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.
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
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.
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.
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.
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