Horizon Blue Cross Blue Shield of New Jersey has announced changes to its medical policy for autism treatment services. The new Autism Spectrum Disorder (ASD) Treatment Services Policy, scheduled to take effect December 1, 2026, will replace Horizon’s current ABA policy and address both Applied Behavior Analysis (ABA) and DIR/Floortime.
What Is Changing?
The new policy reorganizes and clarifies the information providers will be expected to submit when seeking authorization for treatment. Core authorization and documentation requirements will be consolidated into a provider submission checklist, including baseline functioning, measurable treatment goals, caregiver involvement, care coordination, and discharge or fading plans.
Other notable changes and clarifications include:
- Treatment intensity and setting: Providers may be asked for additional clinical justification for the number of treatment hours requested or the setting in which services will be delivered. The policy identifies weekly treatment ranges above which additional justification will be required. These ranges are not characterized as limits on services.
- Continuation and fading: The policy provides more specific guidance for continuing, reducing, or discontinuing treatment and allows for increases when clinically significant regression occurs following a reduction in services.
- School-based ABA: Additional guidance distinguishes medically necessary ABA from services primarily intended to support educational or academic needs.
- DIR/Floortime: The policy includes DIR/Floortime as a treatment that may meet medical-necessity criteria and provides guidance for situations in which ABA and DIR/Floortime are provided concurrently. Autism New Jersey categorizes DIR/Floortime as a “yellow light treatment,” meaning families should proceed with caution. The scientific consensus is that there is currently limited evidence that DIR/Floortime is effective as a treatment for autism.
- Adults with autism: Additional guidance addresses treatment for adults, with an emphasis on functional outcomes, independence, and community participation.
Importantly, Horizon has stated that the new policy does not expand the services subject to prior authorization or medical-necessity review, although it may change how requests are reviewed.
Timeline
Horizon’s Material Adverse Change (MAC) notice is scheduled to be posted September 1, 2026, followed by provider and stakeholder awareness efforts from September through November. The new policy is scheduled to take effect December 1, 2026.
What Could This Mean for Providers and Families?
For families, the impact will depend on how these requirements are applied to individual treatment decisions. Their providers may need to submit more detailed clinical information to support treatment intensity, setting, progress, and the continued need for services. Families who start with a new clinician may need to ensure that they’re working with a clinician who understands this new policy and submits appropriately detailed treatment plans along with their prior authorization requests.
Of particular importance will be how the policy is applied to individuals with more significant and ongoing support needs. For some individuals, treatment goals may include not only acquiring new skills, but also maintaining skills, preventing regression, reducing severe challenging behavior, and maintaining safety. How medical necessity, treatment intensity, and fading are considered in these circumstances will be important to monitor.
Keep Us Informed
We encourage providers and families to keep Autism New Jersey informed about their experiences, particularly regarding authorization decisions, documentation requirements, treatment intensity, continuation or fading of services, and access to care. Hearing directly from the community will help identify trends and inform our efforts.