22-906 Stay Compliant with No Cost-Share for Abortion Services

Date: 12/01/22

Use correct diagnosis codes to ensure abortion and related services have no cost-share

Effective January 1, 2023, physicians and other providers cannot impose cost-sharing for abortion and abortion-related services.

On March 22, 2022, Senate Bill 245 (the Abortion Accessibility Act) was signed into law for California. The bill prohibits health plans and insurers from:

• Applying patient cost-sharing (deductibles, copayments, coinsurance or any other cost-sharing) to abortion and abortion-related services.
• Requirement of utilization management or utilization review on the coverage for outpatient abortion services.

By removing cost barriers and the need for prior authorization, patients can get better access to available health care, including abortion services.

(Note: High Deductible Health Plans (HDHP) will not apply cost-sharing once the member’s deductible is met)

Bill abortion-related diagnosis codes as primary

Physicians and other providers must bill applicable abortion and abortion-related diagnosis codes as the primary/principal position on the claim.

While specific abortion services can be identified by abortion codes and paid at zero cost share, the pre and post services related to abortion will need to be identified by diagnosis code. The claims systems identify the primary diagnosis code on the claim in order to assign benefits. For pre and post abortion services to apply zero cost share, the abortion-related diagnosis code must be billed as primary.

Diagnosis code list available

To ensure coding accuracy, Health Net* has put together a list of abortion-related diagnosis codes, 22-907, ICD-10-CM Codes for Abortion-Related Services. Note that this list may not be all-inclusive and is subject to change. The list is available in the Provider Library at providerlibrary.healthnetcalifornia.com under Forms and References.

Additional information

Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library after logging in to Health Net’s provider website at provider.healthnetcalifornia.com > Provider Library under Quick Links, or go directly to providerlibrary.healthnetcalifornia.com.

If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days, by phone or through the Health Net provider website as listed in the right-hand column on page 1. 

This information applies to Physicians and Participating Physician Groups (PPGs).