Wisconsin Administrative Code
Office of the Commissioner of Insurance
Chapter Ins 3 - Casualty Insurance
Section Ins 3.36 - Coverage of autism spectrum disorders
Universal Citation: WI Admin Code ยง Ins 3.36
Current through August 26, 2024
(1) APPLICABILITY.
(a) This section applies to disability
insurance policies as defined in s.
632.895(1) (a), Stats., except as provided in s.
632.895(12m) (e), Stats., and self-insured health plans
sponsored by the state, county, city, town, village, or school
district.
(b) For a disability
insurance policy covering employees who are affected by a collective bargaining
agreement the coverage under this section first applies as follows:
1. If the collective bargaining agreement
contains provisions consistent with s.
632.895(12m),
Stats., coverage under this section first applies the earliest of any of the
following: the date the disability insurance policy is issued or renewed on or
after November 1, 2009, or the date the self-insured health plan is
established, modified, extended or renewed on or after November 1,
2009.
2. If the collective
bargaining agreement contains provisions inconsistent with s.
632.895(12m),
Stats., the coverage under this section first applies on the date the health
benefit plan is first issued or renewed or a self-insured health plan is first
established, modified, extended, or renewed on or after the earlier of the date
the collectively bargained agreement expires, or the date the collectively
bargained agreement is modified, extended or renewed.
(2)DEFINITIONS. In addition to the definitions in s. 632.895(12m) (a), Stats., in this section:
(a) "Behavior analyst" means a person
certified by the Behavior Analyst Certification Board, Inc., or successor
organization as a board-certified behavior analyst and has been granted a
license under s.
440.312, Stats., to
engage in the practice of behavior analysis.
(b) "Behavioral" means interactive therapies
that target observable behaviors to build needed skills and to reduce problem
behaviors using well-established principles of learning utilized to change
socially important behaviors with the goal of building a range of
communication, social and learning skills, as well as reducing challenging
behaviors.
(c) "Department" means
the Wisconsin department of health services.
(d) "Efficacious treatment" or "efficacious
strategy" means treatment or strategies designed to address cognitive, social
or behavioral conditions associated with autism spectrum disorders; to sustain
and maximize gains made during intensive-level services; or to improve an
individual with autism spectrum disorder's condition.
(e) "Evidence-based therapy" means therapy,
service and treatment that is based upon medical and scientific evidence as
described at s.
632.835(3m) (b) 1, 2. (intro.) and a., Stats., and s.
Ins 18.10(4), is determined to be an
efficacious treatment or strategy and is prescribed to improve the insured's
condition or to achieve social, cognitive, communicative, self-care or
behavioral goals that are clearly defined within the insured's treatment
plan.
(f) "Intensive-level service"
means evidence-based behavioral therapies that are directly based on, and
related to, an insured's therapeutic goals and skills as prescribed by a
physician familiar with the insured. Intensive-level service may include
evidence-based speech therapy and occupational therapy provided by a qualified
therapist when such therapy is based on, or related to, an insured's
therapeutic goals and skills, and is concomitant with evidence-based behavioral
therapy.
(g) "Qualified
intensive-level professional" means an individual working under the supervision
of an outpatient mental health clinic who is a licensed treatment professional
as defined in s.
DHS 35.03(9g), and who has completed at
least 2080 hours of training, education and experience including all of the
following:
1. Fifteen hundred hours
supervised training involving direct one-on-one work with individuals with
autism spectrum disorders using evidence-based, efficacious therapy
models.
2. Supervised experience
with all of the following:
a. Working with
families as part of a treatment team and ensuring treatment
compliance.
b. Treating individuals
with autism spectrum disorders who function at a variety of cognitive levels
and exhibit a variety of skill deficits and strengths.
c. Treating individuals with autism spectrum
disorders with a variety of behavioral challenges.
d. Treating individuals with autism spectrum
disorders who have shown improvement to the average range in cognitive
functioning, language ability, adaptive and social interaction
skills.
e. Designing and
implementing progressive treatment programs for individuals with autism
spectrum disorders.
