Getting Autism Therapy Covered by Insurance in New Jersey

New Jersey’s mandate

P.L. 2009 c. 115 (N.J.S.A. 17B:27-46.1ii and related sections), enacted 2009, requires state-regulated health plans in New Jersey to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: The statute limits ABA to people under 21. Since the Affordable Care Act, the Department of Banking and Insurance has taken the position that the mandate carries no age or monetary limit — so the written law and the regulator's position differ, and the difference is in your favor.

Dollar cap: Do not trust the $36,000 figure you will see quoted everywhere. That was the ORIGINAL 2009 ABA maximum, and the statute indexes it to inflation, with the Commissioner republishing a new figure each year — it had already reached $37,710 for calendar year 2014. Ask DOBI for the figure that applies to your plan year, and ask your insurer to put its number in writing.

New Jersey also requires coverage of medically necessary occupational, physical and speech therapy for a primary diagnosis of autism or another developmental disability, and — unusually — bars an insurer from denying those therapies on the ground that they are not restorative. That last clause is worth quoting: 'not restorative' is a standard denial reason for an autistic child who is developing skills rather than regaining them.

Whether the mandate applies to your plan

This is the question to settle first, because the answer decides whether anything above is enforceable for you. State insurance mandates bind fully insured plans. Self-funded employer plans — where the employer pays claims itself and an insurer only administers them — are generally exempt under federal ERISA, and they cover roughly six in ten people with employer coverage.

Ask your HR department, in writing, which type your plan is. If it is self-funded, P.L. 2009 c. 115 (N.J.S.A. 17B:27-46.1ii and related sections) does not compel coverage — but federal parity law may still help, and many large self-funded employers cover ABA voluntarily. Ask what the plan actually covers rather than assuming the answer is no.

The Medicaid route

NJ FamilyCare covers ABA for children under 21 through EPSDT, which is not subject to the private mandate's ABA maximum.

How Medicaid waivers work covers the route for families who do not qualify on income alone.

When you are denied

1. Get the denial reason in writing. Insurers must give a specific reason, and the appeal has to answer that reason rather than restate the diagnosis.
2. File the internal appeal within the deadline on the denial letter, with a letter of medical necessity that addresses the stated reason directly.
3. Request external review if the internal appeal fails. Fully insured plans carry external review rights, and an independent reviewer overturns denials more often than families expect.
4. Complain to the New Jersey Department of Banking and Insurance on 1-800-446-7467 if you believe P.L. 2009 c. 115 (N.J.S.A. 17B:27-46.1ii and related sections) is being violated. Their consumer pages are here.