New Jersey Medicaid for Autism

July 29, 2022

golden-user

New Jersey Medicaid, also known as NJ FamilyCare, covers ABA therapy and other services for children diagnosed with autism spectrum disorder. 

In this article, we provide comprehensive information about New Jersey Medicaid for autism and explain how families can access this benefit for their children.

What Medicaid Benefits Are There for Children with Autism in New Jersey?

Medicaid started covering applied behavior analysis (ABA) therapy and other treatments for autism in April 2020. Children on the spectrum residing in the state of New Jersey can benefit from Medicaid assistance for a wide range of autism-related services.

“ASD services are available to any NJ FamilyCare Medicaid child member, under the age of 21, who has been diagnosed with ASD, defined by ICD-10-CM diagnosis codes F84.0 through F84.9″ New Jersey Department of Human Service

 

The following treatments are currently covered through the NJ FamilyCare program:

 

• Applied behavior analysis (ABA) therapy
• Physical therapy
• Occupational therapy
• Speech therapy
• Augmentative and alternative communication
• Clinical interventions
• Sensory Integration therapy
• Developmental and relationship-based interventions. 

Coverage of Applied Behavior Analysis (ABA) Therapy

New Jersey has the highest prevalence of children with autism in the nation, out of which more than 40% are in need of ABA therapy. All children diagnosed with autism can get reimbursed for the costs associated with ABA therapy, as long as they are protected under a Medicaid plan. 

NJ FamilyCare reimburses Medicaid-enrolled ABA therapy providers for the following autism treatment services:

• Behavior identification assessments
• Supporting assessments
• Adaptive behavior treatment
• Individual, group, and family adaptive behavior treatments.

 

Continue reading to learn more about eligibility criteria for autism treatments covered by Medicaid.

How to Qualify for Autism Medicaid Services in New Jersey

NJ Family Care members ages 0-21 who have received an autism diagnosis from a qualified healthcare professional are entitled to receive Medicaid services. Since New Jersey residents who qualify for Supplemental Security Income (SSI) are automatically eligible for Medicaid, autistic children can also qualify for Medicaid due to their SSI eligibility.

Receiving an autism diagnosis

To benefit from Medicaid-covered services in New Jersey, your child must have an official autism spectrum disorder (ASD) diagnosis. NJ FamilyCare services can’t be denied based on pre-existing conditions, which means that you can get access to benefits also If your child has an existing autism diagnosis. However, without a formal diagnosis, you won’t be able to use Medicaid benefits, even if your child needs them.

Determining treatment plan

The physician will recommend a treatment for your child or direct you to a specialist who will create a suitable plan. Note that insurance companies will only pay for therapies and treatments that are considered medically necessary.

Finding a provider

After receiving a diagnosis and a treatment plan, the next step is getting in touch with different ABA services to check whether they accept Medicaid. Services must be provided by a licensed or certified clinician contracted with Medicaid/NJ FamilyCare and/or your managed care organization. 

 

Below, we list the best New Jersey Medicaid programs for children with autism spectrum disorder. 

The Best Medicaid Programs for Children with Autism in New Jersey

Aetna

Aetna’s autism benefit covers occupational therapy, speech and physical therapies, behavioral health treatment, and applied behavior analysis (ABA). There are no visit limits for these treatments. However, some Aetna plans don’t cover educational services that are part of your child’s schooling, experimental procedures (allergy testing, acupuncture, art therapy, hippotherapy), and communication aids.

 

Aetna’s Autism Advocate Program can help you understand your benefits, find a suitable network provider for your child, and connect you with resources for caregivers and family support.

Cigna

Cigna covers behavioral health treatments, such as behavior modification, family therapy, and cognitive behavioral therapy, and other medically necessary therapies for children with autism. 

 

To be eligible, your child must have a formal autism diagnosis. Proposed services must be appropriate in terms of type, frequency, and duration, provided by a behavioral health care professional, and therapy must be expected to lead to a meaningful and measurable improvement.

 

Some Cigna plans don’t cover speech-generating devices or services that are not considered medically necessary, for example, classroom environmental manipulation, academic skills training, and parental training. Coverage of medications related to the treatment of autism is subject to the pharmacy benefit portion of the applicable benefit plan.

UHC/Optum

UHC/Optum reimburses ABA services for children between 18 months and 21 years old covered under the NJ FamilyCare Medicaid Program. To be eligible, your child must have autism as the primary diagnosis.

 

Coverage is provided for medically necessary interventions based on the principles of applied behavioral analysis (ABA), in addition to physical therapy, occupational therapy, and speech-language therapy with no benefit limitations. Prescribed assistive communication devices are also covered, as long as they are used as aids in communication related to lack of speech due to autism. 

 

New Jersey benefits don’t include coverage for Picture Exchange Communication Systems (PECS), speech-generating devices, and outpatient prescription medications.

Horizon

Horizon NJ Health covers all medically necessary ABA services for autism determined by a qualified healthcare professional. The following autism-specific treatments are also covered:

• Physical therapy, speech therapy, and occupational therapy
• Sensory integration (SI) therapy provided by an occupational therapist
• Augmentative and alternative communication (AAC) assessments and devices

In addition, the Horizon NJ Autism Care Management Program provides resources, care coordination, as well as psychological and social support for families of autistic children. 

Wellcare

To benefit from the Wellcare coverage, your child must be diagnosed with autism by a multidisciplinary team of practitioners. In addition, the team must indicate that your child’s condition is likely to result in developmental delay. 

 

Wellcare-funded autism services include: 

 

• ABA therapy
• Allied health (occupational, physical, speech, and language therapies)
• Clinical interventions
• Augmentative and alternative communications
• Sensory integration therapy

 

In addition to services available through NJ FamilyCare, children diagnosed with autism who also have an intellectual or developmental disability (IDD) may qualify to receive skill acquisition and capacity-building services. Eligibility for these services is determined by the Department of Children and Families.

Beacon

Beacon enables families of children with autism to access the full range of health services and benefits under their coordinated model of care. The following services are covered in addition to ABA therapy:

• Referrals to behavioral health therapists in order to obtain a comprehensive evaluation and assessment
• Case management
• Care coordination with families and caregivers, healthcare providers, community programs, and education
• Psychotherapy and psychiatric services
• Social skills training
• Paraprofessional supervision

Moreover, Beacon offers parent training and coaching support to educate families about autism diagnosis, available treatment options, coping strategies, support groups, and advocating on a child’s behalf.

EmblemHealth

EmblemHealth (formerly known as GHI) covers ABA therapy services for eligible Medicaid members under the age of 21 who have received a diagnosis of autism spectrum disorder and are referred by a Medicaid-enrolled physician.

 

Autism-related services must be provided by licensed behavior analysts (LBA) or certified behavior analyst assistants (CBAA) working under the supervision of LBAs. Accepted settings include private and group practices, homes, clinics, hospitals, residences, and community settings.

Note that ABA services delivered through telehealth or in school-based health centers, as well as services that are part of an Individualized Education Program (IEP), are not covered by EmblemHealth plans. 

If you are ready to work with the best ABA therapy provider in New Jersey, give us a call at (732) 402-0297. Our dedicated team is ready to help and we will treat you like family.