3.
Academic coursework from a regionally-accredited higher education institution
with demonstrated coursework in the application of evidence-based therapy
models consistent with best practice and research on effectiveness for
individuals with autism spectrum disorders.
(h) "Qualified intensive-level provider"
means an individual identified in s.
632.895(12m) (b) 1 to 4., Stats., acting within the scope of a
currently valid state-issued license for psychiatry, psychology or behavior
analyst, or a social worker acting within the scope of a currently valid
state-issued certificate or license to practice psychotherapy, who provides
evidence-based behavioral therapy in accordance with this section and s.
632.895(12m) (a) 3, Stats., and who has completed at least
2080 hours of training, education and experience which includes all of the
following:
1. Fifteen hundred hours
supervised training involving direct one-on-one work with individuals with
autism spectrum disorders using evidence-based, efficacious therapy
models.
2. Supervised experience
with all of the following:
a. Working with
families as the primary provider and ensuring treatment compliance.
b. Treating individuals with autism spectrum
disorders who function at a variety of cognitive levels and exhibit a variety
of skill deficits and strengths.
c.
Treating individuals with autism spectrum disorders with a variety of
behavioral challenges.
d. Treating
individuals with autism spectrum disorders who have shown improvement to the
average range in cognitive functioning, language ability, adaptive and social
interaction skills.
e. Designing
and implementing progressive treatment programs for individuals with autism
spectrum disorders.
3.
Academic coursework from a regionally-accredited higher education institution
with demonstrated coursework in the application of evidence-based therapy
models consistent with best practice and research on effectiveness for
individuals with autism spectrum disorders.
(i) "Qualified paraprofessional" means an
individual working under the active supervision of a qualified supervising
provider, qualified intensive-level provider or qualified provider and who
complies with all of the following:
1. Is at
least 18 years of age.
2. Obtains a
high school diploma.
3. Completes a
criminal background check.
4.
Obtains at least 20 hours of training that includes subjects related to autism,
evidence-based treatment methods, communication, teaching techniques, problem
behavior issues, ethics, special topics, natural environment, and first
aid.
5. Obtains at least ten hours
of training in the use of behavioral evidence-based therapy including the
direct application of training techniques with an individual who has autism
spectrum disorder present.
6.
Receives regular, scheduled oversight by a qualified supervising provider in
implementing the treatment plan for the insured.
(j) "Qualified professional" means an
individual identified in s.
632.895(12m) (b) 5, Stats., acting under the supervision
of an outpatient mental health clinic certified under s.
51.038,
Stats., acting within the scope of a currently valid state-issued license and
who provides evidence-based therapy in accordance with this section.
(k) "Qualified provider" means an individual
identified in s.
632.895(12m) (b) 1 to 4., Stats., respectively, acting within
the scope of a currently valid state-issued license for psychiatry, psychology
or behavior analyst, or a social worker acting within the scope of a currently
valid state-issued certificate or license to practice psychotherapy and who
provides evidence-based therapy in accordance with this section.
(L) "Qualified supervising provider" means an
individual who is a qualified intensive-level provider and who has completed at
least 4160 hours of experience as a supervisor of less experienced providers,
professionals and paraprofessionals.
(m) "Qualified therapist" means an individual
identified in s.
632.895(12m) (b) 6 or 7., Stats., who is either a
speech-language pathologist or occupational therapist acting within the scope
of a currently valid state-issued license and who provides evidence-based
therapy in accordance with this section, sub. (4) (e).
(n) "Supervision of an outpatient mental
health clinic" for purposes of this section means an individual who meets the
requirements of a qualified supervising provider and who periodically reviews
all treatment plans developed by qualified professionals for insureds with
autism spectrum disorders.
(o)
"Waiver program" means services provided by the department through the Medicaid
Home and Community-Based Services as granted by the Centers for Medicare &
Medicaid Services.
