Tuesday, November 9, 2010

Autism Insurance and Mental Health Parity in Wisconsin

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

I recently had a visitor to this site who arrived via the following Google search: "state of wisconsin no cap on autism insurance"

I think this means that it's time to address autism insurance issues again! [Updated 11/13 to add: I am a well-informed lay-person on these issues, but not in any official capacity. (Want to hire me?) My links are good, but my writing does not have official backing or vetting of any organization.]

Here's the very quick recap: Wisconsin's governor Jim Doyle signed an autism insurance requirement as part of the state budget on June 29, 2009; requiring certain insurers to cover intensive-level autism treatment to the tune of $50,000 per year (with age limits and for a total of four years), and post-intensive at $25,000 per year (no age limits).

I've been documenting this for several years along the way, and have a separate page on this site compiling my writings on the subject. Here also are some links with more information on Wisconsin's autism insurance requirement.

I'll do another post on how that's all going. It's been an interesting ride. Joy's experience has been relatively smooth, though not without frustrating questions along the way. Other people's experiences have been much rockier.

Now another very fine development is coming down the pike -- with the potential to be an immense help to some Wisconsin residents, but also adding an extra layer of confusion and uncertainty until the details are worked out. This new development involves the lifting of the $50,000 and $25,000 caps.

On October 3, 2008, then-president George W. Bush signed Public Law 110-343, the Paul Wellstone & Pete Domenici Mental Health Parity and Addiction Equity Act. This law is aimed at group health plans with more than 50 employees that provide mental health and substance abuse coverage as part of their benefits. The law aims to ensure that mental health financial requirements and treatment limitations are no more restrictive than what the plan specifies for medical and surgical benefits. There's a fine factsheet at Mental Health America that goes into much more detail.

The Wellstone/Domenici Act of 2008 was initially supposed to take effect Jan. 2009, but the insurance rules were not hammered out and published until Feb. 2, 2010. Here is the link to the applicable rule in the U.S. Federal Register (in PDF). On page 11 of the above-linked rule, under applicability date, it says the rules are effective for plan-years beginning on or after July 1, 2010.

Governor Doyle heralded the federal legislation and rules, and made it very clear his administration's interpretation that mental health parity applies to autism, in a March 1, 2010 press release under the headline:
Governor Doyle Announces Expanded Health Insurance Coverage will Benefit Families with Autism
New Federal Laws Will Further Help Children with Autism Access Full Treatment

[Update 11/13, paragraph & quote added] More importantly and officially, this is also the position of Wisconsin's Insurance Commissioner, as included in the final WI OCI rule on autism insurance, which went into effect this October. On page 4, the rule explicitly includes the position that federal mental health parity applies to autism in Wisconsin:
Although there is no direct federal guidance that autism spectrum disorders are subject to federal parity requirements, it is the position of the Commissioner that parity for autism services does apply to group health plans with more than 50 employees based upon preliminary review of the regulations.

We've been aware for some time that at least one of the large health plans in Wisconsin has been pro-active about lifting the caps for autism insurance coverage -- because if you don't have similar caps for surgical/medical treatment, you can't have them for mental health treatment including autism. For us, that's slated for January 1 when our plan renews.

However, we've heard that other plans are not addressing this, or have been trying to push the issue off till January 2012.

Part of this was apparently being enabled by the State of Wisconsin Department of Employee Trust Funds, the entity that administers health plans for State of Wisconsin employees. Their parameters for plans covering state employees were originally written to allow the caps to remain in place for the extra year. When JoyDad found out about this, the phone-calls and e-mails flew, buttressed by the links from the Federal Register and Doyle's press-release -- making it clear that the effective date needs to be January 2011 for state plans and that Governor Doyle's press release made it very clear that his office interprets the parity legislation to apply to autism.

It might have been coincidence (but I think not) when JoyDad got a communication from ETF saying that, after further review, their legal counsel determined that the autism benefit dollar limit would, after all, need to be lifted for state-employee plans beginning January 1, 2011. The correction has been posted, and here's the quote:

On Page 72, the Schedule of Benefits in Uniform Benefits erroneously lists dollar limits for Autism Spectrum Disorders. The bullet should be removed.

On Page 97, Item 6, Coverage of Treatment for Autism Spectrum Disorders erroneously lists dollar limits for the benefit in the second to last sentence. It should read: “Benefits are payable for intensive-level and nonintensive-level services.

Our insurance plan will be lifting the autism-coverage cap for our (state-government-employee) plan starting January 2011, as they had intended.

All the other insurance plans that compete for state employee coverage will have to do likewise. It's unclear what this may mean for their non-state-employee plans. If your health insurance plan in Wisconsin is not intending to lift the caps when your plan renews, you might want to use information and links from this post to help you advocate with them.

The upshot: Wisconsin state government employee insurance plans, and at least one forward-looking insurance company more generally, are lifting the autism coverage caps as of January 2011.

Other insurance companies are not yet on board.

Still other insurance companies are not included in Wisconsin's autism insurance mandate in the first place, nor by Wisconsin's version of mental health parity. A somewhat smaller set is not even included in the federal version of mental health parity.

And, there's been a big election here. For the past two years in Wisconsin, both houses of the legislature plus the governorship have been in the hands of the Democratic party. In the wake of the 2010 elections, all three have flipped Republican -- and quite hard-right Republican at that. I have been told that the new governor Scott Walker has some insight into, and support for, autism-related issues. I also know that the Republican party has not been supportive of insurance mandates in general. [Updated 11/13 to add the following sentence] And, the Insurance Commissioner is appointed by the governor.

Stay tuned. This story is still being written.

Meanwhile, if any of you know how mental health parity is playing out in other states regarding autism coverage, please share in the comments!

UPDATE 11/11 -- This post originally included a paragraph about 2009 WI Act 218, the Wisconsin Mental Health and Substance Abuse Parity Act, signed by Governor Jim Doyle on April 30, 2010, an act which in general strengthens the Domenici/Wellstone parity act, applying it to smaller companies than the federal legislation. However, WI Act 218 contains an exception for autism. The federal act contains no such exception, so the federal rules still apply when it comes to autism (as Governor Doyle celebrated in his press release).


Anonymous said...

For all the stuff I have become accustomed to in my career THIS stuff still shocks and overwhelms me. You lay it all out with seeming aplomb. Thank you. I feel the responsibility to know about this part of the life of a family with a member with autism.


JoyDad said...

It's a lot to keep track of, and it seems like the story changes with some regularity. We're just trying to do our part to help people sort through the morass....

Anonymous said...

And you (both) do it well, JD.

(Why the silence on this post? Question to your regular readers)

Having spent some time in the morass of political wind I keep a safe distance from the sausage-making so as not to be splattered with blood and guts. Perhaps that why the silence of others. But no matter where I place myself, the wind changes. Alas.


JoyMama said...

TherExtras - my (sausage-making) policy-wonk posts tend to get fewer comments from regular readers than my newsy or philosophical posts. That's OK. The wonky posts are more for the record and a wider audience, so that people who come searching for the information can have the update and links all gathered together for them.