reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter H. Utilization Review › Section 1305.356. Contested Case Hearing on and Judicial Review of Independent Review

Sec. 1305.356.  CONTESTED CASE HEARING ON AND JUDICIAL REVIEW OF INDEPENDENT REVIEW.  (a)  A party to a medical dispute that remains unresolved after a review under Section 1305.355 is entitled to a contested case hearing.  A hearing under this subsection shall be conducted by the department's division of workers' compensation in the same manner as a hearing conducted under Section 413.0311, Labor Code.
(b)  At a contested case hearing held under Subsection (a), the administrative law judge conducting the hearing shall consider evidence-based treatment guidelines adopted by the network under Section 1305.304.
(c)  A party that has exhausted all administrative remedies under Subsection (a) and is aggrieved by a final decision of the department's division of workers' compensation may seek judicial review of the decision.
(d)  Judicial review under Subsection (c) shall be conducted in the manner provided for judicial review of a contested case under Subchapter G, Chapter 2001, Government Code, and is governed by the substantial evidence rule.
Added by Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 3, eff. September 1, 2011.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 839 (H.B. 2111), Sec. 1, eff. September 1, 2017.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter I. Complaint Resolution › Section 1305.401. Complaint System Required

Sec. 1305.401.  COMPLAINT SYSTEM REQUIRED.  (a)  Each network shall implement and maintain a complaint system that provides reasonable procedures to resolve an oral or written complaint.
(b)  The network may require a complainant to file the complaint not later than the 90th day after the date of the event or occurrence that is the basis for the complaint.
(c)  The complaint system must include a process for the notice and appeal of a complaint.
(d)  The commissioner may adopt rules as necessary to implement this section.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter I. Complaint Resolution › Section 1305.402. Complaint Initiation and Initial Response; Deadlines for Response and Resolution

Sec. 1305.402.  COMPLAINT INITIATION AND INITIAL RESPONSE; DEADLINES FOR RESPONSE AND RESOLUTION.  (a)  If a complainant notifies a network of a complaint, the network, not later than the seventh calendar day after the date the network receives the complaint, shall respond to the complainant, acknowledging the date of receipt of the complaint and providing a description of the network's complaint procedures and deadlines.
(b)  The network shall investigate and resolve a complaint not later than the 30th calendar day after the date the network receives the complaint.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter I. Complaint Resolution › Section 1305.403. Record of Complaints

Sec. 1305.403.  RECORD OF COMPLAINTS.  (a)  Each network shall maintain a complaint and appeal log regarding each complaint.  The commissioner shall adopt rules designating the classification of network complaints under this section.
(b)  Each network shall maintain a record of and documentation on each complaint, complaint proceeding, and action taken on the complaint until the third anniversary of the date the complaint was received.
(c)  A complainant is entitled to a copy of the network's record regarding the complaint and any proceeding relating to that complaint.
(d)  The department, during any investigation or examination of a network, may review documentation maintained under this subchapter, including original documentation, regarding a complaint and action taken on the complaint.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter I. Complaint Resolution › Section 1305.404. Retaliatory Action Prohibited

Sec. 1305.404.  RETALIATORY ACTION PROHIBITED.  A network may not engage in any retaliatory action against an employer or employee because the employer or employee or a person acting on behalf of the employer or employee has filed a complaint against the network.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter I. Complaint Resolution › Section 1305.405. Posting of Information on Complaint Process Required

Sec. 1305.405.  POSTING OF INFORMATION ON COMPLAINT PROCESS REQUIRED.  (a)  A contract between a network and a provider must require the provider to post, in the provider's office, a notice to injured employees on the process for resolving complaints with the network.
(b)  The notice required under Subsection (a) must include the department's toll-free telephone number for filing a complaint.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter K. Evaluation of Networks; Consumer Report Card › Section 1305.502. Consumer Report Cards

