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Legislation Signed into Law

2018

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.

2009-2010

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.

SB 237
Introduced: 2/2009
Sponsor: Sen. Corman
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:
  1. Suspension or revocation of licensure
  2. Cease and desist order
  3. $5,000 fine for each violation
  4. $10,000 fine for each willful violation (Aggregate fines can’t exceed $500,000 in one year)

2008

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:

  1. Schizophrenia
  2. Bipolar disorder
  3. Obsessive-compulsive disorder
  4. Major depressive disorder
  5. Panic disorder
  6. Anorexia nervosa
  7. Bulimia nervosa
  8. Schizoaffective disorder
  9. Delusional 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).

Autism Coverage

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:

  1. Applied behavioral analysis
  2. Autism service provider
  3. Autism Spectrum disorders
  4. Behavior specialists
  5. Diagnostic assessment of autism spectrum disorders
  6. 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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Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

Definition

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