Bill (SB) 0278, effective 1/1/26.
1/1/26	Reimbursement Timelines and Penalties for Late Claims (under Claims and Provider Reimbursement > Reimbursement)	All	HMO, PPO, Medi-Cal	Updated timelines and information for claims reimbursement and penalties for non-adherence as of 1/1/26, based on Assembly Bill (AB) 3275.
1/1/26	Parity Cost Shares (under Benefits > Behavioral Health)	PPGs Hospitals	HMO, PPO	New document explains how capitated/delegated PPGs and hospitals must ensure claims payments for applicable services to comply with the Mental Health Parity and Addiction Equity Act and related final rule.
1/1/26	Birth Centers (under Benefits > Maternity)	All	Medi-Cal Birth Centers Covered Services	New document outlines hospital transfer policies, licensing standards and reimbursement details. Added link to this document in the “Freestanding Birth Centers” section of Nurse Midwife > Covered Services document. The changes were driven by AB 55, effective 1/1/26.
1/1/26	Transitional Rent (under Benefits)	All	Medi-Cal	New document describes Transitional Rent benefit. Eligible Medi-Cal members can receive up to six months of Transitional Rent assistance to support housing stability.
1/1/26	Community Supports (under CalAIM)	All	Medi-Cal	Updated document descriptions and eligibility criteria for CS services, based on regulatory and Plan changes. Changes included the addition of Transitional Rent and the removal of Community or Home Transition services.
1/1/26	Enteral Nutrition	All	Medi-Cal	Updated prior authorization timeline information in these documents to seven calendar days for Medi-Cal and Medicare, per the Centers for Medicare & Medicaid Services Final Rule CMS-0057-F, effective 1/1/26. The inpatient and outpatient Medi-Cal Prior Authorization forms were also updated and are available under the Forms and References section of the Provider Library at Forms and References.
Prior Authorization	Physicians/ Practitioners PPGs Hospitals	Requesting Prior Authorization or Coordinating a PCP Referral Medi-Cal
All	Prior Authorization Process for Direct Network Providers HMO
Provider Oversight	PPGs	Authorization and Referral Timelines Medi-Cal HMO, PPO
1/1/26	Benefits	Physicians/ Practitioners PPGs Ancillary	Acupuncture Services HMO, PPO	Updated text in these documents to reflect requirements in Department of Managed Health Care All Plan Letter (APL) 25-004, AB 118: Part 1 - Compliance with Large Group Standardized Evidence of Coverage/Disclosure Form, which pertains to use of standardized language in various health plan documents. Changes included updates to the following glossary terms: Approved Clinical Trial Emergency Evidence of Coverage Medical necessity Not Medically Necessary and Not Investigational Participating Provider Psychiatric Emergency Medical Condition
Physicians/ Practitioners PPGs	Chiropractic > Coverage Explanation HMO, PPO
All	Behavioral Health HMO PPO
All	Behavioral Health > Overview HMO, PPO
Physicians/ Practitioners PPGs (HMO only) Hospitals Ancillary	Behavioral Health > Obtaining Behavioral Health and or Substance Abuse Care HMO PPO
All	Essential Health Benefits HMO, PPO
Physicians/ Practitioners PPGs Ancillary	Family Planning > Overview HMO, PPO
All	General Benefit Exclusions and Limitations HMO, PPO
Physicians/ Practitioners PPGs	Vision > Overview HMO, PPO
Eligibility	PPGs	Suspension of Coverage Letter HMO, PPO
Enrollment	All	Subscriber and Member Identification Numbers HMO, PPO
Glossary	All	HMO, PPO, Medi-Cal
Member Rights and Resources	All	HMO, PPO Member Rights and Responsibilities Member Rights and Responsibilities Overview
All	Advanced Directives HMO, PPO
All	Advanced Directives > Provider Responsibilities and Procedures HMO, PPO
Medical Records	Physicians/ Practitioners Hospitals Ancillary	HMO, PPO
All	Advanced Directives HMO, PPO
All	Medical Record Forms and Aids HMO, PPO
Provider Oversight	All	Service and Quality Requirements > Access to Care and Availability Standards HMO PPO
Utilization Management	Physicians/ Practitioners PPGs Hospitals	Continuity of Care HMO, PPO
All	Notification of Hospital Admissions HMO PPO
1/8/26	Injectables (under Forms and References)	All	HMO, PPO, Medi-Cal (PDF)	Updated Injectable Medication HCPCS/Division of Financial Responsibility (DOFR) Crosswalk for the third quarter of 2025.

Effective Date

Document name (and path)

Audience²

Lines of business and Link

Summary

1/1/26

Sensitive Services

(under Benefits > Access to Sensitive Services)

All

Medi-Cal

Added “HIV test result disclosure” section, which clarifies how HIV test results can be disclosed for
Medi-Cal patients and the type of patient authorization required. These changes are driven by Senate Bill (SB) 0278, effective 1/1/26.

1/1/26

Reimbursement Timelines and Penalties for Late Claims
(under Claims and Provider Reimbursement > Reimbursement)

All

HMO, PPO, Medi-Cal

Updated timelines and information for claims reimbursement and penalties for non-adherence as of 1/1/26, based on Assembly Bill (AB) 3275.

