A Guide to Insurance Coverage for Autism in NJ

December 9, 2019

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For parents of children with autism, one of the first things to clarify after receiving an Autism Spectrum Disorder (ASD) diagnosis is the insurance coverage. Thankfully, insurance coverage in New Jersey, at both the state and federal level, provide plenty of protections for patients. 

In this guide to insurance coverage for ASD in NJ, we provide an overview of the protections in place.

First off, what type of benefit plan do you have?

The first thing you need to do is confirm what type of benefit plan you have, as this will determine which health benefits are covered. This will either be:

• A fully insured plan/small group plan/NJ State Health Benefits and the School Employees’ Health Benefits Programs: These plans are regulated by state law, and the New Jersey Autism and Other Developmental Disabilities Mandate 2009 provides specific provisions. The below section provides more details on this.   
• A Self funded plan: These plans are regulated by federal law, rather than state law. As such, these plans have different provisions for ASD coverage. The below section provides more details on these provisions.  

If you’re not sure which type of benefit plan you have, speak to your employer or your insurer. Generally speaking, smaller businesses provide fully insured plans, while larger businesses provide self funded plans.  

coverage on fully insured plans

For parents with fully insured plans, the Autism Insurance Mandate 2009 provides a number of robust protections for patients. These include:

• Prohibiting the denial of coverage on the basis that therapy is not restorative.
• Mandating coverage for incurred expenses for occupational, physical and speech therapy that is medically necessary.
• Mandating coverage for Applied Behaviour Analysis to treat a primary diagnosis of ASD, if it’s prescribed through a treatment plan. 

When the mandate first came into effect, it placed a number of restrictions and limitations on cover. This included:a cap of $36,000 and a 30-visit maximum for therapies per annum, as well as an age cap of 21.  

However, following the Affordable Care Act the mandate no longer has a monetary, visit or age limitation. These changes were effective as of January 2015. 

A few other important points to be aware of with the mandate include:

• Therapy must be prescribed through a treatment plan.
• While physicians are required under the mandate to create a treatment plan, many insurers allow, or in some cases require, a Board Certified Behavior Analyst (BCBA) to do this. You should therefore confirm this with your insurer.
• Insurers may only request an updated treatment plan once every six months.  

coverage on self funded plans   

As discussed above, the Autism Insurance Mandate does not apply to self funded plans. This is due to the fact that these plans are governed by federal rather than state law. 

However, there are still patient protections in place, that can ensure cover for autism. These include:

• The Affordable Care Act. This prohibits insurers from placing annual or lifetime limits, or rejecting cover for pre-existing medical conditions
• The Mental Health Parity and Addiction Equity Act. This prohibits insurers from imposing more restrictions on mental health treatments compared to other medical and surgical treatments. Therefore, insurers can’t place limitations on ASD therapies, if no such limitations exist for the treatment or other medical conditions.         

What are the next steps?

Now you know the different provisions for autism insurance coverage in the state, you can begin your conversations with your insurer to confirm coverage.  

And if you haven’t already done so, you can begin talking to treatment service providers and discuss treatment plans for your child. Your chosen treatment provider will work with you to confirm coverage with your insurance provider. 

If you want to find out more information about the treatment plans we offer, you can learn more here.