PRINTER'S NO. 1252
No. 1104 Session of 1989
INTRODUCED BY WAMBACH, SAURMAN, RYBAK, O'DONNELL, RYAN,
RICHARDSON, HAYES, MANDERINO, ITKIN, McCALL, FOX, RUDY,
RAYMOND, PISTELLA, EVANS, JOHNSON, DeWEESE, PETRARCA,
PHILLIPS, KUKOVICH, SALOOM, RITTER, JACKSON, D. R. WRIGHT,
LASHINGER, KOSINSKI, CAPPABIANCA, DOMBROWSKI, GEIST, LINTON,
LETTERMAN, NAHILL, CALTAGIRONE, MILLER, DIETTERICK, MARKOSEK,
WOZNIAK, JADLOWIEC, MORRIS, STUBAN, CORNELL, STABACK,
FREEMAN, HAGARTY, KASUNIC, CAWLEY, LAUGHLIN, MICHLOVIC,
McVERRY, CARN, TIGUE, MRKONIC, CHADWICK, ROBBINS, CLYMER,
PICCOLA, TRELLO, JAMES, VEON, HECKLER, E. Z. TAYLOR, JOSEPHS,
BELARDI, COWELL, GIGLIOTTI, CIVERA, MICOZZIE, D. F. CLARK,
MELIO, STEIGHNER, McHALE, THOMAS, BURD, HERSHEY, ADOLPH,
PRESTON, LEVDANSKY, DEMPSEY, WILSON, HUGHES, MAINE, WILLIAMS,
VAN HORNE, COY, BUSH, DURHAM, CORRIGAN, BOWLEY, BILLOW,
DISTLER, BUNT, TRICH, BORTNER, OLIVER, ACOSTA, HOWLETT,
J. TAYLOR, J. L. WRIGHT, HARPER, DeLUCA, PETRONE, PRESSMANN,
LESCOVITZ, GRUITZA, LaGROTTA, R. C. WRIGHT, F. TAYLOR,
KAISER, HAYDEN, JAROLIN, McNALLY, BATTISTO, LUCYK, BELFANTI,
SCRIMENTI, ROEBUCK, KONDRICH, ALLEN, HASAY, MARSICO, TELEK,
COLAFELLA, WASS, DAVIES, BLACK, HESS AND COLE, APRIL 10, 1989
REFERRED TO COMMITTEE ON INSURANCE, APRIL 10, 1989
AN ACT
1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2 act relating to insurance; amending, revising, and
3 consolidating the law providing for the incorporation of
4 insurance companies, and the regulation, supervision, and
5 protection of home and foreign insurance companies, Lloyds
6 associations, reciprocal and inter-insurance exchanges, and
7 fire insurance rating bureaus, and the regulation and
8 supervision of insurance carried by such companies,
9 associations, and exchanges, including insurance carried by
10 the State Workmen's Insurance Fund; providing penalties; and
11 repealing existing laws," providing for benefits for drug
12 abuse and dependency.
13 The General Assembly of the Commonwealth of Pennsylvania
14 hereby enacts as follows:
1 Section 1. Sections 601-A, 602-A, 604-A, 605-A and 606-A of
2 the act of May 17, 1921 (P.L.682, No.284), known as The
3 Insurance Company Law of 1921, added June 11, 1986 (P.L.226,
4 No.64), are amended to read:
5 Section 601-A. Definitions.--As used in this article the
6 following words and phrases shall have the meanings given to
7 them in this section:
8 "Alcohol or drug abuse." Any use of alcohol or other drugs
9 which produces a pattern of pathological use causing impairment
10 in social or occupational functioning or which produces
11 physiological dependency evidenced by physical tolerance or
12 withdrawal.
