MedicaidCoverageHigh impact
25-910 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 can still submit claims for abortion-related services using specific codes, but other services may be restricted unless they have court-ordered relief.
Action Required
Immediately: Billing teams at family planning providers must determine if their organization meets 'Prohibited Entity' criteria (nonprofit family planning/reproductive health provider with >$800,000 in 2023 Medicaid payments providing abortions). If affected and without court relief, submit abortion-related claims separately using only codes 59840, 59841, 59850-59852, 59855-59857, S0190, S0191, S0199, including only abortion services and directly related ancillary care. Update billing system to separate these claims from other services.