What insurance policy changes affect CPT 98960?

There are 18 tracked policy changes affecting CPT 98960, including updates from L.A. Care Health Plan, Anthem BCBS, Molina Healthcare. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 98960?

Payers that have issued tracked updates for CPT 98960 include: L.A. Care Health Plan, Anthem BCBS, Molina Healthcare, Nevada Medicaid, Blue Cross Blue Shield of Rhode Island, Harvard Pilgrim Health Care, Medi-Cal, UnitedHealthcare, Aetna, New Mexico Medicaid, EmblemHealth, Florida Blue.

How do I get notified when CPT 98960 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 98960. You will receive a daily digest email whenever a new policy change references this code.

Why do payers change policies for CPT 98960?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

98960 Insurance Policy Changes

CPT 98960 is referenced in 18 tracked payer policy changes from L.A. Care Health Plan, Anthem BCBS, and 10 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 98960 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

High impact
Unsatisfactory Immigration Status (UIS) Member Transition
L.A. Care Health Plan·Effective Jan 1, 2027
Effective January 1, 2027, L.A. Care Health Plan members with Unsatisfactory Immigration Status (UIS) will transition from Medi-Cal managed care to Medi-Cal Fee-for-Service (FFS). Providers must be enrolled in Medi-Cal FFS through PAVE by January 1, 2027 to continue serving these patients and receive reimbursement. Billing workflows must shift from managed care to FFS processes, and providers should familiarize themselves with FFS billing requirements, rates, and newly available care management billing codes.
High impact
[California] Medi-Cal Managed Care fee-for-service transition for members with unsatisfactory immigration status
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Medi-Cal Managed Care members with unsatisfactory immigration status (UIS) will transition to Medi-Cal fee-for-service (FFS) delivery. Providers must be enrolled in Medi-Cal FFS through PAVE by January 1, 2027, to continue serving these members and receive reimbursement. Billing workflows must shift from managed care to FFS processes, including Treatment Authorization Requests (TARs) and FFS-specific billing codes.
High impact
07-29-2026 DHCS policy guide for transition of the unsatisfactory immigration status population from managed care to Medi-Cal fee-for-service – Version 1.0 IE LA SAC SD
Molina Healthcare·Effective Jan 1, 2027
Effective January 1, 2027, Medi-Cal members with unsatisfactory immigration status (UIS) will transition from managed care plans to Medi-Cal Fee-for-Service (FFS). Providers must enroll in Medi-Cal FFS through DHCS to continue serving these patients and receive reimbursement. Billing workflows, care coordination processes, and prior authorization procedures will shift from managed care to FFS requirements.
High impact
Attention Provider Type 17 (Special Clinics) Specialty 181 (Federally Qualified Health Center): Shadow Billing Updates
Nevada Medicaid·Effective Jan 1, 2026
Nevada Medicaid updated shadow billing codes for Federally Qualified Health Centers (FQHCs) effective January 1, 2026. Key changes include: CPT codes 99205, 99242-99245, and H0049 now billable with both medical and behavioral health encounters; CPT 99401 with Modifier FP added with a 2-unit annual limit; and six codes (59514, 59612, 59620, 59812, 99401 with Modifier CR, G2214) are end-dated and no longer billable. Additionally, CPT codes 98960, 98961, and 98962 are restricted to medical encounters only.
High impact
Payment policy updates
Blue Cross Blue Shield of Rhode Island·Effective Jan 1, 2026
BCBSRI has implemented multiple policy changes affecting preventive services, coding, and reimbursement across various specialties. Key changes include new breast cancer screening coverage requirements, updated STI testing billing procedures, hearing aid coverage increases, and several new CPT/HCPCS codes for various services.
High impact
Update: Telehealth flexibilities for Medicare members
Harvard Pilgrim Health Care·Effective Oct 1, 2025
Point32Health will continue telehealth coverage for Medicare Advantage members as supplemental benefits effective October 1, 2025, regardless of CMS decisions. Specific codes across multiple specialties including cardiac rehab, mental health, physical therapy, and pulmonary rehab will remain eligible for telehealth reimbursement.
High impact
Payment policy updates
Blue Cross Blue Shield of Rhode Island·Effective Oct 1, 2025
Multiple policy updates affecting various services including COVID-19 treatments, bundled services, preventive care, and Medicare Advantage acupuncture coverage. Key changes include CPT code corrections for monoclonal antibodies, new bundling restrictions effective October 2025, and elimination of most acupuncture coverage for Medicare Advantage in 2026.
High impact
Updates to Limitation Error Codes
Nevada Medicaid·Effective Apr 28, 2025
Nevada Medicaid has implemented new service limitation error codes and prior authorization requirements for multiple procedure codes effective April 28, 2025. Key changes include new unit limits for allergy testing and therapy codes, prior auth requirements for psychological testing, and restrictions on who can bill certain codes.
High impact
Reminder: Policy Clarifications for Covered Medi-Cal CHW Services
Medi-Cal·Identified Sep 1, 2026
DHCS has published clarifications on Medi-Cal coverage for Community Health Worker (CHW) services, specifically addressing billing requirements for individual services (CPT 98960, HCPCS G0019/G0022) and group services (CPT 98961/98962), telehealth modality use, and health navigation services. The policy emphasizes that CHWs may now assist members with maintaining Medi-Cal enrollment and enrollment in related assistance programs (CalWORKs, CalFRESH) as part of covered health navigation services.
Medium impact
Pennsylvania Medicaid: Support patients with new CHW services benefit
UnitedHealthcare·Effective Jan 1, 2026
Pennsylvania Medicaid now covers Community Health Worker (CHW) services as a preventive benefit effective January 1, 2026. Billing teams must implement new procedure code 98960–U2 (or T1015 for certain clinic settings), limited to 3 units per member per year at $25 per unit, with specific documentation and referral requirements.
Medium impact
Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments (CPB 0788, reviewed 2025-11-19)
Aetna·Effective Nov 19, 2025
Aetna has updated its clinical policy bulletin (CPB 0788) to clarify that 70+ treatments for Alzheimer's disease remain experimental, investigational, or unproven and are not covered. The policy provides a comprehensive list of non-covered procedures and their associated billing codes, including deep brain stimulation, stem cell therapy, various immunotherapies, and pharmacological interventions. Billing teams must ensure claims for these treatments are denied or require prior authorization review based on patient coverage terms.
Medium impact
Payment Policies
Blue Cross Blue Shield of Rhode Island·Effective Sep 1, 2025
BCBSRI now requires lactation consultation services to be billed with the mother as the patient, not the infant. Claims submitted under infants (ages 0-12 months) will be denied, and only one unit of CPT 98960 per date of service will be reimbursed.
Medium impact
Supplement 25-10: Implementation of Community Health Worker (CHW) and Community Health Representatives (CHR) Updates Per Repeal and Replace Letter of Direction
New Mexico Medicaid·Effective Aug 25, 2025
New Mexico Medicaid now covers Community Health Worker (CHW) and Community Health Representative (CHR) services starting August 25, 2025. CHWs/CHRs must enroll as Provider Type 462/Specialty 230, obtain DOH certification, and can bill CPT codes 98960-98962 for patient education services with physician orders or standing orders.
Medium impact
Chronic Disease Self-Management Program for Medicaid and HARP
EmblemHealth·Effective Jun 1, 2025
EmblemHealth will begin covering the Chronic Disease Self-Management Program (CDSMP) for Medicaid and HARP members age 18+ with arthritis diagnoses starting June 1, 2025, using CPT code 98960. This is a new covered benefit for evidence-based group and individual chronic disease management services.
Medium impact
Attention Provider Type 17 (Special Clinics) Specialty 174 (Public Health Clinic): Update Regarding Claims for Education and Training
Nevada Medicaid·Effective May 19, 2025
Nevada Medicaid now allows Public Health Clinics (Provider Type 17, Specialty 174) to submit claims for patient education and training codes 98960-98962 without automatic suspension, effective May 19, 2025. Previously suspended claims dating back to June 2022 have been released for reprocessing.
Medium impact
Attention Provider Type 60 (School Health Services): Modifier GN is No Longer Required on Claims for Procedure Codes 98960, 98961, and 98962
Nevada Medicaid·Effective Apr 7, 2025
Nevada Medicaid has eliminated the requirement for modifier GN on CPT codes 98960, 98961, and 98962 when billed by School Health Services providers (type 60). This change allows non-speech language pathologists to bill these patient education codes without the outpatient speech language service modifier.
Medium impact
Improve Behavioral Health Outcomes with Accurate Reporting
Florida Blue·Identified Jun 16, 2026
Florida Blue updated guidelines for behavioral health HEDIS reporting, emphasizing accurate documentation and coding for mental health and substance use disorder treatments. The policy highlights specific CPT codes 98960-98962 and HCPCS code G0155 for behavioral health screenings and follow-up visits to improve quality scores and patient outcomes.
Medium impact
Coming Soon: Important Policy Reminders and Clarifications for Covered Medi-Cal CHW Services
Medi-Cal·Identified May 3, 2026
California DHCS is updating the Medi-Cal Provider Manual to clarify billing requirements for Community Health Worker (CHW) preventive services, including individual and group billing procedures using specific CPT and HCPCS codes, and telehealth usage guidelines.

