Subchapter I. ALCOHOL ABUSE AND DEPENDENCY BENEFITS
GENERAL
89.601. Applicability.
POLICY REQUIREMENTS
89.611. Deductibles and copayments.
89.612. Minimum covered services.
COVERAGE FOR TREATMENT SERVICES
89.621. Inpatient detoxification services.
89.622. Nonhospital residential treatment and rehabilitation services.
89.623. Outpatient services.
GENERAL
§ 89.601. Applicability.
(a) This subchapter implements Article VI-A of the act (40 P. S. § § 908-1—908-8) relating to mandatory benefits for the treatment of alcohol abuse and dependency.
(b) This subchapter applies to group health or sickness or accident insurance policies providing hospital or medical/surgical coverage and group subscriber contracts for certificates issued by an entity subject to the act, 40 Pa.C.S. Chapters 61 and 63 (relating to hospital plan corporations; and professional health services plan corporations), the Health Maintenance Orgnization Act (40 P. S. § § 1551—1567) or the Fraternal Benefit Society Code (40 P. S. § § 1141.101—1141.905).
(c) Every entity that issues the policies, contracts or certificates described in subsection (b) shall submit forms of the contracts in compliance with this subchapter to the Department by May 25, 1988. The obligation to provide alcohol abuse and dependency benefits applies to policies, contracts and certificates issued or renewed on or after December 8, 1986. A policy, contract or certificate is considered renewed on the date of its renewal or, if the contract had no fixed term as of December 8, 1986, on the first anniversary date on or after December 8, 1986.
Authority The provisions of this § 89.601 issued under sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. § § 66, 186, 411 and 412); and The Insurance Company Law of 1921 (40 P. S. § § 341—391).
Source The provisions of this § 89.601 adopted March 25, 1988, effective March 26, 1988, 18 Pa.B. 1360.
POLICY REQUIREMENTS
§ 89.611. Deductibles and copayments.
(a) Definition. A course of treatment shall be considered to be the full range of detoxification, treatment and supportive services carried out specifically to alleviate the dysfunction of the insured or subscriber.
(b) First instance or course of treatment. In the first instance or course of treatment for alcohol abuse and dependency, no deductible or copayment may be less favorable than those applied to similar classes or categories of treatment for other conditions of physical illness or injury.
(c) Second and subsequent courses of treatment. For the second and subsequent courses of treatment for alcohol abuse and dependency, the total proportion of payment after the deductibles and copayments may not be less than 50% of the allowance for similar classes or categories of treatment for other conditions of physical illness or injury.
Authority The provisions of this § 89.611 issued under sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. § § 66, 186, 411 and 412); and The Insurance Company Law of 1921 (40 P. S. § § 341—391).
Source The provisions of this § 89.611 adopted March 25, 1988, effective March 26, 1988, 18 Pa.B. 1360.
§ 89.612. Minimum covered services.
(a) Nonhospital, residential alcohol treatment services which are included as a covered benefit under Article VI-A of the act (40 P. S. § § 908-1—908-8) shall be covered for a minimum of 30 days per year. The minimum of 30 days per year may not be exchanged for outpatient alcohol treatment services.
(b) Outpatient alcohol treatment services which are included as a covered benefit under Article VI-A of the act shall be covered for a minimum of 30 outpatient, full-session visits or equivalent partial visits per year. The minimum 30 sessions per year may not be exchanged for nonhospital residential alcohol treatment services.
(c) Thirty outpatient, full-session visits or equivalent partial visits, which may be exchanged on a two-for-one basis for up to 15 nonhospital, residential alcohol treatment days, shall be available in addition to the minimum required in subsections (a) and (b).
(d) Treatment services provided in subsections (a)—(c) may be subject to a lifetime limit, for a covered individual, of 90 days of nonhospital, residential alcohol treatment services and 120 outpatient, full-session visits or equivalent partial visits.
Authority The provisions of this § 89.612 issued under sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. § § 66, 186, 411 and 412); and The Insurance Company Law of 1921 (40 P. S. § § 341—391).
Source The provisions of this § 89.612 adopted March 25, 1988, effective March 26, 1988, 18 Pa.B. 1360.
