Chapter Ins 3

Ins 3.35 Ins 3.35 Colorectal cancer screening coverage.

Ins 3.35(1) (1) Applicability.

Ins 3.35(1)(a) (a) This section applies to disability insurance policies as defined at s. 632.895 (1) (a), Stats., unless otherwise excepted in s. 632.895 (16m) (c), Stats., that are issued or renewed on or after December 1, 2010. This section applies to Medicare supplement and cost plans but does not include limited –scope plans including vision and dental, hospital indemnity, income continuation, accident-only benefits, and long-term care policies. This section also applies to self-insured health plans as defined at s. 632.745 (24), Stats.

Ins 3.35(1)(b) (b) For a disability insurance policy and a self-insured health plan covering employees who are affected by a collective bargaining agreement the coverage under this section first applies as follows:

Ins 3.35(1)(b)1. 1. If the collective bargaining agreement contains provisions consistent with s. 632.895 (16m), Stats., coverage under this section first applies the earliest of any of the following: the date the disability insurance policy is issued or renewed on or after December 1, 2010, or the date the self-insured health plan is established, modified, extended or renewed on or after December 1, 2010.

Ins 3.35(1)(b)2. 2. If the collective bargaining agreement contains provisions inconsistent with s. 632.895 (16m), Stats., the coverage under this section first applies on the date the health benefit plan is first issued or renewed or a self-insured health plan is first established, modified, extended, or renewed on or after the earlier of the date the collectively bargained agreement expires, or the date the collectively bargained agreement is modified, extended, or renewed on or after December 1, 2010.

Ins 3.35(2) (2) Definitions. In addition to the definitions contained in s. 632.895 (1), Stats., for purposes of this section all the following apply:

Ins 3.35(2)(a) (a) “Designated guideline” means the recommendations of the U.S. Preventive Services Task Force, the National Cancer Institute, or the American Cancer Society regarding colorectal cancer screening guidelines identified by the insurer or self-insured health plan for compliance.

Ins 3.35(2)(b) (b) “Enrollee” means an insured or enrollee of a health plan subject to s. 632.895 (16m), Stats.

Ins 3.35(2)(c) (c) “Self-insured health plan” means a self-insured governmental health plan offered by the state, county, city, village, town, or school district that provides coverage of any diagnostic or surgical procedure.

Ins 3.35(3) (3) Colorectal cancer screening guidelines and updates.

Ins 3.35(3)(a) (a) Insurers may utilize one or more of the most current colorectal cancer screening guidelines issued by the U.S. Preventive Services Task Force, the National Cancer Institute, or the American Cancer Society as the basis for the coverage offered for preventive colorectal cancer screening tests and procedures. If an insurer or self-insured health plan elects to designate more than one guideline, the insurer or self-insured health plan shall specify the guideline that will be primary in the event of a conflict between the designated guidelines. Insurers shall provide notice of the selected guideline or guidelines and which guideline is primary in a prominent location within the plan summary and in the notice provided to insureds when a benefit is denied based upon the primary guideline.

Ins 3.35(3)(b) (b) Insurers and self-insured health plans shall at least annually review the designated guidelines and incorporate modifications to be effective the first day of the subsequent plan year.

Ins 3.35(4) (4) Covered screening. Insurers offering disability insurance and self-insured health plans shall offer as a covered benefit the screening for colorectal cancer that may be subject to limitations, exclusions and cost-sharing provisions that generally apply under the plan and comply with all of the following:

Ins 3.35(4)(a) (a) Insurers and self-insured health plans shall cover evidence-based, recommended preventive colorectal cancer screening tests or procedures contained in the most current version of the designated guideline.

Ins 3.35(4)(b) (b) In accordance with the most current recommendations from the designated guideline for frequency of testing, insurers and self-insured health plans shall provide as a covered benefit, colorectal cancer screening tests or procedures for enrollees who are 50 years of age or older other than as provided for in sub. (5) (b). Medically appropriate or medically necessary covered screening tests or procedures shall at least include 3 of the following:

Ins 3.35(4)(b)1. 1. Fecal occult blood test.

Ins 3.35(4)(b)2. 2. Flexible sigmoidoscopy.

Ins 3.35(4)(b)3. 3. Colonoscopy.

Ins 3.35(4)(b)4. 4. Computerized tomographic colonography.

Ins 3.35(4)(c) (c) Insurers and self-insured health plans may require the enrollee’s health care provider or the enrollee’s primary care provider to obtain prior authorization for screening tests or procedures when the screening test or procedure is not contained in the most current version of guideline recommendations designated by the insurer or self-insured health plan.

Ins 3.35(4)(d) (d) Disputes regarding coverage of medically appropriate or medically necessary evidence-based screening tests or procedures are subject to internal grievance and independent review as provided by ch. Ins 18.

