Frequently Asked Questions on Mandated Coverage for Autism Services

Last Updated: November 6, 2020


Wisconsin law requires health insurers to cover certain treatments for individuals with autism spectrum disorders. Specifically, coverage of at least $50,000 is required for intensive-level services per year for up to four years and at least $25,000 for nonintensive-level services, adjusted annually by the Consumer Price Index (CPI). (s 632.895 (12m) (c) 1, Wis. Stat.)

For 2020, insurers must provide coverage of at least $64,897 for intensive-level services and $32,448 for nonintensive-level services. Each December, the Office of the Commissioner of Insurance (OCI) publishes the adjusted coverage amounts effective for the following year.
The statute applies to:
  • Group and individual disability (health) insurance policies.
  • Self-insured health plans sponsored by the state, county, city, town, village, or school district providing coverage to dependents.

The statute does NOT apply to:
  • Disability (health) insurance policies covering only certain specified diseases such as cancer.
  • A health care plan offered by a limited service health organization or preferred provider plan that is not also a defined network plan.
  • A long-term care insurance policy.
  • A Medicare replacement policy or a Medicare supplement policy.
  • A self-funded health benefit plan from an employer that’s subject to federal jurisdiction.
  • Group health plans issued in another state covering employees in Wisconsin, unless at least 25% of the employees covered under the plan reside in Wisconsin.
Ask your insurance company or health plan if the mandate applies to you or not to be sure.
If the health insurance policy was issued in Wisconsin, then the policy must include coverage for autism treatment complying with the mandate. The mandate applies to a policy bought in Wisconsin even if the insured moves out of Wisconsin.
To qualify, your child:

  • Needs a primary diagnosis of an autism spectrum disorder,
  • Must be between the ages of 2 and 9 years old for intensive-level services, and
  • Must have a prescription from a physician to receive treatment.
Treatments must be provided by a qualified provider. Contact your insurance company for listings of qualified providers.
Intensive-Level Services
Intensive-level services must be evidence-based, behavioral therapies provided by a qualified health care provider. Evidence on autism treatments is frequently updated, so check with your insurer to find out which services are covered.

Nonintensive-Level Services
Nonintensive-level services must also be evidence-based therapies. Similar to intensive-level services, check with your insurer about which services are covered.

A person with an autism spectrum disorder is NOT required to receive intensive-level services in order to qualify for nonintensive-level services. There is no age limit for receipt of services either.
Intensive-level services are covered starting on a child’s 2nd birthday until his 9th birthday.

There are no age requirements for nonintensive-level services. The table below summarizes the differences between intensive- and nonintensive- level services.
Yes. Wisconsin’s autism mandate requires health insurers to cover behavioral analyst services and behavioral therapy. This treatment refers to interactive approaches aimed at building skills that help the child reduce problem behaviors. It is also used to improve communication, social, self- care, and learning skills.
No. This mandate only applies to services relating to autism spectrum disorder. The services must also meet the definition of either “intensive-level services” or “nonintensive-level services.”
Coverage ends when:

  • The child has received a cumulative four years of intensive-level services. 
  • The child receives services, on average, less than 20 hours a week. The average is calculated over a six month period.
  • The supervising professional consults with a physician and determines less treatment is medically appropriate.
Your insurer will notify you your coverage has changed once the intensive-level phase has ended. The notification must state the reason for the change. Once your child begins nonintensive-level services, he or she cannot resume intensive-level services later.
If a child is diagnosed with an autism spectrum disorder before turning 18 years old and the condition qualifies as a handicap, the child may remain on the parent’s insurance. If the parent changes employers and the child is older than 18 but younger than 26, the child should be eligible for coverage under their parents' insurance until his or her 26th birthday.
Coverage for intensive-level services may last up to four years total. This includes treatment time paid for by the family, other states, or covered by previous insurers. If a child previously received on average more than 20 hours of treatment per week, the time counts against the four years of intensive-level services mandated by the statute.
Intensive-level treatments may be delayed if the child has a significant medical condition or surgery. Treatment may also be delayed if there is a catastrophic event preventing treatment. Notify your insurer when these situations happen.
An insurance company cannot deny a claim under the mandate due to medical necessity. The insurer can deny a claim if it believes the treatment is not supported by evidence. If you receive a denial for this reason, you can dispute the denial through the insurer’s grievance process and an independent review process.
Health insurance covers the cost of autism testing, though copayments and deductibles may apply. These costs do not come out of the funds required under the mandate for that year.
Yes, if your plan requires you to use in-network plan providers for coverage. If your plan permits you to see out-of- network providers for other conditions, they must also accept claims from out-of-network providers for autism treatments. Remember, your plan may have different copayments or deductibles for out-of-network providers, so it may be more affordable to find an in-network provider.
No. You may be able to obtain out-of-network care through a referral from an in-network physician subject to approval by the insurer, but you may be responsible for higher deductibles and copayments for non-network providers. Check with your insurer.
Generally, no, but it may be beneficial so your insurer can determine the most affordable way to provide services.

If your plan requires prior authorization for similar outpatient services, then you may be required to have autism services prior authorized, too. Health maintenance organizations (HMOs) require prior authorization to receive services from out-of-network providers.
The mandate requires certain insurance companies reimburse at least $64,897 for intensive-level services and $32,448 for nonintensive-level services.

Reimbursement means the insurance company is responsible for paying the provider of the services. Payment will be made after services are performed and a claim is submitted to the insurer. The insurer is not required to pay more than the amount mandated by the statute although the policy may provide more coverage.

An insurance company may apply deductibles, coinsurance, or copays that generally apply to other conditions covered under the policy or plan. These amounts are considered part of the coverage you receive. The insurer cannot limit the number of treatment visits for therapies.
The mandate does not require a provider waive fees. Generally, providers are prohibited from reducing fees unless the total fee would impose an undue financial hardship on the individual insured.
Consult your insurer to find out how they allocate out-of-pocket costs between different types of services in your health plan.


Intensive-Level Services
Nonintensive-Level Services
Annual Benefit*
At least $50,000 for services provided
At least $25,000 for services provided
Age Requirement
Must begin after 2 years old
Must begin before 9 years old
None
Time Limit
Up to 4 years of cumulative years
No limit
Minimum Treatment Hours
On average, 20 hours per week
None

*Annually adjusted by CPI and posted to the OCI website.



The purpose of this publication is to summarize the statute and rule requiring health insurers to provide coverage for treatment of autism spectrum disorders.