Autism Mandate FAQs

Q. What is covered by the mandate?

• The mandate requires at least $50,000 coverage for intensive-level services per insured per year, for up to four years.
• The mandate requires at least $25,000 for non-intensive level services per insured per year, with no years limit.

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Q. What the difference between intensive and non intensive treatment for autism spectrum disorder?

• According to the mandate, an individual qualifies for the intensive level treatment if a) the treatment began after 2 years of age and before 9 years of age, b) minimum treatment hours on average are 20 hours per week or more, c) the child has a primary diagnosis of autism spectrum disorder.
• An individual qualifies for the non intensive level treatment if a) the minimum treatment hours are less than 20 hours per week on average and b) the child has a primary diagnosis of autism spectrum disorder.

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Q. How do I know if the mandate applies to my policy and if so, when does the mandate apply to my policy?

• Members covered by a fully insured group policy:  Effective dates started on November 1, 2009, and coincide with the renewal of your employer’s group health insurance policy.  Please check with your employer’s human resources department for your specific effective date.

  Note:  Federal government employees or employees covered by a self-funded health plan are not included in this mandate.  Please check with your employer to ensure the mandate applies to your benefit plan if in doubt.

• Members covered by an Individual policy: For members with policies that are new and issued on or after November 1, 2009, you already have the coverage.
  
  For existing members, coverage will become available as your policy renews between November 1, 2009 and October 31, 2010.  You will be notified of the mandate in your renewal letter.

Please note that mandates are required of all fully insured policies (unless otherwise noted above) and therefore, will be automatically added to your policy as of the dates noted above. There is no allowance for “opting out” or turning down the mandate coverage, regardless of whether you or your family will use the benefit.

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Q. How do I know whether my child qualifies for this coverage and at what level of treatment?
A. To assist you, we recommend that you start by completing the Autism Spectrum Disorder Benefit Questionnaire and submitting it to us.  We will review your child’s case and determine the applicable level of coverage.  Since there are a number of factors involved in determining this benefit, Dean Health Plan cannot assess cases over the phone or provide immediate guidance. As part of the case review, Dean Health Plan may need to contact you or your child’s health care provider for more information, such as medical records or written treatment plans.

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Q. If my child started treatment before the mandate became effective, will you retroactively pay for services that have already begun or for outstanding bills that I have incurred in 2009?
A. No, the coverage under your insurance plan begins upon the effective/renewal date for your particular plan, and Dean Health Plan will only pay for services received on or after the effective date of the coverage.  There will be no retroactive coverage

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Q. Will I be responsible for any costs associated with Autism coverage?
A. Coverage for Autism Spectrum Disorders may be subject to the same deductibles, co-insurance or copayments that generally apply to other conditions covered under the policy or plan. The coverage may not be subject to any special limitations or exclusions, including limitations on the number of treatment visits. Please refer to your benefits documents for details on specific coverage which can be found under the Your Benefit Information.  If you still have questions, please contact our Customer Care Center at (800) 279-1301.

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Q. What health care providers can I use if my child needs to get tested for Autism Spectrum Disorder?
If you are enrolled in an HMO plan, Dean network providers must be used for testing. For Point of Service and PPO plan members, it’s the parent’s choice whether to use an in-network provider. Note that Point of Service and PPO plan members who choose non-network providers will be responsible for differences in costs associated with seeing non-network providers.

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Q. Are the testing and diagnosis covered as part of the mandate?
A. Testing was covered prior to the mandate and does not count towards the mandated annual maximum benefit for either intensive or non intensive treatment.

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Q. What providers can my child see for treatment? What if we are already seeing a provider that is not in your network?
A. Dean Health Plan maintains a list of contracted providers approved for treatment of Autism Spectrum Disorder.

We will require members of HMO plans to use network providers, just as we do for other services. Our case management team will assist with care coordination, including transitioning of existing care to network providers when applicable. Through that process, any questions related to ongoing and continued care with specific providers will be addressed.

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Q. How do you handle Autism Spectrum Disorder patients who are already being covered through the Children’s Waiver Program (Medicaid) or on the waiting list for that program? Is this coverage primary? Does that coverage end?
A. In these cases, your employer’s plan will be the primary coverage.  Your employer plan may require cost sharing, but the Waiver Program may cover these costs.  Please consult Medicaid to confirm coverage.  Also, please inform your health care providers that your employer plan is primary, so they can coordinate benefits with Medicaid.

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Q. Where can I find out more about the mandate and other resources in the state?
More information can be found on the following Web sites:

• State of Wisconsin - including Wisconsin Administrative Rule on Autism Spectrum Disorder coverage
• Wisconsin Early Autism Project
• Children’s Waiver Program

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