Pennsylvania

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).

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.