State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1352-brain-injury
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1352. BRAIN INJURY
Sec. 1352.001. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan, including, subject to this
chapter, a small employer health benefit plan written under
Chapter 1501, that provides benefits for medical or surgical
expenses incurred as a result of a health condition, accident, or
sickness, including an individual, group, blanket, or franchise
insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage or
similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating under Chapter
842;
(3) a fraternal benefit society operating under Chapter 885;
(4) a stipulated premium company operating under Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under Chapter
843;
(8) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844.
(b) Notwithstanding any provision in Chapter 1575, 1579, or 1601
or any other law, this chapter applies to:
(1) a basic plan under Chapter 1575;
(2) a primary care coverage plan under Chapter 1579; and
(3) basic coverage under Chapter 1601.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 1, eff. September 1, 2007.
Sec. 1352.002. EXCEPTION. This chapter does not apply to:
(1) a plan that provides coverage:
(A) only for a specified disease or for another limited benefit
other than an accident policy;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a period during
which an employee is absent from work because of sickness or
injury;
(D) as a supplement to a liability insurance policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by Section
1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as
amended;
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under a motor
vehicle insurance policy; or
(5) a long-term care insurance policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that
the policy provides benefit coverage so comprehensive that the
policy is a health benefit plan as described by Section 1352.001.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1352.003. REQUIRED COVERAGES--HEALTH BENEFIT PLANS OTHER
THAN SMALL EMPLOYER HEALTH BENEFIT PLANS. (a) A health benefit
plan must include coverage for cognitive rehabilitation therapy,
cognitive communication therapy, neurocognitive therapy and
rehabilitation, neurobehavioral, neurophysiological,
neuropsychological, and psychophysiological testing and
treatment, neurofeedback therapy, and remediation required for
and related to treatment of an acquired brain injury.
(b) A health benefit plan must include coverage for post-acute
transition services, community reintegration services, including
outpatient day treatment services, or other post-acute care
treatment services necessary as a result of and related to an
acquired brain injury.
(c) A health benefit plan may not include, in any lifetime
limitation on the number of days of acute care treatment covered
under the plan, any post-acute care treatment covered under the
plan. Any limitation imposed under the plan on days of
post-acute care treatment must be separately stated in the plan.
(d) Except as provided by Subsection (c), a health benefit plan
must include the same payment limitations, deductibles,
copayments, and coinsurance factors for coverage required under
this chapter as applicable to other similar coverage provided
under the health benefit plan.
(e) To ensure that appropriate post-acute care treatment is
provided, a health benefit plan must include coverage for
reasonable expenses related to periodic reevaluation of the care
of an individual covered under the plan who:
(1) has incurred an acquired brain injury;
(2) has been unresponsive to treatment; and
(3) becomes responsive to treatment at a later date.
(f) A determination of whether expenses, as described by
Subsection (e), are reasonable may include consideration of
factors including:
(1) cost;
(2) the time that has expired since the previous evaluation;
(3) any difference in the expertise of the physician or
practitioner performing the evaluation;
(4) changes in technology; and
(5) advances in medicine.
(g) The commissioner shall adopt rules as necessary to implement
this chapter.
(h) This section does not apply to a small employer health
benefit plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 2, eff. September 1, 2007.
Sec. 1352.0035. REQUIRED COVERAGES--SMALL EMPLOYER HEALTH
BENEFIT PLANS. (a) A small employer health benefit plan may not
exclude coverage for cognitive rehabilitation therapy, cognitive
communication therapy, neurocognitive therapy and rehabilitation,
neurobehavioral, neurophysiological, neuropsychological, or
psychophysiological testing or treatment, neurofeedback therapy,
remediation, post-acute transition services, or community
reintegration services necessary as a result of and related to an
acquired brain injury.