Ins 3.35(5) (5) Factors for high risk.

Ins 3.35(5)(a) (a) In accordance with recommended factors for identifying persons at high risk for colorectal cancer developed by the American Cancer Society, insurers and self-insured health plans shall provide as a covered benefit evidence-based colorectal cancer screening tests and procedures at recommended ages and intervals for enrollees determined to be at high risk for developing colorectal cancer. Insurers and self-insured health plans that designated either the U.S. Preventive Services Task Force or the National Cancer Institute as the designated guideline may include additional high risk factors when the guidelines identify factors for persons at high risk for colorectal cancer. All insurers and self-insured health plans shall at a minimum consider all of the following factors, as appropriate, when determining whether an enrollee is at high risk for colorectal cancer:

Ins 3.35(5)(a)1. 1. Personal history of colorectal cancer, polyps or chronic inflammatory bowel disease.

Ins 3.35(5)(a)2. 2. Strong family history in a first-degree relative or two or more second-degree relatives of colorectal cancer or polyps.

Ins 3.35(5)(a)3. 3. Personal history or family history in a first or second-degree relative of hereditary colorectal cancer syndromes.

Ins 3.35(5)(a)4. 4. Other conditions, symptoms or diseases that are recognized as elevating one’s risk for colorectal cancer as determined by the U.S. Preventive Services Task Force, the National Cancer Institute or the American Cancer Society.

Ins 3.35(5)(b) (b) Notwithstanding sub. (4) (b), insurers and self-insured health plans shall provide as a covered benefit evidence-based, recommended colorectal cancer screening tests or procedures for high risk enrollees no later than the earliest recommended age determined to be medically appropriate or medically necessary.

Ins 3.35(5)(c) (c) Disputes regarding an enrollee’s status as being at high risk or factors to be considered as high risk for colon cancer are subject to internal grievance and independent review as provided by ch. Ins 18.

Ins 3.35(6) (6) Preventive services compliance. Notwithstanding s. 632.895 (16m), Stats., insurers and self-insured health plans shall comply with P.L. 111-148 and 45 CFR 147.130 relating to cost-sharing provisions of preventive services including colon cancer screening.

Ins 3.35 History History: EmR1042: emerg. cr. eff. 11-29-10; CR 10-150: cr. Register June 2011 No. 666, eff. 7-1-11.

Ins 3.36 Ins 3.36 Coverage of autism spectrum disorders.

Ins 3.36(1) (1) Applicability.

Ins 3.36(1)(a) (a) This section applies to disability insurance policies as defined in s. 632.895 (1) (a), Stats., except as provided in s. 632.895 (12m) (e), Stats., and self-insured health plans sponsored by the state, county, city, town, village, or school district.

Ins 3.36(1)(b) (b) For a disability insurance policy covering employees who are affected by a collective bargaining agreement the coverage under this section first applies as follows:

Ins 3.36(1)(b)1. 1. If the collective bargaining agreement contains provisions consistent with s. 632.895 (12m), Stats., coverage under this section first applies the earliest of any of the following: the date the disability insurance policy is issued or renewed on or after November 1, 2009, or the date the self-insured health plan is established, modified, extended or renewed on or after November 1, 2009.

Ins 3.36(1)(b)2. 2. If the collective bargaining agreement contains provisions inconsistent with s. 632.895 (12m), Stats., the coverage under this section first applies on the date the health benefit plan is first issued or renewed or a self-insured health plan is first established, modified, extended, or renewed on or after the earlier of the date the collectively bargained agreement expires, or the date the collectively bargained agreement is modified, extended or renewed.

Ins 3.36(2) (2) Definitions. In addition to the definitions in s. 632.895 (12m) (a), Stats., in this section:

Ins 3.36(2)(a) (a) “Behavior analyst” means a person certified by the Behavior Analyst Certification Board, Inc., or successor organization as a board-certified behavior analyst and has been granted a license under s. 440.312, Stats., to engage in the practice of behavior analysis.

Ins 3.36(2)(b) (b) “Behavioral” means interactive therapies that target observable behaviors to build needed skills and to reduce problem behaviors using well-established principles of learning utilized to change socially important behaviors with the goal of building a range of communication, social and learning skills, as well as reducing challenging behaviors.

Ins 3.36(2)(c) (c) “Department” means the Wisconsin department of health services.

Ins 3.36(2)(d) (d) “Efficacious treatment” or “efficacious strategy” means treatment or strategies designed to address cognitive, social or behavioral conditions associated with autism spectrum disorders; to sustain and maximize gains made during intensive-level services; or to improve an individual with autism spectrum disorder’s condition.

Ins 3.36(2)(e) (e) “Evidence-based therapy” means therapy, service and treatment that is based upon medical and scientific evidence as described at s. 632.835 (3m) (b) 1., 2. (intro.) and a., Stats., and s. Ins 18.10 (4), is determined to be an efficacious treatment or strategy and is prescribed to improve the insured’s condition or to achieve social, cognitive, communicative, self-care or behavioral goals that are clearly defined within the insured’s treatment plan.

