DHCS APL 25-011: H.R. 1 – Federal Payments to Prohibited Entities
| Date: | November 11, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Providers |
| Type: | Regulatory |
| Subject: | DHCS APL 25-011: H.R. 1 – Federal Payments to Prohibited Entities |
| Business: | Medi-Cal Managed Care |
The Department of Health Care Services (DHCS) issued an All Plan Letter (APL) 25-011: H.R. 1 – Federal Payments to Prohibited Entities, which provides guidance to Medi-Cal managed care plans (MCPs) on handling of payments to Medi-Cal and Family Planning, Access, Care, and Treatment Program (Family PACT) providers who may be impacted by H.R.1, enacted on July 4, 2025. This APL also provides guidance pertaining to a Temporary Restraining Order (TRO) blocking immediate implementation of Section 71113 in H.R. 1, subsequent Preliminary Injunctions (PIs), and recent Order to Stay.
In accordance with APL 25-011, Health Plan is no longer able to reimburse a Prohibited Entity for non-abortion services with dates of service (DOS) on or after September 11, 2025. However, Health Plan will continue to reimburse a Prohibited Entity for abortion services, as they are already covered by State General Funds.
- A “Prohibited Entity” is defined as a tax-exempt (501(c)(3)) community provider primarily offering family planning or reproductive health that also performs abortions (except in cases of rape, incest, or life endangerment), and that received over $800,000 in Medi‑Cal/FPACT federal and state expenditures in Fiscal Year Refer to APL 25-011 for full definition.
Exception for Abortion Services
All providers, including Medi-Cal and Family PACT providers, who meet the definition of “Prohibited Entity” may continue to submit claims or encounters exclusively for procedural and medication abortion, using the procedure codes listed below, as well as all directly related, ancillary services that are provided as part of the procedural or medication abortion claim or encounter in accordance with existing Medi-Cal policy as outlined in the “Abortions” section of the Medi-Cal Provider Manual.
To ensure appropriate adjudication and compliance with federal requirements, claims or encounters for abortion services should be submitted using the procedural codes below on a separate claim or encounter. This claim or encounter must not include any other services that are not directly related to the abortion service.
- 59840, 59841, 59850-59852, 59855-59857, S0190, S0191, and S0199
Claims/Encounter Submission Instructions
For providers who meet the definition of “Prohibited Entity”, please follow the claims/encounter submission instructions below:
| DOS | Abortion Services | Non-Abortion Services |
| On or before July 3, 2025 | Submit claims | Submit claims |
| July 24, 2025 through September 10, 2025 | Submit claims | Providers who obtained relief under either the July 21 or July 28, 2025 Pls: Submit Claims
Providers who did not obtain relief under either the July 21 or the July 28, 2025 Pls: Do not submit claims |
| On or after September 11, 2025 | Submit claims | Do not submit claims |
For complete details regarding APL 25-011, please visit https://www.dhcs.ca.gov/Documents/MCQMD/APL-HR-1-REVISED-9-17-25.pdf.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