(b) Coverage required under this section may be subject to
deductibles, copayments, coinsurance, or annual or maximum
payment limits that are consistent with the deductibles,
copayments, coinsurance, or annual or maximum payment limits
applicable to other similar coverage provided under the small
employer health benefit plan.
(c) The commissioner shall adopt rules as necessary to implement
this section.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 3, eff. September 1, 2007.
Sec. 1352.004. TRAINING FOR CERTAIN PERSONNEL REQUIRED. (a) In
this section, "preauthorization" means the provision of a
reliable representation to a physician or health care provider of
whether a health benefit plan issuer will pay the physician or
provider for proposed medical or health care services if the
physician or provider provides those services to the patient for
whom the services are proposed. The term includes
precertification, certification, recertification, or any other
activity that involves providing a reliable representation by the
issuer to a physician or health care provider.
(b) The commissioner by rule shall require a health benefit plan
issuer to provide adequate training to personnel responsible for
preauthorization of coverage or utilization review under the
plan. The purpose of the training is to prevent denial of
coverage in violation of Section 1352.003 and to avoid confusion
of medical benefits with mental health benefits. The
commissioner, in consultation with the Texas Traumatic Brain
Injury Advisory Council, shall prescribe by rule the basic
requirements for the training described by this subsection.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 4, eff. September 1, 2007.
Sec. 1352.005. NOTICE TO INSUREDS AND ENROLLEES. (a) A health
benefit plan issuer subject to this chapter, other than a small
employer health benefit plan issuer, must annually notify each
insured or enrollee under the plan in writing about the
coverages described by Section 1352.003.
(b) The commissioner, in consultation with the Texas Traumatic
Brain Injury Advisory Council, shall prescribe by rule the
specific contents and wording of the notice required under this
section.
(c) The notice required under this section must include:
(1) a description of the benefits listed under Section 1352.003;
(2) a statement that the fact that an acquired brain injury does
not result in hospitalization or receipt of a specific treatment
or service described by Section 1352.003 for acute care treatment
does not affect the right of the insured or enrollee to receive
benefits described by Section 1352.003 commensurate with the
condition of the insured or enrollee; and
(3) a statement of the fact that benefits described by Section
1352.003 may be provided in a facility listed in Section
1352.007.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
Sec. 1352.006. DETERMINATION OF MEDICAL NECESSITY; EXTENSION OF
COVERAGE. (a) In this section, "utilization review" has the
meaning assigned by Section 4201.002.
(b) Notwithstanding Chapter 4201 or any other law relating to
the determination of medical necessity under this code, a health
benefit plan shall respond to a person requesting utilization
review or appealing for an extension of coverage based on an
allegation of medical necessity not later than three business
days after the date on which the person makes the request or
submits the appeal. The person must make the request or submit
the appeal in the manner prescribed by the terms of the plan's
health insurance policy or agreement, contract, evidence of
coverage, or similar coverage document. To comply with the
requirements of this section, the health benefit plan issuer must
respond through a direct telephone contact made by a
representative of the issuer. This subsection does not apply to
a small employer health benefit plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
Sec. 1352.007. TREATMENT FACILITIES. (a) A health benefit plan
may not deny coverage under this chapter based solely on the fact
that the treatment or services are provided at a facility other
than a hospital. Treatment for an acquired brain injury may be
provided under the coverage required by this chapter, as
appropriate, at a facility at which appropriate services may be
provided, including:
(1) a hospital regulated under Chapter 241, Health and Safety
Code, including an acute or post-acute rehabilitation hospital;
and
(2) an assisted living facility regulated under Chapter 247,
Health and Safety Code.
