---
title: L.A. Care Health Plan ABA coverage (Medi-Cal).
url: "https://carelu.com/payers/la-care-health-plan-california"
markdown_url: "https://carelu.com/payers/la-care-health-plan-california.md"
state: CA (California)
payer: L.A. Care Health Plan (Medi-Cal)
kind: Medicaid managed care plan (MCO)
parent_program: Medi-Cal (California Medicaid)
description: "How L.A. Care Health Plan covers Medi-Cal Behavioral Health Treatment (ABA) in Los Angeles County — the in-house ASD Program, no autism diagnosis required, form LA5480 and its H-code grid (H0032 = assessment here), the 12-hour FBA cap, the mandatory reporting template, and how Plan Partner members differ."
last_reviewed: September 2026
---

# L.A. Care Health Plan ABA coverage (Medi-Cal).

_Payer Guide · L.A. Care Health Plan · Last updated September 2026 · 8 primary sources_

> Largest Medi-Cal plan (2.08M); BHT in-house via the ASD Program, H-codes on form LA5480, no autism dx required.

L.A. Care Health Plan is the Los Angeles County local initiative and the largest Medi-Cal plan in the state — 2,078,171 members in August 2026. For its directly enrolled Medi-Cal members, BHT is run in-house: "BHT services are provided through L.A. Care’s directly contracted BHT network," not through the member’s medical group and not through Carelon (which handles mild-to-moderate mental health for Medi-Cal and BHT only for L.A. Care’s commercial lines). L.A. Care also has two Medi-Cal Plan Partners — Anthem Blue Cross and Blue Shield of California Promise Health Plan — whose members may carry a different card; check which plan manages the child before submitting.

This plan administers the **Medi-Cal (California Medicaid)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Medi-Cal (California Medicaid) guide](https://carelu.com/payers/medi-cal-california-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — the FBA is requested on form LA5480 as "H0032 for initial ABA assessment ONLY," up to 12 hours (48 units); "Do not schedule services until authorization is obtained" [3]
- **Prior auth for treatment**: Required — BHT needs a "recommendation from a licensed physician or licensed psychologist, and prior authorization from L.A. Care"; direct service (H2019), supervision (H0031) and parent education (S5111) are requested as hours per month on LA5480, with reports on L.A. Care’s mandatory BHT reporting template [1][3][4]
- **Autism diagnosis required?**: No — "a diagnosis of autism or autism spectrum disorder is no longer required for children 0-21"; "A formal recommendation or prescription for ABA from a licensed psychologist or physician is a requirement" [5][3]

## At a glance

- **Plan type:** Local initiative, Two-Plan model (Los Angeles County); Plan Partners: Anthem Blue Cross, Blue Shield Promise
- **Who runs BHT:** L.A. Care’s own BH ASD Program (not the IPA, not Carelon) for direct Medi-Cal members
- **Diagnosis:** Not required — physician/surgeon/psychologist recommendation
- **Assessment auth:** Yes — H0032 on LA5480, up to 12 hours (48 units)
- **Codes:** HCPCS: H0032 assessment, H0031 supervision, H2019 direct, S5111 parent education, H2014 group
- **Submit via:** Fax LA5480 to (213) 438-5054; BHT line 1-888-347-2264; ASDbenefit@lacare.org

## How a BHT request works at L.A. Care

A PCP or family starts it: PCPs call 888-347-2264 or email ASDBenefit@lacare.org, or ask the "patient, parent, or caregiver to contact L.A. Care BHT team directly." The authorization form LA5480 (May 2026) says "All 4 criteria must be met for approval" — the member is under 21, has a licensed physician/surgeon/psychologist recommendation "with documentation demonstrating medical necessity," is medically stable with documentation, and needs no 24-hour or ICF-ID care. The functional behavior assessment is "H0032 for initial ABA assessment ONLY," up to "12hours total (48 units) across modifiers." Treatment is requested as hours per month: H2019 direct service (HN/HC/HP modifiers by tier), H0031-HP case supervision (with an optional second tier), S5111-HP for parent education programs, H2014 social skills group only if contracted. HN-level staff need a transcript and attestation. FBA, progress and closing reports must use L.A. Care’s mandatory BHT Reporting Template, which tracks the first appointment offered after FBA approval against a 10-day timeline. [3][5][4][1]

Watch the codes: L.A. Care uses H0032 for the assessment and H0031 for supervision — the reverse of IEHP and CalOptima. Never copy a code grid across plans. The form linked from L.A. Care’s BH Resources page (LA5480 10/25) is a dead link; use the 05/26 version from the Provider Manuals page. [3][5][4][1]

## Intake gates

The questions that decide whether a family can start with L.A. Care Health Plan (Medi-Cal), and what they have to bring.

