Payments to Medi-Cal Prohibited Entities
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Claims and encounters submitted by providers classified as a Prohibited Entity are processed through Health Net's standard claims adjudication processes.
Prohibited Entities
A provider may be classified as a Prohibited Entity if they meet all of the following criteria:
- Operate as a nonprofit focused on family planning or reproductive health.
- Provide abortion services, except in cases of rape, incest, or life-threatening conditions.
- Received over $800,000 in Medicaid payments during fiscal year 2023.
Permitted activities
All Medi-Cal and Family Planning, Access, Care, and Treatment (PACT) providers, including those affected by H.R. 1, may:
- Assist patients with Presumptive Eligibility for Pregnant People (PE4PP) and Family PACT enrollment.
- Accept eligible patients.
- Deliver services under current Medi-Cal rules, including the prohibition on billing patients directly.
Delegated claims
Providers delegated for claims processing should process claims and encounters submitted by affected providers in accordance with standard Health Net claims processing procedures for covered Medi-Cal services.