MedicaidCoverageHigh impact
25-1075 Updated Guidance: Federal Restrictions on Medi-Cal Payments to Prohibited Entities
Health Net·CA · OB-GYN, Family Medicine·Pharmacy
Effective date
Sep 11, 2025
We identified it
Jun 20, 2026
Summary
Effective September 11, 2025, Medi-Cal claims for non-abortion services cannot be submitted to Prohibited Entities (certain reproductive health providers meeting specific criteria) due to federal funding restrictions. Abortion services using specific CPT codes can still be submitted as they are reimbursed by state funds.
Action Required
Immediately: Billing team must stop submitting Medi-Cal claims for non-abortion services to Prohibited Entities (nonprofit reproductive health providers with >$800K in 2023 Medicaid payments who provide abortion services) for dates of service on or after September 11, 2025. Continue submitting abortion-related claims using CPT codes 59840, 59841, 59850-59852, 59855-59857, S0190, S0191, S0199 as these are reimbursed by state funds. Hold claims for non-abortion services from July 4-September 10, 2025 if provider did not obtain preliminary injunction relief.