NJ Law Mandates Autism Treatment Coverage

By Hilda Pressman, MA, CCC-SLP, BRS-S

Posted on: October 8, 2009

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Governor Jon Corzine (D-NJ) has signed into law a bill (A2238/S1651) that requires insurance companies to cover the screening, evaluation and therapeutic treatment for all individuals diagnosed with autism and other developmental disabilities. The bill, enacted on Aug. 13, was sponsored by Assembly Speaker Joseph J. Roberts (D), who declared the initiative as one of the legacies of his 22-year career in the legislature. Sen. Joseph F. Vitale (D) was the sponsor in the Upper House.

The law will take effect in February. It 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, as well as state and local government plans. Large companies that self-insure or plans that are federally regulated are not required to provide the coverage.
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 (ABA), is covered, but only for children with autism. ABA will be capped at $36,000 per year. This will be reviewed in 2011 and will rise annually based on the consumer price index.

Specific wording in this bill also states that "coverage of these therapies shall not be denied on the basis that the treatment is not restorative." This will make insurance benefits for these therapies accessible to young children who previously had been denied coverage routinely for their treatment. These decisions were based on the treatment being deemed developmental or educational rather than restorative. The law specifically excludes a requirement to provide reimbursement for services provided under an individualized family service plan (IFSP) or individual education plan (IEP) plan. However, parents may submit insurance claims for reimbursement of their cost share portion of covered therapies.
Providers will be responsible for submitting a proposed treatment plan to include diagnosis, frequency and duration of treatment, therapeutic goals and outcomes. This will be submitted at the initiation of treatment and once every six months, substantially helping families and clinicians who previously were asked to submit updated information after as few as eight sessions. When this occurs, interruption in services often results until authorization is given again.

Members of the Healthcare Committee of the New Jersey Speech-Language-Hearing Association (NJSHA) along with Lynn Nowak, executive vice president of Porzio Governmental Affairs, lobbyist for NJSHA, have been working to introduce a bill that would cover speech therapy services for those for whom speech therapy would not be restorative, as well as for individuals with voice disorders and stuttering. They had fruitful meetings with legislators. The committee was made aware of the current bill, originally introduced by Autism NJ, which only specified autism.

The Arc of NJ was able to add the words "and other developmental disabilities." The word "non-restorative" came from the bill that was being written by NJSHA. Lynn Nowak supported the present bill in committee on behalf of NJSHA. The Healthcare Committee of NJSHA is chaired by Barbara Schwerin Bohus, MS, CCC-SLP, and Kathleen Palatucci, MA, CCC-SLP. NJSHA members Robynne Kratchman, MS, CCC-SLP and Hildy Lipner, MA, CCC-SLP were instrumental in working on the law. Theresa Bartolotta, PhD, CCC-SLP is president of NJSHA.

Most people are unaware of the limits to their insurance benefits until they attempt to use them. It is often the speech-language pathologist who has to inform families about the limitations of their coverage. After the insurance company meets its financial obligations as required in the contract, patients may forgo necessary treatment due to an inability to support the cost of their own care.

Human resource managers and employers are similarly unaware of this issue when purchasing insurance plans for their employees. The plan summary that is given to employees usually states "speech therapy 20 sessions per calendar year" without indicating the exclusions or conditions. Exclusions and definitions of what constitutes medical necessity often are unclear, and denial of payment can occur for therapy already performed, leaving the patient responsible for the outstanding bill. Authorized sessions may be doled out in small numbers by the insurer.

Continuing treatment often requires frequent and multiple authorizations with documentation review of clinical progress notes by the insurance company each time. Frequent and regular interruption in treatment and the continuity of care occur while awaiting the next authorization. Resources allocated for addressing authorizations, appeals and retroactive denials result in an increase in paperwork and limitations on available patient contact time.

The Healthcare Committee of NJSHA was awarded grants by the American Speech-Language-Hearing Association (ASHA) and NJSHA to conduct a public awareness campaign this fall, including a series of public service notices in parent and children magazines, and possibly on radio and TV.

The information will urge employees to review policies carefully during the annual renewal period in November and December. They should ask to see a copy of the detailed coverage information and speak with their benefits representative or human resources department about any concerns. Employers often are willing to discuss changes with the insurer and find that adding expanded speech therapy benefits or making changes to allow children to be covered for services has a minimal cost. The goal of the public awareness campaign is to provide information and education to the consumers to enable improved self advocacy and informed decision-making.

Hilda Pressman is a member of the NJSHA Health Care Committee.

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