The California Medi-Cal fee schedule is the public list of maximum rates the Department of Health Care Services (DHCS) will pay providers for each covered service under Fee-for-Service (FFS) billing. DHCS publishes the schedules on the Medi-Cal Providers website and updates them every month. Finding the right file is only the first step; the dollar figure next to a procedure code is a ceiling, and several columns and rules sitting alongside it decide what you are actually paid.
Where to Find the Schedule
The rate files live on the DHCS “Rates” page, organized into categories that include Medi-Cal Provider Rates, Clinical Laboratory and Laboratory Services, Behavioral Health Fee Schedules, and Long Term Care Provider Rates.1Department of Health Care Services. Rates For professional services, follow the Medi-Cal Provider Rates link.
Before the files open, you have to accept the American Medical Association’s licensing agreement covering CPT coding data.1Department of Health Care Services. Rates After that, you can search by individual procedure code or download the full rate files, typically as Excel or PDF. Check the effective date on every file you pull. DHCS separates tables by service type and date, and pulling the wrong file means quoting the wrong rate.
Updates run on a predictable monthly cycle. DHCS refreshes the rates on the 15th of each month, and the revised files post to the site on the 16th.2Medi-Cal Providers. Medi-Cal Rates Claims are paid at the rate in effect on the date of service, not the date of submission, so a schedule saved to your desktop six months ago is not a safe reference.
DHCS also uses All Plan Letters (APLs) to communicate significant policy and rate changes. When an APL announces a change that has not yet appeared in the posted files, it will usually give the effective date and interim billing instructions to bridge the gap.3Department of Health Care Services. Medi-Cal Targeted Provider Rate Increases
When the Fee Schedule Applies
The published schedule governs Fee-for-Service billing only. Under FFS, you submit a claim for each service and the state pays the listed rate. This covers certain carved-out services and beneficiaries not enrolled in a managed care plan.
Managed care runs on different math. The state pays each Managed Care Organization a fixed per-member, per-month capitation amount, and the MCO negotiates its own contract rates with network providers.4MACPAC. Medicaid Managed Care Payment Those negotiated rates can differ significantly from the FFS schedule. If your patient is enrolled in a Medi-Cal managed care plan and you are contracted with that plan, your contract determines your payment, not the state schedule.
How to Read the Columns
The schedule ties a dollar amount to a five-character CPT or HCPCS procedure code. CPT codes cover physician and clinician services; HCPCS Level II covers products, supplies, and services CPT does not, such as ambulance transport and durable medical equipment.5Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System (HCPCS) Around each code sit several columns that decide the actual payment.
Maximum Allowable Reimbursement
The Maximum Allowable Reimbursement (MAR) is the ceiling: the highest dollar amount the state will pay for that code under FFS. It is not a floor and not a guarantee. Actual payment can drop below the MAR based on the other columns.
Cutback Indicator
The Cutback Indicator flags codes subject to a 20% rate reduction when the service is performed in a hospital outpatient department, or for surgical procedures in a surgical clinic. A value of “1” means the reduction applies; “0” means it does not. The reduction does not apply when the place of service is an emergency room.6Medi-Cal Providers. Notes to Rates This is a frequent source of payment surprises. A MAR of $200 billed from an outpatient setting pays $160.
Benefits Restriction
The Benefits Restriction column tells you whether the service requires an approved Treatment Authorization Request (TAR) before it can be billed. A TAR is Medi-Cal’s prior authorization mechanism, reviewed for medical necessity on FFS claims.7Legal Information Institute. California Code of Regulations Title 22 51003 – Treatment Authorization Request Submitting a claim for a TAR-required service without an approved TAR results in denial.
Procedure Type and Targeted Rate Increases
A procedure type of “X” means the listed rate reflects a Targeted Rate Increase (TRI) for specific primary care, obstetric, or non-specialty mental health services. TRI rates took effect January 1, 2024, and brought covered codes up to at least 87.5% of the Medicare rate for eligible provider types.3Department of Health Care Services. Medi-Cal Targeted Provider Rate Increases If your provider type is not on the eligible list for that code, you get the standard Medi-Cal rate even though the schedule displays the higher TRI number. Eligible provider types for primary care codes include physicians, physician assistants, nurse practitioners, podiatrists, certified nurse midwives, psychologists, licensed clinical social workers, and marriage and family therapists, among others.
