Primary Focus: Outpatient Psychiatric Oversight Title/Description: Outpatient Psychiatric Oversight Act Citation: 2018 Act 25 Summary: This Act requires that an outpatient psychiatric clinic shall have a psychiatrist on site for two hours of psychiatric time per week for each full-time equivalent staff member. The Act specifies that fifty percent of the required on-site psychiatric time may be provided by (i) an advanced practice professional or (ii) a psychiatrist off-site using interactive audio and video communication that protects patient confidentiality under Federal and State law in accordance with department-issued guidelines. Effective Date: Enacted May 31, 2018 and to take effect in 60 days. Notes: Enacted from House Bill 478.
Primary Focus: Mandated Benefit: Provider Title/Description: Adoption of Federal Acts Citation: 40 Pa. Stat. Ann. § 908-14 Summary: Insurers shall comply with the Federal acts as contained in sections 2701, 2702, 2705, 2707, 2721, 2753 and 2754 of the Public Health Service Act (58 Stat. 682, 42 U.S.C. § 300gg, 300gg-1, 300gg-5, 300gg-7, 300gg-21, 300gg-53 and 300gg-54). Effective Date: 180 days from March 22, 2010 Notes: Enacted by Pa SB 237.
Status: Signed into Law 3/2010 Summary: This extensive bill, which address many items, has a section that requires insurance plans to comply with the Federal Parity Law . It also set forth penalties for violations:
Suspension or revocation of licensure
Cease and desist order
$5,000 fine for each violation
$10,000 fine for each willful violation (Aggregate fines can’t exceed $500,000 in one year)
Primary Focus: Mandated Benefit: Provider Title/Description: Autism Spectrum Disorders Coverage Citation: 40 Pa. Stat. Ann. § 764h Summary: A health insurance policy or government program covered under this section shall provide to covered individuals or recipients under twenty-one (21) years of age coverage for the diagnostic assessment of autism spectrum disorders and for the treatment of autism spectrum disorders. Effective Date: July 9, 2008 Notes: Amended by HB 1150
Pennsylvania Parity Law
Pennsylvania’s parity provisions are found within the state’s Insurance Company Law of 1921. Please scroll down to page 174 section 635.1. The relevant section ends on pg 179.
The law applies to people with “serious mental illnesses” (SMI), which are defined as:
Major depressive disorder
For people with SMI, plans are required to cover at least 30 days of inpatient care and 60 outpatient visits per year. Patients are allowed to convert every 1 inpatient day to 2 outpatient visits, if they so choose. The law does specify that there cannot be any annual maximum or lifetime maximum in coverage that are different than limits for other medical care.
A separate section of the state insurance law requires large employer fully-insured plans to comply with the Federal Parity Law (scroll to 601-B on page 201).
The law does have an additional subsection addressing autism spectrum disorders for people up to age 21. Plans are required to cover at least $36,000 of treatment for autism every year without any visit limitations. The law provides specific definitions for the following:
Applied behavioral analysis
Autism service provider
Autism Spectrum disorders
Diagnostic assessment of autism spectrum disorders
Terms and conditions for receiving licensure as a behavior specialist
The law explicitly allows insurance plans to use utilization management at least once every 6 months. The law also explicitly grants insureds the right to expedited internal and external review processes upon denial of coverage.
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