Family planning

Assembly Bill 74 (Ting, Chapter 23, Statutes of 2019), Section 2, Item 4260-101-3305, and Senate Bill 74 (Mitchell, Chapter 6, Statutes of 2020), Section 2, Item 4260-101-3305 appropriated Proposition 56 funds to support family planning services for Medi-Cal beneficiaries. The California Department of Health Care Services (DHCS) is implementing these family planning services in managed care in the form of a directed payment arrangement for specified family planning services in accordance with the DHCS-developed payment methodology outlined within the DHCS All Plan Letter 23-008.

The directed payment program is intended to enhance the quality of patient care by ensuring that providers in California who offer family planning services receive enhanced payment for their delivery of family planning services. Timely access to vital family planning services is a critical component of member and population health. This program is focused on the following categories of family planning services:

• Long-acting contraceptives
• Other contraceptives (other than oral contraceptives) when provided as a medical benefit
• Emergency contraceptives when provided as a medical benefit
• Pregnancy testing
• Sterilization procedures (for females and males)

As a reminder, the following services do not require prior authorization (PA) for in-network providers:

• Emergency services
• Post-stabilization services (if medically necessary)
• Nebulizers
• Family planning/well woman checkups — members may self-refer to any Medicaid provider for the following services:
  • Pelvic and breast examinations
  • Lab work
  • Birth control
  • Genetic counseling
  • FDA-approved devices and supplies related to family planning (such as IUD)
  • HIV/STD screening
• Obstetrical care — no authorization is required for in-network physician visits and routine testing.
• Members not affiliated with an IPA or medical group do not require PA from Anthem Blue Cross for physician referrals to an in-network specialist for consultation or a nonsurgical course of treatment.
• Standard X-rays and ultrasounds
• In-network speech therapy and occupational therapy

Members associated with capitated medical groups must self-refer to services within the group.

Note: Self-referable services may be rendered by a willing provider (even a provider without a contract) unless limited by state or federal regulation. We reimburse contracted providers according to the provider's contract. Noncontracted providers are reimbursed at reasonable and customary rates.

Delegated groups should not deny scheduling appointments for family planning services without authorizations.