"Insured" includes an enrollee and a dependent with coverage under the disability insurance policy or self-insured health plan.
"Intensive-level services" means evidence-based behavioral therapy that is designed to help an individual with autism spectrum disorder overcome the cognitive, social, and behavioral deficits associated with that disorder.
"Nonintensive-level services" means evidence-based therapy that occurs after the completion of treatment with intensive-level services and that is designed to sustain and maximize gains made during treatment with intensive-level services or, for an individual who has not and will not receive intensive-level services, evidence-based therapy that will improve the individual's condition.
Subject to pars. (c)
, and except as provided in par. (e)
, every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, shall provide coverage for an insured of treatment for the mental health condition of autism spectrum disorder if the treatment is prescribed by a physician and provided by any of the following who are qualified to provide intensive-level services or nonintensive-level services:
A paraprofessional working under the supervision of a provider listed under subds. 1.
A professional working under the supervision of an outpatient mental health clinic certified under s. 51.038
The coverage required under par. (b)
shall provide 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 4 years, and at least $25,000 for nonintensive-level services per insured per year, except that these minimum coverage monetary amounts shall be adjusted annually, beginning in 2011, to reflect changes in the consumer price index for all urban consumers, U.S. city average, for the medical care group, as determined by the U.S. department of labor. The commissioner shall publish the new minimum coverage amounts under this subdivision each year, beginning in 2011, in the Wisconsin Administrative Register.
Notwithstanding subd. 1.
, the minimum coverage monetary amounts or duration required for treatment under subd. 1.
, need not be met if it is determined by a supervising professional, in consultation with the insured's physician, that less treatment is medically appropriate.
The coverage required under par. (b)
may be subject to deductibles, coinsurance, or copayments that generally apply to other conditions covered under the policy or plan. The coverage may not be subject to limitations or exclusions, including limitations on the number of treatment visits.
This subsection does not apply to any of the following:
A disability insurance policy that covers only certain specified diseases.
A health care plan offered by a limited service health organization, as defined in s. 609.01 (3)
, or by a preferred provider plan, as defined in s. 609.01 (4)
, that is not a defined network plan, as defined in s. 609.01 (1b)
The commissioner shall by rule further define "intensive-level services" and "nonintensive-level services" and define "paraprofessional" for purposes of par. (b) 4.
and "qualified" for purposes of providing services under this subsection. The commissioner may promulgate rules governing the interpretation or administration of this subsection.
Using the procedure under s. 227.24
, the commissioner may promulgate the rules under subd. 1.
for the period before the effective date of the permanent rules promulgated under subd. 1.
, but not to exceed the period authorized under s. 227.24 (1) (c)
. Notwithstanding s. 227.24 (1) (a)
, (2) (b)
, and (3)
, the commissioner is not required to provide evidence that promulgating a rule under this subdivision as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to provide a finding of emergency for a rule promulgated under this subdivision.