Parity is about fairness. Americans with behavioral health conditions often have more difficulty getting the treatment and services they need when compared to individuals seeking other medical care. Explore parity-related information regarding legislation, statutes, and regulatory actions since the Federal Parity Law was passed in 2008.
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.
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.
Autism spectrum disorder is defined as autism disorder, Asperger’s syndrome, and pervasive developmental disorder not otherwise specified.