Sec. 1305.502.  CONSUMER REPORT CARDS.  (a)  Not later than December 1 of each even-numbered year, the group shall develop and issue an informational report card that identifies and compares, on an objective basis, the quality, costs, health care provider availability, and other analogous factors of workers' compensation health care networks operating under the workers' compensation system of this state with each other and with medical care provided outside of networks.
(b)  The group may procure services as necessary to produce the report card.  The report card must include a risk-adjusted evaluation of:
(1)  employee access to care;
(2)  return-to-work outcomes;
(3)  health-related outcomes;
(4)  employee satisfaction with care; and
(5)  health care costs and utilization of health care.
(c)  The report cards may be based on information or data from any person, agency, organization, or governmental entity that the group considers reliable.  The group may not endorse or recommend a specific workers' compensation health care network or plan, or subjectively rate or rank networks or plans, other than through comparison and evaluation of objective criteria.
(d)  The commissioner shall ensure that consumer report cards issued by the group under this section are accessible to the public on the department's Internet website and available to any person on request.  The commissioner by rule may set a reasonable fee for obtaining a paper copy of report cards.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
Amended by:
Acts 2021, 87th Leg., R.S., Ch. 670 (H.B. 1753), Sec. 1, eff. June 15, 2021.
Acts 2021, 87th Leg., R.S., Ch. 856 (S.B. 800), Sec. 21, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter K. Evaluation of Networks; Consumer Report Card › Section 1305.503. Confidentiality Requirements

Sec. 1305.503.  CONFIDENTIALITY REQUIREMENTS.  (a)  As necessary to implement this subchapter, the department may access information from an executive agency that is otherwise confidential under any law of this state, including the Texas Workers' Compensation Act.
(b)  Confidential information provided to or obtained by the department under this section remains confidential and is not subject to disclosure under Chapter 552, Government Code.  The department may not release, and a person may not gain access to, any information that:
(1)  could reasonably be expected to reveal the identity of an injured employee; or
(2)  discloses provider discounts or differentials between payments and billed charges for individual providers or networks.
(c)  Information that is in the possession of the department and that relates to an individual injured employee, and any compilation, report, or analysis produced from the information that identifies an individual injured employee, are not:
(1)  subject to discovery, subpoena, or other means of legal compulsion for release to any person; or
(2)  admissible in any civil, administrative, or criminal proceeding.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter L. Disciplinary Actions › Section 1305.551. Determination of Violation; Notice

Sec. 1305.551.  DETERMINATION OF VIOLATION; NOTICE.  (a)  If the commissioner determines that a network, insurance carrier, or any other person or third party operating under this chapter, including a third party to which a network delegates a function, or any third party with which a network contracts for management services, is in violation of this chapter, rules adopted by the commissioner under this chapter, or applicable provisions of the Labor Code or rules adopted under that code, the commissioner or a designated representative may notify the network, insurance carrier, person, or third party of the alleged violation and may compel the production of any documents or other information as necessary to determine whether the violation occurred.
(b)  The commissioner's designated representative may initiate the proceedings under this section.
(c)  A proceeding under this section is a contested case under Chapter 2001, Government Code.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1305 - Workers' Compensation Health Care Networks › Subchapter L. Disciplinary Actions › Section 1305.552. Disciplinary Actions

Sec. 1305.552.  DISCIPLINARY ACTIONS.  If under Section 1305.551 the commissioner determines that a network, insurance carrier, or other person or third party described under Section 1305.551 has violated or is violating this chapter, rules adopted by the commissioner under this chapter, or the Labor Code or rules adopted under that code, the commissioner may:
(1)  suspend or revoke a certificate issued under this code;
(2)  impose sanctions under Chapter 82;
(3)  issue a cease and desist order under Chapter 83;
(4)  impose administrative penalties under Chapter 84; or
(5)  take any combination of these actions.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1351 - Home Health Services › Section 1351.001. Definitions

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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1351 - Home Health Services › Section 1351.002. Applicability of Chapter

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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1351 - Home Health Services › Section 1351.003. Applicability of General Provisions of Other Law

