Policy UpdatesMedicaidJuly 26, 2023

Proposition 56 directed payments for family planning services

Background

On November 8, 2016, California voters approved Proposition 56 to increase the excise tax rate on cigarettes and tobacco products. Under Proposition 56, a portion of the tobacco tax revenue is allocated to the California Department of Health Care Services (DHCS) for use as the nonfederal share of healthcare expenditures in accordance with the annual state budget process 

DHCS appropriated Proposition 56 funds to support family planning services for Medi-Cal beneficiaries, which DHCS is implementing in managed care in the form of a directed payment arrangement for specified family planning services in accordance with DHCS’ developed payment methodology outlined below. 

Update

The Centers for Medicare & Medicaid Services (CMS) has approved this directed payment arrangement for the rating periods of July 1, 2019, to December 31, 2020, and calendar year (CY) 2021. DHCS has also requested approval from CMS for this directed payment arrangement for CY 2022 and CY 2023. Visit the 
Proposition 56 - Family Planning Services webpage for details. 

Eligible contracted and non-contracted providers will be paid a uniform and fixed dollar add-on amount for specified family planning services. The uniform dollar add-on amounts of the directed payments vary by procedure code:

Procedure 

code[1] 

Description 

Uniform dollar add-on amount 

Dates of service[2] 

J7294

Contraceptive vaginal ring: segesterone acetate and ethinyl estradiol

$301

1/1/2022–ongoing

J7295

Contraceptive vaginal ring: ethinyl estradiol and etonogestrel

$301

1/1/2022–ongoing

J7296

Levonorgestrel-releasing intrauterine contraceptive system, 19.5 mg 

$2,727

7/1/2019–ongoing

J7297

Levonorgestrel-releasing intrauterine contraceptive system, 52 mg

$2,053

7/1/2019–ongoing

J7298

Levonorgestrel-releasing intrauterine contraceptive system, 52 mg

$2,727

7/1/2019–ongoing

J7300

Intrauterine copper contraceptive

$2,426

7/1/2019–ongoing

J7301

Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg

$2,271

7/1/2019–ongoing

J7303

Contraceptive vaginal ring

$301

7/1/2019–12/31/2021

J7304

Contraceptive patch

$110

7/1/2019–12/31/2021

J7304U1

Contraceptive patch: norelgestromin and ethinyl estradiol

$110

1/1/2022–ongoing

J7304U2

Contraceptive patch: levonorgestrel and ethinyl estradiol

$110

1/1/2022–ongoing

J7307

Etonogestrel (contraceptive) implant system, including implant and supplies

$2,671

7/1/2019–ongoing

J3490U5

Emergency contraception: ulipristal acetate, 30 mg

$72

7/1/2019–ongoing

J3490U6

Emergency contraception: levonorgestrel, 0.75 mg (2) and  1.5 mg (1)

$50

7/1/2019–ongoing

J3490U8

Depo-Provera

$340

7/1/2019–ongoing

1197610

Remove contraceptive capsule

$399

7/1/2019–ongoing

1198110

Insert drug implant device

$835

7/1/2019–ongoing

5525010

Removal of sperm duct(s)

$521

7/1/2019–ongoing

5830010

Insert intrauterine device

$673

7/1/2019–ongoing

5830110

Remove intrauterine device

$195

7/1/2019–ongoing

5834010

Catheter for hysterography

$371

7/1/2019–ongoing

5855510

Hysteroscopy diagnosis, separate procedure

$322

7/1/2019–12/31/2019

5856510

Hysteroscopy sterilization

$1,476

7/1/2019–12/31/2019

5860010

Division of fallopian tube

$1,515

7/1/2019–ongoing

5861510

Occlude fallopian tube(s)

$1,115

7/1/2019–ongoing

5866110

Laparoscopy remove adnexa

$978

7/1/2019–ongoing

5867010

Laparoscopy tubal cautery

$843

7/1/2019–ongoing

5867110

Laparoscopy tubal block

$892

7/1/2019–ongoing

5870010

Removal of fallopian tube

$1,216

7/1/2019–ongoing

81025

Urine pregnancy test

$6

7/1/2019–ongoing

How will we process payments?

Providers will receive monthly checks via mail along with remittance advice. 

How will I receive my payment?

Providers will receive payments directly via a direct-to-provider payment process from Anthem Blue Cross (Anthem). Independent physician associations will not receive supplemental payments. If you would like to receive line-level detail for the payments, send an email to prop56@anthem.com and we will send you a secure detail file within two weeks of receipt of your email. Please provide the following information:

  • Billing tax ID(s) 
  • Provider name 
  • Check number 
  • Contact name
  • Contact phone number 
  • Secure email address 

How do I file a provider grievance?

Providers may file grievances up to 180 calendar days from the date the provider becomes aware of the issue by:

  • Calling the Medi-Cal Customer Care Center at 800-407-4627 (outside Los Angeles County) or
     888-285-7801 (inside Los Angeles County). 
  • Visiting the provider website.
  • Faxing the Grievance and Appeals Department at 866-387-2968. 
  • Mailing a letter to:

Anthem Blue Cross

Grievance and Appeals Department

P.O. Box 60007

Los Angeles, CA 90060-0007 

What if I have questions or concerns?

Send Proposition 56-related questions to prop56@anthem.com.



1 Services billed for the following Current Procedural Terminology codes with modifiers UA or UB are excluded from these directed payments: 11976, 11981, 55250, 58300, 58301, 58340, 58555, 58565, 58600, 58615, 58661, 58670, 58671, and 58700.
2 “Ongoing” means the directed payment is in effect, subject to CMS approval and future appropriation of funds by the California legislature, until discontinued by DHCS via an amendment.

CABC-CD-031642-23