What Else Can Cut or Block Your Payment
Even a correctly read row can pay less than expected, or nothing, because of rules that sit outside the schedule.
Global Surgery Periods
Some surgical codes carry a global surgery indicator, meaning the listed rate covers the procedure plus related pre- and post-operative services. Billing separately for visits inside the global window will be denied.
Medi-Cal generally follows Medicare’s framework, which assigns one of three post-operative windows to surgical codes:8Centers for Medicare and Medicaid Services. Global Surgery Booklet
- 0-day period for endoscopies and certain minor procedures, with no pre- or post-operative days beyond the procedure itself.
- 10-day period for other minor procedures, covering the day of surgery plus the following 10 days.
- 90-day period for major procedures, covering one day before surgery, the day of surgery, and 90 days after.
Follow-up visits, post-surgical pain management, dressing changes, and suture removal are bundled into the surgical payment. A genuinely unrelated service or a return to the operating room during the global period can sometimes be billed separately with the appropriate modifiers, but the default assumption is that post-op care is included.
NCCI Edits
Two codes both appearing in the schedule with valid rates does not always mean you can bill them together. The National Correct Coding Initiative maintains Procedure-to-Procedure edits that define code pairs which should not be reported for the same patient on the same day, and state Medicaid programs, including Medi-Cal, apply them.9Centers for Medicare and Medicaid Services. NCCI for MedicaidMedicaid NCCI Edit Files When one code is a component of a more comprehensive code, billing both is double-counting; the lower-paying code is typically denied. NCCI also publishes Medically Unlikely Edits capping units of service per code per day. A published rate does not override an edit.
Filing Deadline
Medi-Cal requires original FFS claims to be received within six months following the month in which services were rendered. A service provided on April 15 must be submitted before October 31.10Medi-Cal Providers. Claim Submission and Timeliness Overview Late claims face payment reduction or denial. This is tighter than the federal ceiling, which allows states to permit up to 12 months from the date of service.11eCFR. 42 CFR 447.45 – Timely Claims Payment Managed care plans may impose their own filing windows, so check the contract separately.
The Rate Is Also the Ceiling for the Patient
The MAR is not just what the state pays. It is what can be collected in total for a covered service. Federal law prohibits Medicaid providers from billing beneficiaries for the difference between usual charges and the Medicaid payment.12Office of the Law Revision Counsel. 42 U.S. Code 1396a – State Plans for Medical Assistance California reinforces this under Welfare and Institutions Code Section 14019.4.13Department of Health Care Services. Balance Billing Federal law lets a state reduce future payments to the provider by up to three times the amount improperly collected from a beneficiary.
What’s Changed in Recent Rates
Two developments shape the current numbers on the schedule. AB 118 (2023) directed DHCS to implement Targeted Rate Increases effective January 1, 2024, bringing primary care, obstetric, and non-specialty mental health services to at least 87.5% of the Medicare rate for eligible providers. That change also folded in the elimination of earlier AB 97 payment reductions and rolled Proposition 56 supplemental payments into the base rate.3Department of Health Care Services. Medi-Cal Targeted Provider Rate Increases
California voters then approved Proposition 35 at the November 2024 general election, making the Managed Care Organization tax permanent (subject to continued federal approval) and dedicating the revenue to Medi-Cal beginning in 2025. Proposition 35 preserved the January 2024 TRI rates but made inoperative the additional payment increases that SB 159 (2024) would have triggered on or after January 1, 2025.3Department of Health Care Services. Medi-Cal Targeted Provider Rate Increases Even with the 2024 increases, many service categories outside the TRI list still pay below Medicare and commercial benchmarks, so reading the specific row for the specific code remains the only reliable way to know what a claim will be worth.