Tuesday, October 20, 2009

Wisconsin Autism Insurance Rule Published

NOTE: For more information, including links to all my posts on autism insurance in Wisconsin, visit Wisconsin Autism Insurance - Updates from Elvis Sightings

Apologies in advance to my regular readers for yet another policy-wonk, Wisconsin-specific post.

But, this is information that needs to get out there. I'll do a very sketchy first pass at it, and at a later date I will link to the consumer fact-sheets that the Autism Society of Wisconsin (ASW) and other organizations are now feverishly developing.

[NOTE: If you have any specific questions that you would like the factsheet/FAQs to address, please let me know in the comments. I have an "in" with one of the movers-and-shakers who is working on the FAQs, and I've been asked to pass your questions along!]

So, here's the deal. The legislation that passed in the Wisconsin State Budget in June 2009, requiring insurers to cover autism treatment, was just the first step. The second step is that the Office of the Commissioner of Insurance (OCI) for the state had to hammer out the corresponding changes to the insurance rules, on a short timeline. To make this happen, the OCI convened an Autism Working Group, a group of insurance company reps, legislators, advocates, parents, and providers who have been working like crazy since July to define terms for the document that spells out what insurance companies do and don't need to do.

That document is now published, at http://www.oci.wi.gov/rules/0336em09.pdf (note that it opens a PDF document).

The press release announcing the document is at http://www.oci.wi.gov/pressrel/1009autism.htm.

The document is what is known as an "emergency rule." This means that, while it goes into effect immediately due to time constraints, and in this case is good for one year, an ongoing process has yet to take place that involves hearings (at the OCI and likely also before the Joint Committee for Review of Administrative Rules) and a legislative process and further opportunities to monkey with the document before it becomes permanently enshrined in the rules.

However, until that long drawn-out administrative rule finalization process happens, the emergency rule applies, for at least a year.

The emergency rule takes effect November 1, and will start affecting actual insurance coverage whenever the insurer's next new plan-year begins after that date. For many insurers, that new plan-year will begin January 1, 2010 -- so that is when coverage would actually start.

Here are a few highlights (note that this is my own reading, backed by additional conversations with people involved in the process -- but I am no expert. The upcoming FAQ from the ASW & friends will be much more authoritative):
  • Wisconsin's Medicaid Waiver program (which is how Joy currently gets her treatment) was the basis from which the Autism Working Group began their deliberations -- the insurance coverage is meant to be reasonably similar on the whole to what people are getting through the waiver right now, though there are plenty of differences, both good and not-so-good.

  • The group did not spell out which specific treatments have to be covered, though behavioral principles are a necessary component. Instead, they hammered out a set of requirements as to what level of published evidence qualifies a treatment to be "evidence-based" for purposes of the rule. The introduction to the document states that this was done such that ongoing research can be taken into account without needing to change the rule. My understanding from outside conversations is that the evidence-requirements were crafted with the intent to include the treatments that are being covered by the waiver program right now.

  • Insurers will be required to cover up to FOUR years of intensive-level autism treatment (to the tune of $50,000 per year as stated in the legislation), as opposed to the up-to-three years covered by the waiver program. However, any intensive-level service that has already happened when insurance coverage starts, whether under the waiver or out-of-pocket, counts toward those four years.

  • (update to original post) As stated in the legislation, insurers are also required to cover what they're calling "post-intensive" treatment to the tune of $25,000 per year. This is autism-related treatment for people of any age. Since I am not as familiar with post-intensive services under the waiver, I can't make a good comparison -- but I think that the post-intensive waiver coverage is somehow time-limited (certain ages? certain number of years?) and the post-intensive insurance coverage, as I understand it, is not.

  • Those who have been reading Elvis Sightings for a while may remember my ranting and advocacy around the waiver program's [in-my-view-unreasonable] insistence on having all therapy take place in the home (as opposed to including other natural settings). Good news -- the language in the new rule only requires a majority of the treatment to take place when a parent is present, and that it should be "provided in an environment most conducive to achieving the goals of the insured’s treatment plan." Can you say, "Joy's awesome daycare at Lynda's place"? Sure, I knew you could! Woo hoo!

  • Another change from the waiver program, this one not so fortunate: under this rule, insurers are not required to cover therapists' travel-time. I do not know how this will work out in practice; some service-provider agencies may choose to "eat" this cost in order to continue to be able to hire therapists...

  • While there is not a list of specifically included therapies, there is a specific list of exclusions. Among the therapies NOT covered: acupuncture, hippotherapy, auditory integration therapy, chelation, cranial sacral therapy, hyperbaric oxygen therapy. (See the rule document for a complete list.)

Well, that's a few highlights from my perspective.

There are many questions yet to be answered, and most caseworkers and providers and insurers haven't got these answers just yet... will my particular insurer cover my particular therapy provider? How does my Katie Beckett (non-waiver) medical assistance coverage play in? Does our family still keep our county caseworker if the waiver was where that relationship started? What about co-pays & deductibles? Et cetera.

We just don't know yet. But the answers will have to be worked out soon.

Joy's particular service provider ("Agency 2") has recommended that current waiver-based clients with insurance contact their insurers. Our plan is to make that contact and ask the insurer the question: how can we proceed in order to avoid any kind of gap in treatment coverage?

Stay tuned.

(P.S. My thanks to JoyDad for helping me sort out the administrative rule-making process!)


mama edge said...

Excellent overview. Afraid it's all a bit late for me, but I celebrate for those who will benefit.

JoyMama said...

mama edge - thank you for (inadvertently) pointing out a glaring oversight in my post. The new insurance coverage is applicable across the lifespan. "Post-intensive" coverage is, as I understand it, meant to cover adults too. So this just might not be as inapplicable as my original post made it appear...

