CHAPTER 1355. BENEFITS FOR CERTAIN MENTAL DISORDERS

State Codes and Statutes

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INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1355. BENEFITS FOR CERTAIN MENTAL DISORDERS

SUBCHAPTER A. GROUP HEALTH BENEFIT PLAN COVERAGE

FOR CERTAIN SERIOUS MENTAL ILLNESSES AND OTHER DISORDERS

Sec. 1355.001. DEFINITIONS. In this subchapter:

(1) "Serious mental illness" means the following psychiatric

illnesses as defined by the American Psychiatric Association in

the Diagnostic and Statistical Manual (DSM):

(A) bipolar disorders (hypomanic, manic, depressive, and mixed);

(B) depression in childhood and adolescence;

(D) obsessive-compulsive disorders;

(E) paranoid and other psychotic disorders;

(F) schizo-affective disorders (bipolar or depressive); and

(G) schizophrenia.

(2) "Small employer" has the meaning assigned by Section

1501.002.

(3) "Autism spectrum disorder" means a neurobiological disorder

that includes autism, Asperger's syndrome, or Pervasive

Developmental Disorder--Not Otherwise Specified.

(4) "Neurobiological disorder" means an illness of the nervous

system caused by genetic, metabolic, or other biological factors.

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. 7, eff. September 1, 2007.

Sec. 1355.002. APPLICABILITY OF SUBCHAPTER. (a) This

subchapter applies only to a group health benefit plan that

provides benefits for medical or surgical expenses incurred as a

result of a health condition, accident, or sickness, including:

(1) a group insurance policy, group insurance agreement, group

hospital service contract, or group evidence of coverage that is

offered by:

(A) an insurance company;

(B) a group hospital service corporation operating under Chapter

842;

(D) a stipulated premium company operating under Chapter 884; or

(E) a health maintenance organization operating under Chapter

843; and

(2) to the extent permitted by the Employee Retirement Income

Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a plan

offered under:

(A) a multiple employer welfare arrangement as defined by

Section 3 of that Act; or

(B) another analogous benefit arrangement.

(b) Notwithstanding any provision in Chapter 1575 or 1579 or any

other law, Section 1355.015 applies to:

(1) a basic plan under Chapter 1575; and

(2) a primary care coverage plan under Chapter 1579.

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

2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1107, Sec. 1, eff. September 1, 2009.

Sec. 1355.003. EXCEPTION. (a) This subchapter does not apply

to coverage under:

(1) a blanket accident and health insurance policy, as described

by Chapter 1251;

(2) a short-term travel policy;

(3) an accident-only policy;

(4) a limited or specified-disease policy that does not provide

benefits for mental health care or similar services;

(5) except as provided by Subsection (b), a plan offered under

Chapter 1551 or Chapter 1601;

(6) a plan offered in accordance with Section 1355.151; or

(7) a Medicare supplement benefit plan, as defined by Section

1652.002.

(b) For the purposes of a plan described by Subsection (a)(5),

"serious mental illness" has the meaning assigned by Section

1355.001.

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

2005.

Sec. 1355.004. REQUIRED COVERAGE FOR SERIOUS MENTAL ILLNESS.

(a) A group health benefit plan:

(1) must provide coverage, based on medical necessity, for not

less than the following treatments of serious mental illness in

each calendar year:

(A) 45 days of inpatient treatment; and

(B) 60 visits for outpatient treatment, including group and

individual outpatient treatment;

(2) may not include a lifetime limitation on the number of days

of inpatient treatment or the number of visits for outpatient

treatment covered under the plan; and

(3) must include the same amount limitations, deductibles,

copayments, and coinsurance factors for serious mental illness as

the plan includes for physical illness.

(b) A group health benefit plan issuer:

(1) may not count an outpatient visit for medication management

against the number of outpatient visits required to be covered

under Subsection (a)(1)(B); and

(2) must provide coverage for an outpatient visit described by

Subsection (a)(1)(B) under the same terms as the coverage the

issuer provides for an outpatient visit for the treatment of

physical illness.

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

2005.

Sec. 1355.005. MANAGED CARE PLAN AUTHORIZED. A group health

benefit plan issuer may provide or offer coverage required by

Section 1355.004 through a managed care plan.

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

2005.

