According to information collected in 2010 by the Centers for Disease Control and Prevention ("CDC"), the number of children diagnosed with Autism Spectrum Disorder (ASD) continues to rise. For example, in 2006, 1 in 110 was identified whereas that number increased to a national average of 1 in 68 children in 2010. The numbers in the Garden State (1 in 45) are especially troubling as they well exceed the national average.
Recognizing the need to focus in on viable options for the treatment of autism and other developmental disabilities, New Jersey joined 14 other states in passing a law mandating autism insurance coverage. As initially chartered in 2009, the " New Jersey Autism Coverage Act" requires certain carriers subject to the oversight of the Department of Banking and Insurance, to cover medically necessary therapy for individuals up to 21 years of age. This therapy includes Applied Behavior Analysis (ABA), as well as occupational (OT), physical (PT) and speech (SLP) therapies.
New Jersey's autism mandate was more recently updated for 2015. AsAutism New Jersey reports, the New Jersey Individual Health Coverage Program Board and the New Jersey Small Employer Health Coverage Board adopted amendments (effective January 2015) to expand the coverage of ABA to adults over the age of 21 and to remove the 30 visit limitation previously established for occupational, speech and physical therapies to treat autism.
A multi- disciplinary provider approach including skilled providers in the areas of ABA, OT, SLP and PT has reaped positive results in autism treatment. However, because autism treatment continues to break new ground, providers must carefully navigate the coding process and licensure requirements to ensure payment by the insurance carrier under the mandate. In addition, parents and caretakers alike should review the law carefully to determine whether and how it applies to their particular type of insurance and the statutory conditions for treatment coverage.
Provider Practice Tip: Understand how the mandate and the 2015 amendments apply to your practice. Since insurers may use different codes for the same treatment, check updates and alerts to ensure that your billing practices comport with insurer requirements. Now that New Jersey has mandated coverage for autism, providers should seek to be on the "front end" of all coding, legal issues, and licensing requirements.
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