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.