Fully Insured Plans and ABA

January 06, 2023

This article is a part of our
Health Insurance and Autism series.


COMING SOON!
If you have a fully insured health care plan, you most likely get your insurance in one of two ways:
  1. you bought an individual/family health plan on the New Jersey insurance marketplace yourself
  2. you get insurance through an employer headquartered in New Jersey. (Click here if your employer is headquartered out of state.)
If this sounds like you, read on.

Minimum Coverage Requirements

Your fully insured New Jersey plan is required by law to cover the following:

✓  Screening and diagnostic testing for autism
✓  Medically necessary applied behavior analysis
✓  Medically necessary physical therapy, occupational therapy, and speech therapy
✓  Reimbursement for a parent’s cost sharing portion of Early Intervention services

These minimum coverage requirements were written into law in 2009 under the Autism Insurance Mandate. For more information about this law, read Bulletin 10-02 from the New Jersey Department of Banking and Insurance (DOBI).

In other words, you can’t offer nothing, and if you offer something, it needs to have the same rules.


Legal Protections – Take Your Knowlege to the Next Level

Up next are two laws that form the cornerstone of your behavioral health benefits.

Essential Health Benefits

Insurance plans must have some behavioral health benefits. All fully insured plans purchased in New Jersey must cover each of 10 “essential health benefits” (EHBs) as a result of the Affordable Care Act, which was passed in 2010. One of these 10 named EHBs is Mental Health and Substance Use Disorder Services. This category includes behavioral health treatment. As a result, no New Jersey fully insured plan can refuse to cover behavioral health treatment altogether.

Parity

What’s more, federal law states that when your plan offers mental and behavioral health benefits, it must do so in parity with any medical or surgical benefits it offers. Your health insurance plans can’t apply a limitation on its coverage of outpatient behavioral health benefits (such as Applied Behavior Analysis therapy) if the same limitation is not applied to substantially all coverage for outpatient medical or surgical benefits. The federal law that guarantees parity is the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

At this point, you may be asking yourself, “why is parity important?” The parity requirement makes sure that insurance carriers can’t discriminate and offer less coverage for a condition simply because it affects someone’s mental or behavioral health.

Here Are Some Examples of MHPAEA Violations

The following policies are examples that, whether explicitly written into a plan or carried out in practice, would violate MHPAEA’s parity requirement:

  • Carrier puts a dollar cap on coverage of medically necessary ABA when no such dollar cap exists for physical therapy due to a back injury
  • Carrier requires a parent to be present or to participate during ABA therapy sessions but would not require the same parent participation for a child during their chemotherapy sessions
  • Carrier states that a beneficiary is only covered for a maximum of 100 hours of ABA per plan year, when no such hour cap exists for an outpatient dialysis treatment


Exceptions/Considerations:
Health plans are governed by the laws of the state in which they are issued. If you have an employer headquartered in another state, the information in this article may not apply to you. You may be able to get additional information, help, and resources from that state’s government insurance agency or department of consumer protection.

Need Help?

If you can’t figure out what type of health insurance you have, or if you have other questions about insurance and how to use it to cover autism diagnostic evaluations or applied behavior analysis, visit our insurance hub>>

Connect with an Autism New Jersey Helpline Specialist. Call 800.4.AUTISM or email information@autismnj.org.