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Directed payments for family planning services update

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DHCS APL 22-011 – Prop 56 Directed Payments for Family Planning Services

DHCS provided updated guidance on directed payments, funded by the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56), for the provision of specified family planning services with dates of service on or after July 1, 2019.

The Alliance will continue to pay qualified contracted and non-contracted providers a uniform and fixed dollar add-on amount for the specified family planning services (listed below) provided to a Medi-Cal managed care member who is not dually eligible for Medi-Cal and Medicare Part B (regardless of enrollment in Medicare Part A or Part D) with dates of service on or after July 1, 2019, in accordance with the CMS-approved preprint for this program, which will be made available on DHCS’ Directed Payments Program website upon CMS approval.

The uniform dollar add-on amounts of the directed payments vary by procedure code:

Procedure Code Description Uniform Dollar Add- on Amount Dates of Service
J7294 CONTRACEPTIVE VAGINAL RING: SEGESTERONE ACETATE AND ETHINYL ESTRADIOL $301.00 1/1/2022 – Ongoing
J7295 CONTRACEPTIVE VAGINAL RING: ETHINYL ESTRADIOL AND ETONOGESTREL $301.00 1/1/2022 – Ongoing
J7296 LEVONORGESTREL-RELEASING IU COC SYS 19.5 MG $2,727.00 7/1/2019 – Ongoing
J7297 LEVONORGESTREL-RLS INTRAUTERINE COC SYS 52 MG $2,053.00 7/1/2019 – Ongoing
J7298 LEVONORGESTREL-RLS INTRAUTERINE COC SYS 52 MG $2,727.00 7/1/2019 – Ongoing
J7300 INTRAUTERINE COPPER CONTRACEPTIVE $2,426.00 7/1/2019 – Ongoing
J7301 LEVONORGESTREL-RLS INTRAUTERINE COC SYS 13.5 MG $2,271.00 7/1/2019 – Ongoing
J7303 CONTRACEPTIVE VAGINAL RING $301.00 7/1/2019 – 12/31/2021
J7304 CONTRACEPTIVE PATCH $110.00 7/1/2019 – 12/31/2021
J7304U1 CONTRACEPTIVE PATCH: NORELGESTROMIN AND ETHINYL ESTRADIOL $110.00 1/1/2022 – Ongoing
J7304U2 CONTRACEPTIVE PATCH: LEVONORGESTREL AND ETHINYL ESTRADIOL $110.00 1/1/2022 – Ongoing
J7307 ETONOGESTREL CNTRACPT IMPL SYS INCL IMPL & SPL $2,671.00 7/1/2019 – Ongoing
J3490U5 EMERG CONTRACEPTION: ULIPRISTAL ACETATE 30 MG $72.00 7/1/2019 – Ongoing
J3490U6 EMERG CONTRACEPTION: LEVONORGESTREL 0.75 MG (2) & 1.5 MG (1) $50.00 7/1/2019 – Ongoing
J3490U8 DEPO-PROVERA $340.00 7/1/2019 – Ongoing
11976 REMOVE CONTRACEPTIVE CAPSULE $399.00 7/1/2019 – Ongoing
11981 INSERT DRUG IMPLANT DEVICE $835.00 7/1/2019 – Ongoing
58300 INSERT INTRAUTERINE DEVICE $673.00 7/1/2019 – Ongoing
58301 REMOVE INTRAUTERINE DEVICE $195.00 7/1/2019 – Ongoing
55250 REMOVAL OF SPERM DUCT(S) $521.00 7/1/2019 – Ongoing
58340 CATHETER FOR HYSTEROGRAPHY $371.00 7/1/2019 – Ongoing
58555 HYSTEROSCOPY DX SEP PROC $322.00 7/1/2019 – 12/31/2019
58565 HYSTEROSCOPY STERILIZATION $1,476.00 7/1/2019 – 12/31/2019
58600 DIVISION OF FALLOPIAN TUBE $1,515.00 7/1/2019 – Ongoing
58615 OCCLUDE FALLOPIAN TUBE(S) $1,115.00 7/1/2019 – Ongoing
58661 LAPAROSCOPY REMOVE ADNEXA $978.00 7/1/2019 – Ongoing
58670 LAPAROSCOPY TUBAL CAUTERY $843.00 7/1/2019 – Ongoing
58671 LAPAROSCOPY TUBAL BLOCK $892.00 7/1/2019 – Ongoing
58700 REMOVAL OF FALLOPIAN TUBE $1,216.00 7/1/2019 – Ongoing
81025 URINE PREGNANGY TEST $6.00 7/1/2019 – Ongoing