Insurance 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, (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 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. The policy of the Foundation is to do everything it can to help a patient receive every medical and therapeutic benefit possible, as mandated by Pennsylvania state law.