Sec. 1355.006. COVERAGE FOR CERTAIN CONDITIONS RELATED TO

CONTROLLED SUBSTANCE OR MARIHUANA NOT REQUIRED. (a) In this

section, "controlled substance" and "marihuana" have the meanings

assigned by Section 481.002, Health and Safety Code.

(b) This subchapter does not require a group health benefit plan

to provide coverage for the treatment of:

(1) addiction to a controlled substance or marihuana that is

used in violation of law; or

(2) mental illness that results from the use of a controlled

substance or marihuana in violation of law.

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

2005.

Sec. 1355.007. SMALL EMPLOYER COVERAGE. An issuer of a group

health benefit plan to a small employer must offer the coverage

described by Section 1355.004 to the employer but is not required

to provide the coverage if the employer rejects the coverage.

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

2005.

Sec. 1355.015. REQUIRED COVERAGE FOR CERTAIN CHILDREN. (a) At

a minimum, a health benefit plan must provide coverage as

provided by this section to an enrollee who is diagnosed with

autism spectrum disorder from the date of diagnosis until the

enrollee completes nine years of age. If an enrollee who is

being treated for autism spectrum disorder becomes 10 years of

age or older and continues to need treatment, this subsection

does not preclude coverage of treatment and services described by

Subsection (b).

(b) The health benefit plan must provide coverage under this

section to the enrollee for all generally recognized services

prescribed in relation to autism spectrum disorder by the

enrollee's primary care physician in the treatment plan

recommended by that physician. An individual providing treatment

prescribed under this subsection must be a health care

practitioner:

(1) who is licensed, certified, or registered by an appropriate

agency of this state;

(2) whose professional credential is recognized and accepted by

an appropriate agency of the United States; or

(3) who is certified as a provider under the TRICARE military

health system.

services" may include services such as:

(1) evaluation and assessment services;

(2) applied behavior analysis;

(3) behavior training and behavior management;

(4) speech therapy;

(5) occupational therapy;

(6) physical therapy; or

(7) medications or nutritional supplements used to address

symptoms of autism spectrum disorder.

(d) Coverage under Subsection (b) may be subject to annual

deductibles, copayments, and coinsurance that are consistent with

annual deductibles, copayments, and coinsurance required for

other coverage under the health benefit plan.

(e) Notwithstanding any other law, this section does not apply

to a standard health benefit plan provided under Chapter 1507.

Added by Acts 2007, 80th Leg., R.S., Ch.

877, Sec. 8, eff. September 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1107, Sec. 2, eff. September 1, 2009.

SUBCHAPTER B. ALTERNATIVE MENTAL HEALTH TREATMENT BENEFITS

Sec. 1355.051. DEFINITIONS. In this subchapter:

(1) "Crisis stabilization unit" means a 24-hour residential

program that provides, usually for a short term, intensive

supervision and highly structured activities to individuals who

demonstrate a moderate to severe acute psychiatric crisis.

(2) "Individual treatment plan" means a treatment plan with

specific attainable goals and objectives that are appropriate to:

(A) the patient; and

(B) the program's treatment modality.

(3) "Residential treatment center for children and adolescents"

means a child-care institution that:

(A) is accredited as a residential treatment center by:

(i) the Council on Accreditation;

(ii) the Joint Commission on Accreditation of Healthcare

Organizations; or

(iii) the American Association of Psychiatric Services for

Children; and

(B) provides residential care and treatment for emotionally

disturbed children and adolescents.

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

2005.

Sec. 1355.052. APPLICABILITY OF SUBCHAPTER. This subchapter

applies to a group health benefit plan that is delivered or

issued for delivery in this state and that is:

(1) an accident and health insurance group policy;

(2) a group policy issued by a group hospital service

corporation operating under Chapter 842; or

(3) a group health care plan provided by a health maintenance

organization operating under Chapter 843.

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

2005.

Sec. 1355.053. REQUIRED COVERAGE FOR CERTAIN ILLNESSES AND

DISORDERS. A group health benefit plan that provides coverage

for treatment of mental or emotional illness or disorder for a

covered individual when the individual is confined in a hospital

must also provide coverage for treatment in a residential

treatment center for children and adolescents or a crisis

stabilization unit that is at least as favorable as the coverage

the plan provides for treatment of mental or emotional illness or

disorder in a hospital.

