Six Months of No Measurable Progress Is Now Grounds to Discontinue ABA

For years the answer to “whose criteria?” was the Council of Autism Service Providers. Health Net bulletin 26-196, published February 13 2026, changed that for its Medi-Cal population effective April 20 2026: clinical policies CA.CP.BH.104 and CA.CP.BH.105 now govern, and they supersede the CASP criteria for members under 21. CASP criteria stay in force for commercial and individual and family plans.

So a single payer now runs two different rulebooks depending on which card the family carries.

The clause to read first

Section II sets out when ABA “may be appropriate for discontinuation and/or transfer to alternative or less intensive levels of care.” One item is the CMS toolkit's outcomes push arriving as an operational rule:

“There has been no clinically significant progress or measurable improvement towards treatment plan goals for a period of at least six months, and there is not a reasonable expectation that a revised treatment plan could lead to clinically significant progress.”

The policy then names what that looks like: a consistent lack of change in behavior-reduction and skill-acquisition data; an increase in behaviors targeted for reduction; failure to meet predefined mastery criteria for a specified duration; and gains that are not generalizable or durable and do not transfer to the community “after successive progress review periods and repeated modifications to the treatment plan.”

Two other discontinuation grounds are worth knowing because they are judgment calls a reviewer makes about your file. Services delivered “in lieu of school” for members aged six or older. And treatment or intensity “being provided for the convenience or preference of the member/enrollee, parent/guardian, or other non-ABA service providers.”

It is not the restriction story you would expect

Most payer policy this year has moved one way. This one does not, and the protective clauses are unusually explicit.

• Hours cap at six a day and 30 a week — exceedable where clinical documentation justifies it, the policy naming high-intensity or high-frequency behaviors and significant skill deficits as examples.
• School time cannot be used to cut hours. The policy states twice that “the number of medically necessary BHT hours may not be reduced based on time spent in school or participating in other activities.”
• Parent participation is not required. The plan of care must incorporate supervision and caregiver training, and then the policy adds the note plainly: “Parent/guardian participation is not required.”
• IEP services are protected. “BHT Services included in the IEP must not be reduced or discontinued without formal amendment of the IEP,” and the managed care plan is responsible for medically necessary BHT that a local educational agency has discontinued.

Set that against South Carolina, where any ABA service delivered without routine 97156 caregiver guidance is non-covered outright — no family training, nothing is reimbursable. Two payers, opposite rules, same clinical question. If you operate in both, your treatment plans cannot say the same thing.

This is a Centene policy, not a California one

CP.BH.104 is the parent policy and it is already deployed across Centene's markets. Arizona Complete Health adopted CP.BH.104 and CP.BH.105 effective June 1 2025, across all lines of business — Medicaid, Medicare Advantage and Marketplace — with a supervision ratio of one to two hours per ten hours of direct treatment, or two hours where direct treatment runs under ten hours a week, and notice that claims lacking supervision documentation may face recoupment. The same reference number appears in Centene plan libraries in Missouri, Washington, Oregon, New York and the Ambetter markets.

California is not the first. It is the point at which the policy displaced CASP's guidelines for a state Medicaid population, which is the part worth watching wherever you practice.

The limits

The bulletin gives no rationale for replacing CASP beyond saying the change supports more individualized, needs-based care. The policy is written against California's EPSDT framework and All Plan Letters 23-005 and 23-010, so the California edition is not the same document as the one operating in Arizona or Missouri — check your own state's version rather than this one. And discontinuation criteria describe when services “may be appropriate” for discontinuation, not an automatic trigger; the EPSDT standard still governs, and six months of flat data is the beginning of a conversation with a reviewer, not the end of one.

What you must know or do

• Clinical directors: pull every Health Net Medi-Cal case that has run more than six months and check whether the last two progress reviews show measurable movement on the plan's own goals. Where they do not, the file needs either a revised plan with a stated rationale or a documented reason the current one should continue. That is the exact question the policy asks.
• Anyone billing over 30 hours a week: the justification has to be in the plan, not produced at appeal. The policy names high intensity, high frequency and significant skill deficits — use its language.
• If a plan has ever cut hours because a child started school: this policy forbids that, in terms, twice. Worth revisiting any authorization reduced on that basis.
• Anyone with a member whose IEP includes BHT: those services cannot be reduced or discontinued without a formal IEP amendment, and the managed care plan carries what the district drops. That is leverage most providers do not know they have.
• Everyone else: find out whether your Centene plan runs CP.BH.104 and what its supervision ratio is. Arizona's is one to two hours per ten, with recoupment named for missing documentation — and a supervision ratio you are not tracking is a recoupment you have not seen yet.