(3)VERIFIED DIAGNOSIS.
(a) Insurers and self-insured health plans
shall provide coverage for services to an insured who has a primary verified
diagnosis of autism spectrum disorder made by a diagnostician skilled in
testing and in the use of empirically-validated tools specific for autism
spectrum disorders.
(b) Insurers
and self-insured health plans shall accept as valid and provide coverage for
the diagnostic testing in addition to the benefit mandated by s.
632.895(12m),
Stats. For the diagnosis to be valid for autism spectrum disorder, the testing
tools shall be appropriate to the presenting characteristics and age of the
insured and be empirically validated for autism spectrum disorders to provide
evidence that the insured meets the criteria for autism spectrum disorder in
the most recent edition of the Diagnostic and Statistical Manual of Mental
Disorders published by the American Psychiatric Association. Insurers and
self-insured health plans may require confirmation of a primary diagnosis
through completion of empirically-validated tools or tests from each of the
following categories: intelligence, parent report, language skills, adaptive
behavior, and direct observation of the child.
(c) An insurer and a self-insured health plan
may require an insured to obtain a second opinion from a diagnostician
experienced in the use of empirically-validated tools specific for autism
spectrum disorders who is mutually agreeable to the insured or the insured's
parent or authorized representative and to the insurer or self-insured health
plan. An insurer and a self-insured health plan shall cover the cost of the
second opinion and the cost of the second opinion shall be in addition to the
benefit mandated by s.
632.895(12m),
Stats.
(d) Insurers and
self-insured health plans may require that the assessment include both a
standardized parent interview regarding current concerns and behavioral history
as well as direct, structured observation of social and communicative behavior
and play. The diagnostic evaluation shall also assess those factors that are
not specific to autism spectrum disorders including degree of language
impairment, cognitive functioning, and the presence of nonspecific behavioral
disorders.
(4)INTENSIVE-LEVEL SERVICES.
(a)
Coverage for intensive-level
services. Insurers and self-insured health plans shall provide
coverage for evidence-based behavioral intensive-level therapy for an insured
with a verified diagnosis of autism spectrum disorder, the majority of which
shall be provided to the insured when the parent or legal guardian is present
and engaged and all of the prescribed therapy is consistent with all of the
following requirements:
1. Based upon a
treatment plan developed by an individual who at least meets the requirements
of a qualified intensive-level provider or a qualified intensive-level
professional that includes at least 20 hours per week over a six-month period
of time of evidence-based behavioral intensive therapy, treatment, and services
with specific cognitive, social, communicative, self-care, or behavioral goals
that are clearly defined, directly observed and continually measured and that
address the characteristics of autism spectrum disorders. Treatment plans shall
require that the insured be present and engaged in the intervention.
2. Implemented by qualified providers,
qualified professionals or qualified therapists, or qualified
paraprofessionals.
3. Provided in
an environment most conducive to achieving the goals of the insured's treatment
plan.
4. Implemented identified
therapeutic goals developed by the team including training and consultation,
participation in team meetings and active involvement of the insured's
family.
5. Commenced after an
insured is two years of age and before the insured is nine years of
age.
6. Provided by a qualified
intensive-level provider or qualified intensive-level professional who directly
observes the insured at least once every two months.
(b)
Forty-eight cumulative
months. Insurers and self-insured health plans shall provide up to
forty-eight months of intensive-level services. Insurers and self-insured
health plans may credit against the required forty-eight months of
intensive-level services any previous intensive-level services the insured
received regardless of payor. Insurers and self-insured health plans may
require documentation including medical records and treatment plans to verify
any evidence-based behavioral therapy the insured received for autism spectrum
disorders that was provided to the insured prior to the insured attaining nine
years of age. Insurers and self-insured health plans may consider any
evidence-based behavioral therapy that was provided to the insured for an
average of 20 or more hours per week over a continuous six-month period to be
intensive-level services.
