MedicaidCoverageHigh impact
25-1073 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 under H.R. 1 now prohibit Medi-Cal payments to certain reproductive health providers for non-abortion services as of September 11, 2025, after court injunctions were stayed. Billing teams must stop submitting claims for non-abortion services from these prohibited entities but continue submitting abortion-related claims using specific codes.
Action Required
Immediately: Billing teams must stop submitting Medi-Cal claims for non-abortion services from prohibited entities (nonprofit family planning providers that received over $800,000 in Medicaid payments in FY 2023) for services rendered on or after September 11, 2025. Continue submitting abortion services claims using CPT codes 59840, 59841, 59850-59852, 59855-59857, and HCPCS codes S0190, S0191, S0199, ensuring these are submitted separately from other services. Hold claims for non-abortion services from prohibited providers rendered July 4-September 10, 2025 unless the provider obtained preliminary injunction relief.