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Legislation Signed into Law

2017-2018

Primary Focus: Mandated Benefit: Provider
Title/Description: Restrictions on Health Care Services
Citation: Wis. Stat. Ann. § 632.87
Summary: No policy, plan, or contract may exclude coverage for mental health or behavioral treatment or services provided by the charter school established under a contract under s. 118.40 (2x) (cm), if the policy, plan, or contract covers the mental health or behavioral health treatment or services when provided by another health care provider.
Wis. Stat. Ann. § 632.87 further discusses other services that must be covered by policies, plans, and contracts.
Effective Date: July 17, 2017
Notes: Amended by Wis. AB 6.

Primary Focus: Mandated Benefit: Provider
Title/Description: Mental Health Services Provided by a Recovery Charter School
Citation: Wis. Stat. Ann. § 609.717
Summary: Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (4m).
Effective Date: July 17, 2017
Notes: Amended by Wis. AB 6.

2013-2014

AB 458 (go to link and scroll to first action under “history” to find sponsors)
Introduced: 10/2013
Sponsor: Many
Status: Signed into law 2/2014
Summary: This bill changed state law so that Medicaid plans would cover the following:

  • Telehealth mental health services, even if they are provided by an out-of-state provider
  • In-home services without requiring fail-first protocol

2009-2010

Primary Focus: Mandated Benefit: Provider
Title/Description: Coverage of Mental Disorders, Alcoholism, and other Diseases
Citation: Wis. Stat. Ann. § 632.89
Summary: Wis. Stat. Ann. § 632.89 states that if a group health benefit plan or self-insured plan provides coverage for any inpatient, outpatient, or transitional hospital treatment, then it must also cover services inpatient, outpatient, and transitional services for the treatment of nervous or mental disorders, alcoholism, or other drug abuse problems.
Wis. Stat. Ann. § 632.89 also requires that the exclusions and limitations, deductibles, copayments, coinsurance, annual and lifetime payment limitations, out of pocket limits, out of network charges, day, visit or appointment limits, limitations regarding referrals to nonphysician providers and treatment programs, and duration or frequency of coverage limits under these plans cannot be more restrictive than the treatment limitations applied to substantially all other coverage under the plan.
Effective Date: April 29, 2010
Notes: Amended by Wis. SB 362.

Primary Focus: Mandated Benefit: Provider
Title/Description: Mandatory Coverage
Citation: Wis. Stat. Ann. § 632.895
Summary: Disability insurance policies self-insured health plans of the state or a county, city, town, village, or school district shall provide coverage for an insured of treatment for autism spectrum disorder if the treatment is prescribed by a physician and provided by any who are qualified to provide intensive-level services or nonintensive-level services. Certain minimum coverage amounts are required, and the coverage may only be subject to the deductibles, coinsurance, or copayments that generally apply to other conditions covered under the policy or plan.
Wis. Stat. Ann. § 632.895 also discusses generally other conditions that must be covered under certain insurance plans.
Effective Date: June 29, 2009
Notes: Amended by Wis. AB 75.

Wisconsin Parity Law

Behavioral Health Coverage

This section requires small employer fully-insured plans with more than 10 employees, large employer fully-insured plans, and self-insured state, county, city, village, and school district plans to cover behavioral health services for inpatient care, outpatient care, and intermediate levels of care if they provide services in these categories for other medical treatment.

Financial requirements, annual maximums, lifetime maximums, outpatient visit limits, out-of-pocket limits, and durational limits (like inpatient day limits) for behavioral health services cannot be “more restrictive” than what is in place for other medical services. Plans are also required to have only one deductible that includes behavioral health treatment. Individual plans must also abide by this if they cover behavioral health services.

Plans can be exempted from this section of the law if they can demonstrate that their overall costs increased by 2% in the first year of complying with this section, or if costs increased by 1% in any subsequent year.

Plans are required to disclose to enrollees and their providers the plan’s criteria for making medical necessity determinations. Plans are also required to disclose to enrollees the reasons for any denials or restrictions of treatment.

Autism Coverage

This section requires individual plans, small employer fully-insured plans with more than 10 employees, large employer fully-insured plans, and self-insured state, county, city, village, and school district plans to cover autism services.

Plans must cover an annual maximum of $50,000 for “intensive-level services” and $25,000 for “non-intensive-level services” (these terms are defined in the law). At least 30 hours per week of these “intensive-level services” must be covered for the first 4 years of treatment. These annual maximums can be adjusted for inflation each year.

Deductibles, copayments, and coinsurance must be the same as what is in place for other medical services.

Autism spectrum disorder is defined as autism disorder, Asperger’s syndrome, and pervasive developmental disorder not otherwise specified.

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Wisconsin Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

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