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Consumer Guide to Pennsylvania’s Drug and Alcohol Insurance Law: Pennsylvania Act 106 of 1989
Introduction
Know your rights. Pennsylvania law Act 106 of 1989 requires most group health insurance plans to include coverage for addiction treatment. The only prerequisite for addiction treatment is certification and referral by a licensed physician or a licensed psychologist.
This Consumer Guide to Pennsylvania’s Drug and Alcohol Insurance Law (Act 106 of 1989) explains the law’s provisions, which apply to most group insurance policies drafted in the state of Pennsylvania, including Health Maintenance Organizations (HMO’s). The guide explains what your insurance company must pay for. It details how to get help through your insurance company, and how to choose a treatment provider that knows about and can help you utilize the law. Step by step instructions show you how to file an Act 106 complaint and what the forms look like, should you need to file.
The purpose of this guide is to educate the “consumer.” The person who knows their rights is well informed and empowered to advocate for their rights.
If you have questions, if you want more information, if you need support: Help is available. Call 1-800-221-6333 and ask for PRO-ACT’s Client Insurance Advocate.
Alcohol and Other Drug Treatment: What must most insurance companies pay for?
Act 106 of 1989 is a Pennsylvania law. Under most group insurance plans in Pennsylvania, you are entitled to certain alcohol and other drug treatment benefits. Here are the types of help and amounts of time for each type of treatment your insurance must provide.
Minimum Benefits Under Act 106:
- Up to 7 days detoxification per year – 28 days per lifetime
- Minimum of 30 days non-hospital residential rehabilitation per year – 90 days per lifetime
- Minimum of 30 full session visits of outpatient or equal partial hospitalization visits (sometimes called Intensive Outpatient) per year – 120 total visits per lifetime
Pennsylvania’s Drug and Alcohol Insurance Law (Act 106 of 1989) requires most group health insurance policies drafted in the state of Pennsylvania, including Health Maintenance Organizations (HMO’s), to include these mandated minimum benefits for treatment of alcohol and drug addiction. All treatment services must be provided in a program licensed by the Pennsylvania Department of Health specifically to provide alcohol and other drug treatment.
How to Get Help For an alcohol or other drug problem through your insurance company
Remember – under Pennsylvania law (Act 106 of 1989) most insurance is required to provide the minimum benefit of:
- 7 days detox (28 days lifetime)
- 30 days rehab (90 days lifetime)
- 30 outpatient (includes partial/intensive outpatient) sessions (120 lifetime)
To get this benefit you need a Certification and Referral from a doctor or a licensed psychologist (see sample on page 10). This can be your family doctor or you can call PRO-ACT’s Client Insurance Advocate, free of charge, at: 1-800-221-6333. We can help you. You can also call a drug and alcohol treatment program directly. If you do, ask:
- Do you accept my insurance?
- Do you follow the PA drug and alcohol insurance law (Act 106 of 1989)?
- Will you help me get the Certification and Referral needed to obtain the full benefit listed above?
How to Choose a Treatment Program That knows about Pennsylvania’s Drug and Alcohol Insurance Law (Act 106 of 1989)
Now that you have names and numbers of treatment programs from your insurance company, call those places and ask:
Do you know about Pennsylvania’s Drug and Alcohol Insurance Law (Act 106 of 1989)?
If no, then get the person’s name and tell them someone from PRO-ACT will call them back. Then, call The Advocacy Line at 1-800-221-6333; ask for PRO-ACT’s Client Insurance Advocate. Tell the Client Insurance Advocate that you need help with a treatment program that does not know about Act 106.
If yes, then ask, “Will you use my physician’s (or licensed psychologist’s) certification and referral to get my insurance company to pay for my addiction treatment if it is an insurance plan that must comply with Pennsylvania’s Drug and Alcohol Insurance Law (Act 106 of 1989)?”
Then ask, “If my insurance company will not accept my physician’s (or licensed psychologist’s) certification and referral for my treatment, will you follow through with my insurance company’s grievance and appeal process?”
Ask, "If my insurance company will not accept my physician’s (or licensed psychologist's) certification and referral (prescription) for my treatment, will you follow through with my insurance company's grievance and appeal process and file a complaint with the PA Insurance Department and Attorney General's office?"
If you have any questions or want help with any part of this process, call The Advocacy Line at 1-800-221-6333 and ask for PRO-ACT’s Client Insurance Advocate.