(b) This section does not apply to a small employer health
benefit plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
Sec. 1352.008. CONSUMER INFORMATION. The commissioner shall
prepare information for use by consumers, purchasers of health
benefit plan coverage, and self-insurers regarding coverages
recommended for acquired brain injuries. The department shall
publish information prepared under this section on the
department's Internet website.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1352-brain-injury
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1352. BRAIN INJURY
Sec. 1352.001. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan, including, subject to this
chapter, a small employer health benefit plan written under
Chapter 1501, that provides benefits for medical or surgical
expenses incurred as a result of a health condition, accident, or
sickness, including an individual, group, blanket, or franchise
insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage or
similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating under Chapter
842;
(3) a fraternal benefit society operating under Chapter 885;
(4) a stipulated premium company operating under Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under Chapter
843;
(8) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844.
(b) Notwithstanding any provision in Chapter 1575, 1579, or 1601
or any other law, this chapter applies to:
(1) a basic plan under Chapter 1575;
(2) a primary care coverage plan under Chapter 1579; and
(3) basic coverage under Chapter 1601.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 1, eff. September 1, 2007.
Sec. 1352.002. EXCEPTION. This chapter does not apply to:
(1) a plan that provides coverage:
(A) only for a specified disease or for another limited benefit
other than an accident policy;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a period during
which an employee is absent from work because of sickness or
injury;
(D) as a supplement to a liability insurance policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by Section
1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as
amended;
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under a motor
vehicle insurance policy; or
(5) a long-term care insurance policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that
the policy provides benefit coverage so comprehensive that the
policy is a health benefit plan as described by Section 1352.001.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1352.003. REQUIRED COVERAGES--HEALTH BENEFIT PLANS OTHER
THAN SMALL EMPLOYER HEALTH BENEFIT PLANS. (a) A health benefit
plan must include coverage for cognitive rehabilitation therapy,
cognitive communication therapy, neurocognitive therapy and
rehabilitation, neurobehavioral, neurophysiological,
neuropsychological, and psychophysiological testing and
treatment, neurofeedback therapy, and remediation required for
and related to treatment of an acquired brain injury.
(b) A health benefit plan must include coverage for post-acute
transition services, community reintegration services, including
outpatient day treatment services, or other post-acute care
treatment services necessary as a result of and related to an
acquired brain injury.
(c) A health benefit plan may not include, in any lifetime
limitation on the number of days of acute care treatment covered
under the plan, any post-acute care treatment covered under the
plan. Any limitation imposed under the plan on days of
post-acute care treatment must be separately stated in the plan.
(d) Except as provided by Subsection (c), a health benefit plan
must include the same payment limitations, deductibles,
copayments, and coinsurance factors for coverage required under
this chapter as applicable to other similar coverage provided
under the health benefit plan.
(e) To ensure that appropriate post-acute care treatment is
provided, a health benefit plan must include coverage for
reasonable expenses related to periodic reevaluation of the care
of an individual covered under the plan who:
(1) has incurred an acquired brain injury;
(2) has been unresponsive to treatment; and
(3) becomes responsive to treatment at a later date.
(f) A determination of whether expenses, as described by
Subsection (e), are reasonable may include consideration of
factors including:
(1) cost;
(2) the time that has expired since the previous evaluation;
(3) any difference in the expertise of the physician or
practitioner performing the evaluation;
(4) changes in technology; and
(5) advances in medicine.
(g) The commissioner shall adopt rules as necessary to implement
this chapter.
(h) This section does not apply to a small employer health
benefit plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 2, eff. September 1, 2007.
Sec. 1352.0035. REQUIRED COVERAGES--SMALL EMPLOYER HEALTH
BENEFIT PLANS. (a) A small employer health benefit plan may not
exclude coverage for cognitive rehabilitation therapy, cognitive
communication therapy, neurocognitive therapy and rehabilitation,
neurobehavioral, neurophysiological, neuropsychological, or
psychophysiological testing or treatment, neurofeedback therapy,
remediation, post-acute transition services, or community
reintegration services necessary as a result of and related to an
acquired brain injury.
(b) Coverage required under this section may be subject to
deductibles, copayments, coinsurance, or annual or maximum
payment limits that are consistent with the deductibles,
copayments, coinsurance, or annual or maximum payment limits
applicable to other similar coverage provided under the small
employer health benefit plan.
