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Health Insurance and Public Policy

Autism New Jersey's Public Policy team continues to work on behalf of families and providers on the important issue of health insurance coverage.

Autism Mandate -- Passage

Autism New Jersey played a critical role in the passage of P.L. 2009 c. 115 Health Benefits Coverage for Autism and Other Developmental Disabilities in 2009, spearheaded by legislative champion, Speaker Joseph Roberts, Jr. Later that year, Autism New Jersey worked with the Department of Banking and Insurance (DOBI) to provide technical assistance on provider qualifications for ABA services. In early 2010, DOBI issued a bulletin, based in part on Autism New Jersey's recommendations, to provide implementation guidance to carriers, families, behavior analysts, and other providers. The autism insurance mandate went into effect on February 9, 2010.

Since its passage, Autism New Jersey has provided information and outreach to increase families’ access to reimbursable services via our Helpline.  Click here for Health Insurance Resources.

Autism Mandate -- Implementation Concerns

We are encouraged that some families have accessed these benefits and their children are making meaningful progress as a result. However, there have also been obstacles to coverage for many families. The New Jersey State Assembly Financial Institutions and Insurance Committee, chaired by Assemblyman Gary Schaer (D-36), responded to these concerns by holding a hearing on March 7, 2013. Autism New Jersey provided testimony that identified challenges for families, providers, and carriers alike. Given the additional and detailed testimony provided by parents, Chairman Schaer directed all relevant stakeholders to work together in an effort to increase access to reimbursable services as the law intended.

Autism Mandate Stakeholder Group -- Working together to address the issues

Stakeholder Group September 2013

Immediately following the hearing, Autism New Jersey, Autism Speaks, and attorney Jodi Bouer began authoring a report that outlined the autism and provider communities’ concerns. This report served as the basis for the first meeting of stakeholders on September 16, 2013 hosted by Autism New Jersey.  The meeting included parents, providers, DOBI, the New Jersey Association of Health Plans, Aetna, AmeriHealth, Horizon, United Healthcare, and the New Jersey Association for Behavior Analysis. Following an overview of challenges experienced by parents and providers, DOBI emphasized legal requirements and its commitment to investigating violations of the law. The carriers stated their motivation to address individual and systemic challenges. Overall, the stakeholder group had a productive initial dialogue and continues to meet and collaborate to address pivotal issues such as coding, provider credentialing, network adequacy, claims processing and authorization, and utilization management.

The Stakeholder Workgroup has been meeting since September 2013. Read about our most recent meeting on September 30, 2015.

Key Advocacy Activities

Autism New Jersey is leading the charge to address some of the more pressing systemic issues and barriers that are preventing families from accessing services and coverage via the mandate.  We remain committed to improving access to quality, evidenced-based treatment for individuals with autism and to help lessen the financial burden on families.  We serve as a collective voice on behalf of families and providers and give higher-level access to insurance carriers to address concerns and resolve systemic issues.  

Working to improve reimbursement rates:

Autism New Jersey facilitates discussions with carriers to ensure reimbursement for all components of medically-necessary coverage such as assessments, treatment from a team of providers when necessary, and supervision. Autism New Jersey has successfully advocated with an insurance carrier to reverse their decision to lower rates and to provide retroactive compensation for services paid at the lower rate.

Expanding mandated coverage to medically-necessary treatments adults:

Autism New Jersey provided critical technical assistance to the Department of Banking and Insurance (DOBI) regarding the state of the evidence for the effectiveness of Applied Behavior Analysis (ABA) for adults with autism. Autism New Jersey summarized the peer-reviewed literature and found substantial support for the medical necessity and effectiveness of ABA for adults with autism. Based on DOBI’s agreement with this conclusion and the federal Mental Health Parity Equity and Addiction Act of 2008 (MHPAEA), DOBI removed the age cap on ABA benefits of the autism insurance mandate for the Individual and Small Employer insurance markets. This precedent-setting decision to cover ABA services for adults with autism could positively influence decision makers to broaden the availability in other public and private insurance markets.

Helping consumers and providers navigate Insurance:

Our advocacy work has improved system transparency and helped provide easier access to important information to help cut the red-tape and get providers and families the information needs to resolve issues, such as:   

Claims and Authorizations:  Who do I call at my Insurance Company for help?

Finding a provider in your network.  Helping consumers obtain exceptions when you can't find a provider in-network.

How to file a complaint with Department of Banking and Insurance.

CPT Code Crosswalk:. This new resource is now available for providers to help achieve consistency in utilization and implementation of – and ultimately in establishing valuation and reimbursement rates for – the new Category III codes for reporting adaptive behavior assessment and treatment services

Questions?

Given the depth of our knowledge and the relationships we have established to effect change, we welcome your questions regarding insurance coverage and are here to help parents and providers navigate the entire process. Call our Helpline at 800.4.AUTISM or email us at information@autismnj.org.


Hot Topic:  Health Insurance

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 Public Policy White Paper:

ABA for Adults with Autism:  A Review of the Evidence

Insurance Coverage of Applied Behavior Analysis for Adults with Autism:  A Review of the Evidence
Prepared for the NJ Department of Banking and Insurance

 

AUTISM NEW JERSEY
500 Horizon Drive, Suite 530 Robbinsville, NJ 08691
Phone: 609.588.8200; 800.4.AUTISM | Fax: 609.588.8858
Email: information@autismnj.org

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