Ins 3.36(10)(b)(b) Drugs and devices. Insurers and self-insured health plans shall not provide coverage for pharmaceuticals or durable medical equipment through s. 632.895 (12m), Stats. Coverage of pharmaceuticals and durable medical equipment shall be covered in compliance with the terms of the insured’s policy.

Ins 3.36(10)(c)(c) Fraudulent claims. Insurers and self-insured health plans shall not be required to pay claims that have been determined to be fraudulent.

Ins 3.36(10)(d)(d) Parents of children diagnosed with autism spectrum disorders. Insurers and self-insured health plans shall not be required to pay for treatment rendered by parents or legal guardians who are otherwise qualified providers, qualified supervising providers, qualified therapists, qualified professionals or qualified paraprofessionals for treatment rendered to their own children.

Ins 3.36(10)(e)(e) Denial of coverage. If an insurer or self-funded health plan generally provides benefits for an illness or injury, the insurer or self-funded health plan may not deny benefits otherwise provided for treatment of that illness or injury solely because the illness or injury relates to the insured’s autism spectrum disorder.

Ins 3.36(11)(a)(a) Insurers and self-insured health plans shall cover treatments, therapies and services to an insured diagnosed with autism spectrum disorders in locations including the provider’s office, clinic or in a setting conducive to the acquisition of the target skill. Treatments may be provided in schools when they are related to the goals of the treatment plan and do not duplicate services provided by a school.

Ins 3.36(11)(b)(b) Insurers and self-insured health plans are not required to cover therapy, treatment or services when provided to an insured who is residing in a residential treatment center, inpatient treatment or day treatment facility.

Ins 3.36(11)(c)(c) Insurers and self-insured health plans are not required to cover the cost for the facility or location or for the use of a facility or location when treatment, services or evidence-based therapy are provided outside an insured’s home.

Ins 3.36(12)(12) Annual publication CPI adjustment. The commissioner shall publish to the office of the commissioner of insurance website on or before December 1 of each year beginning December 1, 2011, the consumer price index for urban consumers as determined by the U.S. Department of Labor and publish the adjusted dollar amount in accordance with s. 632.895 (12m) (c) 1., Stats. The adjusted dollar amount published each December shall be used by insurers and self-insured health plans when complying with s. 632.895 (12m), Stats., effective the following January 1 for newly issued policies or on the first date of a modified, extended or renewed policy or certificate after January 1.

Ins 3.36(14)(a)(a) Insurers and self-insured health plans are required to verify the licensure, certification and all training or other credentials of a qualified supervising or intensive-level provider, a qualified provider and a qualified therapist.

Ins 3.36(14)(b)(b) Insurers and self-insured health plans shall require the following:

Ins 3.36(14)(b)1.1. All service providers employing qualified paraprofessionals to verify the qualified paraprofessional’s credentials and to document that such employee or contractee has not been convicted of a felony or any crime involving maltreatment of a child in any jurisdiction and to periodically review and verify continuing compliance with this paragraph.

Ins 3.36(14)(b)2.2. Certified outpatient mental health clinics employing or contracting for the services of qualified intensive-level professionals or qualified professionals to verify the credentials of a qualified intensive-level professional or qualified professional and to document that such employee or contractee has not been convicted of a felony or any crime involving maltreatment of a child in any jurisdiction and to periodically review and verify continuing compliance with this paragraph.

Ins 3.36(14)(c)(c) A provider, therapist, or professional working under the supervision of a certified outpatient mental health clinic, who is approved by the department and who has a signed Medicaid provider agreement to provide services through the waiver program to individuals with autism spectrum disorders prior to November 1, 2009 shall be deemed to be a qualified intensive-level provider or qualified intensive-level professional through October 31, 2011. Beginning November 1, 2011 any provider, therapist or professional shall comply with the training and education requirements for a qualified supervising provider, qualified intensive-level provider, qualified provider, qualified intensive-level professional, qualified professional or qualified therapist.

Ins 3.36(14)(d)(d) An insurer or self-insured health plans may elect to contract with certain providers, therapists and professionals who do not meet all of the requirements necessary to be considered qualified supervising providers, qualified intensive-level providers, qualified providers, qualified therapists, qualified intensive-level professionals or qualified professionals but who are approved by the department and who have a signed Medicaid provider agreement to provide services through the waiver program to individuals with autism spectrum disorders and who meet any criteria established by the insurer or self-insured health plan. The insurer or self-insured health plans shall have a verifiable and established process for rendering its determination for otherwise qualified supervising provider, qualified intensive-level provider, qualified provider, qualified intensive-level professional, qualified professional or qualified therapist.