Wisconsin Regulations

This bulletin assists health care providers and insurers in understanding and applying mandated health care benefits law as it relates to the treatment of nervous and mental disorders or substance use disorders. Furthermore, the bulletin discusses Wisconsin law, the federal Mental Health Parity Act of 1996, the Mental Health Parity and Addiction Equity Act of 2008, and the Affordable Care Act.

All ACA-compliant comprehensive individual and small group health insurance policies must include a set of health care services called essential health benefits. These benefits include:

• Ambulatory patient services;
• Emergency services;
• Hospitalization;
• Maternity and newborn care;
• Mental health and substance use disorder services, including behavioral health treatment;
• Prescription drugs;
• Rehabilitative and habilitative services and devices;
• Laboratory services;
• Preventive and wellness services and chronic disease management; and
• Pediatric services.

Essential health benefits must be covered with no annual or lifetime dollar limits.

Inpatient hospital mental health and AODA care shall be covered when prescribed by a physician and when provided within a hospital institution for mental disease. Outpatient psychotherapy services shall be covered services under certain conditions and subject to certain exceptions. Outpatient alcohol and drug abuse treatment services shall be covered services under certain conditions and subject to certain exceptions. Alcohol and drug abuse day treatment services shall be covered services under certain conditions and subject to certain exceptions. Mental health day treatment or day hospital services shall be covered services under certain conditions and subject to certain exceptions.

The Office of the Commissioner of Insurance (OCI) created a fact sheet (pdf | Get Adobe® Reader®) on mandated benefits for the treatment of nervous, mental health, and substance use disorders. The fact sheet focuses on what services must be covered, requirements for different plans, treatment limitations, and financial requirements.

The Office of the Commissioner of Insurance (OCI) created a fact sheet (pdf | Get Adobe® Reader®) on mandated benefits in health insurance policies. Page 7 – 8 contains a sections on mental health parity.

The Office of the Commissioner of Insurance (OCI) performed a market conduct examination (pdf | Get Adobe® Reader®) of Health Tradition Health Plan. Among many other things, the OCI found that the plan did not have anything addressing the plan’s obligation to cover the annual maximums for autism coverage in their explanation of benefit documents (page 8). The OCI formally recommended that the plan change this to be in compliance with the law.

The Office of the Commissioner of Insurance (OCI) issued a regulation regarding the section of the state insurance law about parity. In addition to reinforcing what is in that section of the law (which is summarized at the bottom of this page), it clarified that plans must not have treatment limitations that are “more restrictive” than what is used for other medical services, as specified in state law and in the Federal Parity Law. The regulation also has detailed instructions for what is required of plans that want to apply for the cost exemption to the parity section of the state insurance law.

Page 7 of this Office of the Commissioner of Insurance (OCI) newsletter (pdf | Get Adobe® Reader®) briefly describes the then-recent regulation issued by the OCI regarding the section of the state insurance law about parity.

Insurers and self-insured health plans shall provide coverage for services to an insured who has a primary verified diagnosis of autism spectrum disorder made by a diagnostician skilled in testing and in the use of empirically-validated tools specific for autism spectrum disorders.

The Office of the Commissioner of Insurance (OCI) issued a regulation regarding the section of the state insurance law about autism coverage. The regulation is very detailed and addresses the following:

• Defines “qualified” intensive-level providers, intensive-level professionals, paraprofessionals, professional, provider, supervising provider, and therapist (2h-m)
• What qualifies as a “verified diagnosis” for which insurers must cover services (3a-d)
• Defines intensive-level services (4a-e)
• Defines non-intensive-level services (5a-e)
• Information on how to transfer coverage from intensive-level to non-intensive level (6a-c)
• Research standards for treatment criteria (8a-c)
• Things that plans specifically do NOT have to cover (10a-d)
• Locations of services (11a-c)
• The annual adjustment of the annual maximum for inflation

The Office of the Commissioner of Insurance (OCI) issued a bulletin that, among other things, summarized the then recently-passed bill that updated the parity section of the state insurance law. It also informed plans that OCI would be issuing regulations regarding this section of the insurance law, which they did the following year (summarized above under “7/2011).

The Office of the Commissioner of Insurance (OCI) created the “Mental Health Parity Subgroup” to advise the OCI on the then-proposed regulations regarding the section of the state insurance law about parity. The subgroup had five health insurance company members, one insurance agent member, three members from the business community, three members from hospitals, three provider representatives, two consumer advocates, and two legislative members.

The Office of the Commissioner of Insurance (OCI) issued a bulletin that, among many other things, summarized the then recently-passed section of the law about autism coverage (this section of the law is summarized at the bottom of this page under “Wisconsin Parity Law,” “Autism Coverage”)