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

2005.

Sec. 1355.054. CONDITIONS FOR COVERAGE. (a) Benefits of

coverage provided under this subchapter may be used only in a

situation in which:

(1) the covered individual has a serious mental illness that

requires confinement of the individual in a hospital unless

treatment is available through a residential treatment center for

children and adolescents or a crisis stabilization unit; and

(2) the covered individual's mental illness:

(A) substantially impairs the individual's thought, perception

of reality, emotional process, or judgment; or

(B) as manifested by the individual's recent disturbed behavior,

grossly impairs the individual's behavior.

(b) The service for which benefits are to be paid from coverage

provided under this subchapter must be:

(1) based on an individual treatment plan for the covered

individual; and

(2) provided by a service provider licensed or operated by the

appropriate state agency to provide those services.

subject to the same benefit maximums, durational limitations,

deductibles, and coinsurance factors that apply to inpatient

psychiatric treatment under the coverage.

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

2005.

Sec. 1355.055. DETERMINATIONS FOR TREATMENT IN A RESIDENTIAL

TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS. (a) Treatment in

a residential treatment center for children and adolescents must

be determined as if necessary care and treatment were inpatient

care and treatment in a hospital.

(b) For the purposes of determining policy benefits and benefit

maximums, each two days of treatment in a residential treatment

center for children and adolescents is the equivalent of one day

of treatment of mental or emotional illness or disorder in a

hospital or inpatient program.

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

2005.

Sec. 1355.056. DETERMINATIONS FOR TREATMENT BY A CRISIS

STABILIZATION UNIT. (a) Treatment by a crisis stabilization

unit must be determined as if necessary care and treatment were

inpatient care and treatment in a hospital.

(b) For the purposes of determining plan benefits and benefit

maximums, each two days of treatment in a crisis stabilization

unit is the equivalent of one day of treatment of mental or

emotional illness or disorder in a hospital or inpatient program.

stabilization unit licensed or certified by the Texas Department

of Mental Health and Mental Retardation shall be reimbursed.

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

2005.

Sec. 1355.057. REVIEW AND ADJUSTMENT OF MINIMUM RATIOS OF

REIMBURSEMENT. (a) The commissioner shall monitor and review

the minimum ratios of reimbursement for alternative treatments

required by Sections 1355.055 and 1355.056.

(b) If the commissioner finds that the limits provided by this

subchapter are creating an artificial increase in the costs of

services, the commissioner by rule may adjust the ratios to the

extent necessary to prevent the artificial increase.

(b), the commissioner must give notice and hold a hearing to:

(1) consider information related to the adjustment; and

(2) determine whether the information justifies the adjustment.

(d) The department shall review the reimbursement ratios at

least every two years.

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

2005.

Sec. 1355.058. ASSISTANCE OF THE TEXAS DEPARTMENT OF MENTAL

HEALTH AND MENTAL RETARDATION. (a) The Texas Department of

Mental Health and Mental Retardation shall assist the department

in carrying out the department's responsibilities under this

subchapter.

(b) The department and the Texas Department of Mental Health and

Mental Retardation by rule may adopt a memorandum of

understanding to carry out this subchapter.

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

2005.

SUBCHAPTER C. PSYCHIATRIC DAY TREATMENT FACILITIES

Sec. 1355.101. DEFINITION. In this subchapter, "psychiatric day

treatment facility" means a mental health facility that:

(1) provides treatment for individuals suffering from acute

mental and nervous disorders in a structured psychiatric program

using individualized treatment plans with specific attainable

goals and objectives that are appropriate to the patient and the

program's treatment modality; and

(2) is clinically supervised by a doctor of medicine who is

certified in psychiatry by the American Board of Psychiatry and

Neurology.

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

2005.

Sec. 1355.102. APPLICABILITY OF SUBCHAPTER. This subchapter

applies to a group policy of accident and health insurance

delivered or issued for delivery in this state, including a group

policy issued by a group hospital service corporation operating

under Chapter 842.

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

2005.

Sec. 1355.103. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.

The provisions of Chapter 1201, including provisions relating to

the applicability, purpose, and enforcement of that chapter,

construction of policies under that chapter, rulemaking under

that chapter, and definitions of terms applicable in that

chapter, apply to this subchapter.

