Insurance Federation of Pennsylvania, Inc. v. Commonwealth, Insurance Department

929 A.2d 1243, 2007 Pa. Commw. LEXIS 403
CourtCommonwealth Court of Pennsylvania
DecidedJuly 26, 2007
StatusPublished
Cited by7 cases

This text of 929 A.2d 1243 (Insurance Federation of Pennsylvania, Inc. v. Commonwealth, Insurance Department) is published on Counsel Stack Legal Research, covering Commonwealth Court of Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Insurance Federation of Pennsylvania, Inc. v. Commonwealth, Insurance Department, 929 A.2d 1243, 2007 Pa. Commw. LEXIS 403 (Pa. Ct. App. 2007).

Opinion

OPINION BY Judge

SMITH-RIBNER.

This matter is on remand from the Pennsylvania Supreme Court. The Insurance Federation of Pennsylvania, Inc. and other trade associations and health insurers and licensed managed care plans (together, Insurers) filed a petition for review in the Court’s original jurisdiction on January 9, 2004 in the nature of a complaint for declaratory judgment. Insurers request a declaration that the notice published by the Insurance Department (Department) at 33 Pa. B. 4041 (2003) entitled “Drug and Alcohol Use and Dependency Coverage” (Notice 2003-06), explaining the Department’s interpretation of statutes relating to insurance coverage for drug and alcohol dependency treatment and regulation of managed health care, is inconsistent with those statutes.

First is the act requiring coverage for drug and alcohol abuse and dependency in all general group health insurance policies known as “Act 106,” Sections 601-A-608-A of The Insurance Company Law of 1921 (Insurance Company Law), Act of May 17, 1921, P.L. 682, as amended, added by Section 10 of the Act of June 11, 1986, P.L. 226, as amended by Section 8 of the Act of December 22, 1989, P.L. 755, 40 P.S. §§ 908-1-908-8. Second is the act relating to quality health care accountability and protection, including delivery of managed care generally, known as “Act 68,” Sections 2101-2194 of the Insurance Company Law, added primarily by Section 1 of the Act of June 17, 1998, P.L. 464, 40 P.S. §§ 991.2101-991.2194. 1

The parties filed cross motions for judgment on the pleadings, agreeing that the issue is a legal one requiring no further facts to decide. The Court heard argument and scheduled re-argument before the Court an banc, but in a memorandum opinion of April 25, 2005 a majority decided that the controversy was not ripe and that the Court therefore lacked jurisdiction to decide it. On direct appeal from that ruling the Supreme Court, by per curiam order of February 21, 2006, vacated that order, citing Arsenal Coal Co. v. Commonwealth, Department of Environmental Resources, 505 Pa. 198, 477 A.2d 1333 (1984), and remanded to this Court for a consideration of the merits. See Insurance Fed’n of Pa., Inc. v. Commonwealth, Insurance Department, 586 Pa. 268, 893 A.2d 69 (2006). 1 The parties have filed briefs in support of their motions and briefs in opposition to the opposing motions, and the matter was argued again before the Court en banc.

I

In 1989 the legislature provided the requirement of coverage for drug and alcohol *1245 abuse and dependency treatment in Section 602-A(a) of Act 106, 40 P.S. § 908-2(a): “All group health or sickness or accident insurance policies providing hospital or medical/surgical coverage ... shall in addition to other provisions ... include within the coverage those benefits for alcohol or other drug abuse and dependency as provided in sections 603-A, 604-A and 605-A.” The first benefit described is for inpatient detoxification. 2 Section 603-A, 40 P.S. § 908-3, provides for inpatient detoxification as follows:

(a) Inpatient detoxification as a covered benefit under this article shall be provided either in a hospital or in an inpatient non-hospital facility which has a written affiliation agreement with a hospital for emergency, medical and psychiatric or psychological support services, meets minimum standards for client-to-staff ratios and staff qualifications which shall be established by the Department of Health and is licensed as an alcoholism and/or drug addiction treatment program.

Under Section 603-A(c), 40 P.S. § 908-3(c), treatment may be subject to a lifetime limit of four admissions, and reimbursement may be limited to seven days each.

The second benefit is for non-hospital residential or other drug services, provided in Section 604-A of Act 106, 40 P.S. § 908-4 (emphasis added):

(a) Minimal additional treatment as a covered benefit under this article shall be provided in a facility which meets minimum standards for client-to-staff ratios and staff qualifications which shall be established by the Office of Drug and Alcohol Programs and is appropriately licensed by the Department of Health as an alcoholism or drug addiction treatment program. Before an insured may qualify to receive benefits under this section, a licensed physician or licensed psychologist must certify the insured as a person suffering from alcohol or other drug abuse or dependency and refer the insured for the appropriate treatment.
(b) The following services shall be covered under this section:
(1) Lodging and dietary services.
(2) Physician, psychologist, nurse, certified addictions counselor and trained staff services.
(3) Rehabilitation therapy and counseling.
(4) Family counseling and intervention.
(5) Psychiatric, psychological and medical laboratory tests.
(6) Drugs, medicines, equipment use and supplies.

Under Section 604-A(c), 40 P.S. § 908-4(c), non-hospital residential treatment must be covered for a minimum of 30 days per year and may be subject to a lifetime limit of 90 days.

The third benefit is for outpatient alcohol or other drug services as set forth in Section 605-A of Act 106, 40 P.S. § 908-5 (emphasis added):

(a) Minimal additional treatment as a covered benefit under this article shall be provided in a facility appropriately licensed by the Department of Health as *1246 an alcoholism or drug addiction treatment program. Before an insured, may qualify to receive benefits under this section, a licensed'physician or licensed psychologist must certify the insured as a person suffering from alcohol or other drug abuse or dependency and refer the insured for the appropriate treatment.

The same services are provided for as in Section 604-A(b), 40 P.S. § 908-4(b), except for lodging and dietary services, and under Section 605-A(c), 40 P.S. § 908 — 5(c), coverage is required for a minimum of 30 full-session outpatient visits or equivalent partial visits per year and may be subject to a lifetime limit of 120 full-session outpatient visits or equivalent partial visits. The Department adopted regulations to implement the above provisions at 31 Pa. Code §§ 89.601-89.623.

In 1998 the legislature passed Act 68, consumer protection legislation that regulates the delivery of health services by managed care plans (MCPs). 3 Section 2111, 40 P.S. § 991.2111, provides that MCPs, inter alia, shall “(3) Adopt and maintain a definition of medical necessity used by the plan in determining health care services.” Section 2136(a)(1), 40 P.S.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cash America Net of Nevada, LLC v. Commonwealth, Department of Banking
8 A.3d 282 (Supreme Court of Pennsylvania, 2010)
Clairton Slag, Inc. v. Department of General Services
2 A.3d 765 (Commonwealth Court of Pennsylvania, 2010)
Cash America Net of Nevada, LLC v. Commonwealth
978 A.2d 1028 (Commonwealth Court of Pennsylvania, 2009)
Insurance Federation of Pennsylvania, Inc. v. Commonwealth
970 A.2d 1108 (Supreme Court of Pennsylvania, 2009)

Cite This Page — Counsel Stack

Bluebook (online)
929 A.2d 1243, 2007 Pa. Commw. LEXIS 403, Counsel Stack Legal Research, https://law.counselstack.com/opinion/insurance-federation-of-pennsylvania-inc-v-commonwealth-insurance-pacommwct-2007.