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 1352.003. Required Coverages--Health Benefit Plans Other Than Small Employer Health Benefit Plans

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 annual or lifetime limitation on the number of days of acute care treatment covered under the plan, any post-acute care treatment covered under the plan.
(c-1)  A health benefit plan may not limit the number of days of covered post-acute care, including any therapy or treatment or rehabilitation, testing, remediation, or other service described by Subsections (a) and (b), or the number of days of covered inpatient care to the extent that the treatment or care is determined to be medically necessary as a result of and related to an acquired brain injury. The insured's or enrollee's treating physician shall determine whether treatment or care is medically necessary for purposes of this subsection in consultation with the treatment or care provider, the insured or enrollee, and, if appropriate, members of the insured's or enrollee's family. The determination is subject to review under Section 1352.006.
(d)  Except as provided by Subsection (c) or (c-1), a health benefit plan must include the same amount limitations, deductibles, copayments, and coinsurance factors for coverage  required under this chapter as applicable to other medical conditions for which coverage is 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 (H.B. 1919), Sec. 2, eff. September 1, 2007.
Acts 2013, 83rd Leg., R.S., Ch. 370 (H.B. 2929), Sec. 3, eff. September 1, 2013.