- **Age limit**: Under 21 — "L.A. Care covers BHT for all Members under 21 years of age"; the PCP flyer says "0-21." No minimum age. [1][5]
- **Who may diagnose**: A licensed physician, surgeon or psychologist — the 2026 manual says "licensed physician or licensed psychologist" in one section and "licensed physician, surgeon, or psychologist" in the BHT chapter. [1][2]
- **Diagnostic tools required**: None required for the recommendation. For the FBA and progress reports the template asks for skills assessments "(e.g., VB-MAPP, Vineland, AFFLS, PEAK, etc.)," a preference assessment, and a functional or ABC analysis "Required for all target behaviors being addressed." [4]
- **Referral required?**: A PCP or the family can start it — PCPs call 888-347-2264 or email ASDBenefit@lacare.org, or have the "patient, parent, or caregiver … contact L.A. Care BHT team directly"; supporting documents (CDE, EPSDT results, recommendation) go by fax to 213-438-5054. BHT does not go through the member’s medical group or IPA. [5][1]
- **Prior-auth decision time**: L.A. Care’s 2026 manual counts days from receipt (day 0) but publishes numeric decision times only for its D-SNP line, so the state rule governs its Medi-Cal BHT requests: APL 21-011 — standard decisions within five business days of receiving the information reasonably necessary, never more than 14 calendar days, and 72 hours expedited — capped from January 1, 2026 at 7 calendar days by 42 CFR 438.210(d). Separately, L.A. Care tracks the provider’s first appointment offer within 10 days of FBA approval. Reauthorization: the treatment plan is reviewed at least every six months (APL 23-010). [1][10][11][4]
- **Other insurance (who pays first)**: When another payer is primary, "Providers must follow the primary payor’s billing rules"; secondary claims go to L.A. Care within 180 calendar days of the primary’s determination with its RA or denial, and L.A. Care pays cost-sharing "up to the lower amount of its fee schedule or the Medicare/other insurance-allowed amount." Medi-Cal is payer of last resort (APL 22-027). L.A. Care does not say whether its own BHT authorization is required when commercial insurance is primary — ask the BHT Department. [1][12]
- **Diagnosis recency** _(plan-dependent)_: L.A. Care publishes no age limit on the recommendation (checked LA5480, the reporting template and the 2026 manual), and APL 23-010 sets none. Its reporting template requires skills-assessment results "Updated results required annually" and preference assessments every six months. [4][7]
  - Ask the plan: L.A. Care BHT Department (1-888-347-2264 / ASDbenefit@lacare.org) — how recent the recommendation must be.
- **Telehealth** _(plan-dependent)_: No BHT-specific rule. L.A. Care’s general telehealth section requires a participating provider, disallows telehealth "when the Member and participating Provider are in the same physical location," and excludes "texting, facsimile or email only." Beyond that the Medi-Cal telehealth rule applies, which does not settle technician-delivered 97153/H2019 by video. [1][9]
  - Ask the plan: L.A. Care BHT Department (1-888-347-2264) — which BHT codes it will authorize by telehealth.

## Delivery and billing rules

Coverage decides whether L.A. Care Health Plan (Medi-Cal) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Daily limits / MUEs**: The only published cap is on the assessment: "up to 12hours total (48 units)." No daily or weekly treatment cap is published — treatment is requested as hours per month — and APL 23-010 prohibits hour caps. [3][7]
- **Session-note signature**: Reports (FBA, progress, closing) need a "Qualified Autism Service Provider Signature," credentials and date, plus a statement that the report "has been thoroughly discussed with client’s parent(s)" and the parent’s agreement or disagreement. No session-note rule is published. [4]
- **Place of service**: Treatment "is typically conducted in children’s homes for hours a day and in other community settings" (PCP flyer); the reporting template has school sections (IEP, coordination with the school) and a "Location(s) of Services" field. The state rule underneath (APL 23-010) covers home, clinic, community and school. [5][4][7]
- **Supervision** _(plan-dependent)_: Case supervision is authorized separately — H0031-HP required, with an optional second tier (HC for BCaBA/master’s, HN for bachelor’s). L.A. Care publishes no supervision ratio. [3]
  - Ask the plan: L.A. Care BHT Department or your BHT provider contract.
- **Bill as provider** _(plan-dependent)_: Rendering level rides on the modifier: HP (BCBA-D/BCBA/licensed master’s), HC (BCaBA or master’s), HN (bachelor’s), HQ (group). The form captures the requesting and servicing organization; no NPI or enrollment rule is published. [3]
  - Ask the plan: Your L.A. Care BHT contract — rendering vs. billing NPI for technician time.
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not published — no L.A. Care rule on billing supervision (H0031) and direct service (H2019) for the same clock time; note L.A. Care authorizes HCPCS codes, not 97153/97155. [3]
  - Ask the plan: Your L.A. Care BHT contract or Provider Solutions (866-522-2736).