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

2005.

Sec. 1355.104. REQUIRED COVERAGE FOR TREATMENT IN PSYCHIATRIC

DAY TREATMENT FACILITY. (a) A group insurance policy that

provides coverage for treatment of mental or emotional illness or

disorder when an individual is confined in a hospital must also

provide coverage for treatment obtained under the direction and

continued medical supervision of a doctor of medicine or doctor

of osteopathy in a psychiatric day treatment facility that

provides organizational structure and individualized treatment

plans separate from an inpatient program.

(b) The psychiatric day treatment facility coverage required by

this section may not be less favorable than the hospital coverage

and must be subject to the same durational limits, deductibles,

and coinsurance factors.

that:

(1) the treatment obtained in a psychiatric day treatment

facility be provided by a facility that treats a patient for not

more than 8 hours in any 24-hour period;

(2) the attending physician certify that the treatment is in

lieu of hospitalization; and

(3) the psychiatric day treatment facility be accredited by the

Program for Psychiatric Facilities, or its successor, of the

Joint Commission on Accreditation of Healthcare Organizations.

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

2005.

Sec. 1355.105. DETERMINATIONS FOR TREATMENT IN PSYCHIATRIC DAY

TREATMENT FACILITY. (a) Benefits provided under this subchapter

shall be determined as if necessary care and treatment in a

psychiatric day treatment facility were inpatient care and

treatment in a hospital.

(b) For the purpose of determining policy benefits and benefit

maximums, each full day of treatment in a psychiatric day

treatment facility is the equivalent of one-half of one day of

treatment of mental or emotional illness or disorder in a

hospital or inpatient program.

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

2005.

Sec. 1355.106. OFFER OF COVERAGE REQUIRED; ALTERNATIVE BENEFITS.

(a) An insurer shall offer, and a policyholder is entitled to

reject, coverage under a group insurance policy for treatment of

mental or emotional illness or disorder when confined in a

hospital or in a psychiatric day treatment facility.

(b) A policyholder may select an alternative level of benefits

under the group insurance policy if the alternative level is

offered by or negotiated with the insurer.

benefits and benefit maximums for treatment in a psychiatric day

treatment facility equal to at least one-half of that provided

for treatment in a hospital, except that benefits for treatment

in a psychiatric day treatment facility may not exceed the usual

and customary charges of the facility.

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

2005.

SUBCHAPTER D. CERTAIN COVERAGES PROVIDED BY LOCAL GOVERNMENTS

Sec. 1355.151. PROHIBITION ON EXCLUSION OR LIMITATION OF CERTAIN

COVERAGES. (a) In this section, "serious mental illness" has

the meaning assigned by Section 1355.001.

(b) A political subdivision that provides group health insurance

coverage, health maintenance organization coverage, or

self-insured health care coverage to the political subdivision's

officers or employees may not contract for or provide coverage

that is less extensive for serious mental illness than the

coverage provided for any other physical illness.

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

2005.

SUBCHAPTER E. BENEFITS FOR TREATMENT BY TAX-SUPPORTED INSTITUTION

Sec. 1355.201. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.

The provisions of Chapter 1201, including provisions relating to

the applicability, purpose, and enforcement of that chapter,

construction of policies under that chapter, rulemaking under

that chapter, and definitions of terms applicable in that

chapter, apply to this subchapter.

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

2005.

Sec. 1355.202. PROHIBITION OF EXCLUSION OF MENTAL HEALTH OR

MENTAL RETARDATION BENEFITS FOR TREATMENT BY TAX-SUPPORTED

INSTITUTION. (a) An individual or group accident and health

insurance policy delivered or issued for delivery to a person in

this state that provides coverage for mental illness or mental

retardation may not exclude benefits under that coverage for

support, maintenance, and treatment provided by a tax-supported

institution of this state, or by a community center for mental

health or mental retardation services, that regularly and

customarily charges patients who are not indigent for those

services.

(b) In determining whether a patient is not indigent, as

provided by Subchapter B, Chapter 552, Health and Safety Code, a

tax-supported institution of this state or a community center for

mental health or mental retardation services shall consider any

insurance policy or policies that provide coverage to the patient

for mental illness or mental retardation.

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

2005.

State Codes and Statutes

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