MedicaidCoverageHigh impact
25-911 Critical Update: How New Federal Restrictions May Affect Your Medi-Cal Payments
Health Net·CA · OB-GYN, Family Medicine·Prior Authorization
Effective date
Jul 4, 2025
We identified it
Jun 20, 2026
Summary
New federal law H.R. 1 restricts Medicaid payments to certain family planning providers ("Prohibited Entities") for one year starting July 4, 2025. Providers affected by this restriction can only submit claims for specific abortion-related services using designated CPT codes, unless they received court relief.
Action Required
Immediately: Billing teams at affected providers must determine if their organization meets "Prohibited Entity" criteria (nonprofit family planning/reproductive health provider with >$800k in 2023 Medicaid payments providing abortions). If affected and without court relief, separate abortion-related claims using only codes 59840, 59841, 59850-59852, 59855-59857, S0190, S0191, S0199 from all other services. Submit these claims separately and include only abortion services and directly related ancillary care. Continue processing claims for services provided before July 4, 2025 normally.