This week, Wisconsin Governor Jim Doyle announced an emergency rule (the “Rule”) interpreting and implementing Section 632.895 (12m) of the Wisconsin Statutes which mandates that insurers and self-insured health plans provide coverage for the treatment of autism spectrum disorders.  Specifically, Section 632.895 (12m) requires that every disability insurance policy (except disability policies that cover only certain specified diseases), self-insured health plan and defined network plan[1] provide coverage for the treatment of autism spectrum disorders, if the treatment is prescribed by a physician, of:  (i) at least $50,000 for intensive-level services per insured per year with a minimum of 30 to 35 hours of care per week for a minimum duration of four years; and (ii) at least $25,000 for nonintensive-level services per insured per year.  Beginning in 2011, the minimum coverage amounts will be adjusted annually to reflect changes based on the consumer price index.

The Rule sets forth the parameters of “intensive-level services” and “nonintensive-level services.”   Intensive-level services means evidence-based behavioral therapy, treatment and services for insureds ages two through nine with a verified diagnosis of autism spectrum disorder.  The therapy, treatment and services must be based on specific cognitive, social, communicative, self-care or behavioral goals as prescribed by a physician familiar with the insured and implemented by qualified providers, qualified professionals, qualified therapists or qualified paraprofessionals as defined in the Rule.  Evidence-based behavioral therapy, treatment and services provided to an insured for an average of 20 hours or more per week over a continuous six-month period may be considered by insurers and self-insureds as intensive-level services.  Nonintensive-level services means services that are provided to insureds:  (i) after they have completed intensive-level services to sustain and maximize gains obtained through such intensive-level services; or (ii) that have not and will not receive intensive-level services, but who will benefit from such services.  The statute and Rule apply to policies issued or renewed on or after November 1, 2009.

Click here for our previous blog on developments in other states regarding autism coverage legislation.

[1] “Defined network plan” means a health benefit plan that requires an enrollee of the health benefit plan, or creates incentives, including financial incentives, for an enrollee of the health benefit plan, to use providers that are managed, owned, under contract with, or employed by the insurer offering the health benefit plan.  Wis. Stat. § 609.1.