13 "Detoxification." The process whereby an alcohol-intoxicated
14 or drug-intoxicated or alcohol-dependent or drug-dependent
15 person is assisted, in a facility licensed by the Department of
16 Health, through the period of time necessary to eliminate, by
17 metabolic or other means, the intoxicating alcohol or other
18 drugs, alcohol and other drug dependency factors or alcohol in
19 combination with drugs as determined by a licensed physician,
20 while keeping the physiological risk to the patient at a
21 minimum.
22 "Hospital." A facility licensed as a hospital by the
23 Department of Health, the Department of Public Welfare, or
24 operated by the Commonwealth and conducting an alcoholism or
25 drug addiction treatment program licensed by the Department of
26 Health.
27 "Inpatient care." The provision of medical, nursing,
28 counseling or therapeutic services twenty-four hours a day in a
29 hospital or non-hospital facility, according to individualized
30 treatment plans.
19890H1104B1252 - 2 -
1 "Non-hospital facility." A facility, licensed by the
2 Department of Health, for the care or treatment of alcohol-
3 dependent or other drug-dependent persons, except for
4 transitional living facilities.
5 "Non-hospital residential care." The provision of medical,
6 nursing, counseling or therapeutic services to patients
7 suffering from alcohol or other drug abuse or dependency in a
8 residential environment, according to individualized treatment
9 plans.
10 "Outpatient care." The provision of medical, nursing,
11 counseling or therapeutic services in a hospital or non-hospital
12 facility on a regular and predetermined schedule, according to
13 individualized treatment plans.
14 "Partial hospitalization." The provision of medical,
15 nursing, counseling or therapeutic services on a planned and
16 regularly scheduled basis in a hospital or non-hospital facility
17 licensed as an alcoholism or drug addiction treatment program by
18 the Department of Health, designed for a patient or client who
19 would benefit from more intensive than are offered in outpatient
20 treatment but who does not require inpatient care.
21 Section 602-A. Mandated Policy Coverages and Options.--(a)
22 All group health or sickness or accident insurance policies
23 providing hospital or medical/surgical coverage and all group
24 subscriber contracts or certificates issued by any entity
25 subject to this act, 40 Pa.C.S. Ch. 61 (relating to hospital
26 plan corporations) or Ch. 63 (relating to professional health
27 services plan corporations), the act of December 29, 1972
28 (P.L.1701, No.364), known as the "Health Maintenance
29 Organization Act," or the act of July 29, 1977 (P.L.105, No.38),
30 known as the "Fraternal Benefit Society Code," providing
19890H1104B1252 - 3 -
1 hospital or medical/surgical coverage, shall in addition to
2 other provisions required by this act include within the
3 coverage those benefits for alcohol or other drug abuse and
4 dependency as provided in sections 603-A, 604-A and 605-A.
5 (b) The benefits specified in subsection (a) may be provided
6 through a combination of such policies, contracts or
7 certificates.
8 (c) The benefits specified in subsection (a) may be provided
9 through prospective payment plans.
10 (d) The provisions of subsection (a) shall not apply to
11 Medicare or Medicaid supplemental contracts or limited coverage
12 accident and sickness policies, such as, but not limited to,
13 cancer insurance, polio insurance, dental care and similar
14 policies as may be identified as exempt from this section by the
15 Insurance Commissioner.
16 Section 604-A. Non-hospital Residential Alcohol or Other
17 Drug Services.--(a) Minimal additional treatment as a covered
18 benefit under this article shall be provided in a facility which
19 meets minimum standards for client-to-staff ratios and staff
20 qualifications which shall be established by the Office of Drug
21 and Alcohol Programs and is appropriately licensed by the
22 Department of Health as an alcoholism or drug addiction
23 treatment program. Before an insured may qualify to receive
24 benefits under this section, a licensed physician or licensed
25 psychologist must certify the insured as a person suffering from
26 alcohol or other drug abuse or dependency and refer the insured
27 for the appropriate treatment.
28 (b) The following services shall be covered under this
29 section:
30 (1) Lodging and dietary services.
