State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1351-home-health-services

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1351. HOME HEALTH SERVICES

Sec. 1351.001. DEFINITIONS. In this chapter:

(1) "Health services" includes:

(A) skilled nursing by a registered nurse or a licensed

vocational nurse under the supervision of at least one registered

nurse and at least one physician;

(B) physical, occupational, speech, or respiratory therapy;

(C) the services of a home health aide under the supervision of

a registered nurse; and

(D) the furnishing of medical equipment and supplies other than

drugs or medicines.

(2) "Home health agency" means a business that:

(A) provides home health services; and

(B) is licensed by the Texas Department of Human Services under

Chapter 142, Health and Safety Code.

(3) "Home health services" means the provision of health

services for payment or other consideration in a patient's

residence under a plan of care that is:

(A) established, approved in writing, and reviewed at least

every two months by the attending physician; and

(B) certified by the attending physician as necessary for

medical purposes.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.002. APPLICABILITY OF CHAPTER. (a) This chapter

applies to a group health benefit plan that is delivered or

issued for delivery in this state and that is a group policy of

accident and health insurance, including a policy issued by a

group hospital service corporation operating under Chapter 842.

(b) This chapter applies to an accident and health insurance

policy issued by a stipulated premium company subject to Chapter

884.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.003. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.

The provisions of Chapter 1201, including provisions relating to

the applicability, purpose, and enforcement of that chapter, the

construction of policies under that chapter, rulemaking under

that chapter, and definitions of terms applicable in that

chapter, apply to this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.004. EXCEPTION. This chapter does not apply to:

(1) a group policy of accident and health insurance that

provides coverage only for:

(A) a specified disease or diseases;

(B) vision care;

(C) dental care;

(D) hospital indemnity;

(E) prescription drugs; or

(F) other limited benefits;

(2) a blanket insurance policy, as described by Chapter 1251;

(3) a short-term travel insurance policy;

(4) an accident-only insurance policy;

(5) a hospital indemnity insurance policy;

(6) a limited or specified disease insurance policy;

(7) an insurance policy or contract issued under a right of

conversion; or

(8) an insurance policy or contract designed for issuance to a

person eligible for Medicare coverage.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.005. COVERAGE REQUIRED. Except as provided by Section

1351.008, a group health benefit plan must provide coverage for

home health services provided by a home health agency.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.006. REIMBURSEMENT FOR HOME HEALTH SERVICES: PHYSICIAN

CERTIFICATION REQUIRED. A group health benefit plan issuer may

not provide reimbursement for home health services provided under

the plan unless the attending physician certifies that

hospitalization or confinement in a skilled facility would be

required if a treatment plan for home health care were not

provided.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.007. LIMITATIONS AND EXCLUSIONS ON COVERAGE PERMITTED.

(a) A group health benefit plan may include:

(1) a limitation on the number of visits for home health

services for which benefits are payable, subject to Subsection

(b);

(2) an exclusion for home health services coverage for:

(A) custodial care;

(B) services provided by an individual who:

(i) resides in the covered individual's home; or

(ii) is a member of the covered individual's family; or

(C) services provided to a covered individual who is eligible

for Medicare coverage;

(3) annual deductible and coinsurance provisions for home health

services coverage that are not less favorable than the deductible

or coinsurance provisions applicable to hospital services

coverage under the plan; and

(4) other coverage limitations or exclusions consistent with the

remaining provisions of the plan.

(b) A limitation under Subsection (a)(1) may not limit each

individual covered under the plan to fewer than 60 visits in any

calendar year or continuous 12-month period.

(c) For purposes of this section, each of the following is

considered to be one visit for home health services:

(1) a visit by a representative of a home health agency;

(2) four hours of home health aide service; and

(3) if home health aide service extends beyond four hours, each

additional four hours or portion of that four-hour period.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.008. REJECTION OF COVERAGE BY PLAN HOLDER; NEGOTIATION

OF ALTERNATIVE COVERAGE. (a) If the holder of a group health

benefit plan rejects in writing the coverage required under this

chapter, the plan issuer:

(1) may not include the coverage in the plan; and

(2) is not required to:

(A) offer the coverage to the plan holder; or

(B) provide the coverage under the plan.

