Wisconsin law requires that insurers cover evidence-based therapy services for individuals with autism spectrum disorders when provided by qualified providers. Autism mandate benefits are provided for members enrolled in Security Health Plan’s group or individual (excluding Medicare Select) products. The autism mandate was effective November 1, 2009; it applies to policies newly issued or to existing policies at their renewal after that date.
Brief summary of mandate requirements
The Office of the Commissioner of Insurance issued regulations interpreting the statute, which can be found in Wisconsin Administrative Code INS 3.36. We strongly encourage you to review the regulation to understand what you must comply with for services to be covered by this mandate and to be aware of services that are not covered under this mandate.
Therapies must be prescribed by a physician and provided by a psychiatrist, psychologist, licensed clinical social worker, outpatient mental health clinic, occupational therapist, speech therapist, or a paraprofessional working under the supervision of a qualified psychiatrist, psychologist or licensed clinical social worker. These providers must meet certain training requirements in order to be considered qualified providers.
“Autism spectrum disorder” means any of the following:
a. Autism disorder
b. Asperger’s syndrome
c. Pervasive developmental disorder not otherwise specified
1. Intensive level services
- Coverage required: for up to 4 years*
- Age requirements: Begins after age 2 but before age 9
2. Non-intensive level services
- Coverage required:
- Covered when intensive autism therapy is completed or
- In cases when an individual will not receive intensive therapy
- Age requirements: none
Treatment plan is developed by a qualified provider, supervising provider, professional or therapist that includes specific goals that are clearly defined, directly observed and continually measured and that address the characteristics of autism spectrum disorder.
a. Treatment plan will include:
1. The diagnosis
2. Who made the diagnosis
3. How the diagnosis was made
Was a standard assessment tool used?
Was testing involved?
4. What were the sources of data and observation-teachers, parents, direct?
5. What is the severity level (DSM)?
6. Recommended treatment
• Non intensive
7. Goals for treatment
• Communication skills
• Social skills
8. Estimated time of treatment
9. Provided in an environment most conducive to achieving the goals of the insured treatment plan
10. Implements identified therapeutic goals developed by the team including training and consultation, participation in team meetings and active involvement of the insured’s family.
11. Progress assessment, requires that progress be assessed and documented throughout the course of treatment. Security Health Plan will request and review the insured’s treatment plan and the summary of progress on a periodic basis.
To request a full version copy of a specific Security Health Plan Medical policy, call 1-800-548-1224 ext. 19671.
Regardless of a member’s coverage, you should always check all his or her benefits prior to providing services by logging on to Security Health Online at www.securityhealth.org or calling our provider assistance line at 1-800-548-1224.