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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1351 - Home Health Services › Section 1351.004. Exception

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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1351 - Home Health Services › Section 1351.005. Coverage Required

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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1351 - Home Health Services › Section 1351.006. Reimbursement for Home Health Services: Physician Certification Required

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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1351 - Home Health Services › Section 1351.007. Limitations and Exclusions on Coverage Permitted

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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1351 - Home Health Services › Section 1351.008. Rejection of Coverage by Plan Holder; Negotiation of Alternative Coverage

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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1351 - Home Health Services › Section 1351.009. Additional Coverage Not Precluded

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.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1352 - Brain Injury › Section 1352.001. Applicability of Chapter

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 1551, 1575, 1579, or 1601 or any other law, this chapter applies to:
(1)  a basic coverage plan under Chapter 1551;
(2)  a basic plan under Chapter 1575;
(3)  a primary care coverage plan under Chapter 1579; and
(4)  basic coverage under Chapter 1601.
(c)  This chapter applies to group health coverage made available by a school district in accordance with Section 22.004, Education Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 877 (H.B. 1919), Sec. 1, eff. September 1, 2007.
Acts 2013, 83rd Leg., R.S., Ch. 370 (H.B. 2929), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1352 - Brain Injury › Section 1352.002. Exception; Application to Qualified Health Plan

Sec. 1352.002.  EXCEPTION; APPLICATION TO QUALIFIED HEALTH PLAN.  (a) 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.
(b)  This chapter does not apply to a standard health benefit plan issued under Chapter 1507.
(c)  To the extent that a change in law made to this chapter after January 1, 2013, would otherwise require this state to make a payment under 42 U.S.C. Section 18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 C.F.R. Section 155.20, is not required to provide a benefit under this section that exceeds the specified essential health benefits required under 42 U.S.C. Section 18022(b).
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 370 (H.B. 2929), Sec. 2, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1352 - Brain Injury › Section 1352.0035. Required Coverages--Small Employer Health Benefit Plans

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 amount limits that are consistent with the deductibles, copayments, coinsurance, or annual or maximum amount  limits applicable to other medical conditions for which coverage is 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 (H.B. 1919), Sec. 3, eff. September 1, 2007.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 370 (H.B. 2929), Sec. 4, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1352 - Brain Injury › Section 1352.004. Training for Certain Personnel Required

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 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 (H.B. 1919), Sec. 4, eff. September 1, 2007.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.38, eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.35, eff. January 1, 2016.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1352 - Brain Injury › Section 1352.005. Notice to Insureds and Enrollees

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 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 (H.B. 1919), Sec. 5, eff. September 1, 2007.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.39, eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.36, eff. January 1, 2016.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1352 - Brain Injury › Section 1352.006. Determination of Medical Necessity; Extension of Coverage

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 (H.B. 1919), Sec. 5, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1352 - Brain Injury › Section 1352.007. Treatment Facilities

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.
(c)  The issuer of a health benefit plan, including a preferred provider benefit plan or health maintenance organization plan, that contracts with or approves admission to a service provider under this chapter may not, solely because a facility is licensed by this state as an assisted living facility, refuse to contract with or approve admission to that facility to provide services that are:
(1)  required under this chapter;
(2)  within the scope of the license of an assisted living facility; and
(3)  within the scope of the services provided under a CARF-accredited rehabilitation program for brain injury or another nationally recognized accredited rehabilitation program for brain injury.
(d)  The issuer of a health benefit plan that requires or encourages insureds or enrollees to use health care providers designated by the plan shall ensure that the services required by this chapter that are within the scope of the license of an assisted living facility and that may be provided under a program described by Subsection (c)(3) are made available and accessible to the insureds or enrollees at an adequate number of assisted living facilities.
(e)  A health benefit plan may not treat care provided in accordance with this chapter as custodial care solely because it is provided by an assisted living facility if the facility holds a CARF accreditation or other nationally recognized accreditation for a rehabilitation program for brain injury.
(f)  To ensure the health and safety of insureds and enrollees, the commissioner may require that a licensed assisted living facility that provides covered post-acute care other than custodial care under this chapter to an insured or enrollee with acquired brain injury hold a CARF accreditation or other nationally recognized accreditation for a rehabilitation program for brain injury.
Added by Acts 2007, 80th Leg., R.S., Ch. 877 (H.B. 1919), Sec. 5, eff. September 1, 2007.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 370 (H.B. 2929), Sec. 5, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1352 - Brain Injury › Section 1352.008. Consumer Information