(b) If a plan holder rejects in writing the coverage required

under this chapter, the plan holder and the plan issuer may

negotiate coverage for home health services other than the

coverage required under this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.009. ADDITIONAL COVERAGE NOT PRECLUDED. This chapter

does not preclude a group health benefit plan issuer from

providing coverage for home health services that exceeds the

coverage required under this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1351-home-health-services

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1351. HOME HEALTH SERVICES

Sec. 1351.001. DEFINITIONS. In this chapter:

(1) "Health services" includes:

(A) skilled nursing by a registered nurse or a licensed

vocational nurse under the supervision of at least one registered

nurse and at least one physician;

(B) physical, occupational, speech, or respiratory therapy;

(C) the services of a home health aide under the supervision of

a registered nurse; and

(D) the furnishing of medical equipment and supplies other than

drugs or medicines.

(2) "Home health agency" means a business that:

(A) provides home health services; and

(B) is licensed by the Texas Department of Human Services under

Chapter 142, Health and Safety Code.

(3) "Home health services" means the provision of health

services for payment or other consideration in a patient's

residence under a plan of care that is:

(A) established, approved in writing, and reviewed at least

every two months by the attending physician; and

(B) certified by the attending physician as necessary for

medical purposes.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.002. APPLICABILITY OF CHAPTER. (a) This chapter

applies to a group health benefit plan that is delivered or

issued for delivery in this state and that is a group policy of

accident and health insurance, including a policy issued by a

group hospital service corporation operating under Chapter 842.

(b) This chapter applies to an accident and health insurance

policy issued by a stipulated premium company subject to Chapter

884.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.003. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.

The provisions of Chapter 1201, including provisions relating to

the applicability, purpose, and enforcement of that chapter, the

construction of policies under that chapter, rulemaking under

that chapter, and definitions of terms applicable in that

chapter, apply to this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.004. EXCEPTION. This chapter does not apply to:

(1) a group policy of accident and health insurance that

provides coverage only for:

(A) a specified disease or diseases;

(B) vision care;

(C) dental care;

(D) hospital indemnity;

(E) prescription drugs; or

(F) other limited benefits;

(2) a blanket insurance policy, as described by Chapter 1251;

(3) a short-term travel insurance policy;

(4) an accident-only insurance policy;

(5) a hospital indemnity insurance policy;

(6) a limited or specified disease insurance policy;

(7) an insurance policy or contract issued under a right of

conversion; or

(8) an insurance policy or contract designed for issuance to a

person eligible for Medicare coverage.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.005. COVERAGE REQUIRED. Except as provided by Section

1351.008, a group health benefit plan must provide coverage for

home health services provided by a home health agency.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.006. REIMBURSEMENT FOR HOME HEALTH SERVICES: PHYSICIAN

CERTIFICATION REQUIRED. A group health benefit plan issuer may

not provide reimbursement for home health services provided under

the plan unless the attending physician certifies that

hospitalization or confinement in a skilled facility would be

required if a treatment plan for home health care were not

provided.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.007. LIMITATIONS AND EXCLUSIONS ON COVERAGE PERMITTED.

(a) A group health benefit plan may include:

(1) a limitation on the number of visits for home health

services for which benefits are payable, subject to Subsection

(b);

(2) an exclusion for home health services coverage for:

(A) custodial care;

(B) services provided by an individual who:

(i) resides in the covered individual's home; or

(ii) is a member of the covered individual's family; or

(C) services provided to a covered individual who is eligible

for Medicare coverage;

(3) annual deductible and coinsurance provisions for home health

services coverage that are not less favorable than the deductible

or coinsurance provisions applicable to hospital services

coverage under the plan; and

(4) other coverage limitations or exclusions consistent with the

remaining provisions of the plan.

(b) A limitation under Subsection (a)(1) may not limit each

individual covered under the plan to fewer than 60 visits in any

calendar year or continuous 12-month period.

(c) For purposes of this section, each of the following is

considered to be one visit for home health services:

(1) a visit by a representative of a home health agency;

(2) four hours of home health aide service; and

(3) if home health aide service extends beyond four hours, each

additional four hours or portion of that four-hour period.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.008. REJECTION OF COVERAGE BY PLAN HOLDER; NEGOTIATION

OF ALTERNATIVE COVERAGE. (a) If the holder of a group health

benefit plan rejects in writing the coverage required under this

chapter, the plan issuer:

(1) may not include the coverage in the plan; and

(2) is not required to:

(A) offer the coverage to the plan holder; or

(B) provide the coverage under the plan.

(b) If a plan holder rejects in writing the coverage required

under this chapter, the plan holder and the plan issuer may

negotiate coverage for home health services other than the

coverage required under this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.009. ADDITIONAL COVERAGE NOT PRECLUDED. This chapter

does not preclude a group health benefit plan issuer from

providing coverage for home health services that exceeds the

coverage required under this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.