Ins 3.36(2)(f) (f) “Intensive-level service” means evidence-based behavioral therapies that are directly based on, and related to, an insured’s therapeutic goals and skills as prescribed by a physician familiar with the insured. Intensive-level service may include evidence-based speech therapy and occupational therapy provided by a qualified therapist when such therapy is based on, or related to, an insured’s therapeutic goals and skills, and is concomitant with evidence-based behavioral therapy.

Ins 3.36(2)(g) (g) “Qualified intensive-level professional” means an individual working under the supervision of an outpatient mental health clinic who is a licensed treatment professional as defined in s. DHS 35.03 (9g), and who has completed at least 2080 hours of training, education and experience including all of the following:

Ins 3.36(2)(g)1. 1. Fifteen hundred hours supervised training involving direct one-on-one work with individuals with autism spectrum disorders using evidence-based, efficacious therapy models.

Ins 3.36(2)(g)2. 2. Supervised experience with all of the following:

Ins 3.36(2)(g)2.a. a. Working with families as part of a treatment team and ensuring treatment compliance.

Ins 3.36(2)(g)2.b. b. Treating individuals with autism spectrum disorders who function at a variety of cognitive levels and exhibit a variety of skill deficits and strengths.

Ins 3.36(2)(g)2.c. c. Treating individuals with autism spectrum disorders with a variety of behavioral challenges.

Ins 3.36(2)(g)2.d. d. Treating individuals with autism spectrum disorders who have shown improvement to the average range in cognitive functioning, language ability, adaptive and social interaction skills.

Ins 3.36(2)(g)2.e. e. Designing and implementing progressive treatment programs for individuals with autism spectrum disorders.

Ins 3.36(2)(g)3. 3. Academic coursework from a regionally-accredited higher education institution with demonstrated coursework in the application of evidence-based therapy models consistent with best practice and research on effectiveness for individuals with autism spectrum disorders.

Ins 3.36(2)(h) (h) “Qualified intensive-level provider” means an individual identified in s. 632.895 (12m) (b) 1. to 4., Stats., acting within the scope of a currently valid state-issued license for psychiatry, psychology or behavior analyst, or a social worker acting within the scope of a currently valid state-issued certificate or license to practice psychotherapy, who provides evidence-based behavioral therapy in accordance with this section and s. 632.895 (12m) (a) 3., Stats., and who has completed at least 2080 hours of training, education and experience which includes all of the following:

Ins 3.36(2)(h)1. 1. Fifteen hundred hours supervised training involving direct one-on-one work with individuals with autism spectrum disorders using evidence-based, efficacious therapy models.

Ins 3.36(2)(h)2. 2. Supervised experience with all of the following:

Ins 3.36(2)(h)2.a. a. Working with families as the primary provider and ensuring treatment compliance.

Ins 3.36(2)(h)2.b. b. Treating individuals with autism spectrum disorders who function at a variety of cognitive levels and exhibit a variety of skill deficits and strengths.

Ins 3.36(2)(h)2.c. c. Treating individuals with autism spectrum disorders with a variety of behavioral challenges.

Ins 3.36(2)(h)2.d. d. Treating individuals with autism spectrum disorders who have shown improvement to the average range in cognitive functioning, language ability, adaptive and social interaction skills.

Ins 3.36(2)(h)2.e. e. Designing and implementing progressive treatment programs for individuals with autism spectrum disorders.

Ins 3.36(2)(h)3. 3. Academic coursework from a regionally-accredited higher education institution with demonstrated coursework in the application of evidence-based therapy models consistent with best practice and research on effectiveness for individuals with autism spectrum disorders.

Ins 3.36(2)(i) (i) “Qualified paraprofessional” means an individual working under the active supervision of a qualified supervising provider, qualified intensive-level provider or qualified provider and who complies with all of the following:

Ins 3.36(2)(i)1. 1. Is at least 18 years of age.

Ins 3.36(2)(i)2. 2. Obtains a high school diploma.

Ins 3.36(2)(i)3. 3. Completes a criminal background check.

Ins 3.36(2)(i)4. 4. Obtains at least 20 hours of training that includes subjects related to autism, evidence-based treatment methods, communication, teaching techniques, problem behavior issues, ethics, special topics, natural environment, and first aid.

Ins 3.36(2)(i)5. 5. Obtains at least ten hours of training in the use of behavioral evidence-based therapy including the direct application of training techniques with an individual who has autism spectrum disorder present.

Ins 3.36(2)(i)6. 6. Receives regular, scheduled oversight by a qualified supervising provider in implementing the treatment plan for the insured.

