LRBs0006/1
PJK:cjs/wlj/bjk:jf
2009 - 2010 LEGISLATURE
SENATE SUBSTITUTE AMENDMENT 1,
TO 2009 SENATE BILL 3
February 6, 2009 - Offered by Senator Robson.
SB3-SSA1,1,5
1An Act to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 111.91 (2) (n), 120.13 (2) (g),
2185.981 (4t) and 185.983 (1) (intro.); and
to create 609.87 and 632.895 (16) of
3the statutes;
relating to: health insurance coverage of autism treatment,
4providing an exemption from emergency rule procedures, and granting
5rule-making authority.
Analysis by the Legislative Reference Bureau
This substitute amendment requires health insurance policies and
self-insured governmental and school district health plans to cover the cost of
treatment for an insured for autism, Asperger's syndrome, and pervasive
developmental disorder not otherwise specified if the treatment is prescribed by a
physician and provided by a psychiatrist, a psychologist, a social worker who is
certified or licensed to practice psychotherapy, a paraprofessional working under the
supervision of any of those three types of providers, a professional working under the
supervision of an outpatient mental health clinic, a speech-language pathologist, or
an occupational therapist. The providers must be qualified to provide the services.
The coverage provided must be at least $60,000 for intensive-level services per year
per insured, with a minimum of 30 to 35 hours of care per week for a minimum
duration of four years, and at least $30,000 for post-intensive-level services per year
per insured. Beginning in 2011, the minimum coverage monetary amounts will be
adjusted annually to reflect changes in the medical consumer price index. The
commissioner of insurance will publish the new minimum amounts each year in the
Wisconsin Administrative Register. The commissioner must also promulgate a rule
that further defines "intensive-level services," "post-intensive-level services,"
"paraprofessional," and "qualified" for purposes of the coverage requirement and
may promulgate rules for the requirement's interpretation or administration.
The coverage requirement applies to both individual and group health
insurance policies and plans, including defined network plans and cooperative
sickness care associations; to health care plans offered by the state to its employees,
including a self-insured plan; and to self-insured health plans of counties, cities,
towns, villages, and school districts. The requirement specifically does not apply to
limited-scope benefit plans, medicare replacement or supplement policies,
long-term care policies, or policies covering only certain specified diseases.
The coverage may be subject to any deductibles, coinsurance, or copayments
that apply generally under the policy or plan, but may not be subject to any
limitations or exclusions, including limitations on the number of treatment visits.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB3-SSA1, s. 1
1Section
1. 40.51 (8) of the statutes is amended to read:
SB3-SSA1,2,52
40.51
(8) Every health care coverage plan offered by the state under sub. (6)
3shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.746 (1) to (8)
4and (10), 632.747, 632.748, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to
5(5) (6), 632.895 (5m) and (8) to
(15) (16), and 632.896.
SB3-SSA1, s. 2
6Section
2. 40.51 (8m) of the statutes is amended to read:
SB3-SSA1,2,97
40.51
(8m) Every health care coverage plan offered by the group insurance
8board under sub. (7) shall comply with ss. 631.95, 632.746 (1) to (8) and (10), 632.747,
9632.748, 632.83, 632.835, 632.85, 632.853, 632.855, and 632.895 (11) to
(15) (16).
SB3-SSA1, s. 3
10Section
3. 66.0137 (4) of the statutes is amended to read:
SB3-SSA1,3,311
66.0137
(4) Self-insured health plans. If a city, including a 1st class city, or
12a village provides health care benefits under its home rule power, or if a town
13provides health care benefits, to its officers and employees on a self-insured basis,
1the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
2632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.85, 632.853, 632.855, 632.87 (4),
and 3(5)
, and (6), 632.895 (9) to
(15)
(16), 632.896, and
767.25 (4m) (d) 767.513 (4).
SB3-SSA1, s. 4
4Section
4. 111.91 (2) (n) of the statutes is amended to read:
SB3-SSA1,3,65
111.91
(2) (n) The provision to employees of the health insurance coverage
6required under s. 632.895 (11) to (14)
and (16).
SB3-SSA1, s. 5
7Section
5. 120.13 (2) (g) of the statutes is amended to read:
SB3-SSA1,3,118
120.13
(2) (g) Every self-insured plan under par. (b) shall comply with ss.
949.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.746 (10) (a) 2. and (b) 2., 632.747 (3),
10632.85, 632.853, 632.855, 632.87 (4)
and, (5)
, and (6), 632.895 (9) to
(15)
(16), 632.896,
11and
767.25 (4m) (d) 767.513 (4).
SB3-SSA1, s. 6
12Section
6. 185.981 (4t) of the statutes is amended to read:
SB3-SSA1,3,1613
185.981
(4t) A sickness care plan operated by a cooperative association is
14subject to ss. 252.14, 631.17, 631.89, 631.95, 632.72 (2), 632.745 to 632.749, 632.85,
15632.853, 632.855, 632.87 (2m), (3), (4),
and (5)
, and (6), 632.895 (10) to
(15) (16), and
16632.897 (10) and chs. 149 and 155.