(c) The commissioner shall adopt rules as necessary to implement
this section.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 3, eff. September 1, 2007.
Sec. 1352.004. TRAINING FOR CERTAIN PERSONNEL REQUIRED. (a) In
this section, "preauthorization" means the provision of a
reliable representation to a physician or health care provider of
whether a health benefit plan issuer will pay the physician or
provider for proposed medical or health care services if the
physician or provider provides those services to the patient for
whom the services are proposed. The term includes
precertification, certification, recertification, or any other
activity that involves providing a reliable representation by the
issuer to a physician or health care provider.
(b) The commissioner by rule shall require a health benefit plan
issuer to provide adequate training to personnel responsible for
preauthorization of coverage or utilization review under the
plan. The purpose of the training is to prevent denial of
coverage in violation of Section 1352.003 and to avoid confusion
of medical benefits with mental health benefits. The
commissioner, in consultation with the Texas Traumatic Brain
Injury Advisory Council, shall prescribe by rule the basic
requirements for the training described by this subsection.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 4, eff. September 1, 2007.
Sec. 1352.005. NOTICE TO INSUREDS AND ENROLLEES. (a) A health
benefit plan issuer subject to this chapter, other than a small
employer health benefit plan issuer, must annually notify each
insured or enrollee under the plan in writing about the
coverages described by Section 1352.003.
(b) The commissioner, in consultation with the Texas Traumatic
Brain Injury Advisory Council, shall prescribe by rule the
specific contents and wording of the notice required under this
section.
(c) The notice required under this section must include:
(1) a description of the benefits listed under Section 1352.003;
(2) a statement that the fact that an acquired brain injury does
not result in hospitalization or receipt of a specific treatment
or service described by Section 1352.003 for acute care treatment
does not affect the right of the insured or enrollee to receive
benefits described by Section 1352.003 commensurate with the
condition of the insured or enrollee; and
(3) a statement of the fact that benefits described by Section
1352.003 may be provided in a facility listed in Section
1352.007.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
Sec. 1352.006. DETERMINATION OF MEDICAL NECESSITY; EXTENSION OF
COVERAGE. (a) In this section, "utilization review" has the
meaning assigned by Section 4201.002.
(b) Notwithstanding Chapter 4201 or any other law relating to
the determination of medical necessity under this code, a health
benefit plan shall respond to a person requesting utilization
review or appealing for an extension of coverage based on an
allegation of medical necessity not later than three business
days after the date on which the person makes the request or
submits the appeal. The person must make the request or submit
the appeal in the manner prescribed by the terms of the plan's
health insurance policy or agreement, contract, evidence of
coverage, or similar coverage document. To comply with the
requirements of this section, the health benefit plan issuer must
respond through a direct telephone contact made by a
representative of the issuer. This subsection does not apply to
a small employer health benefit plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
Sec. 1352.007. TREATMENT FACILITIES. (a) A health benefit plan
may not deny coverage under this chapter based solely on the fact
that the treatment or services are provided at a facility other
than a hospital. Treatment for an acquired brain injury may be
provided under the coverage required by this chapter, as
appropriate, at a facility at which appropriate services may be
provided, including:
(1) a hospital regulated under Chapter 241, Health and Safety
Code, including an acute or post-acute rehabilitation hospital;
and
(2) an assisted living facility regulated under Chapter 247,
Health and Safety Code.
