MedicaidReimbursementHigh impact
Provider Payment Reductions and Billing Guidelines
L.A. Care Health Plan·CA·Reimbursement
Effective date
Feb 20, 2025
We identified it
Jun 20, 2026
Summary
L.A. Care Health Plan implements a 1% automatic payment reduction on most claims per state mandate, with specific exemptions for family planning, pediatric sub-acute facilities, and services under the new Targeted Rate Increase (TRI) Fee Schedule. Provider Administered Drugs (PADs) billing requirements have been clarified with specific coverage verification responsibilities for providers.
Action Required
Immediately: Billing team must verify all Provider Administered Drugs (PADs) against the Contract Drugs List and Medi-Cal Rx Pharmacy Reimbursable Physician Administered Drugs list before billing. Update billing workflows to route PADs covered under these lists as pharmacy claims, and PADs not covered as medical claims subject to 1% reduction. Contact L.A. Care Direct Network Account Manager or email DirectNetwork@lacare.org for TRI Fee Schedule questions.