MedicaidReimbursementHigh impact
Provider Payment Reductions and Billing Guidelines
L.A. Care Health Plan·CA·Reimbursement
We identified it
Jun 20, 2026
Summary
L.A. Care Health Plan implemented a 1% automatic payment reduction on claims per state mandate, with exemptions for certain services including family planning and services under the new TRI Fee Schedule. Provider Administered Drugs (PADs) billing requirements changed - they must now be verified against specific drug lists to determine if they should be billed as pharmacy or medical claims.
Action Required
Immediately: Billing team must verify all Provider Administered Drugs against the Contract Drugs List and Medi-Cal Rx Pharmacy Reimbursable PAD list before billing. Update billing workflows to check drug lists first - bill as pharmacy claims if on the lists, otherwise bill as medical claims subject to 1% reduction. Contact LACareTRI@lacare.org for TRI Fee Schedule questions and DirectNetwork@lacare.org for general inquiries. Do not assume previous L.A. Care pharmacy coverage guarantees current Medi-Cal Rx coverage.