(b) This section does not apply to a small employer health
benefit plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
Sec. 1352.008. CONSUMER INFORMATION. The commissioner shall
prepare information for use by consumers, purchasers of health
benefit plan coverage, and self-insurers regarding coverages
recommended for acquired brain injuries. The department shall
publish information prepared under this section on the
department's Internet website.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
State Codes and Statutes
Statutes >
Texas >
Insurance-code >
Title-8-health-insurance-and-other-health-coverages >
Chapter-1352-brain-injury INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1352. BRAIN INJURY
Sec. 1352.001. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan, including, subject to this
chapter, a small employer health benefit plan written under
Chapter 1501, that provides benefits for medical or surgical
expenses incurred as a result of a health condition, accident, or
sickness, including an individual, group, blanket, or franchise
insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage or
similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating under Chapter
842;
(3) a fraternal benefit society operating under Chapter 885;
(4) a stipulated premium company operating under Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under Chapter
843;
(8) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844.
(b) Notwithstanding any provision in Chapter 1575, 1579, or 1601
or any other law, this chapter applies to:
(1) a basic plan under Chapter 1575;
(2) a primary care coverage plan under Chapter 1579; and
(3) basic coverage under Chapter 1601.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 1, eff. September 1, 2007.
Sec. 1352.002. EXCEPTION. This chapter does not apply to:
(1) a plan that provides coverage:
(A) only for a specified disease or for another limited benefit
other than an accident policy;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a period during
which an employee is absent from work because of sickness or
injury;
(D) as a supplement to a liability insurance policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by Section
1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as
amended;
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under a motor
vehicle insurance policy; or
(5) a long-term care insurance policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that
the policy provides benefit coverage so comprehensive that the
policy is a health benefit plan as described by Section 1352.001.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1352.003. REQUIRED COVERAGES--HEALTH BENEFIT PLANS OTHER
THAN SMALL EMPLOYER HEALTH BENEFIT PLANS. (a) A health benefit
plan must include coverage for cognitive rehabilitation therapy,
cognitive communication therapy, neurocognitive therapy and
rehabilitation, neurobehavioral, neurophysiological,
neuropsychological, and psychophysiological testing and
treatment, neurofeedback therapy, and remediation required for
and related to treatment of an acquired brain injury.
(b) A health benefit plan must include coverage for post-acute
transition services, community reintegration services, including
outpatient day treatment services, or other post-acute care
treatment services necessary as a result of and related to an
acquired brain injury.
(c) A health benefit plan may not include, in any lifetime
limitation on the number of days of acute care treatment covered
under the plan, any post-acute care treatment covered under the
plan. Any limitation imposed under the plan on days of
post-acute care treatment must be separately stated in the plan.
(d) Except as provided by Subsection (c), a health benefit plan
must include the same payment limitations, deductibles,
copayments, and coinsurance factors for coverage required under
this chapter as applicable to other similar coverage provided
under the health benefit plan.
(e) To ensure that appropriate post-acute care treatment is
provided, a health benefit plan must include coverage for
reasonable expenses related to periodic reevaluation of the care
of an individual covered under the plan who:
(1) has incurred an acquired brain injury;
(2) has been unresponsive to treatment; and
(3) becomes responsive to treatment at a later date.
(f) A determination of whether expenses, as described by
Subsection (e), are reasonable may include consideration of
factors including:
(1) cost;
(2) the time that has expired since the previous evaluation;
(3) any difference in the expertise of the physician or
practitioner performing the evaluation;
(4) changes in technology; and
(5) advances in medicine.
(g) The commissioner shall adopt rules as necessary to implement
this chapter.
(h) This section does not apply to a small employer health
benefit plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 2, eff. September 1, 2007.
Sec. 1352.0035. REQUIRED COVERAGES--SMALL EMPLOYER HEALTH
BENEFIT PLANS. (a) A small employer health benefit plan may not
exclude coverage for cognitive rehabilitation therapy, cognitive
communication therapy, neurocognitive therapy and rehabilitation,
neurobehavioral, neurophysiological, neuropsychological, or
psychophysiological testing or treatment, neurofeedback therapy,
remediation, post-acute transition services, or community
reintegration services necessary as a result of and related to an
acquired brain injury.
