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Toll Free HelpLine 1-800-274-3258 | |
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PHLP provides free legal services and advocacy to Pennsylvanians having trouble accessing publicly funded health care coverage or services. For assistance, call our helpline at 1-800-274-3258 or 1-866-236-6310 TTY or e-mail us at staff@phlp.org. |
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Drug
and Alcohol Issues
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Below is information on how to obtain drug and alcohol services. The information describes how to obtain services if you have Medical Assistance, Medicare, private health insurance or are uninsured. Accessing Drug and Alcohol Treatment for Medical Assistance Recipients All categories of MA eligibility cover some level of drug and alcohol services. Below is information on accessing these services for persons in HealthChoices (the MA managed care system) or in Access (the MA Fee-For-Service system). HealthChoices If you are enrolled in HealthChoices, there are three ways that you
can access drug and alcohol services.
The levels of drug and alcohol treatment available through your MA-MCO are:
See our Publications Page for more information on accessing Drug and Alcohol services through HealthChoices in your area. If your Managed Care Organizations (MCO) denies treatment you need, reduces your services, or terminates services you are receiving you can appeal the decision directly to the Managed Care Organization, request a Fair Hearing from the Department of Public Welfare (DPW), or do both. For more information on appeal decisions about treatment, see our page on Complaints, Grievances, and Fair Hearings. Access Card/Fee-For-Service If you are enrolled in the Access Card/Fee-For-Service system, you can access drug and alcohol treatment by calling the Pennsylvania Department of Health Single County Authority (Drug and Alcohol Program) in your county. You will either be scheduled for an assessment at the county, or you will be given the names of at least two drug and alcohol programs to call directly for an assessment. Click here to find contact information for the Single County Authority in your county. The levels of drug and alcohol treatment available through MA Fee-For-Service are:
Your county may offer additional services. There are some limits on the type or amount of drug and alcohol services you may be able to receive. These limits depend on your category of Medical Assistance eligibility. Children are always entitled to any treatment that is medically necessary. Check the MA "Fee-For-Service Consumer Handbook" for more information about your coverage. If Medical Assistance denies treatment you need, reduces your services, or terminates services you are receiving you can appeal the action by requesting a fair hearing with DPW. You are entitled to a decision in writing if MA denies, reduces or stops services. That decision must tell you how to file an appeal. See our Publications Page for more information on accessing Drug and Alcohol services through Access Card/Fee-For-Service in your area.
Recipients on Medicare can access limited drug and alcohol treatment through their Medicare coverage. Part A covers some drug and alcohol treatment received in a hospital, including room, meals, nursing and other services. Part B covers some services provided by drug and alcohol professionals (whether inpatient or outpatient), outpatient therapies, lab tests and partial hospitalization. The Medicare program does not cover a certain "package" or defined amount of specific services. Rather, it covers a portion of the cost of health care, including drug and alcohol services, which are reasonable and medically necessary according to Medicare's written standards. Part B never covers more than 50% of outpatient drug and alcohol services. To access drug and alcohol services through Medicare, you should ask your doctor or call 1-800-MEDICARE to check if Medicare is likely to cover the treatment or service you need. Medicare does not prior authorize treatment or services and will not tell you ahead of time whether a treatment or service will definitely be covered in your situation. Medicare does not cover the total cost of most treatment and services, so recipients are normally required to pay deductibles and co-payments. If you have Medical Assistance (MA) as well as Medicare, your MA can be used to cover co-pays and deductibles. If you have MA and Medicare your providers must accept that coverage as payment in full and cannot bill you for any balance on covered services. If Medicare denies you any service you have appeal rights. See your "Medicare & You 2007" handbook for details on appeals. See our Publications Page for more information on accessing drug and alcohol services through Medicare.
Whether or not your private health insurance covers drug and alcohol treatment depends on whether the plan is an ERISA or non-ERISA plan. The Employee Retirement and Income Security Act is a federal law that sets standards for certain health plans offered by employers. If you get insurance through your employer, call and ask your employer's benefits manager if the plan is an ERISA or non-ERISA plan. ERISA plans may, but are not required to cover drug and alcohol treatment. Non-ERISA plans and other group health plans are required to cover at least the following drug and alcohol services:
Read your private insurance member handbook or your insurance contract to confirm what is covered for you and to see how to access services. Those materials will also contain information about appealing a denial of services.
If you currently have no health insurance, you may still be able to get drug and alcohol services. There are two options for those without insurance. The first option is to explore your eligibility for Medical Assistance. The second option is to contact the Pennsylvania Department of Health Single County Authority (Drug and Alcohol Program) in your county. Click here to contact the Single County Authority in your county. Qualifying for Medical Assistance Persons who are undergoing active treatment for drug or alcohol addiction may be eligible for full Medical Assistance if participation in the treatment program precludes employment, and the program is licensed and approved by the Department of Health or is administered by an agency of the federal government. The applicant must also meet the citizenship, residency, income (income limits for this program vary by county, ranging from $174-$215/month for an individual), and resource ($250 for an individual; $1,000 for 2 or more in the household) guidelines to be eligible for MA. To apply, complete the PA 600 Form and mail the application along with supporting documents that show you are undergoing active treatment to the local County Assistance Office. The applicant will be contacted by the CAO to schedule a face-to-face interview upon receipt of the application. It is possible to apply for MA in person and get an interview on the same day. Be sure to have all required documents when going to the CAO. NOTE: Since there is a nine-month lifetime limit for eligibility under this category its best to try to qualify for MA under another category first. For more information on Medical Assistance eligibility, see our MA Eligibility Page.
If you do not have health insurance and are not eligible for Medical Assistance under the program described above, contact the Pennsylvania Department of Health Single County Authority (Drug and Alcohol Program) in your county for information on ways to access services. Click here to find contact information for the Single County Authority in your county. When you call your county Single County Authority you will be scheduled for an assessment to see what type of treatment you need. You will also be asked about your income to see if you can afford to pay for part of your treatment. The levels of drug and alcohol treatment available through the county are:
Your county may also provide additional services. The County has different ways of paying for your treatment when you have no insurance. Whether or not you get the type of treatment you need depends on the money the County has available. However, some level of treatment should always be available to you. Accessing Drug and Alcohol Treatment for Children In order to get drug and alcohol treatments for children, you should follow the same steps listed previously depending on the type of health insurance coverage your child has. Remember that children who receive medical assistance are entitled to any treatment that is medically necessary. If your child is on CHIP, she will also receive some drug and alcohol services. The following types of drug and alcohol treatment are available through CHIP:
Read your CHIP Member Handbook or check with your plan directly to see what other drug and alcohol services may be covered. See our Publications Page for more information on accessing drug and alcohol services for children.
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Last Updated: March 2007 |
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