Amendments to Insurance Mandate Expand Coverage

February 06, 2015

parents playing on computer with young girl

Provide First-of-its-Kind Access to ABA Coverage for Adults with Autism

The New Jersey Individual Health Coverage Program Board and the New Jersey Small Employer Health Coverage Program Board (IHC and SEH Boards) have adopted amendments to the individual and small employer health benefits that expands coverage of Applied Behavior Analysis (ABA) to adults with autism and removes visit limitations for occupational, physical and speech therapies to treat autism. The amendments were adopted in November 2014 and are effective as of January 2015.

Under the New Jersey Autism and Other Developmental Disabilities insurance mandate, individual and small employer health benefits carriers are required to cover medically necessary ABA for the treatment of autism. However until now, the coverage included an age cap of 21 years. In addition, coverage of medically necessary occupational, physical and speech therapies was also subject to a 30-visit limit for the treatment of autism. Autism New Jersey supported both of the amendments, which will enable individuals with autism age 21 and over to receive ABA services and enable individuals with autism to receive occupational, physical and speech therapies beyond 30 visits. Autism New Jersey provided its expertise to DOBI regarding the medical necessity of ABA intervention and extensive research on the effectiveness of ABA in treating the symptoms of autism in adulthood.

As described in written testimony, Autism New Jersey Executive Director Dr. Suzanne Buchanan stated, “The proposal reflects the state of the evidence which convincingly demonstrates both the medical necessity and benefit of ABA intervention for adults with autism. We are thrilled to announce this expansion of coverage and commend DOBI and Ellen DeRosa, its Executive Director of the Individual and Small Employer Health Coverage Programs, for her initiative and responsiveness to the healthcare needs of adults with autism. The expansion will help thousands of adults with autism obtain critical services, promote the maintenance of educational gains, and improve their everyday lives as adults.”

“My son has benefited from ABA more than any other intervention we’ve tried since his diagnosis 16 years ago,” explains Kim Strasser. “The concept of insurance not allowing ABA services for adults who have aged out of an education program providing ABA would be similar to taking a lifesaving pharmaceutical away from someone with a chronic illness.”

“It is critical for my son to have access to coverage for ABA,” Bernadette Lynch insists. “Autism is a lifelong disability. Behavioral services are a critical component of successfully supporting adults with autism as long as they live. I can’t thank Autism New Jersey enough for their role in assisting DOBI and for supporting families like ours across the state.”

Since 2013, Autism New Jersey has had a leadership role in addressing concerns related to the implementation of the insurance mandate via a stakeholder workgroup comprised of parents, Board Certified Behavior Analysts, the New Jersey Association of Behavior Analysts, the New Jersey Association of Health Plans, and representatives from each of insurance carriers. This workgroup has opened the lines of communications between parents, providers, advocates, and the insurance carriers. Now, this workgroup will expand its focus to ensure that the coverage needs of adults with autism are met. “Autism New Jersey is grateful for the vision and direction of Assemblyman Gary Schaer who held a hearing on the mandate implementation and directed the stakeholders to form a workgroup,” said Buchanan.

“This long-overdue change will create much needed parity for adults with autism,” said Assemblyman Gary Schaer (D-Bergen/Passaic). “As we all know, autism does not disappear when an individual turns 21. Neither should critical health coverage. I applaud Autism New Jersey for their relentless advocacy to make these changes a reality. As we learned during Assembly hearings, occupational and behavioral health services can play a crucial role in ensuring individuals with autism thrive to their fullest potential.”

The summaries of both rule proposals explained that the amendments addressed the requirements of the federal Mental Health Parity Equity and Addiction Act of 2008.

The amendments affect all fully insured plans in New Jersey offered by small employers or purchased by individual consumers. For more information about autism and insurance benefits, please contact Autism New Jersey at 800.4.AUTISM or email information@autismnj.org.