(c)
Travel. Insurers and self-insured health plans shall not
include coverage of travel time for qualified providers, qualified supervising
providers, qualified professionals, qualified therapists or qualified
paraprofessionals when calculating the number of hours of care provided per
week and are not required to separately reimburse for travel time.
(d)
Progress assessment.
Insurers and self-insured health plans shall require that progress be assessed
and documented throughout the course of treatment. Insurers and self-insured
health plans may request and review the insured's treatment plan and the
summary of progress on a periodic basis.
(e)
Concomitant therapy.
Insurers and self-insured health plans shall provide coverage pursuant to s.
632.895(12m) (c), Stats., for a qualified therapist when
services are rendered concomitant with intensive-level evidence-based
behavioral therapy and all of the following:
1. The qualified therapist provides
evidence-based therapy to an insured who has a primary diagnosis of an autism
spectrum disorder.
2. The insured
is actively receiving behavioral services from a qualified intensive-level
provider or qualified intensive-level professional.
3. The qualified therapist develops and
implements a treatment plan consistent with their license and this
section.
(5)NONINTENSIVE-LEVEL SERVICES.
(a)
Coverage for nonintensive-level
services. Insurers and self-insured health plans shall provide
coverage for an insured with a verified diagnosis of autism spectrum disorder
for nonintensive-level services that are evidence-based and that are provided
to an insured by a person who is at least a qualified provider, a qualified
professional, a qualified therapist or a qualified paraprofessional in either
of the following conditions:
1. After the
completion of intensive-level services and designed to sustain and maximize
gains made during intensive-level services treatment.
2. To an insured who has not and will not
receive intensive-level services but for whom nonintensive-level services will
improve the insured's condition.
(b)
Requirements for
coverage. Insurers and self-insured health plans shall provide
coverage for evidence-based therapy that is consistent with all of the
following requirements:
1. Based upon a
treatment plan developed by an individual who minimally meets the requirements
as a qualified provider, a qualified professional or a qualified therapist that
includes specific evidence-based therapy goals that are clearly defined,
directly observed and continually measured and that address the characteristics
of autism spectrum disorders. Treatment plans shall require that the insured be
present and engaged in the intervention.
2. Implemented by a person who is at least a
qualified provider, qualified professional, qualified therapist, or a qualified
paraprofessional.
3. Provided in an
environment most conducive to achieving the goals of the insured's treatment
plan.
4. Implements identified
therapeutic goals developed by the team including training and consultation,
participation in team meetings and active involvement of the insured's
family.
(c)
Services. Insurers and self-insured health plans shall provide
coverage for nonintensive-level services that may include direct or
consultative services when provided by qualified providers, qualified
supervising providers, qualified professionals, qualified therapists, or
qualified paraprofessionals.
(d)
Progress assessment. Insurers and self-insured health plans
shall require that progress be assessed and documented throughout the course of
treatment. Insurers and self-insured health plans may request and review the
insured's treatment plan and the summary of progress on a periodic
basis.
(e)
Travel.
Insurers and self-insured health plans shall not include coverage of travel
time by qualified providers, qualified supervising providers, qualified
professionals, qualified therapists or qualified paraprofessionals when
calculating the number of hours of care provided per week and are not required
to separately reimburse for travel time.
(6)TRANSITION TO NONINTENSIVE-LEVEL SERVICES.
(a) Notice of transition by
insurer. Insurers and self-insured plans shall provide notice to the
insured or the insured's authorized representative regarding change in an
insured's level of treatment. The notice shall indicate the reason for
transition that may include any of the following:
1. The insured has received forty-eight
cumulative months of intensive-level services.
2. The insured no longer requires
intensive-level services as supported by documentation from a qualified
supervising provider, qualified intensive-level provider, or a qualified
intensive-level professional.
3.
The insured no longer receives evidence-based behavioral therapy for at least
20 hours per week over a six-month period of time.
