The Department of Insurance (DOI) issued a notice on August 8 advising all entities subject to Act 106 of 1989 of their obligations under Commonwealth law in the provision of coverage for alcohol or other drug abuse and dependency benefits. The notice is good news for D&A providers that work with private insurance companies. Compliance with Act 106 had been problematic. Act 106 requires all group health plans in Pennsylvania including insurance and Health Maintenance Organizations (HMO) to provide coverage for the treatment of alcohol and drug addictions.The mandated benefits are:
- Up to 7 days of detoxification per year, 28 days per lifetime
- Minimum of 30 days rehabilitation per year, 90 days per life time, and
- Minimum of 30 units of outpatient/partial hospitalization per year, 120 units per lifetime.
This notice clarifies that the plans must provide treatment services and that the only requirement before an insured person obtains non-hospital residential, inpatient detox, and outpatient coverage is a certification and referral from a licensed physician or licensed psychologist. One important aspect of this notice is that it clarifies that the HMO/MCO (Managed Care Organization) cannot override the certifying and referring physician’s order for the type and/or duration of treatment. The only area that the HMO/MCO can change is the location of the treatment.
This notice is in line with the recommendations from the Legislative Budget and Finance Committee report issued spring of 2003. D&A advocates have been working hard for years to find ways to force compliance with the requirements in Act 106. This notice will certainly help to make that happen. The notice can be accessed on the Pennsylvania Bulletin web site (www.pabulletin.com) or by calling PCPA. For more information contact Lynn Cooper at the Association.