1/1/26

Parity Cost Shares

(under Benefits > Behavioral Health)

PPGs

Hospitals

HMO, PPO

New document explains how capitated/delegated PPGs and hospitals must ensure claims payments for applicable services to comply with the Mental Health Parity and Addiction Equity Act and related final rule.

1/1/26

Birth Centers
(under Benefits > Maternity)

All

Medi-Cal

Birth Centers

Covered Services

New document outlines hospital transfer policies, licensing standards and reimbursement details. Added link to this document in the “Freestanding Birth Centers” section of Nurse Midwife > Covered Services document. The changes were driven by AB 55, effective 1/1/26.

1/1/26

Transitional Rent

(under Benefits)

All

Medi-Cal

New document describes Transitional Rent benefit. Eligible Medi-Cal members can receive up to six months of Transitional Rent assistance to support housing stability.

1/1/26

Community Supports

(under CalAIM)

All

Medi-Cal

Updated document descriptions and eligibility criteria for CS services, based on regulatory and Plan changes. Changes included the addition of Transitional Rent and the removal of Community or Home Transition services.

1/1/26

Enteral Nutrition

All

Medi-Cal

Updated prior authorization timeline information in these documents to seven calendar days for Medi-Cal and Medicare, per the Centers for Medicare & Medicaid Services Final Rule CMS-0057-F, effective 1/1/26. The inpatient and outpatient Medi-Cal Prior Authorization forms were also updated and are available under the Forms and References section of the Provider Library at Forms and References.

Prior Authorization

Physicians/
Practitioners

PPGs

Hospitals

Requesting Prior Authorization or Coordinating a PCP Referral

Medi-Cal

All

Prior Authorization Process for Direct Network Providers

Provider Oversight

PPGs

Authorization and Referral Timelines

1/1/26

Benefits

Physicians/
Practitioners

PPGs

Ancillary

Acupuncture Services

HMO, PPO

Updated text in these documents to reflect requirements in Department of Managed Health Care All Plan Letter (APL) 25-004, AB 118: Part 1 - Compliance with Large Group Standardized Evidence of Coverage/Disclosure Form, which pertains to use of standardized language in various health plan documents.

Changes included updates to the following glossary terms:

Approved Clinical Trial
Emergency
Evidence of Coverage
Medical necessity
Not Medically Necessary and Not Investigational
Participating Provider
Psychiatric Emergency Medical Condition

Physicians/
Practitioners

PPGs

Chiropractic > Coverage Explanation

HMO, PPO

All

Behavioral Health

All

Behavioral Health > Overview

HMO, PPO

Physicians/
Practitioners

PPGs (HMO only)

Hospitals

Ancillary

Behavioral Health > Obtaining Behavioral Health and or Substance Abuse Care

All

Essential Health Benefits

HMO, PPO

Physicians/
Practitioners

PPGs

Ancillary

Family Planning > Overview

HMO, PPO

All

General Benefit Exclusions and Limitations

HMO, PPO

Physicians/
Practitioners

PPGs

Vision > Overview

HMO, PPO

Eligibility

PPGs

Suspension of Coverage Letter

HMO, PPO

Enrollment

All

Subscriber and Member Identification Numbers

HMO, PPO

Glossary

All

HMO, PPO, Medi-Cal

Member Rights and Resources

All

HMO, PPO

Member Rights and Responsibilities

Member Rights and Responsibilities Overview

All

Advanced Directives

HMO, PPO

All

Advanced Directives > Provider Responsibilities and Procedures

HMO, PPO

Medical Records

Physicians/
Practitioners

Hospitals

Ancillary

HMO, PPO

All

Advanced Directives

HMO, PPO

All

Medical Record Forms and Aids

HMO, PPO

Provider Oversight

All

Service and Quality Requirements > Access to Care and Availability Standards

Utilization Management

Physicians/
Practitioners

PPGs

Hospitals

Continuity of Care

HMO, PPO

All

Notification of Hospital Admissions

1/8/26

Injectables

(under Forms and References)

All

HMO, PPO, Medi-Cal (PDF)

Updated Injectable Medication HCPCS/Division of Financial Responsibility (DOFR) Crosswalk for the third quarter of 2025.

²All – The provider operations manual document applies to physicians/practitioners, PPGs, hospitals and ancillary providers, unless noted otherwise.

This information applies to Physicians, Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.

Last Updated: 02/05/2026

26-156 Provider Communications Posted Online and Operations Manual Updates for January 2026

Access the Provider Library for the latest operational and Plan updates and changes to better service your patients

1Medi-Cal (all counties) indicates that the communication applies to Medi-Cal Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.

2All – The provider operations manual document applies to physicians/practitioners, PPGs, hospitals and ancillary providers, unless noted otherwise.

¹Medi-Cal (all counties) indicates that the communication applies to Medi-Cal Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.

²All – The provider operations manual document applies to physicians/practitioners, PPGs, hospitals and ancillary providers, unless noted otherwise.