Policy Attachment

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Attachment B to Policy # 10.06.01d Outpatient Speech Therapy


View the policy for this attachment here:

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For members enrolled in New Jersey's commercial products, New Jersey A-2238 (Autism Mandate) affects policies, plans, and/or contracts that provide hospital and medical expense benefits pursuant to New Jersey law or approved for issuance or renewal by the Commissioner of the Department of Banking and Insurance.


COVERAGE FOR CERTAIN THERAPIES FOR THE TREATMENT OF AUTISM OR ANOTHER DEVELOPMENTAL DISABILITY

• An insurer must provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability. For a primary diagnosis of autism or another developmental disability, an insurer must provide coverage for expenses incurred for the following medically necessary treatments as prescribed through the treatment plan:
  • Occupational therapy
  • Physical therapy
  • Speech therapy

• The following limitations/provisions also apply to these covered individuals:
  • Insurers shall be responsible for the cost of medically necessary treatment up to $36,000 per year. The benefit amount will be adjusted annually based on the consumer price index (CPI) and made known by the Commissioner of the Department of Banking and Insurance.
  • The benefits provided must be provided to the same extent as for any other medical condition under policy, but cannot be subject to limits on the number of visits that a covered individual may make to provider of behavioral interventions.
  • Coverage cannot be denied on the basis that the treatment is not restorative.
  • In addition, for covered individuals under twenty-one (21) years of age with a primary diagnosis of autism, an insurer must provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis (ABA) and related structured behavioral programs as described in the treatment plan and provided or supervised by an individual who is certified by the Behavior Analyst Certification Board as a Board Certified Analyst.

• Coverage does not affect educational services provided under an individualized family service plan (IFSP) or an individualized education program (IEP), except that coverage is included for expenses incurred by members who participate in an IFSP through a family cost share.

TREATMENT PLAN

The treatment plan (a plan for the treatment of autism and other developmental disabilities) must include all elements necessary for the insurer to appropriately provide benefits. The insurer may request an updated treatment plan for the treatment of autism and other developmental disabilities once every (6) six months, subject to its utilization review requirements, including case management, concurrent review, and other managed care provisions. A more frequent review can be agreed upon by the insurer and the treating physician who is developing the treatment plan due to emerging clinical circumstances. In order for the insurer to appropriately provide benefits, the treatment plan must include, but is not limited to, the following elements:

• A diagnosis
• Proposed treatment by type, frequency, and duration
• The anticipated outcomes stated as goals
• The frequency by which the treatment plan will be updated
• The treating physician's signature

Version Effective Date: 11/13/2009