(b) Notice of break in service by
insured. Insurers and self-insured plans may require an insured or an
insured's authorized representative to promptly notify the insurer or
self-insured plan if the insured requires and qualifies for intensive-level
services but the insured or the insured's family or caregiver is unable to
receive intensive-level services for an extended period of time. The insured or
the insured's authorized representative shall indicate the specific reason or
reasons the insured or the insured's family or caregiver is unable to comply
with an intensive-level service treatment plan. Reasons for requesting
intensive-level services be interrupted for an extended period of time may
include a significant medical condition, surgical intervention and recovery,
catastrophic event or any other reason the insurer or self-insured plan
determines to be acceptable.
(c)
Documentation. Insurers and self-insured plans may not deny
intensive-level services to an insured for failing to maintain at least 20
hours per week of evidence-based behavioral therapy over a six-month period
when the insured or the insured's authorized representative complied with par.
(b) or the insured or the insured's authorized representative can document that
the insured failed to maintain at least 20 hours per week of evidence-based
behavioral therapy due to waiting for waiver program services.
(7)NOTICE TO INSUREDS. Insurers and self-insured plans shall provide written notice regarding claims submitted and processed for the treatment of autism spectrum disorders to the insured or insured's parents or authorized representative and include the total amount expended to date for the current policy year. The notice may be included with the explanation of benefits form or in a separate communication provided on a periodic basis during the course of treatment.
(8)RESEARCH THAT IS THE BASIS FOR EFFICACIOUS TREATMENT OR EFFICACIOUS STRATEGIES. Research designs that are sufficient to demonstrate that a treatment or strategy when used solely or in combination with other treatments or strategies, is effective in addressing the cognitive, social, and behavioral challenges associated with autism spectrum disorders demonstrates significant improvement shall include at least one of the following:
(a) Two or more high quality
experimental or quasi-experimental group design studies that meet all of the
following criteria:
1. A clearly defined
population for whom inclusion criteria have been delineated in a reliable,
valid manner.
2. Outcome measures
with established reliability and construct validity.
3. Independent evaluators who are not aware
of the particular treatment utilized.
(b) Five or more single subject design
studies that meet all of the following criteria:
1. Studies must have been published in a
peer-reviewed scientific or medical journal.
2. Studies must have been conducted by three
different researchers or research groups in three different geographical
locations.
3. The body of studies
must have included 20 or more participants.
(c) One high quality randomized or
quasi-experimental group design study that meets all of the criteria in par.
(a) and three high-quality single-subject design studies that meet all of the
criteria in par. (b).
(9)DISPUTES. An insurer's or a self-insured health plan's determination regarding diagnosis and level of service may be considered an adverse determination if the insured disagrees with the determination. The insured or the insured's authorized representative may file a grievance in accordance with s. Ins 18.03. The insured or the insured's authorized representative may seek independent review of the coverage denial determination in accordance with s. Ins 18.11.
(10)NON-REQUIRED COVERAGE.
(a)
Services. Insurers and
self-insured health plans are not required to cover any of the following:
1. Acupuncture.
2. Animal-based therapy including
hippotherapy.
3. Auditory
integration training.
4. Chelation
therapy.
5. Child care
fees.
6. Cranial sacral
therapy.
7. Custodial or respite
care.
8. Hyperbaric oxygen
therapy.
9. Special diets or
supplements.
(b)
Drugs and devices. Insurers and self-insured health plans
shall not provide coverage for pharmaceuticals or durable medical equipment
through s.
632.895(12m),
Stats. Coverage of pharmaceuticals and durable medical equipment shall be
covered in compliance with the terms of the insured's policy.
(c)
Fraudulent claims.
Insurers and self-insured health plans shall not be required to pay claims that
have been determined to be fraudulent.
(d)
Parents of children diagnosed
with autism spectrum disorders. Insurers and self-insured health plans
shall not be required to pay for treatment rendered by parents or legal
guardians who are otherwise qualified providers, qualified supervising
providers, qualified therapists, qualified professionals or qualified
paraprofessionals for treatment rendered to their own children.