State Codes and Statutes


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State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1351-home-health-services

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1351. HOME HEALTH SERVICES

Sec. 1351.001. DEFINITIONS. In this chapter:

(1) "Health services" includes:

(A) skilled nursing by a registered nurse or a licensed

vocational nurse under the supervision of at least one registered

nurse and at least one physician;

(B) physical, occupational, speech, or respiratory therapy;

(C) the services of a home health aide under the supervision of

a registered nurse; and

(D) the furnishing of medical equipment and supplies other than

drugs or medicines.

(2) "Home health agency" means a business that:

(A) provides home health services; and

(B) is licensed by the Texas Department of Human Services under

Chapter 142, Health and Safety Code.

(3) "Home health services" means the provision of health

services for payment or other consideration in a patient's

residence under a plan of care that is:

(A) established, approved in writing, and reviewed at least

every two months by the attending physician; and

(B) certified by the attending physician as necessary for

medical purposes.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.002. APPLICABILITY OF CHAPTER. (a) This chapter

applies to a group health benefit plan that is delivered or

issued for delivery in this state and that is a group policy of

accident and health insurance, including a policy issued by a

group hospital service corporation operating under Chapter 842.

(b) This chapter applies to an accident and health insurance

policy issued by a stipulated premium company subject to Chapter

884.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.003. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.

The provisions of Chapter 1201, including provisions relating to

the applicability, purpose, and enforcement of that chapter, the

construction of policies under that chapter, rulemaking under

that chapter, and definitions of terms applicable in that

chapter, apply to this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.004. EXCEPTION. This chapter does not apply to:

(1) a group policy of accident and health insurance that

provides coverage only for:

(A) a specified disease or diseases;

(B) vision care;

(C) dental care;

(D) hospital indemnity;

(E) prescription drugs; or

(F) other limited benefits;

(2) a blanket insurance policy, as described by Chapter 1251;

(3) a short-term travel insurance policy;

(4) an accident-only insurance policy;

(5) a hospital indemnity insurance policy;

(6) a limited or specified disease insurance policy;

(7) an insurance policy or contract issued under a right of

conversion; or

(8) an insurance policy or contract designed for issuance to a

person eligible for Medicare coverage.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.005. COVERAGE REQUIRED. Except as provided by Section

1351.008, a group health benefit plan must provide coverage for

home health services provided by a home health agency.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.006. REIMBURSEMENT FOR HOME HEALTH SERVICES: PHYSICIAN

CERTIFICATION REQUIRED. A group health benefit plan issuer may

not provide reimbursement for home health services provided under

the plan unless the attending physician certifies that

hospitalization or confinement in a skilled facility would be

required if a treatment plan for home health care were not

provided.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.007. LIMITATIONS AND EXCLUSIONS ON COVERAGE PERMITTED.

(a) A group health benefit plan may include:

(1) a limitation on the number of visits for home health

services for which benefits are payable, subject to Subsection

(b);

(2) an exclusion for home health services coverage for:

(A) custodial care;

(B) services provided by an individual who:

(i) resides in the covered individual's home; or

(ii) is a member of the covered individual's family; or

(C) services provided to a covered individual who is eligible

for Medicare coverage;

(3) annual deductible and coinsurance provisions for home health

services coverage that are not less favorable than the deductible

or coinsurance provisions applicable to hospital services

coverage under the plan; and

(4) other coverage limitations or exclusions consistent with the

remaining provisions of the plan.

(b) A limitation under Subsection (a)(1) may not limit each

individual covered under the plan to fewer than 60 visits in any

calendar year or continuous 12-month period.

(c) For purposes of this section, each of the following is

considered to be one visit for home health services:

(1) a visit by a representative of a home health agency;

(2) four hours of home health aide service; and

(3) if home health aide service extends beyond four hours, each

additional four hours or portion of that four-hour period.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.008. REJECTION OF COVERAGE BY PLAN HOLDER; NEGOTIATION

OF ALTERNATIVE COVERAGE. (a) If the holder of a group health

benefit plan rejects in writing the coverage required under this

chapter, the plan issuer:

(1) may not include the coverage in the plan; and

(2) is not required to:

(A) offer the coverage to the plan holder; or

(B) provide the coverage under the plan.

(b) If a plan holder rejects in writing the coverage required

under this chapter, the plan holder and the plan issuer may

negotiate coverage for home health services other than the

coverage required under this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1351.009. ADDITIONAL COVERAGE NOT PRECLUDED. This chapter

does not preclude a group health benefit plan issuer from

providing coverage for home health services that exceeds the

coverage required under this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.


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