Government

Insurers sue Pa. over coverage of addicts' medical care

NEWS IN BRIEF — Posted Sept. 20, 2004

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An association representing most of the large group insurance plans operating in Pennsylvania filed a lawsuit in August asking a judge to permit them to set their own limits on the treatment of drug addicts and alcoholics. Their suit challenges a state agency's determination that payers have no right to apply managed care restrictions to patients with those conditions.

The Philadelphia-based Insurance Federation of Pennsylvania says that the state's insurance department erred when it ruled that Act 6, a minimum mandated benefits law passed in 1993, required that restrictions, such as prior authorization, are not allowed if a doctor determines an addict's care is medically necessary. The act requires group policies to cover seven days of detoxification, 30 days of inpatient care and 30 outpatient visits. Consumer activists have charged that insurers have often ignored the requirements.

Sam Marshall, president of the insurance federation, said the law is unclear and that "there's a lot of confusion out there" among health plans about when to apply it.

Note: This item originally appeared at http://www.ama-assn.org/amednews/2004/09/20/gvbf0920.htm.

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