HARRISBURG — Pennsylvanians battling drug and alcohol addiction will not need a second opinion from their HMO before entering treatment programs, a state appeals court ruled.
In a unanimous decision released Thursday, Commonwealth Court ruled that group insurance companies and HMOs must cover drug and alcohol treatment costs for policy holders referred to detoxification, rehabilitation and outpatient programs by a doctor or psychologist.
The ruling will help about 15,000 state residents with private insurance who seek substance abuse treatment each year, said Deborah Beck, president of the Drug and Alcohol Service Providers Organization of Pennsylvania.
"It’s a really important decision that I think gives power back to doctors and psychologists," said Beck, whose Harrisburg-based organization represents licensed treatment centers and school-run counseling programs. "Somebody at the end of an 800 number in another state … should never be making these decisions."
The case centered on a 1989 state law that required insurance companies to cover drug and alcohol treatment services.
Aetna, Independence Blue Cross, the Insurance Federation of Pennsylvania and other managed-care groups sued the state Insurance Department, arguing that insurers should be allowed to review drug and alcohol treatment referrals to keep down costs and make sure treatment is appropriate.
But the court sided with the Insurance Department’s interpretation that treatment would be covered as long as a doctor or psychologist prescribed the treatment.
Samuel R. Marshall, Insurance Federation of Pennsylvania Inc. president and chief executive officer, said he was unsure if the ruling would be appealed to the state Supreme Court.
Marshall said state law allows insurers to review treatment in other health care areas before paying for care and believed it was reasonable that drug and alcohol services be included.
The reviews would be conducted by physicians or psychologists, Marshall said.
"I think utilization review can help get better treatment," Marshall said. "Excess utilization and high utilization patterns drive up the cost of health care and, therefore, the cost of health insurance. The experience across the country is that when you don’t have scrutiny over treatment patterns, you do get increased cost."
But Beck said limiting obstacles to treatment is important when dealing with addicts.
"If you make [getting treatment] complicated, the addict will disappear and die," Beck said. "This is a life-saving law upheld by the court."
source: Bucks County Courier Times
author: Kori Walter