## What intake should collect for L.A. Care Health Plan (Medi-Cal)

- **Which plan manages the child:** L.A. Care direct vs. a Plan Partner card (Anthem Blue Cross, Blue Shield Promise) — the BHT process differs.
- **Recommendation with documentation:** From a licensed physician, surgeon or psychologist, showing medical necessity — no autism diagnosis needed.
- **Medical stability note:** LA5480 requires documentation (e.g. a physician note) that the child is medically stable.
- **Staff credentials for HN tier:** Transcript and attestation for bachelor’s-level (HN) staff.
- **Other coverage:** Commercial insurance pays first; L.A. Care needs the primary’s RA or denial for secondary claims.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does L.A. Care cover ABA therapy?

Yes — as Behavioral Health Treatment for Medi-Cal members under 21. No autism diagnosis is needed; a licensed physician, surgeon or psychologist must recommend it, and L.A. Care must authorize it.

### How do I request ABA from L.A. Care?

Fax form LA5480 (05/26) with the recommendation and documentation to (213) 438-5054, or call the BHT team at 1-888-347-2264. The FBA is requested as H0032, up to 12 hours.

### Does the member’s medical group handle ABA?

No. For L.A. Care’s direct Medi-Cal members, BHT goes through L.A. Care’s own BHT network, not the IPA. Members on a Plan Partner card (Anthem Blue Cross, Blue Shield Promise) may follow that plan’s process.

## Primary sources

1. [L.A. Care — 2026 Universal Provider Manual (LA4289)](https://www.lacare.org/sites/default/files/la4289_upm_202512.pdf)
2. [L.A. Care — 2026 Universal Provider Manual Errata v3 (9/23/2026)](https://www.lacare.org/sites/default/files/la8085_upm_errata_list_v3_20260923.pdf)
3. [L.A. Care — BHT/ABA Authorization Request Form LA5480 (05/26)](https://www.lacare.org/sites/default/files/la5480_bht_authorization_form_202605.pdf)
4. [L.A. Care — Behavioral Health Treatment Reporting Template (PL6030, 09/25)](https://www.lacare.org/sites/default/files/la6030_lac_bht_reporting_template_202509.pdf)
5. [L.A. Care — BHT Coverage for Members Under 21 (PCP flyer PL1757, 11/23)](https://www.lacare.org/sites/default/files/pl1757_bht_pcp_flyer_202311_0.pdf)
6. [L.A. Care — Behavioral Health Services (provider page)](https://www.lacare.org/providers/tools/behavioral-health-services)
7. [DHCS APL 23-010 (Revised 11/22/2023) — BHT Coverage for Members Under 21](https://www.dhcs.ca.gov/file/apl23-010-pdf/)
8. [CHHS Open Data — Medi-Cal Managed Care Enrollment Report (August 2026)](https://data.chhs.ca.gov/dataset/medi-cal-managed-care-enrollment-report)
9. [Medi-Cal Provider Manual — Telehealth Modalities (tele mod), Nov 2025](https://mcweb.apps.prd.cammis.medi-cal.ca.gov/file/manual?fn=telemod.pdf)
10. [DHCS APL 21-011 (Revised 8/31/2022) — Grievance and Appeals Requirements](https://www.dhcs.ca.gov/file/apl21-011-pdf/)
11. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes](https://www.ecfr.gov/current/title-42/section-438.210)
12. [DHCS APL 22-027 — Cost Avoidance and Post-Payment Recovery for Other Health Coverage](https://www.dhcs.ca.gov/file/apl22-027-pdf/)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.