Monday, October 18, 2010

Autism Benefits For New Jersey Residents

There is good news in New Jersey for parents of kids with autism. On January 14, 2010 the New Jersey Department of Insurance and Banking issued a letter to all hospitals, medical health services and insurance companies to implement special benefits for the treatment of autism and other developmental disabilities.

The directive, known as chapter 115 requires that insurance companies offer:

  • 1. Payment for expenses incurred in screening and diagnosing autism or other developmental disabilities.
  • 2. Coverage for expenses incurred for medically essential physical therapy, occupational therapy and speech therapy services for the treatment of autism or another developmental disability.
  • 3. Coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis (ABA) and related structured behavioral programs for treatment of autism in individuals under 21 years old.
  • 4. A benefit for the coverage of the Family Cost Share expense incurred for certain health care services obtained through the New Jersey Early Intervention System (NJEIS).

In addition, carriers must provide the coverage without consideration of whether the services are restorative or have a restorative effect.

The New Jersey Developmentally Disabled Rights Act defines the regulation to include a severe, continual disability of an individual which is attributable to a mental or bodily impairment or combination of mental or physical impairments. It is applicable to those who were diagnosed before the age of 22 and are to be expected to continue their condition forever.

Coverage would be for those who are limited in self-care, expressive language, learning, mobility, self-direction and capacity for independent living. Developmental disability includes severe disabilities such as mental retardation, autism, cerebral palsy, epilepsy, spina-bifida and other neurological impairments. The state interprets "autism" to mean autism and associated conditions also known as "Autism Spectrum Disorder." This would include conditions classified under "Pervasive Developmental Disorder".

The New Jersey autism law requires that carriers provide coverage for expenses incurred by someone who is under 21 years of age and diagnosed with autism for medically necessary treatments of the autism based on ABA, an acronym for applied behavioral analysis. The ABA method of behavioral intervention strategies includes functional analysis and assessment, communication training, imitation training and procedures designed to reduce challenging and dangerous behaviors. Also included are reinforcement systems, including differential reinforcement, and strategies to promote generalization.

Most states, including New Jersey, have no professional license for ABA practitioners. The National Behavior Analyst Certification Board does provide credentials that practitioners of ABA may obtain upon satisfaction of their sets of standards.

The Legislature limits coverage of ABA services for persons under age 21 that has autism spectrum disorder to $36,000 per calendar year Chapter 115 establishes limits for the Family Cost Share expense benefit, as follows: Carriers are only required to provide a benefit for the Family Cost Share expense associated with the provision of occupational therapy, speech therapy, physical therapy, and behavioral interventions based on ABA or related structured behavior services. Carriers are only required to provide a benefit for the Family Cost Share outlay when the service in question is provided to a child diagnosed with autism or other developmental disability. Carriers cannot deny payment for the Family Cost Share cost on the basis that treatment with any of the Chapter 115-identified therapies is not curative.

Allen Bree writes articles for The NJ Autism Center, a NJ Autism resource that specializes in the ABA program. Their website is

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