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PA Bulletin, Doc. No. 03-1566


Drug and Alcohol Use and Dependency Coverage; Notice 2003-06

[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 nonhospital 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 precertification or utilization reviews, provided, however, that the decision of the precertification 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,

Insurance Commissioner

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

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