New Jersey A 1571: Requires certain health benefits coverage for diagnosing and treating autism and other developmental disabilities.

Bill Text

A1571 

ASSEMBLY, No. 1571 

STATE OF NEW JERSEY

222nd LEGISLATURE

� 

PRE-FILED FOR INTRODUCTION IN THE 2026 SESSION

Sponsored by:

Assemblyman SEAN T. KEAN

District 30 (Monmouth and Ocean)

Co-Sponsored by:

Assemblywoman Flynn and Assemblyman Scharfenberger

SYNOPSIS

���� Requires certain health benefits coverage for 
diagnosing and treating autism and other developmental disabilities.

CURRENT VERSION OF TEXT 

���� Introduced Pending Technical Review by Legislative 
Counsel.

��

An Act requiring certain health benefits coverage for 
the diagnosis and treatment of autism and other developmental disabilities and 
amending P.L.2009, c.115.

���� Be It 
Enacted by the Senate and General Assembly of 
the State of New Jersey:

���� 1.��� Section 1 of P.L.2009, 
c.115 (C.17:48-6ii) is amended to read as follows:

���� 1.��� Notwithstanding any 
other provision of law to the contrary, every hospital service corporation 
contract that provides hospital and medical expense benefits and is delivered, 
issued, executed, or renewed in this State pursuant to P.L.1938, c.366 
(C.17:48-1 et seq.), or approved for issuance or renewal in this State by the 
Commissioner of Banking and Insurance, on or after the effective date of this 
act, shall provide coverage pursuant to the provisions of this section.

���� a.���� (1)� The 
hospital service corporation shall provide coverage for expenses incurred in 
screening and diagnosing autism or another developmental disability, including, 
but not limited to, central auditory processing disorder, childhood apraxia of 
speech, sensory processing disorder, and social communication disorder.

���� (2)�� Practitioners shall 
use the DSM IV-TR when rendering an autism diagnosis under this section, but an 
obligation to provide coverage for expenses pursuant to this section shall be 
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, 
or any other version of the DSM or ICD-CM published on or after January 1, 2000.

���� b.��� When the covered 
person's primary diagnosis is autism, central auditory processing disorder, 
childhood apraxia of speech, sensory processing disorder, social communication 
disorder, or another developmental disability, the hospital service 
corporation shall provide coverage for expenses incurred for medically 
necessary occupational therapy, physical therapy, and speech therapy, as 
prescribed through a treatment plan.� Coverage of these therapies shall not be 
denied on the basis that the treatment is not restorative or on the basis of 
any other exclusionary or otherwise limiting language.

���� c.���� When the covered person 
is under 21 years of age and the covered person's primary diagnosis is autism or 
social communication disorder, the hospital service corporation shall 
provide coverage for expenses incurred for medically necessary behavioral 
interventions based on the principles of applied behavioral analysis and 
related structured behavioral programs, as prescribed through a treatment plan and 
as administered directly by, or under the supervision of, a practitioner, 
subject to the provisions of this subsection. 

���� (1)�� Except as provided in 
paragraph (3) of this subsection, the benefits provided pursuant to this 
subsection shall be provided to the same extent as for any other medical 
condition under the contract, but shall not be subject to limits on the number 
of visits that a covered person may make to a provider of behavioral 
interventions.

���� (2)�� The benefits provided 
pursuant to this subsection shall not be denied on the basis that the treatment 
is not restorative.

���� (3)�� (a) �The maximum benefit 
amount for a covered person in any calendar year through 2011 shall be $36,000.

���� (b)�� Commencing on January 1, 
2012, the maximum benefit amount shall be subject to an adjustment, to be 
promulgated by the Commissioner of Banking and Insurance and published in the 
New Jersey Register no later than February 1 of each calendar year, which shall 
be equal to the change in the consumer price index for all urban consumers for 
the nation, as prepared by the United States Department of Labor, for the 
calendar year preceding the calendar year in which the adjustment to the 
maximum benefit amount is promulgated. 

���� (c)�� The adjusted maximum 
benefit amount shall apply to a contract that is delivered, issued, executed, 
or renewed, or approved for issuance or renewal, in the 12-month period 
following the date on which the adjustment is promulgated. 

���� (d)�� Notwithstanding the 
provisions of this paragraph to the contrary, a hospital service corporation 
shall not be precluded from providing a benefit amount for a covered person in 
any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) 
and (b) of this paragraph.

���� d.��� The treatment plan 
required pursuant to subsections b. and c. of this section shall include all 
elements necessary for the