(b) Coverage required under this section may be subject to
deductibles, copayments, coinsurance, or annual or maximum
payment limits that are consistent with the deductibles,
copayments, coinsurance, or annual or maximum payment limits
applicable to other similar coverage provided under the small
employer health benefit plan.
(c) The commissioner shall adopt rules as necessary to implement
this section.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 3, eff. September 1, 2007.
Sec. 1352.004. TRAINING FOR CERTAIN PERSONNEL REQUIRED. (a) In
this section, "preauthorization" means the provision of a
reliable representation to a physician or health care provider of
whether a health benefit plan issuer will pay the physician or
provider for proposed medical or health care services if the
physician or provider provides those services to the patient for
whom the services are proposed. The term includes
precertification, certification, recertification, or any other
activity that involves providing a reliable representation by the
issuer to a physician or health care provider.
(b) The commissioner by rule shall require a health benefit plan
issuer to provide adequate training to personnel responsible for
preauthorization of coverage or utilization review under the
plan. The purpose of the training is to prevent denial of
coverage in violation of Section 1352.003 and to avoid confusion
of medical benefits with mental health benefits. The
commissioner, in consultation with the Texas Traumatic Brain
Injury Advisory Council, shall prescribe by rule the basic
requirements for the training described by this subsection.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 4, eff. September 1, 2007.
Sec. 1352.005. NOTICE TO INSUREDS AND ENROLLEES. (a) A health
benefit plan issuer subject to this chapter, other than a small
employer health benefit plan issuer, must annually notify each
insured or enrollee under the plan in writing about the
coverages described by Section 1352.003.
(b) The commissioner, in consultation with the Texas Traumatic
Brain Injury Advisory Council, shall prescribe by rule the
specific contents and wording of the notice required under this
section.
(c) The notice required under this section must include:
(1) a description of the benefits listed under Section 1352.003;
(2) a statement that the fact that an acquired brain injury does
not result in hospitalization or receipt of a specific treatment
or service described by Section 1352.003 for acute care treatment
does not affect the right of the insured or enrollee to receive
benefits described by Section 1352.003 commensurate with the
condition of the insured or enrollee; and
(3) a statement of the fact that benefits described by Section
1352.003 may be provided in a facility listed in Section
1352.007.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
Sec. 1352.006. DETERMINATION OF MEDICAL NECESSITY; EXTENSION OF
COVERAGE. (a) In this section, "utilization review" has the
meaning assigned by Section 4201.002.
(b) Notwithstanding Chapter 4201 or any other law relating to
the determination of medical necessity under this code, a health
benefit plan shall respond to a person requesting utilization
review or appealing for an extension of coverage based on an
allegation of medical necessity not later than three business
days after the date on which the person makes the request or
submits the appeal. The person must make the request or submit
the appeal in the manner prescribed by the terms of the plan's
health insurance policy or agreement, contract, evidence of
coverage, or similar coverage document. To comply with the
requirements of this section, the health benefit plan issuer must
respond through a direct telephone contact made by a
representative of the issuer. This subsection does not apply to
a small employer health benefit plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
Sec. 1352.007. TREATMENT FACILITIES. (a) A health benefit plan
may not deny coverage under this chapter based solely on the fact
that the treatment or services are provided at a facility other
than a hospital. Treatment for an acquired brain injury may be
provided under the coverage required by this chapter, as
appropriate, at a facility at which appropriate services may be
provided, including:
(1) a hospital regulated under Chapter 241, Health and Safety
Code, including an acute or post-acute rehabilitation hospital;
and
(2) an assisted living facility regulated under Chapter 247,
Health and Safety Code.
(b) This section does not apply to a small employer health
benefit plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
Sec. 1352.008. CONSUMER INFORMATION. The commissioner shall
prepare information for use by consumers, purchasers of health
benefit plan coverage, and self-insurers regarding coverages
recommended for acquired brain injuries. The department shall
publish information prepared under this section on the
department's Internet website.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 5, eff. September 1, 2007.
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