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Time-Limited Supplemental Payment for Specific Family Planning Services

December 9, 2019

Effective for dates of service from July 1, 2019, through December 31, 2021, supplemental payments will be allocated under the California Healthcare Research and Prevention Tobacco Tax Act of 2016 (Proposition 56) for the following specified Medi-Cal family planning services under the Medi-Cal Fee-for-Service program. An Erroneous Payment Correction will be implemented reprocess affected claims.

Procedure Code Description Supplemental Payment Amount
J7296 Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg $2,727
J7297 Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg  2,053
J7298 Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg 2,727
J7300 Intrauterine copper contraceptive 2,426
J7301 Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg 2,271
J7307 Etonogestrel (contraceptive) implant system, including implant and supplies 2,671
J3490U8 Medroxyprogesterone acetate, 150 mg 340
J7303 Contraceptive supply, hormone containing vaginal ring, each 301
J7304 Contraceptive supply, hormone containing patch, each 110
J3490U5 EMERG CONTRACEPTION: Ulipristal acetate 30 mg 72
J3490U6 EMERG CONTRACEPTION: Levonorgestrel 0.75 mg (2) & 1.5 mg (1) 50
11976 Removal, implantable contraceptive capsules 399
11981 Insertion, non-biodegradable drug delivery implant 835
58300 Insertion of intrauterine device (IUD) 673
58301 Removal of intrauterine device (IUD) 195
81025 Urine pregnancy test, by visual color comparison methods 6
55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) 521
58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography 371
58555 Hysteroscopy, diagnostic (separate procedure) 322
58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants 1,476
58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral 1,515
58615 Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach 1,115
58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) 978
58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 843
58671 Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) 892
58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) 1,216