Frequently Asked Questions about insurance coverage for Alcohol and other drug treatment:

  1. What must my insurance company pay for?
  2. How to Choose a Treatment Program that knows about Act 106 of 1989?
  3. How to File an Act 106 of 1989 complaint?
  4. How do insurance companies determine the level of treatment that I may need?
  5. What is the text of ACT 106?
  6. Act 106 of 1989 - Information for Treatment Providers

1. What must my insurance company 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:

  1. Up to 7 days detoxification per year - 28 days per lifetime (Includes hospital or non-hospital residential detoxification)

    "Detoxification" is a safe way to withdraw from alcohol or other drugs. "Residential" means you stay there all day and over night.
  2. Minimum of 30 days non-hospital residential rehabilitation per year - 90 days per lifetime
  3. Minimum of 30 full session visits of outpatient or equal partial hospitalization visits (sometimes called Intensive Outpatient) per year - 120 total visits per lifetime

These are services where you do not stay overnight at the treatment program.

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.

A client advocate is available to help you, free of charge, with getting treatment through your insurance company. Call PRO-ACT's Act 106 Client Advocate at 1-800-221-6333.

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2. How to Choose a Treatment Program that knows about Act 106 of 1989?

Now you have names and numbers of treatment programs from your insurance company, call those places and ask:

Q: Do you know about Act 106 of 1989?

If No, Then:
Get the person's name and tell them someone from PRO-ACT will call them back.

Next:
Call The Advocacy Line at 1-800-221-6333; ask for PRO-ACT's Client Advocate. Tell the Client 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 Act 106 of 1989?"

Next:
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 Advocate.

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3. 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 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 these FORMS:

A.) "Health Care Complaint Form" - this form is available 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.

Make sure 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:
B.) "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 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 Advocate.

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4. How do insurance companies determine the level of treatment that I may need?

Most often insurance companies use an instrument called the ASAM to determine the level of care you need for your alcohol or other drug problem e.g residential or outpatient.

Suggested Guidelines for patient placement:

The following six dimensions (problem areas) have been identified by the American Society of Addiction Medicine (ASAM) as being most frequently considered when making patient placement decisions and when formulating the patient's individual treatment plan:

  • Acute intoxication and/or withdrawal potential
  • Biomedical conditions and complications
  • Emotional/behavioral conditions and complications (e.g. psychiatric conditions, psychological or emotional/behavioral complications of known or unknown origin, poor impulse control, changes in mental status, or transient neuropsychiatric complications)
  • Treatment acceptance/resistance
  • Relapse/continued use potential
  • Recovery/living environment

The diagnostic terminology suggested here is consistent with the language in the DSM-IV. Accurate diagnosis and assessment require knowledge of problem severity and the level of difficulty of resolving identified problems.

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5. What is the text of ACT 106?

Bulletin Issued by Insurance Commissioner Advising Effected Insurance Companies of Their Obligations under Act 106 of 1989

Drug and Alcohol Use and Dependency Coverage; Notice 2003-06, Issued by the Pennsylvania Insurance Commission; [33 Pa.B. 4041]

This notice is issued to advise all entities subject to Act 106 of 1989 (act) (40 P.S. ?? 908-1--908-8) of their obligations under Commonwealth law in the provision of coverage for alcohol or other drug abuse and dependency benefits. The act requires specific coverage of drug and alcohol treatment services in certain group insurance policies or contracts. Drug and alcohol use and dependency are recognized in this Commonwealth as public health problems with serious workplace, health care, community and criminal justice ramifications. The Insurance Department (Department) releases the following guidance concerning the provision of benefits under the act.

The act specifies that all group policies, contracts and certificates subject to the act providing hospital or medical/surgical coverage shall include within that coverage certain benefits for alcohol or other drug abuse and dependency. Under the act, the only lawful prerequisite before an insured obtains non-hospital residential and outpatient coverage for alcohol and drug dependency treatment is a certification and referral from a licensed physician or licensed psychologist. It is the Department's determination that the same prerequisite applies for inpatient detoxification coverage. The certification and referral in all instances controls both the nature and duration of treatment. The location of treatment is subject to the insuring entity's requirements regarding the use of participating providers.

Act 68 of 1998 (40 P.S. ?? 991.2101--991.2193), governing quality health care accountability and protection, does not change the requirements under the act and should be read in conjunction with these existing requirements. Thus, an entity subject to Act 68 may utilize pre-certification or utilization reviews, provided, however, that the decision of the pre-certification or utilization review does not limit the act certification and referral by the licensed physician or licensed psychologist.

Questions regarding this notice should be addressed to Ronald A. Gallagher, Jr., P.E., Deputy Commissioner, Office of Consumer and Producer Services, Insurance Department, 13th Floor, Strawberry Square, Harrisburg, PA 17120, ra-in-Act106@state.pa.us.

M. DIANE KOKEN,
Insurance Commissioner

[Pennsylvania Bulletin (Pa.B.) Doc. No. 03-1566. Filed for public inspection August 8, 2003, 9:00 a.m.]

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6. Act 106 of 1989 - Information for Treatment Providers

Information for Treatment Providers

For individuals with commercial insurance presenting for treatment, remember that Act 106 of 1989 provides a minimum level of required coverage for most insurance plans. Following are six key steps in accessing these benefits:

Step 1: Determine that the patient is a current subscriber of the insurance plan

Step 2: Determine that the plan is covered under Act 106

  • Is it a group health plan?
  • Is it sold (have an agent for) in the state of Pennsylvania.
  • Is it a non-self-insured plan?
  • If yes to all of the above, the plan is covered under Act 106.
  • Is it CHIP? - If yes, it is a covered plan.

Step 3: Obtain a certification and referral as required under Act 106 of 1989

  • The client should have a certification and referral from their physician or licensed psychologist. The document MUST contain the words, "Certification and Referral" and MUST indicate the type of treatment needed and for how long.
  • If the client has not brought one, have your physician see them and provide the certification and referral for the level of care and length of stay that is needed.
  • A sample certification and referral is enclosed.

Step 4: Contact the Insurance Company

  • Advise that the patient is at your program for treatment based on the certification and referral from a physician (or licensed psychologist). Request an authorization number to bill for these services. (This is not a request for clinical pre-certification as this is not required under Act 106 of 1989; you may need to provide the Insurance Commissioners Policy Statement of August 8, 2003 with the certification and referral.)

Step 5: Have the patient complete the Attorney General Forms at time of intake to include:

  • "Health Care Complaint Form": To include, in client's handwriting:
  • Explanation of complaint, e.g., "I need to ensure that I can obtain my benefits for drug and alcohol treatment."
  • Specific Resolution: "I want the insurance company to pay for the treatment certified and referred for me by my physician."
  • Client signature.
  • Write L. Williams name on the upper left side of the Complaint Form and cc: Deb Beck on bottom
  • "Authorization to Release Medical and Insurance Records" form and the "Authorization to Release Medical and Insurance Records Related to Substance Abuse" form from the Pennsylvania Office of Attorney General.
  • "Consent to Release Information" forms for PRO-ACT and Deb Beck to ensure ability to work with advocates throughout the case.

These forms are enclosed and should be completed at intake to ensure that they are available in the event the insurance company does not pay for the treatment services.

Step 6: If you have ANY problems, call 1-800-221-6333

  • This is The PRO-ACT Advocacy Line that will connect you to a Client Advocate at no charge. A Client Advocate will help you during regular business hours.
  • After hours, be SURE to leave a message so that you can be helped on the next business day.

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