COVERAGE FOR TREATMENT SERVICES
§ 89.621. Inpatient detoxification services.
Inpatient detoxification services which are included as a covered benefit under Article VI-A of the act (40 P. S. § § 908-1—908-8) shall be provided in a facility which meets Department of Health minimum drug and alcohol standards for client-to-staff ratios and staff qualifications and which is one of the following:
(1) A hospital licensed under 28 Pa. Code Chapter 157 (relating to drug and alcohol services) and complying with § § 157.21—157.25 (relating to inpatient hospital activities—detoxification).
(2) A psychiatric hospital licensed under 28 Pa. Code Chapter 709 Subchapter K (relating to standards for inpatient hospital drug and alcohol activities offered in a freestanding psychiatric hospital) and complying with § 709.122 (relating to detoxification).
(3) A freestanding treatment facility licensed under 28 Pa. Code Chapter 709 (relating to standards for licensure of freestanding treatment facilities) and complying with 28 Pa. Code Chapter 709, Subchapter F (relating to standards for inpatient nonhospital activities—short-term detoxification) and which has a written affiliation agreement with a hospital for emergency, medical and psychiatric or psychological support services.
(4) A health care facility issued a certificate of compliance under 28 Pa. Code Chapter 711 (relating to standards for certification of treatment activities which are a part of a health care facility) and complying with 28 Pa. Code Chapter 711, Subchapter E (relating to standards for inpatient nonhospital activities—short-term detoxification) and which has a written affiliation agreement with a hospital for emergency, medical and psychiatric or psychological support services.
Authority The provisions of this § 89.621 issued under sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. § § 66, 186, 411 and 412); and The Insurance Company Law of 1921 (40 P. S. § § 341—391).
Source The provisions of this § 89.621 adopted March 25, 1988, effective March 26, 1988, 18 Pa.B. 1360.
§ 89.622. Nonhospital, residential treatment and rehabilitation services.
Nonhospital, residential treatment and rehabilitation services which are included as a covered benefit under Article VI-A of the act (40 P. S. § § 908-1—908-8) shall be provided in a facility which meets Department of Health minimum drug and alcohol standards for client-to-staff ratios and staff qualifications and which is one of the following:
(1) A freestanding treatment facility licensed under 28 Pa. Code Chapter 709 (relating to standards for licensure of freestanding treatment facilities) and complying with 28 Pa. Code Chapter 709, Subchapter E (relating to standards for inpatient nonhospital activities—residential treatment and rehabilitation).
(2) A health care facility issued a certificate of compliance under 28 Pa. Code Chapter 711 (relating to standards for certification of treatment activities which are a part of a health care facility) and complying with 28 Pa. Code Chapter 711, Subchapter D (relating to standards for inpatient nonhospital activities—residential treatment and rehabilitation).
Authority The provisions of this § 89.622 issued under sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. § § 66, 186, 411 and 412); and The Insurance Company Law of 1921 (40 P. S. § § 341—391).
Source The provisions of this § 89.622 adopted March 25, 1988, effective March 26, 1988, 18 Pa.B. 1360.
§ 89.623. Outpatient services.
Outpatient alcohol services which are included as a covered benefit under Article VI-A of the act (40 P. S. § § 908-1—908-8) shall be provided in a facility which is one of the following:
(1) A freestanding treatment facility licensed under 28 Pa. Code Chapter 709 (relating to standards for licensure of freestanding treatment facilities) and complying with Chapter 709 Subchapter I (relating to standards for outpatient activities).
(2) A psychiatric hospital licensed under 28 Pa. Code Chapter 709.
(3) A health care facility issued a certificate of compliance under 28 Pa. Code Chapter 711 (relating to standards for certification of treatment activities which are a part of a health care facility) and complying with 28 Pa. Code Chapter 711, Subchapter H (relating to standards for outpatient activities).
Authority The provisions of this § 89.623 issued under sections 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S. § § 66, 186, 411 and 412); and The Insurance Company Law of 1921 (40 P. S. § § 341—391).
Source The provisions of this § 89.623 adopted March 25, 1988, effective March 26, 1988, 18 Pa.B. 1360.
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