JoyDad said...

The coverage-over-the-lifespan thing was one of the big advantages of the bill that got passed vs. the competing bills from the other side of the aisle. It was one of the things I highlighted in my testimony in front of the Assembly committee. While we all want early intervention to work miracles, the fact is that some of our kiddos who need services will grow up into adults who need services. Shouldn't oughta be a cliff for them to fall off of at age 18 or 21...

Casdok said...

This is one of the things i love about blogging - sharing information :)

hasmigt said...

It is my understanding that the WI insurance coverage only applied to fully-funded insurance that is obtained thru government (local, public and otherwise) employment. For instance my insurance will not cover it (Wheaton Franc Healthcare-huge WI employer) b/c we have a self-funded insurance. Please read below from ASW:

The autism mandate, contained in the state budget, is effective for newly
issued policies on or after November 1, 2009. For existing policies the law
is effective upon the renewal date of the policies on or after November 1,
2009. (This means if a policy just renewed Sept 1 2009 the law would not be
effective until the policy renewed Sept 1, 2010.) For plans or policies
tied to a collective bargaining agreement, it first applies to the renewal
date on or after November 1, 2009.
The law applies to disability insurance policies, excluding limited services
or specific/single disease policies (ie dental only, vision only), long-term
care and Medicare supplement policies. The law also applies to self-funded
governmental policies (i.e. state, county, city, town, village, or school
district) plans but would not apply to a non-governmental self-funded plan
(ie ABC company self-funded plan). This applies to both individual and
group health insurance plans.
If you are uncertain whether your employer sponsored health insurance is
insured or self-funded you should ask your human resource department or call
your insurer.
Insurers or self-funded governmental plans shall provide coverage for the
primary diagnosis of autism spectrum disorders for a minimum of $50,000 per
year for intensive evidence-based behavioral services or $25,000 for
nonintensive evidence-based services.
The Office of the Commissioner of Insurance promulgated emergency rules
implementing and interpreting this law that are effective November 1, 2009
and there will be a public hearing for both the emergency and permanent rule
later this fall.
A Frequently Asked Questions (FAQ) in plain language on the subject of
Autism Insurance will soon be available on the ASW listserve and on the ASW

JoyMama said...

hasmigt - Important point, that my summary missed. The legislation (unfortunately) does not apply to all insurers. I think there is an issue of jurisdiction, as in the legislature can't mandate the non-governmental self-insurers to do something like this?

Fortunately the MA waiver continues to be available for those whose insurance does not fall into the categories that the legislation covers. Unfortunately, the waiver has its limitations.

All this will be further complicated by whatever happens with health-care reform at the national level: I think there's autism-coverage language currently in measure that's working in the Senate, and then there's a separate Autism Treatment Acceleration Act that seems to be on hold while the bigger reform measure works its way through. I have no clue (yet) as to the specifics of which insurers are affected by those.

Thanks for the contribution!

hasmigt said...

Thank you for your reply. It looks like I will hav eto find a job then that offers fully funded insurance, so I can get my son another year of therapy. I will likely compile a list of WI employers that offer fully-funded insurance and will post here for others who may be interested...not that it's easy to get a job these days.

Thanks again

JoyMama said...

hasmigt - I hope my input is helpful, but I just want to be sure that you're checking everything out independently! Don't rely too much on anonymous bloggers... make sure you get a complete answer from your current insurer, etc. An employer list would be a nice resource - I'd encourage you to post it to the ASW list too.

Best of luck to you!

JoyDad said...

The legislation applies to employer-provided health insurance whether the employer is a private company or a government entity.

The exception is for private employer self-funded plans, (where the employer pays claims directly rather than paying premiums to an insurer who then pays the claims) which aren't subject to regulation by the Office of Commissioner of Insurance. Self-funded plans don't have to follow ANY mandate under state law, not just the new one dealing with autism coverage.

I heard testimony at the Assembly hearing that approximately 85% of the self-funded plans in Wisconsin follow state mandates even though they aren't required to. So it depends on the individual decisions of the employer as to whether they will cover autism treatments and if they do whether they will follow the coverage limits in the new law.

hasmigt said...

hmmm...that makes sense but conflicts with what my son's caseworker just told me. Read below:

Yes, you are understanding this correctly. The mandate will only require insurance coverage for children covered under insurance for public entities (schools, county, city, state, village). Therefore the mandate will only affect families whose insurance falls under that category. Some families who receive insurance through a company in a border state such as Illinois or Minnesota may also be affected b/c these states already have mandates in place. The Children's Services Section/ Department of Health Services is working on policies and a FAQ document which will hopefully be released soon. Let me know if I did not answer your questions.

JoyDad said...

Maybe your caseworker is making a distinction between public self-funded plans (those self-funded plans that are offered by county or municipal governments) and private self-funded plans. Public self-funded plans would have to follow the state mandates. It is only private self-funded plans that do not have to follow the mandate.

I probably didn't make the distinction between public and private self-funded plans clear enough in my previous comment. Sorry for the confusion.

Anonymous said...

Thanks for posting this. I am hoping ASW comes out with a FAQ sheet soon. What if we cannot afford our deductible and the cost of our coinsurance? I have 2 children on the spectrum.

JoyMama said...

Anonymous @1:55pm - thanks for your comment. The uncertainty is one of the hardest things about this! The one thing I have heard about co-pays since I initially wrote is that DHS intends to do whatever they can to work with families on a case-by-case basis when deductibles and co-pays are a problem. What exactly that will look like, though, I do not know.

I do know that the FAQs continue to be under intense development! I look forward to linking to them as soon as ever I can.