SB3-SSA1, s. 7
17Section
7. 185.983 (1) (intro.) of the statutes is amended to read:
SB3-SSA1,3,2418
185.983
(1) (intro.) Every such voluntary nonprofit sickness care plan shall be
19exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41,
20601.42, 601.43, 601.44, 601.45, 611.67, 619.04, 628.34 (10), 631.17, 631.89, 631.93,
21631.95, 632.72 (2), 632.745 to 632.749, 632.775, 632.79, 632.795, 632.85, 632.853,
22632.855, 632.87 (2m), (3), (4),
and (5)
, and (6), 632.895 (5) and (9) to
(15) (16), 632.896,
23and 632.897 (10) and chs. 609, 630, 635, 645, and 646, but the sponsoring association
24shall:
SB3-SSA1, s. 8
25Section
8. 609.87 of the statutes is created to read:
SB3-SSA1,4,2
1609.87 Coverage of treatment for autism spectrum disorders. Defined
2network plans are subject to s. 632.895 (16).
SB3-SSA1, s. 9
3Section
9. 632.895 (16) of the statutes is created to read:
SB3-SSA1,4,44
632.895
(16) Treatment for autism spectrum disorders. (a) In this subsection:
SB3-SSA1,4,55
1. "Autism spectrum disorder" means any of the following:
SB3-SSA1,4,66
a. Autism disorder.
SB3-SSA1,4,77
b. Asperger's syndrome.
SB3-SSA1,4,88
c. Pervasive developmental disorder not otherwise specified.
SB3-SSA1,4,109
2. "Insured" includes an enrollee and a dependent with coverage under the
10disability insurance policy or self-insured health plan.
SB3-SSA1,4,1311
3. "Intensive-level services" means evidence-based behavioral therapy that is
12designed to help an individual with autism spectrum disorder overcome the
13cognitive, social, and behavioral deficits associated with that disorder.
SB3-SSA1,4,1414
4. "Physician" has the meaning given in s. 146.34 (1) (g).
SB3-SSA1,4,1915
5. "Post-intensive-level services" means therapy that occurs after the
16completion of treatment with intensive-level services and that is designed to sustain
17and maximize gains made during treatment with intensive-level services or, for an
18individual who has not and will not receive intensive-level services, therapy that
19will improve the individual's condition.
SB3-SSA1,4,2520
(b) Subject to pars. (c) and (d), and except as provided in par. (e), every disability
21insurance policy, and every self-insured health plan of the state or a county, city,
22town, village, or school district, shall provide coverage for an insured of treatment
23for the mental health condition of autism spectrum disorder if the treatment is
24prescribed by a physician and provided by any of the following who are qualified to
25provide intensive-level services or post-intensive-level services:
SB3-SSA1,4,26
11. A psychiatrist, as defined in s. 146.34 (1) (h).
SB3-SSA1,5,22
2. A person who practices psychology, as described in s. 455.01 (5).
SB3-SSA1,5,43
3. A social worker, as defined in s. 252.15 (1) (er), who is certified or licensed
4to practice psychotherapy, as defined in s. 457.01 (8m).
SB3-SSA1,5,65
4. A paraprofessional working under the supervision of a provider listed under
6subds. 1. to 3.
SB3-SSA1,5,87
5. A professional working under the supervision of an outpatient mental health
8clinic certified under s. 51.038.
SB3-SSA1,5,99
6. A speech-language pathologist, as defined in s. 459.20 (4).
SB3-SSA1,5,1010
7. An occupational therapist, as defined in s. 448.96 (4).
SB3-SSA1,5,1911
(c) 1. The coverage required under par. (b) shall provide at least $60,000 for
12intensive-level services per insured per year, with a minimum of 30 to 35 hours of
13care per week for a minimum duration of 4 years, and at least $30,000 for
14post-intensive-level services per insured per year, except that these minimum
15coverage monetary amounts shall be adjusted annually, beginning in 2011, to reflect
16changes in the consumer price index for all urban consumers, U.S. city average, for
17the medical care group, as determined by the U.S. department of labor. The
18commissioner shall publish the new minimum coverage amounts under this
19subdivision each year, beginning in 2011, in the Wisconsin Administrative Register.
SB3-SSA1,5,2320
2. Notwithstanding subd. 1., the minimum coverage monetary amounts or
21duration required for treatment under subd. 1., need not be met if it is determined
22by a supervising professional, in consultation with the insured's physician, that less
23treatment is medically appropriate.
SB3-SSA1,6,224
(d) The coverage required under par. (b) may be subject to deductibles,
25coinsurance, or copayments that generally apply to other conditions covered under
1the policy or plan. The coverage may not be subject to limitations or exclusions,
2including limitations on the number of treatment visits.
SB3-SSA1,6,33
(e) This subsection does not apply to any of the following:
SB3-SSA1,6,44
1. A disability insurance policy that covers only certain specified diseases.