By: Valerie A. Powers Smith, Esq.

In the Fall of 2009, the State of New Jersey passed a bill (P.L. 2009, C. 115) requiring health benefits coverage for certain therapies for the treatment of autism and other developmental disabilities. The law became effective on February 9, 2010.

Under the Bill, coverage for the following services would be mandated:

1. Screening & diagnosis for autism and other developmental disabilities;
2. Medically necessary OT, ST, and PT as prescribed through a treatment plan; coverage of these therapies is not to be denied on the basis of that the treatment is not restorative; and
3. For children under 21 years of age where the primary diagnosis is autism, medically necessary behavioral interventions based on ABA and related structured behavioral programs, as prescribed through a treatment plan.

On January 14, 2010, the New Jersey Department of Banking & Insurance ("DOBI") issued Bulletin 10-02 to provide guidance to all covered health insurance plans[1] on the implementation of P.L. 2009, C. 115; since it will be unable to promulgate and accept the regulations to govern the new law before the February 9, 2010 effective date.

The following are key points regarding the mandated coverage:

1. Therapy Coverage: Health plans must provide the above-listed services in the same manner as other medical conditions under the health insurance contract and with no limitations applied to behavioral interventions for a covered person under 21 years of age. With regard to therapies, DOBI advises that while the therapy limit for these services shall not be unlimited, they shall also not be counted towards the contract allowance for other illnesses or injuries.
2. Qualified ABA Practitioners: ABA practitioners delivering behavioral interventions based on ABA & related structured behavioral programs should be credentialed by the national Behavior Analyst Certification Board as either a Board Certified Behavior Analyst-Doctoral ("BCBA-D") or Board Certified Behavior Analyst ("BCBA"); or shall perform services under the direct supervision one that is.
3. Annual Health Benefit: Group health plans not subject to the requirements of the federal Mental Health Parity and Addiction Equity Act of 2008 ("MHPAEA") or exempt there under, may apply the annual health benefit cap of $36,000; whereas, DOBI cautions other health plans that application of the annual health benefit cap of $36,000 may conflict with their compliance with MHPAEA.
4. Early Intervention Family Cost Share: Carriers must provide benefits for coverage of the Family Cost Share expense incurred by covered persons for the provision of certain health services obtained in accordance with a treatment plan developed as a result of, or in conjunction with, an Individualized Family Support Plan for a child deemed eligible for early intervention services through the State of New Jersey with the following caveat: only for the above-listed mandated services provided for children diagnosed with autism or another developmental disability.

Valerie A. Powers Smith, Esq., maintains her legal practice throughout New Jersey and Pennsylvania specializing in the following special needs and disability law subject areas: health care insurance, Medicaid, Medicare, special needs trust, trust administration, estate planning & administration, guardianships, and accessing federal and state government disability-based benefits. Valerie can be contacted at Slovak Baron & Empey, LLP at 103 Carnegie Center Blvd.; Ste. 300, Princeton, New Jersey; (609) 955-3393; (609) 520-8731 (f); or powers@sbelawyers.com.

Footnotes:

[1] Health, hospital, medical service corporations (N.J.S.A. 17:48E-1, et seq., N.J.S.A. 17:48-1, et seq., and N.J.S.A. 17:48A-1, et seq.); Individual health insurance policies (N.J.S.A. 17B, et seq.); Group health insurance policies (N.J.S.A. 17B, et seq.); Health benefits plans issued pursuant to N.J. Individual Health Coverage (N.J.S.A. 17B:27A-2, et seq.); Health benefits plans issued pursuant to N.J. Small Employer Health Benefits Programs (N.J.S.A. 17B:27A-17, et seq.); HMOs (N.J.S.A. 26:2J-1, et seq.); State Health Benefits Program (N.J.S.A. 52:14-3D); and School Employees' Health Benefits Program (N.J.S.A. 52:14-17.46-1, et seq.).