Ins 3.36(5)(a)1. 1. After the completion of intensive-level services and designed to sustain and maximize gains made during intensive-level services treatment.

Ins 3.36(5)(a)2. 2. To an insured who has not and will not receive intensive-level services but for whom nonintensive-level services will improve the insured’s condition.

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)2. 2. Implemented by a person who is at least a qualified provider, qualified professional, qualified therapist, or a qualified paraprofessional.

Ins 3.36(5)(b)3. 3. Provided in an environment most conducive to achieving the goals of the insured’s treatment plan.

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) (6) Transition to nonintensive-level services.

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)1. 1. The insured has received forty-eight cumulative months of intensive-level services.

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)(a)3. 3. The insured no longer receives evidence-based behavioral therapy for at least 20 hours per week over a six-month period of time.

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.

Ins 3.36(8) (8) Research that is the basis for efficacious treatment or efficacious strategies. Research designs that are sufficient to demonstrate that a treatment or strategy when used solely or in combination with other treatments or strategies, is effective in addressing the cognitive, social, and behavioral challenges associated with autism spectrum disorders demonstrates significant improvement shall include at least one of the following:

Ins 3.36(8)(a) (a) Two or more high quality experimental or quasi-experimental group design studies that meet all of the following criteria:

Ins 3.36(8)(a)1. 1. A clearly defined population for whom inclusion criteria have been delineated in a reliable, valid manner.

Ins 3.36(8)(a)2. 2. Outcome measures with established reliability and construct validity.

Ins 3.36(8)(a)3. 3. Independent evaluators who are not aware of the particular treatment utilized.

Ins 3.36(8)(b) (b) Five or more single subject design studies that meet all of the following criteria:

Ins 3.36(8)(b)1. 1. Studies must have been published in a peer-reviewed scientific or medical journal.

Ins 3.36(8)(b)2. 2. Studies must have been conducted by three different researchers or research groups in three different geographical locations.

Ins 3.36(8)(b)3. 3. The body of studies must have included 20 or more participants.

Ins 3.36(8)(c) (c) One high quality randomized or quasi-experimental group design study that meets all of the criteria in par. (a) and three high-quality single-subject design studies that meet all of the criteria in par. (b).

Ins 3.36(9) (9) Disputes. An insurer’s or a self-insured health plan’s determination regarding diagnosis and level of service may be considered an adverse determination if the insured disagrees with the determination. The insured or the insured’s authorized representative may file a grievance in accordance with s. Ins 18.03. The insured or the insured’s authorized representative may seek independent review of the coverage denial determination in accordance with s. Ins 18.11.