Health Net Swapped CASP for Centene's Own ABA Criteria in Medi-Cal on April 20

Health Net bulletin 26-196, dated February 13, changed whose rulebook decides medical necessity for ABA in its Medi-Cal plan. From April 20, 2026, clinical policy CA.CP.BH.104 replaces the Council of Autism Service Providers (CASP) criteria for Medi-Cal patients under 21, and CA.CP.BH.105 sets the documentation requirements. CASP criteria still apply to Health Net's commercial employer group plans (HMO/POS, PPO) and its Ambetter HMO and PPO individual and family plans.

The bulletin covers Health Net's Medi-Cal service areas, including Los Angeles, Sacramento, San Joaquin, Stanislaus and Tulare counties.

The turn: one payer, two rulebooks

The card a family carries now decides the standard. A Medi-Cal child is reviewed against Centene's policy, and a child on a Health Net commercial plan is still reviewed against CASP. A practice with both on its caseload is writing reauthorization packets for two different sets of criteria from the same payer.

What the same policy family enforces elsewhere

CP.BH.104 is a Centene reference number used across its markets. Two sister plans' public notices show what gets enforced under it:

• Arizona Complete Health has used CP.BH.104 for all lines of business since June 1, 2025. Documentation must show “1-2 hours of supervision per 10 hours of direct treatment or 2 hours of supervision if direct treatment is under 10 hours/week,” and “insufficient supervision of direct treatment may result in recoupment.” The plan says its data shows “a high number of claims lacking required supervision hours.”
• Meridian in Illinois reviews claims after payment for at least one hour of 97155 per 10 hours of direct treatment. Its example: 100 hours of treatment with 6 of supervision means repaying 40 hours of 97153.

Whether California's edition sets the same ratio is something to check in the policy itself.

What no Medi-Cal plan's criteria can do

DHCS's All Plan Letter 23-010 binds every Medi-Cal managed care plan, whatever criteria it adopts:

• “MCPs must not reduce the number of Medically Necessary BHT hours that a Member is determined to need by the hours the Member spends at school or participating in other activities.”
• “Blanket limitations or restrictions on benefits and services, such as caps on number of hours, are prohibited.”
• Plans “cannot require participation by parents/guardians.”
• BHT services in a member's IEP “must not be reduced or discontinued without formal amendment of the IEP,” and the plan is “solely financially responsible” for them until the IEP is amended.
• The treatment plan is reviewed “no less than once every six months.”

The limits

Centene marks the text of its clinical policies as not for reproduction, so this article quotes only Health Net's public bulletin, its sister plans' public notices and the state's All Plan Letter. It doesn't describe the policy's own discontinuation or hours criteria. Read CA.CP.BH.104 in Health Net's provider library before relying on any threshold. The bulletin gives no reason for the switch beyond supporting “more individualized, needs‑based care.”

An earlier version of this article quoted the policy text directly. It has been rewritten from public sources.

What you must know or do

• Intake and billing: tag every Health Net client by product. Medi-Cal under 21 is reviewed under CA.CP.BH.104, and commercial or Ambetter under CASP. Write each reauthorization to the right one.
• Clinical directors: open CA.CP.BH.104 and CA.CP.BH.105 in Health Net's provider library and check your reauthorization template against their discontinuation and documentation sections.
• Billers: divide 97155 hours by 97153 hours for each Health Net Medi-Cal client. The sister plans enforce one hour in ten, with recoupment.
• If a Medi-Cal denial or reduction cites school hours, a missing parent or a flat hour cap, cite APL 23-010 in the appeal.