Last Updated: October 6, 2025
Printable version of publication: Fact Sheet on the Treatment of Opioid Addiction & Other Substance Use Disorders - opens in new window
Coverage by Law
Wisconsin law requires certain health
insurance policies including inpatient, outpatient, and transitional treatment benefits to treat nervous and mental disorders and substance use disorders. [s. 632.89, Wis. Stat.] This law applies to group health insurance policies and contracts, self-insured state governmental health plans, and individual health policies issued in Wisconsin. For individual health insurance policies, the Wisconsin law applies only to the extent an insurer elects to offer
coverage.
Federal employee group plans (e.g., postal carrier's plans) and self-insured employer group plans falling within the terms of the federal Employee Retirement Income Security Act (ERISA), are exempt from Wisconsin law. Wisconsin law does not apply to most policies issued to a group based in another state if both the policyholder and group exist primarily for purposes other than to procure insurance and fewer than 25% of the insured persons are Wisconsin residents.
The federal Affordable Care Act requires all non-grandfathered individual and small employer plans (one to 50 employees) to cover the treatment of nervous and mental disorders or substance use disorders as an
essential health benefit. This means coverage cannot be subject to any annual or lifetime dollar limits.
Additionally, MHPAEA (also known as the mental health parity law) requires coverage provided by a group health benefit plan, a governmental self-insured health plan, or an individual health plan for the treatment of mental health, behavioral health, and substance use disorders must be equal to the coverage offered for medical and surgical treatments.
Mandatory Coverage
Under state law, three services must be covered:
Inpatient Services
- Services for the treatment of substance use disorders provided to an insured in a hospital
Outpatient Services
Nonresidential services for the treatment of substance use disorders provided to an
insured by any of the following:
- A program in an outpatient treatment facility approved by the Department of Health Services
- A licensed physician who has completed a residency in psychiatry
- A psychologist licensed under Wisconsin law
- A licensed mental health professional who specializes in mental health or substance use disorders
Transitional Treatment Services
- Services provided to an insured in a less restrictive manner than are inpatient hospital services but in a more intensive manner than are outpatient services. (Programs providing these services are certified by the Wisconsin Department of Health Services.)
Medical Necessity
All plans and policies affected by the law must provide both inpatient and outpatient services. However, a group health benefit plan, a governmental self-insured health plan, and an individual health benefit plan providing
coverage for the treatment of mental health disorders or substance use disorders must provide the criteria for determining medical necessity under the plan with respect to that coverage.
Denials
If one of these plans denies
coverage for the treatment of mental health disorders or substance use disorders, they must explain to the
insured the reason for the denial. This requirement is in addition to complying with current law with respect to explaining restrictions or terminations of coverage.
Deductibles
An insurer may apply the same
deductible amount and/or
copayment amount to substance use disorders they apply to all other benefits.
Coverage for treatment of mental health and substance use disorders may be no more restrictive in the following areas than the most common limitations applied to other coverage under the plan:
-
exclusions and limitations
- deductibles
-
copays
-
coinsurance
- annual and lifetime payment limitations
-
out-of-pocket limits
- out-of-network charges
- day, visit, or appointment limits
- limitations regarding
referrals to non-physician providers and treatment programs
- duration or frequency of coverage limits under the plan
Prescription Drugs
Prescription drugs are also included as part of the
coverage for the treatment of substance use disorders, but only if they are provided as part of your
insurance plan. Prescription drugs are covered if the drugs are prescribed for a patient who is receiving treatment on either an inpatient or outpatient basis, and if the prescription drugs are for the treatment of substance use disorders. If a health plan does not provide coverage for prescription drugs, then they are not included as part of the mandated coverage.
Contact your health insurer prior to seeking treatment.
As always, confirm that the treatment you want to pursue is covered by your health insurance plan. Confirm the provider, both the entity and practitioner, is in your
network. Also, discuss your
out-of-pocket expenses for seeking treatment (copays,
coinsurance,
deductibles, etc.).
Disputes Related to Coverage
If you have a specific
complaint about your health
insurance, you should first contact your insurance company or agent for assistance. If you do not receive an answer, you may complete the Office of the Commissioner of Insurance (OCI) complaint form to receive an answer to your question or to file a complaint.
What types of complaints does OCI handle?
OCI handles
complaints involving health, life and annuity, and property and casualty insurance companies and their agents. Examples of complaints include:
coverage issues,
claim disputes,
premium problems, sales misrepresentations,
policy cancellations, and refunds. Either the insured individual or his or her representative may file a complaint.
How to file a complaint
-
Complete it online
- Mail it to:
Office of the Commissioner of Insurance
P.O. Box 7873
Madison, WI 53707-7873
- Or Fax it to (608) 264-8115.
Questions or problems with the complaint form?
Other Resources
Prevention
Treatment
Recovery
Find Out More
Department of Health Services - opens in new window
(608) 266-1865
For questions regarding the federal Mental Health Parity and Addiction Equity Act, contact:
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services - opens in new window
(800) 633-4227
(877) 486-2048 TTY
Employee Benefits Security Administration (EBSA) - opens in new window
U.S. Department of Labor (DOL)
(866) 4-USA-DOL
(866) 487-2365