19890H1104B1252 - 4 -
1 (2) Physician, psychologist, nurse, certified addictions
2 counselor and trained staff services.
3 (3) Rehabilitation therapy and counseling.
4 (4) Family counseling and intervention.
5 (5) Psychiatric, psychological and medical laboratory tests.
6 (6) Drugs, medicines, equipment use and supplies.
7 (c) The treatment under this section shall be covered, as
8 required by this act, for a minimum of thirty (30) days per year
9 for residential care. Additional days shall be available as
10 provided in section 605-A(d). Treatment may be subject to a
11 lifetime limit, for any covered individual, of ninety (90) days.
12 Section 605-A. Outpatient Alcohol or Other Drug Services.--
13 (a) Minimal additional treatment as a covered benefit under
14 this article shall be provided in a facility appropriately
15 licensed by the Department of Health as an alcoholism or drug
16 addiction treatment program. Before an insured may qualify to
17 receive benefits under this section, a licensed physician or
18 licensed psychologist must certify the insured as a person
19 suffering from alcohol or other drug abuse or dependency and
20 refer the insured for the appropriate treatment.
21 (b) The following services shall be covered under this
22 section:
23 (1) Physician, psychologist, nurse, certified addictions
24 counselor and trained staff services.
25 (2) Rehabilitation therapy and counseling.
26 (3) Family counseling and intervention.
27 (4) Psychiatric, psychological and medical laboratory tests.
28 (5) Drugs, medicines, equipment use and supplies.
29 (c) Treatment under this section shall be covered as
30 required by this act for a minimum of thirty outpatient, full-
19890H1104B1252 - 5 -
1 session visits or equivalent partial visits per year. Treatment
2 may be subject to a lifetime limit, for any covered individual,
3 of one hundred and twenty outpatient, full-session visits or
4 equivalent partial visits.
5 (d) In addition, treatment under this section shall be
6 covered as required by this act for a minimum of thirty separate
7 sessions of outpatient or partial hospitalization services per
8 year, which may be exchanged on a two-to-one basis to secure up
9 to fifteen additional non-hospital, residential alcohol
10 treatment days.
11 Section 606-A. Deductibles, Copayment Plans and Prospective
12 Pay.--(a) Reasonable deductible or copayment plans, or both,
13 after approval by the Insurance Commissioner, may be applied to
14 benefits paid to or on behalf of patients during the course of
15 alcohol or other drug abuse or dependency treatment. In the
16 first instance or course of treatment, no deductible or
17 copayment shall be less favorable than those applied to similar
18 classes or categories of treatment for physical illness
19 generally in each policy.
20 (b) In the first instance or course of treatment under a
21 prospective payment plan, no deductible or copayment shall be
22 less favorable than those applied to similar classes or
23 categories of treatment for physical illness generally in each
24 policy.
25 Section 2. Section 18 of the act of June 11, 1986 (P.L.226,
26 No.64), entitled "An act amending the act of May 17, 1921
27 (P.L.682, No.284), entitled 'An act relating to insurance;
28 amending, revising, and consolidating the law providing for the
29 incorporation of insurance companies, and the regulation,
30 supervision, and protection of home and foreign insurance
19890H1104B1252 - 6 -
1 companies, Lloyds associations, reciprocal and inter-insurance
2 exchanges, and fire insurance rating bureaus, and the regulation
3 and supervision of insurance carried by such companies,
4 associations, and exchanges, including insurance carried by the
5 State Workmen's Insurance Fund; providing penalties; and
6 repealing existing laws,' further providing for investments;
7 requiring alcohol abuse and dependency coverage; providing civil
8 immunity for persons who furnish or receive information relating
9 to suspected fraudulent insurance activities; creating a task
10 force to conduct a review of various factors used in determining
11 automobile insurance premiums; and making an appropriation," is
12 repealed.
13 Section 3. This act shall take effect immediately.
B2L40JLW/19890H1104B1252 - 7 -