MedicaidCoverageHigh impact
25-1074 Updated Guidance: Federal Restrictions on Medi-Cal Payments to Prohibited Entities
Health Net·CA · OB-GYN, Family Medicine·Prior Authorization
Effective date
Sep 11, 2025
We identified it
Jun 20, 2026
Summary
Federal restrictions now prohibit Medi-Cal payments to certain family planning providers for non-abortion services as of September 11, 2025, following court injunction stays. Providers classified as Prohibited Entities can only submit claims for abortion services using specific CPT codes, while non-abortion service claims must not be submitted.
Action Required
Immediately: Billing teams must identify if their practice qualifies as a Prohibited Entity (501c3 nonprofit, primarily family planning/reproductive health, provides abortion services except rape/incest/life-threatening, received >$800K Medicaid in FY2023). If yes, stop submitting all Medi-Cal claims for non-abortion services rendered on/after September 11, 2025. Only submit abortion-related claims using CPT codes 59840, 59841, 59850-59852, 59855-59857, S0190, S0191, S0199. Hold claims for non-abortion services from July 4-September 10, 2025 unless preliminary injunction relief was obtained. Failure to comply will result in claim denials and payment restrictions.