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 (H.B. 1919), Sec. 5, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1353 - Immunization or Vaccination Protocols Under Managed Care Plans › Section 1353.001. Prohibited Conduct

Sec. 1353.001.  PROHIBITED CONDUCT.  A managed care entity may not:
(1)  require a physician participating in a managed care plan to issue an immunization or vaccination protocol for an immunization or vaccination to be administered to an enrollee in the plan;
(2)  limit an enrollee's benefits for immunizations or vaccinations to circumstances in which an immunization or vaccination protocol is issued;
(3)  provide a financial incentive to a physician to issue an immunization or vaccination protocol;  or
(4)  impose a financial or other penalty on a physician who refuses to issue an immunization or vaccination protocol.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1353 - Immunization or Vaccination Protocols Under Managed Care Plans › Section 1353.002. Rules

Sec. 1353.002.  RULES.  The commissioner may adopt rules to implement this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1354 - Eligibility for Benefits for Alzheimer's Disease › Section 1354.001. Applicability of Chapter

Sec. 1354.001.  APPLICABILITY OF CHAPTER.  This chapter applies only to a health benefit plan that:
(1)  provides coverage for Alzheimer's disease;  and
(2)  is an individual or group policy, contract, certificate, or evidence of coverage that is delivered or issued for delivery in this state by an insurer or a group hospital service corporation operating under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle E - Benefits Payable Under Health Coverages › Chapter 1354 - Eligibility for Benefits for Alzheimer's Disease › Section 1354.002. Proof of Organic Disease

Sec. 1354.002.  PROOF OF ORGANIC DISEASE.  If a health benefit plan requires demonstrable proof of organic disease or other proof before the health benefit plan issuer will authorize payment of benefits for Alzheimer's disease, that proof requirement is satisfied by a clinical diagnosis of Alzheimer's disease made by a physician licensed in this state, including a history and physical, neurological, and psychological or psychiatric evaluations, and laboratory studies.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › 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 › Section 1355.001. Definitions

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;
(C)  major depressive disorders (single episode or recurrent);
(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 (H.B. 1919), Sec. 7, eff. September 1, 2007.
2023 Texas Statutes › 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 › Section 1355.002. Applicability of Subchapter

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;
(C)  a fraternal benefit society operating under Chapter 885;
(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 (H.B. 451), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › 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 › Section 1355.003. Exception

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.
2023 Texas Statutes › 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 › Section 1355.004. Required Coverage for Serious Mental Illness

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.
2023 Texas Statutes › 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 › Section 1355.005. Managed Care Plan Authorized

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.
2023 Texas Statutes › 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 › Section 1355.006. Coverage for Certain Conditions Related to Controlled Substance or Marihuana Not Required

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.
2023 Texas Statutes › 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 › Section 1355.007. Small Employer Coverage

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.
2023 Texas Statutes › 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 B. Alternative Mental Health Treatment Benefits › Section 1355.051. Definitions

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.
2023 Texas Statutes › 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 B. Alternative Mental Health Treatment Benefits › Section 1355.052. Applicability of Subchapter

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.
2023 Texas Statutes › 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 B. Alternative Mental Health Treatment Benefits › Section 1355.053. Required Coverage for Certain Illnesses and Disorders

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.
2023 Texas Statutes › 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 B. Alternative Mental Health Treatment Benefits › Section 1355.054. Conditions for Coverage

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.
(c)  Benefits under coverage provided under this subchapter are 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.