Insurance Reform for Services for People with Autism
By: S. Paul Prior, Esq.
As of June 18, 2009, both the State of New Jersey Assembly and Senate passed a Bill, S.2238, requiring health benefits coverage for certain therapies for the treatment of autism and other developmental disabilities. The Bill is headed to the Governor’s Office for signature.
Under the Bill, coverage for the following services would be mandated
1. Screening & diagnosis for autism and other developmental disabilities;
2. Medically necessary OT, ST, and PT as prescribed through a treatment plan ; coverage of these therapies is not to be denied on the basis of that the treatment is not restorative; and
3. For children under 21 years of age where the primary diagnosis is autism, medically necessary behavioral interventions based on ABA and related structured behavioral programs, as prescribed through a treatment plan.
Health plans must provide the above-listed services in the same manner as other medical conditions under the health insurance contract and with no limitations applied to behavioral interventions for a covered person under 21 years of age.
The provisions of this Bill are not to be construed to require that benefits be provided to reimburse the cost of the services provided under an individual family support plan (IFSP) or IEP, or affect any requirement to provide those services except that the required benefits do include coverage for expenses incurred by participants in an IFSP through a family cost share.
The annual maximum benefit for the above-listed services through 2011 is $36,000. On January 1, 2012, the maximum benefit amount will be subject to an adjustment, to be promulgated by the Commissioner of the New Jersey Department of Banking & Insurance and published in the New Jersey Register no later than February 1 of each calendar year. The annual adjustment to the maximum benefit amount shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the U.S. Department of Labor.
The following health plans would be subject to these mandates:
1. Health, hospital, medical service corporations (N.J.S.A. 17:48E-1, et seq., N.J.S.A. 17:48-1, et seq., and N.J.S.A. 17:48A-1, et seq.);
2. Individual health insurance policies (N.J.S.A. 17B, et seq.);
3. Group health insurance policies (N.J.S.A. 17B, et seq.);
4. Health benefits plans issued pursuant to N.J. Individual Health Coverage (N.J.S.A. 17B:27A-2, et seq.);
5. Health benefits plans issued pursuant to N.J. Small Employer Health Benefits Programs (N.J.S.A. 17B:27A-17, et seq.);
6. HMOs (N.J.S.A. 26:2J-1, et seq.);
7. State Health Benefits Program (N.J.S.A. 52:14-3D); and
8. School Employees’ Health Benefits Program (N.J.S.A. 52:14-17.46-1, et seq.).
New Jersey is the 14th state, which includes the Commonwealth of Pennsylvania, to provide medically necessary care to those with autism and other developmental disabilities.
In the Commonwealth of Pennsylvania, each of the below-listed plans must be in compliance on the date the policy or contract is renewed on or after July 1, 2009 with the Act 62 of 2008 (HB 1150), which mandates coverage by private insurance companies for diagnostic assessments and treatment of autism spectrum disorders for children and young adults under the age of 21 who are covered under:
1. An employee group health insurance policy for an employer with at least 51 employees (self-insured or self-funded polices are exempt); or
2. Medicaid (a.k.a., Medical Assistance); or
3. The Children’s Health Insurance Program (CHIP); or
4. Adult Basic (for ages 18 and older).
Pennsylvania’s law specifically mandates coverage of the following:
1. Diagnostic assessments of autism spectrum disorders; and
2. Treatment of autism spectrum disorders, including prescription medications and blood level tests, services rendered by a psychiatrist or psychologist, applied behavioral analysis (ABA), therapies (speech/language, occupational, and physical), and other “rehabilitative care”.
It is important to note that the above-listed services are only covered if the treatment is (1) medically necessary; (2) for an autism spectrum disorder; (3) identified in a treatment plan created by the treating physician or psychologist; and (4) provided by an autism service provider. It is equally important to be aware that coverage is limited to $36,000 per year for diagnostic and treatment costs (adjusted annually for inflation beginning 2012).
Hinkle,
Fingles, & Prior a multi-state law practice with offices in Lawrenceville, Cherry Hill, Florham Park, and Paramus, New Jersey, and Plymouth Meeting and Bala Cynwyd, Pennsylvania. They lecture and write frequently on topics of elder law, estate planning, special needs trusts, guardianship, special education, health care insurance & Medicaid, and accessing adult services and are available to speak to groups in New Jersey and Pennsylvania at no charge.
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2009 Hinkle, Fingles & Prior, Attorneys at Law. All rights reserved.
