DID YOU KNOW...

Disability determination is made by government agencies using ADA guidelines, based upon an assessment of the individual child, not based upon a particular medical or educational diagnosis. Some children with autism spectrum disorder may meet the criteria for disability, while others might not.



DID YOU KNOW...

Headstart programs provide a setting with educational opportunities, meals, and dental & medical care. Headstart, as a federally funded program, is required to accept a certain number of children with disabilities, including autism, annually. Find out more.

HEALTH INSURANCE

MANDATED COVERAGE FOR AUTISM SERVICES IN WISCONSIN

Since November 1, 2009, per Section 632.895 (12m), Wis. Stat., private insurers are required to cover certain treatments for individuals with autism spectrum disorders. ‘Certain treatments’ generally refers to evidence-based therapies, such as Applied Behavior Analysis (ABA) therapies.

These covered services may be intensive in-home therapy for more than 20 hours per week, or non-intensive (less than 20 hours a week – either in the child’s home or in a clinic setting).

It should be noted that diets, special foods (like gluten free, for example) & supplementation are not considered ‘evidence based’ at this time, so these things – and any fees with consultants to implement them - do not meet the requirements for coverage under this rule.

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PRIVATE HEALTH INSURANCE

As with any new health diagnosis, take the time to review the details of your health plan. Become familiar with coverage, limitations, and exclusions. Read the fine print.

Services frequently utilized by families of children on the autism spectrum include speech therapy, occupational therapy and sometimes psychotherapy / counseling services, nutritionists, among others.

Under the statewide mandate for coverage of evidence-based therapies (ABA), those services are also covered by private insurance plans.

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COMMUNITY-FUNDED HEALTH CARE COVERAGE

BadgerCare: BadgerCare is a program enacted in 1997 to make health care coverage available for the working poor. It provides family-based coverage (usually by enrollment in an HMO) for uninsured families with certain income limits.

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Medicaid: Medicaid is a health insurance program which is operated by the state, using a combination of state and federal dollars to provide health insurance coverage to the elderly, blind or disabled. Eligibility considers state residency, if the applicant is of age (65 or older) or they are blind or disabled, and family income and assets.

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Katie Beckett / Medicaid: The Katie Beckett program gives a path to Medicaid for those families with children that meet the long-term disability requirements for Medicaid, but exceed income guidelines. The program is named for a child from Iowa who became severely handicapped after an illness. Her family fought to allow her to be cared for at home rather than a medical institution – citing that it ultimately cost the state less money to support the family to keep the child at home. In 1981, President Reagan announced the Katie Beckett Medicaid program to provide home health care for these children.

It’s important to note that as secondary coverage to private health insurance, Medicaid / Katie Beckett can cover co-pays and deductibles for eligible children – freeing up family resources for other needed things. Even if you have good private insurance, Medicaid (or determination of eligibility for Medicaid) may lead to eligibility for other programs & services which can add up quickly.

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IMPORTANT NOTES

Applications for all of the community-based health coverage programs mentioned above go through one online application portal. When you apply, the system determines your eligibility for all of these programs.

Even though mandated coverage for autism services is in place by State law, the partially federally-funded Medicaid program does not have the requirement to cover ABA therapies.

Medicaid does not provide any medical coverage for ABA. See our Therapies Explained page for other ways ABA treatment can be paid for, if needed.

Health plan coverage under Badgercare however, when enrolled in a HMO, does include coverage for ABA under the legislation.

Please note: This information was compiled by a parent volunteer from public sources, and is not health advice or a commitment of coverage or benefits. Families are encouraged to review the terms and coverage offered by their private health plan, and to apply for community services as soon as possible. Your local community services office, upon receipt of your application, can confirm what programs & services are the best fit for your family.

For specific questions about your circumstances regarding this topic, contact your Regional Center for Children & Youth with Special Health Care Needs. The Centers are staffed by specialists who can help get answers, find services and connect you to community resources. Their services are free, unbiased and private.