Wisconsin State-Regulated Insurance Coverage

Wisconsin requires meaningful coverage for autism under state-regulated plans.

Wisconsin’s autism insurance bill, 632.895(12m) Wis. Stat Act 28 Section 609.87 and its associated emergency rule were enacted in 2009. The law became effective on November 1, 2009.

To which plan types does the state autism insurance law apply?

  • Individual Plans - YES
  • Fully Insured Large Group Plans - YES
  • Fully Insured Small Group Plans - YES

What services are covered by law?

  • Diagnosis
  • Evidence-based behavioral therapy (e.g. Applied Behavior Analysis)
  • Psychiatric and psychological care
  • Speech therapy and occupational therapy

Does Wisconsin have caps on coverage?

The law imposes a maximum annual benefit of $50,000 for “intensive-level services” for a minimum of 4 years between the ages of 2-9 years. After the four-year intensive-level service period has expired, it requires coverage of $25,000 annually for “non-intensive-level services.” There is no age limit on coverage for non-intensive level services.

“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.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits.  This includes quantitative treatment limits like age and dollar caps.  Learn more here.

Where can I find more details about the Wisconsin autism insurance law?

The Wisconsin Commission of Insurance FAQ page provides additional information.

The text of 632.895(12m) Wis. Stat Act 28 Section 609.87 and the associated emergency rule are linked.

If you have additional questions, please email advocacy@autismspeaks.org.

 

Last Updated: December 2019

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