Insurance companies in New Jersey will be required to cover screening, evaluation, and treatment (including speech-language treatment) for individuals diagnosed with autism and other developmental disabilities under a new law that takes effect Feb. 1, 2010.
The law will apply to insurance companies regulated by the state, such as Horizon Blue Cross Blue Shield of New Jersey (the largest insurer in the state) and state and local government plans. Large companies that self-insure and federally regulated plans are exempt.
Under the new law, insurance companies must cover "expenses incurred for medically necessary occupational, physical, and speech therapy as prescribed through a treatment plan" for individuals with autism or other developmental disabilities. Behavioral treatment, such as applied behavioral analysis, is covered, but only for children with autism, and is capped at $36,000 per year. (This figure will be reviewed in 2011 and will be adjusted annually based on the Consumer Price Index.)
Specific wording in the bill also states that "coverage of these therapies shall not be denied on the basis that the treatment is not restorative." With this language, treatment will be accessible to young children who have routinely been denied coverage for their treatment because insurers deemed it "developmental" or "educational"—not restorative. The law specifically excludes reimbursement for services provided under an individual family service plan (for pre-schoolers) or individualized education plan (for students). However, co-payments for early intervention treatment or for any special services offered in school may be reimbursed by insurers.
Providers must submit a proposed treatment plan that includes diagnosis, frequency, and duration of treatment; therapeutic goals; and outcomes. This plan must be submitted at the initiation of treatment and once every six months; previous requirements for updates after as few as eight sessions caused undue reporting burdens and frequent service interruptions while clinicians waited for treatment reauthorization.
The bill was a combination of efforts by the New Jersey Speech-Language-Hearing Association (NJSHA) and its lobbyist, Lynn Nowak; Autism New Jersey; and Arc of New Jersey. NJSHA President Theresa Bartolotta and the NJSHA Healthcare Committee (including co-chairs Barbara Schwerin Bohus and Kathleen Palatucci and members Robynne Kratchman and Hildy Lipner) were working toward introduction of a bill that would cover restorative speech-language treatment and treatment for voice disorders and stuttering. At the same time, Autism New Jersey had introduced a bill specifying coverage only for autism treatment. NJSHA was able to add the term "non-restorative," and Arc was able to add the words "and other developmental disabilities."
The NJSHA Healthcare Committee was awarded grants from NJSHA and ASHA's State Advocates for Reimbursement program to conduct a public awareness campaign to help consumers self-advocate and make informed decisions. The campaign will urge employees to review their policies carefully during the renewal period in November and December, to obtain detailed coverage information, and to speak with their benefits representative or human resources department about any concerns.