Articles

What is a "Developmental Disability" Under the Recent NJ Health Insurance Mandate for the Treatment of Autism and Other Developmental Disabilities?
By: Valerie A. Powers Smith, Esq.

According to the New Jersey Department of Banking & Insurance's January 14, 2010 Bulletin 10-02 providing guidance to all covered health insurance plans on the implementation of P.L. 2009, C. 115, the Department believes the following definition should be used: a developmental disability is defined as "a severe, chronic disability of a person which:

1. is attributable to a mental or physical impairment or combination of mental or physical impairment;
2. is manifest before age 22;
is likely to continue indefinitely;
3. results in substantial functional limitations in three or more of the following areas of major life activity, that is, self-care, receptive and expressive language, learning, mobility, self-direction and capacity for independent living or economic self-sufficiency; and
4. reflects the need for a combination and sequence of special inter-disciplinary or generic care, treatment or other services which are of lifelong or extended duration and are individually planned and coordinated. Developmental disability includes but is not limited to severe disabilities attributable to mental retardation, autism, cerebral palsy, epilepsy, spina-bifida and other neurological impairments where the above criteria are met[.]"

The Department further believes that the terms "autism" as used in Chapter 115 means autism and related conditions often included under the phrase, "Autism Spectrum Disorder." Clinically, this would include several conditions classified under the Pervasive Developmental Disorder.

According to the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition, Text Revised (DSM-IV-TR), autism, Asperger Syndrome, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder, Not Otherwise Specified ("PDD, NOS") are classified as Pervasive Developmental Disorders, which are also often referred to as Autism Spectrum Disorders. It is important to note that commenter's to the new edition of the DSM-IV-TR, the DSM-5, have recommended the removal of Rett Syndrome from the aforementioned classification. The Department seems to indicate that not covering Rett Syndrome would be appropriate.

The DSM-IV-TR also lists the following disorders as developmental disorders under its "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" chapter:

1. Learning Disorders (that is, reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified);
2. Motor Skills Disorders (that is, developmental coordination disorder);
3. Communication Disorders (that is, Expressive Language Disorder, Mixed Receptive/Expressive Language Disorder, Phonological Disorder, Stuttering, and Communication Disorder Not Otherwise Specified);
4. Attention-Deficit and Disruptive Behavior Disorders (that is, AD/HD, Conduct Disorder, ODD, Disruptive Behavior Disorder Not Otherwise Specified);
5. Feeding and Eating Disorders of Infacy or Early Childhood (that is, Pica, Rumination Disorder, and Feeding and Eating Disorders of Infacy or Early Childhood Not Otherwise Specified);
6. Tic Disorders (that is, Tourette's Disorder, Chronic Motor or Vocal Tic Disorder, Transient Tic Disorder, and Tic Disorder Not Otherwise Specified);
7. Elimination Disorders (that is, Encopresis and Enuresis); and
8. Other Disorders of Infancy, Childhood, or Adolescence (that is, Separation Anxiety Disorder, Reactive Attachment Disorder, Stereotypic Movement Disorder, and Disorder of Infancy, Childhood, or Adolescence Not Otherwise Specified).

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.