How to File An Act 106 of 1989 Complaint
Okay, you have a certification and referral from your licensed physician or licensed psychologist. The words “Certification and Referral” appear and this document shows the type of care and length of stay. You called your insurance company and got treatment programs. You chose a program that knows about Pennsylvania’s Drug and Alcohol Insurance Law (Act 106 of 1989) and will follow through with your insurance company’s “grievance and appeal” process, if needed. If you are denied anyway, here are 3 actions you must take. Do these to get into treatment or to stay in treatment.
Action #1: Very Important Phone Call
Ask the staff at your treatment program to call your insurance company and “request an appeal of the decision” to deny your treatment. If you must make the call yourself, do so; tell your insurance company you are calling because they denied your treatment and say, “I request an appeal of the decision.”
Once you call and appeal, you cannot be discharged until the appeal process is done. So, make this call immediately!
Action #2: Very Important Paperwork
Ask staff at your treatment program to give you and help you fill out a “Health Care Complaint Form.” This 5 page packet is from the Pennsylvania Office of Attorney General (phone: 717-705-6938; fax: 717-787-1190); it also includes the “Authorization to Release Medical and Insurance Records” form and the “Authorization to Release Medical and Insurance Records Related to Substance Abuse” form.
A sample of the Health Care Complaint Form is included in the printed version of this Consumer Guide, and online from the Pennsylvania Attorney General.
Make sure that you:
- Attach a copy of your physician’s/licensed psychologist’s certification and referral to the Attorney General’s Complaint Form.
- Write L. Williams name on the upper left side of the Complaint Form.
- Specify the nature of the complaint.
- Sign the Complaint Form.
- Sign the two Authorization to Release Medical and Insurance Records forms.
- Write cc: Deb Beck on the bottom of the Attorney General’s Complaint Form. (This will be used by D. Beck, Statewide Act 106 Advocate, to track cases and to assist in obtaining insurance benefits.)
Mail or fax all of the above to:
Linda Williams,
Health Care Section
Office of the Attorney General
14th Floor, Strawberry Square
Harrisburg, PA 17120
Fax: 717-787-1190
Carolyn Morris, Director
PA Insurance Department
Bureau of Consumer Protection
13th Floor, Strawberry Square
Harrisburg, PA 17120
Fax: 717-787-8585
Deb Beck
Drug and Alcohol Service Providers of Pennsylvania (DASPOP)
P.O. Box 230
2033 Lingelstown Road
Harrisburg, PA 17110
Fax: 717-657-7784
Next, fill out an “Insurance Complaint Form” from the Pennsylvania Insurance Department, Bureau of Consumer Services (phone: 717-787-2317; fax: 717-787-8585).
Mail or fax this form with a copy of your certification and referral to:
Carolyn Morris, Director
Bureau of Consumer Protection
13th Floor, Strawberry Square
Harrisburg, PA 17120
Fax: 717-787-8585
Action #3: If you want help
If you must get these forms or fill them out yourself, do so. If you want help, call The Advocacy Line at 1-800-221-6333 and ask to speak to PRO-ACT’s Client Insurance Advocate.
Conclusion
Under Pennsylvania’s Drug and Alcohol Insurance Law (Act 106 of 1989), the decisions about the type of treatment and length of stay are to be made by a licensed physician or licensed psychologist – not the insurance company. In August 2003, the Pennsylvania Insurance Department published a policy that says the only prerequisite for addiction treatment is certification and referral by a licensed physician or psychologist. That medical professional determines the length and type of care the patient needs. The PA Insurance Department has pledged to enforce the law if an insurance company fails to comply with Act 106.
We have faith in your ability to recover and congratulate you for having the courage to seek treatment. After reading this Consumer Guide to Pennsylvania’s Drug and Alcohol Insurance Law (Act 106 of 1989), it is our hope that you now know your rights to treatment, according to Pennsylvania law. If you have questions about Act 106, or how to utilize it, please call the Advocacy/Information Line at 1-800-221-6333 during regular business hours and ask for PRO-ACT’s Client Insurance Advocate. If you want help navigating the drug and alcohol healthcare system, or if you would simply like support or information about drug and alcohol concerns, the line is available 24-hours a day.
Get the Full Consumer Guide
The full, printed version of this Consumer Guide includes samples of all the forms mentioned in this guide, as well as information for treatment providers, doctors, and licensed psychologists. Please contact us to order printed or electronic copies of the full guide.
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