PRO-ACT Makes Progress in Demand for Treatment

by Marc Belanger

On August 8, PRO-ACT (Pennsylvania Recovery Organization-Achieving Community Together) and Southeast Pennsylvania Demand Treatment! met with local treatment providers to discuss what to do when behavioral health and other payers do not pay for prescribed services.

Pennsylvania is the home of Act 106, which requires group health insurance plans to include coverage for addiction treatment — 7 days detoxification per year, 30 days inpatient per year, and 30 units of outpatient per year, all with lifetime limits.

However, treatment providers have an extremely difficult time getting behavioral health and managed care companies to comply with the law. Payers, for example, ask providers for research showing the importance of more than a few days' inpatient treatment. With the wealth of research supporting the importance of length of treatment, the question distracts from the reality that these companies must comply with the law.

Some treatment providers have been intimidated, and many feel they are in an awkward position. Behavioral health or managed care companies name the treatment facilities that can be used. Treatment providers go along with insurers and provide less care than they feel is appropriate, but they could be sued for providing too little care. If they treat, they may have a very long wait for reimbursement. Managed care companies cannot deny the number of days a physician has prescribed; however, they are only liable for 30 days.

While the providers were meeting, Deb Beck, president of the Drug and Alcohol Service Providers Organization of Pennsylvania received a cell phone call notifying her that a notice supporting prescriptive power of the physician had been placed in the Pennsylvania Bulletin that morning.

Beck said, “We're on the cusp of a major power shift. Under Act 106, there is no role for managed care in managing treatment.”

The notice, “Drug and Alcohol Use and Dependency Coverage; Notice 2003-06“, was signed by Pennsylvania's Insurance Commissioner. It provides clear guidance on provision of benefits under Act 106. It states that certification or referral from a licensed physician or licensed psychologist is the only lawful prerequisite needed before an insured person receives inpatient, residential or outpatient treatment.

Additionally, several families have won reimbursements from insurance companies for out-of-pocket money spent on treatment. Babette Benham, client advocate for PRO-ACT, has helped provide support, empowerment, and coaching. Two families received $17,500, one family received $11,500, and another got over $4,500.

As Beverly Haberle, president of the Bucks County Council on Alcoholism and Drug Dependence, said, “Not all families can pay this kind of money up front, so it is important that treatment providers work together with physicians and patients and their families toward enforcement of the law.”

As part of PRO-ACT's state-wide effort, advocates are being trained to work in other parts of the state duplicating the efforts in the five counties of SE Pennsylvania. The advocate training is scheduled for September 29.

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