All billing codes J3590 99213 99214 99212 99202 99203

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Unsatisfactory Immigration Status (UIS) Member Transition

[California] Medi-Cal Managed Care fee-for-service transition for members with unsatisfactory immigration status

07-29-2026 DHCS policy guide for transition of the unsatisfactory immigration status population from managed care to Medi-Cal fee-for-service – Version 1.0 IE LA SAC SD

Attention Provider Type 17 (Special Clinics) Specialty 181 (Federally Qualified Health Center): Shadow Billing Updates

Payment policy updates

Update: Telehealth flexibilities for Medicare members

Payment policy updates

Updates to Limitation Error Codes

Reminder: Policy Clarifications for Covered Medi-Cal CHW Services

Pennsylvania Medicaid: Support patients with new CHW services benefit

Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments (CPB 0788, reviewed 2025-11-19)

Payment Policies

Supplement 25-10: Implementation of Community Health Worker (CHW) and Community Health Representatives (CHR) Updates Per Repeal and Replace Letter of Direction

Chronic Disease Self-Management Program for Medicaid and HARP

Attention Provider Type 17 (Special Clinics) Specialty 174 (Public Health Clinic): Update Regarding Claims for Education and Training

Attention Provider Type 60 (School Health Services): Modifier GN is No Longer Required on Claims for Procedure Codes 98960, 98961, and 98962

Improve Behavioral Health Outcomes with Accurate Reporting

Coming Soon: Important Policy Reminders and Clarifications for Covered Medi-Cal CHW Services