Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter W - COVERAGE FOR ACQUIRED BRAIN INJURY › Section 21.3106 - Small Employer Health Benefit Plans

Current through Reg. 49, No. 28; July 12, 2024
(a) Required Coverage. Under Insurance Code
				  §
										1352.0035(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
				  psychological testing or treatment, neurofeedback therapy, remediation,
				  postacute transition services, or community reintegration services, if the
				  services are medically necessary as a result of and related to an acquired
				  brain injury.
(b) Deductibles,
				  Copayments, Coinsurance, and Lifetime Limitations. Under Insurance Code §
										1352.0035(b),
				  small employer health benefit plan coverage of acquired brain injury may be
				  subject to deductibles, copayments, coinsurance, or annual or maximum dollar
				  amount or number of visit limits consistent with the deductibles, copayments,
				  coinsurance, or annual or maximum dollar amount or number of visit limits
				  applicable to other medical conditions for which coverage is provided under the
				  small employer health benefit plan.
(c) Maintenance and Prevention; Treatment
				  Goals. Treatment goals for services required by Insurance Code §
										1352.0035
				  may include the maintenance of functioning or the prevention or slowing of
				  further deterioration.
(d) Other
				  Coverage Limitations. The coverage for services required by Insurance Code
				  §
										1352.0035
				  may be subject to limitations and exclusions that are generally applicable to
				  other physical illnesses or injuries under the health benefit plan. These types
				  of exclusions or limitations include, but are not limited to, limitations or
				  exclusions for services that may be limited or excluded because they are solely
				  educational in nature, experimental or investigational, not medically
				  necessary, or services for which the enrollee failed to obtain proper
				  preauthorization under the requirements of the health benefit plan.
(e) Permitted Coverage Exclusions. The types
				  of limitations or exclusions permitted under subsection (d) of this section do
				  not include limitations or exclusions under a health benefit plan that meet the
				  definition of a therapy or service required under subsection (a) of this
				  section. For example, if a health benefit plan contains an exclusion for
				  biofeedback therapy, the issuer may deny coverage for biofeedback therapy for
				  any diagnosis except an acquired brain injury diagnosis because biofeedback
				  falls within the definition of "neurofeedback therapy" as defined in §
										21.3102 of
				  this subchapter, and coverage is required for it under subsection (a) of this
				  section. However, if the same health benefit plan also contains an exclusion
				  for services that are not authorized prior to service, the issuer may, as
				  allowed by subsection (d) of this subsection, deny coverage based on the prior
				  authorization exclusion.
(f)
				  Permitted Coverage Denials. A small employer health benefit plan may deny
				  coverage or apply a limitation or exclusion in a health benefit plan for a
				  service required under Insurance Code Chapter 1352 if the service is prescribed
				  for a condition that, although a result of, or related to, an acquired brain
				  injury, was sustained in an activity or occurrence for which coverage for other
				  medical conditions under the health benefit plan is limited or excluded (e.g.,
				  acts of war, participation in a riot, etc.).