Ins 3.36(2)(j) (j) “Qualified professional” means an individual identified in s. 632.895 (12m) (b) 5., Stats., acting under the supervision of an outpatient mental health clinic certified under s. 51.038, Stats., acting within the scope of a currently valid state-issued license and who provides evidence-based therapy in accordance with this section.

Ins 3.36(2)(k) (k) “Qualified provider” means an individual identified in s. 632.895 (12m) (b) 1. to 4., Stats., respectively, acting within the scope of a currently valid state-issued license for psychiatry, psychology or behavior analyst, or a social worker acting within the scope of a currently valid state-issued certificate or license to practice psychotherapy and who provides evidence-based therapy in accordance with this section.

Ins 3.36(2)(L) (L) “Qualified supervising provider” means an individual who is a qualified intensive-level provider and who has completed at least 4160 hours of experience as a supervisor of less experienced providers, professionals and paraprofessionals.

Ins 3.36(2)(m) (m) “Qualified therapist” means an individual identified in s. 632.895 (12m) (b) 6. or 7., Stats., who is either a speech-language pathologist or occupational therapist acting within the scope of a currently valid state-issued license and who provides evidence-based therapy in accordance with this section, sub. (4) (e).

Ins 3.36(2)(n) (n) “Supervision of an outpatient mental health clinic” for purposes of this section means an individual who meets the requirements of a qualified supervising provider and who periodically reviews all treatment plans developed by qualified professionals for insureds with autism spectrum disorders.

Ins 3.36(2)(o) (o) “Waiver program” means services provided by the department through the Medicaid Home and Community-Based Services as granted by the Centers for Medicare & Medicaid Services.

Ins 3.36(3) (3) Verified diagnosis.

Ins 3.36(3)(a) (a) 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.

Ins 3.36(3)(b) (b) Insurers and self-insured health plans shall accept as valid and provide coverage for the diagnostic testing in addition to the benefit mandated by s. 632.895 (12m), Stats. For the diagnosis to be valid for autism spectrum disorder, the testing tools shall be appropriate to the presenting characteristics and age of the insured and be empirically validated for autism spectrum disorders to provide evidence that the insured meets the criteria for autism spectrum disorder in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Insurers and self-insured health plans may require confirmation of a primary diagnosis through completion of empirically-validated tools or tests from each of the following categories: intelligence, parent report, language skills, adaptive behavior, and direct observation of the child.

Ins 3.36(3)(c) (c) An insurer and a self-insured health plan may require an insured to obtain a second opinion from a diagnostician experienced in the use of empirically-validated tools specific for autism spectrum disorders who is mutually agreeable to the insured or the insured’s parent or authorized representative and to the insurer or self-insured health plan. An insurer and a self-insured health plan shall cover the cost of the second opinion and the cost of the second opinion shall be in addition to the benefit mandated by s. 632.895 (12m), Stats.

Ins 3.36(3)(d) (d) Insurers and self-insured health plans may require that the assessment include both a standardized parent interview regarding current concerns and behavioral history as well as direct, structured observation of social and communicative behavior and play. The diagnostic evaluation shall also assess those factors that are not specific to autism spectrum disorders including degree of language impairment, cognitive functioning, and the presence of nonspecific behavioral disorders.

Ins 3.36(4) (4) Intensive-level services.

Ins 3.36(4)(a) (a) Coverage for intensive-level services. Insurers and self-insured health plans shall provide coverage for evidence-based behavioral intensive-level therapy for an insured with a verified diagnosis of autism spectrum disorder, the majority of which shall be provided to the insured when the parent or legal guardian is present and engaged and all of the prescribed therapy is consistent with all of the following requirements:

Ins 3.36(4)(a)1. 1. Based upon a treatment plan developed by an individual who at least meets the requirements of a qualified intensive-level provider or a qualified intensive-level professional that includes at least 20 hours per week over a six-month period of time of evidence-based behavioral intensive therapy, treatment, and services with specific cognitive, social, communicative, self-care, or behavioral goals that are clearly defined, directly observed and continually measured and that address the characteristics of autism spectrum disorders. Treatment plans shall require that the insured be present and engaged in the intervention.

Ins 3.36(4)(a)2. 2. Implemented by qualified providers, qualified professionals or qualified therapists, or qualified paraprofessionals.

Ins 3.36(4)(a)3. 3. Provided in an environment most conducive to achieving the goals of the insured’s treatment plan.

Ins 3.36(4)(a)4. 4. Implemented identified therapeutic goals developed by the team including training and consultation, participation in team meetings and active involvement of the insured’s family.

Ins 3.36(4)(a)5. 5. Commenced after an insured is two years of age and before the insured is nine years of age.

Ins 3.36(4)(a)6. 6. Provided by a qualified intensive-level provider or qualified intensive-level professional who directly observes the insured at least once every two months.