Ins 3.36(4)(b)(b) Forty-eight cumulative months. Insurers and self-insured health plans shall provide up to forty-eight months of intensive-level services. Insurers and self-insured health plans may credit against the required forty-eight months of intensive-level services any previous intensive-level services the insured received regardless of payor. Insurers and self-insured health plans may require documentation including medical records and treatment plans to verify any evidence-based behavioral therapy the insured received for autism spectrum disorders that was provided to the insured prior to the insured attaining nine years of age. Insurers and self-insured health plans may consider any evidence-based behavioral therapy that was provided to the insured for an average of 20 or more hours per week over a continuous six-month period to be intensive-level services.

Ins 3.36(4)(c)(c) Travel. Insurers and self-insured health plans shall not include coverage of travel time for qualified providers, qualified supervising providers, qualified professionals, qualified therapists or qualified paraprofessionals when calculating the number of hours of care provided per week and are not required to separately reimburse for travel time.

Ins 3.36(4)(d)(d) Progress assessment. Insurers and self-insured health plans shall require that progress be assessed and documented throughout the course of treatment. Insurers and self-insured health plans may request and review the insured’s treatment plan and the summary of progress on a periodic basis.

Ins 3.36(4)(e)(e) Concomitant therapy. Insurers and self-insured health plans shall provide coverage pursuant to s. 632.895 (12m) (c), Stats., for a qualified therapist when services are rendered concomitant with intensive-level evidence-based behavioral therapy and all of the following:

Ins 3.36(5)(a)(a) Coverage for nonintensive-level services. Insurers and self-insured health plans shall provide coverage for an insured with a verified diagnosis of autism spectrum disorder for nonintensive-level services that are evidence-based and that are provided to an insured by a person who is at least a qualified provider, a qualified professional, a qualified therapist or a qualified paraprofessional in either of the following conditions:

Ins 3.36(5)(b)(b) Requirements for coverage. Insurers and self-insured health plans shall provide coverage for evidence-based therapy that is consistent with all of the following requirements:

Ins 3.36(5)(b)1.1. Based upon a treatment plan developed by an individual who minimally meets the requirements as a qualified provider, a qualified professional or a qualified therapist that includes specific evidence-based therapy 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(5)(b)4.4. Implements 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(5)(c)(c) Services. Insurers and self-insured health plans shall provide coverage for nonintensive-level services that may include direct or consultative services when provided by qualified providers, qualified supervising providers, qualified professionals, qualified therapists, or qualified paraprofessionals.

Ins 3.36(5)(d)(d) Progress assessment. Insurers and self-insured health plans shall require that progress be assessed and documented throughout the course of treatment. Insurers and self-insured health plans may request and review the insured’s treatment plan and the summary of progress on a periodic basis.

Ins 3.36(5)(e)(e) Travel. Insurers and self-insured health plans shall not include coverage of travel time by qualified providers, qualified supervising providers, qualified professionals, qualified therapists or qualified paraprofessionals when calculating the number of hours of care provided per week and are not required to separately reimburse for travel time.

Ins 3.36(6)(a)(a) Notice of transition by insurer. Insurers and self-insured plans shall provide notice to the insured or the insured’s authorized representative regarding change in an insured’s level of treatment. The notice shall indicate the reason for transition that may include any of the following:

Ins 3.36(6)(a)2.2. The insured no longer requires intensive-level services as supported by documentation from a qualified supervising provider, qualified intensive-level provider, or a qualified intensive-level professional.

Ins 3.36(6)(b)(b) Notice of break in service by insured. Insurers and self-insured plans may require an insured or an insured’s authorized representative to promptly notify the insurer or self-insured plan if the insured requires and qualifies for intensive-level services but the insured or the insured’s family or caregiver is unable to receive intensive-level services for an extended period of time. The insured or the insured’s authorized representative shall indicate the specific reason or reasons the insured or the insured’s family or caregiver is unable to comply with an intensive-level service treatment plan. Reasons for requesting intensive-level services be interrupted for an extended period of time may include a significant medical condition, surgical intervention and recovery, catastrophic event or any other reason the insurer or self-insured plan determines to be acceptable.

Ins 3.36(6)(c)(c) Documentation. Insurers and self-insured plans may not deny intensive-level services to an insured for failing to maintain at least 20 hours per week of evidence-based behavioral therapy over a six-month period when the insured or the insured’s authorized representative complied with par. (b) or the insured or the insured’s authorized representative can document that the insured failed to maintain at least 20 hours per week of evidence-based behavioral therapy due to waiting for waiver program services.

Ins 3.36(7)(7) Notice to insureds. Insurers and self-insured plans shall provide written notice regarding claims submitted and processed for the treatment of autism spectrum disorders to the insured or insured’s parents or authorized representative and include the total amount expended to date for the current policy year. The notice may be included with the explanation of benefits form or in a separate communication provided on a periodic basis during the course of treatment.