(e)
Denial of coverage. If
an insurer or self-funded health plan generally provides benefits for an
illness or injury, the insurer or self-funded health plan may not deny benefits
otherwise provided for treatment of that illness or injury solely because the
illness or injury relates to the insured's autism spectrum disorder.
(11)LOCATIONS FOR SERVICES.
(a) Insurers and self-insured health plans
shall cover treatments, therapies and services to an insured diagnosed with
autism spectrum disorders in locations including the provider's office, clinic
or in a setting conducive to the acquisition of the target skill. Treatments
may be provided in schools when they are related to the goals of the treatment
plan and do not duplicate services provided by a school.
(b) Insurers and self-insured health plans
are not required to cover therapy, treatment or services when provided to an
insured who is residing in a residential treatment center, inpatient treatment
or day treatment facility.
(c)
Insurers and self-insured health plans are not required to cover the cost for
the facility or location or for the use of a facility or location when
treatment, services or evidence-based therapy are provided outside an insured's
home.
(12)ANNUAL PUBLICATION CPI ADJUSTMENT. The commissioner shall publish to the office of the commissioner of insurance website on or before December 1 of each year beginning December 1, 2011, the consumer price index for urban consumers as determined by the U.S. Department of Labor and publish the adjusted dollar amount in accordance with s. 632.895(12m) (c) 1, Stats. The adjusted dollar amount published each December shall be used by insurers and self-insured health plans when complying with s. 632.895(12m), Stats., effective the following January 1 for newly issued policies or on the first date of a modified, extended or renewed policy or certificate after January 1.
(14)VERIFICATION OF SERVICE PROVIDERS.
(a) Insurers and
self-insured health plans are required to verify the licensure, certification
and all training or other credentials of a qualified supervising or
intensive-level provider, a qualified provider and a qualified
therapist.
(b) Insurers and
self-insured health plans shall require the following:
1. All service providers employing qualified
paraprofessionals to verify the qualified paraprofessional's credentials and to
document that such employee or contractee has not been convicted of a felony or
any crime involving maltreatment of a child in any jurisdiction and to
periodically review and verify continuing compliance with this
paragraph.
2. Certified outpatient
mental health clinics employing or contracting for the services of qualified
intensive-level professionals or qualified professionals to verify the
credentials of a qualified intensive-level professional or qualified
professional and to document that such employee or contractee has not been
convicted of a felony or any crime involving maltreatment of a child in any
jurisdiction and to periodically review and verify continuing compliance with
this paragraph.
(c) A
provider, therapist, or professional working under the supervision of a
certified outpatient mental health clinic, who is approved by the department
and who has a signed Medicaid provider agreement to provide services through
the waiver program to individuals with autism spectrum disorders prior to
November 1, 2009 shall be deemed to be a qualified intensive-level provider or
qualified intensive-level professional through October 31, 2011. Beginning
November 1, 2011 any provider, therapist or professional shall comply with the
training and education requirements for a qualified supervising provider,
qualified intensive-level provider, qualified provider, qualified
intensive-level professional, qualified professional or qualified
therapist.
(d) An insurer or
self-insured health plans may elect to contract with certain providers,
therapists and professionals who do not meet all of the requirements necessary
to be considered qualified supervising providers, qualified intensive-level
providers, qualified providers, qualified therapists, qualified intensive-level
professionals or qualified professionals but who are approved by the department
and who have a signed Medicaid provider agreement to provide services through
the waiver program to individuals with autism spectrum disorders and who meet
any criteria established by the insurer or self-insured health plan. The
insurer or self-insured health plans shall have a verifiable and established
process for rendering its determination for otherwise qualified supervising
provider, qualified intensive-level provider, qualified provider, qualified
intensive-level professional, qualified professional or qualified
therapist.
Disclaimer: These regulations may not be the most recent version. Wisconsin may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
