Pennsylvania Act 106: Your Inpatient Rehab Coverage Rights
Pennsylvania Act 106 of 1989 guarantees every resident on a fully-insured group health plan a minimum of 30 days of non-hospital residential rehab per year — with no prior authorization allowed to reduce that minimum (Pennsylvania Insurance Department).
What Act 106 Is
Pennsylvania Act 106 of 1989 is a state law codified at 40 P.S. §§ 908-1 through 908-8. It requires every fully-insured group health insurance policy and HMO contract issued in Pennsylvania to provide a minimum level of coverage for alcohol and drug abuse treatment. The Pennsylvania Insurance Department enforces it.
Talk to a placement advisor now.
Call (215) 302-0133 for free insurance verification. No obligation. Advisors answer around the clock.
The Only Lawful Prerequisite
The only thing your insurance can lawfully require before approving non-hospital residential or outpatient coverage is a written certification and referral from a licensed physician or licensed psychologist. The Pennsylvania Insurance Department has determined that the same rule applies to inpatient detox. The certification controls both the nature and the duration of treatment. Your insurance company cannot use prior authorization, utilization review, or medical necessity determinations to reduce coverage below the Act 106 minimum.
Which Plans Are Covered by Act 106
Covered: fully-insured group health plans issued in Pennsylvania, including PPO, HMO, EPO, and POS plans offered by employers and purchased from carriers like Aetna, Cigna, Independence Blue Cross, Highmark, UnitedHealthcare, and others. Not covered by Act 106 directly: individual marketplace plans (ACA exchange), self-funded employer plans (ERISA), Medicare, Medicaid, and out-of-state plans. However, federal parity law (MHPAEA) and the Affordable Care Act's Essential Health Benefits provide similar protections for many of these plans.
How Act 106 Interacts With Federal Parity
The federal Mental Health Parity and Addiction Equity Act (MHPAEA) requires that substance use benefits be no more restrictive than medical/surgical benefits. When Act 106 and parity apply together: Act 106 sets the floor (30 days residential minimum), and parity raises the ceiling to whatever your medical/surgical benefits allow. If your plan covers 60 inpatient medical/surgical days, it must cover 60 inpatient substance-use days. Pennsylvania specifically has not issued its own regulations under the state parity law, so the PA Insurance Department uses federal MHPAEA rules as guidance.
What To Do If Coverage Is Denied
First: get the denial in writing. Second: request your plan's internal appeal. Third: if the internal appeal is denied, file with the Pennsylvania Insurance Department Consumer Services Bureau at 1-877-881-6388. The Bureau investigates Act 106 and parity violations. Licensed treatment programs and placement advisors can provide clinical documentation supporting the appeal. Many initial denials are overturned when appealed with the correct documentation.
Talk to a placement advisor now.
Call (215) 302-0133 for free insurance verification. No obligation. Advisors answer around the clock.
Frequently Asked Questions
Does Act 106 apply to my employer's plan?
Can my insurance make me try outpatient before inpatient?
What if I'm on an individual marketplace plan?
Who enforces Act 106?
Talk to a placement advisor now.
Call (215) 302-0133 for free insurance verification. No obligation. Advisors answer around the clock.