Insurance
for Addiction Treatment in Pennsylvania
Insurance coverage for addiction treatment is
mandated by law in Pennsylvania. All group health
plans, including health maintenance organizations,
are required by Act 106 of 1989 to provide coverage
for the treatment of alcohol and drug addictions.
There are specific parameters for treatment of
substance abuse that insurance companies in Pennsylvania
are required to adhere to. The Commonwealth's Insurance
Commission and the State Insurance Department have
consistently reaffirmed Act 106, the regulation
stating that insurance providers must provide certain
minimum coverage for treatment.
According to Act 106, a person seeking addiction
treatment through insurance coverage needs only
a certification of the medical problem and referral
by a licensed physician or psychologist. It is
the doctor who should determine the patient's level
of care and length of stay in an outpatient, inpatient
or detoxification treatment program.
These days, "managed care" organizations
would prefer to have a say in how much coverage
a patient gets - thus determining how much treatment,
and for how long. Under Act 106, managed care should
not play a role in this determination, except to
say what treatment facilities are in their network.
According to Act 106, all group insurance policies
in Pennsylvania must pay for these minimum levels
of treatment of substance addiction:
•Up to seven days of detoxification per year,
28 days per lifetime (hospital or non-hospital
residential detoxification), 4 admissions per lifetime.
•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.
Again, managed care companies may not overrule
the recommendation for length and type of care
that is certified by the referring physician or
psychologist.
If the health plan is an HMO, the patient does
need to use an in-network facility. However, the
doctor making the original referral does not need
to be a member of the HMO's network.
If you, a loved one or employee is having trouble
accessing insurance coverage for treatment, discuss
this with the financial counselor or other admissions
staff members at Livengrin. The policy of Livengrin
Foundation is to do everything it can to help
a patient receive every medical and therapeutic
benefit possible, as mandated by Pennsylvania state
law.
