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Pennsylvania Insurance Rights

Insurance coverage for addiction treatment is law in Pennsylvania.  All group health plans in Pennsylvania, including insurance health maintenance organizations, are required by Act 106 of 1989 to provide coverage for the treatment of alcohol and drug addictions.

 
Mandated Minimum Benefits:

--Up to seven days of detoxification per year, 28 days per lifetime (hospital or non-hospital residential detoxification)

--Minimum of 30 days of rehabilitation per year, 90 days per lifetime (non-hospital residential)

--Minimum of 30 units of outpatient/partial hospitalization per year, 120 units per lifetime (outpatient/partial hospitalization)

All services must be provided in facilities licensed by the Department of Health to provide alcohol and drug addiction treatment services.

ACT 106 UPDATE: JULY 2007

PA COMMONWEALTH COURT RULES IN FAVOR OF ACT 106 OF 1989
 

On 7/26/07, the PA Commonwealth Court released its ruling on Act 106 of 1989.  
The Court has ruled in favor of the Insurance Department (Act 106 of 1989) saying:
 Based on its analysis of the issues and the law, the Court concludes that the Department's 

position in this matter in this matter is correct, and therefore declares that Act 106 requires health insurers to provide mandatory coverage for alcohol and drug treatment once an insured receives a certification and a referral for treatment from a licensed physician and/or licensed psychologist. 

Accordingly, the Court holds that the Department is entitled to judgment on the pleading as a
a matter of law. 
 

"Insurance  Industry Sues Over Coverage for Addicts"

The Patriot News-September 8, 2004

Opposed by state regulators, counties and prosecutors, the insurance industry is hoping to convince judges that health maintenance organizations, not a patient's doctor or psychologist, should decide what kind of treatment drug addicts and alcoholics should receive.

State  officials and advocates for the addicted say the current decision-making process varies by insurer.  Complaints over denied services, or doctors being overruled by insurers, have poured into state regulators in recent years.

After the Insurance Department stated last year that only the referral of physicians and psychologists is needed for treatment, members of the insurance industry sued in January.  Insurers, citing a 1998 law that governed managed care, say HMOs must be able to review referrals for drug and alcohol coverage, as they do to all other forms of coverage.

Commonwealth Court judges are scheduled to hear arguments in the case today.  A decision could take months.  An attorney for the insurers, Jayson R. Wolfgang denied comment on the issue, as did Sam Marshall, the president of the Insurance Federation of Pennsylvania.

The Attorney General's Office and the state Department of Insurance contend that a 1986 law that mandated coverage for alcohol addiction, and was updated in 1989 to mandate coverage for drug addiction should be unaffected by the 1998 law.

District Attorneys say better access to treatment will result in lower crime rates. Counties contend that insurers are forcing taxpayer-funded social service agencies, courts and law enforcement authorities to shoulder more of the cost of dealing with addicts.

Advocates for the addicted say access to inpatient  or outpatient treatment for their clients has declined dramatically since insurers began contracting with health maintenance organizations in the 1990s.

Pennsylvania Health Law Project:

Pennsylvania Health Law Project is a non-profit public interest law firm that provides free legal assistance to low-income, elderly, or disabled residents of Pennsylvania.  Among other things, PHLP helps people apply for Medical Assistance (MA), the Children's Health Insurance Plan (CHIP), and Medicaid Waivers, all of which provide drug and alcohol treatment. 

PHLP also advocates for clients in these programs to get the full range of treatment they are entitled to and appeals the denial of treatment.  We also advocate for policies that increase access and quality
of treatment.

PHLP is intended to increase access and quality of drug and alcohol treatment for juveniles under age 21 who are from low-income families. 

If you are having difficulty getting the treatment you need for a young person who you think might be eligible for Pennsylvania's CHIP or MA Programs, contact the PHLP Help Line Monday through Friday, 9:00 a.m. to 5:00 p.m:  1-800-274-3258