Each limited service HMO evidence of coverage providing coverage
for mental health and chemical dependency services and benefits must:
(1) cover, in compliance with the limited service HMO's
standards of medical necessity, court-ordered mental health and chemical
dependency treatment and may, if clearly disclosed, require the enrollee
to have the treatment completed by a participating physician or provider
in the HMO delivery network, as defined in Insurance Code §843.002
(concerning Definitions), or as otherwise arranged by the limited
service HMO;
(2) comply with Chapter 21, Subchapter P, of this title
(relating to Mental Health Parity)
(3) provide primary mental health and chemical dependency
services and benefits, including:
(A) for treatment of serious mental illness, as defined
in Insurance Code Chapter 1355, Subchapter A, (concerning Group Health
Benefit Plan Coverage for Certain Serious Mental Illnesses and Other
Disorders), up to 45 inpatient days per year and up to 60 outpatient
visits per year, which include assessment or screening, treatment
planning, and crisis services;
(B) for treatment of nonserious mental illness, up
to 30 inpatient days per year and up to 30 outpatient visits per year,
which include screening and assessment, treatment planning, and crisis
services;
(C) treatment of chemical dependency in compliance
with the levels of care and clinical criteria specified in Chapter
3, Subchapter HH, of this title (relating to Standards for Reasonable
Cost Control and Utilization Review for Chemical Dependency Treatment
Centers); and
(D) any other services necessary and appropriate to
treat mental health and chemical dependency services or required by
the Insurance Code, Health and Safety Code, and other applicable laws
and regulations of this state; and
(4) demonstrate the capacity to provide, and may provide,
secondary intensive rehabilitative, and community support services
for mental illness and chemical dependency, including, but not limited
to, case management, partial hospitalization, residential, acute day
treatment, intensive outpatient service, Assertive Community Treatment
teams, and habilitative or rehabilitative services for pervasive developmental
disorders.
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