| (a) Purpose. The purposes of this subchapter are to:
(1) ensure that enrollees in health benefit plans receive
coverage for certain services for acquired brain injury and to facilitate
the recovery and progressive rehabilitation of survivors of acquired
brain injuries to the extent possible to their preinjury condition
by making available therapies that are medically necessary, clinically
proven, goal-oriented, efficacious, based on individualized treatment
plans, and provided by, or ordered and provided under, the direction
of a licensed healthcare practitioner with the goal of returning the
individual to, or maintaining the individual in, the most integrated
living environment appropriate to the individual;
(2) ensure that an issuer provides coverage for services
related to an acquired brain injury under the medical and surgical
provisions of the health benefit plan; and
(3) require the issuer of a health benefit plan to
provide adequate training of individuals responsible for preauthorization
of coverage or utilization review under the plan in order to prevent
wrongful denial of coverage required under Insurance Code Chapter
1352 and this subchapter, and to avoid confusion of medical and surgical
benefits with mental and behavioral health benefits.
(b) Severability. If a court of competent jurisdiction
holds that any provision of this subchapter is inconsistent with any
statutes of this state, is unconstitutional, or for any other reason
is invalid, the remaining provisions remain in full effect. If a court
of competent jurisdiction holds that the application of any provision
of this subchapter to particular persons, or in particular circumstances,
is inconsistent with any statutes of this state, is unconstitutional,
or for any other reason is invalid, the provision remains in full
effect as to other persons or circumstances.
(c) Applicability. Nothing in this subchapter requires
the issuer of a health benefit plan to provide coverage for services
that are not: medically necessary; clinically proven; goal-oriented;
efficacious; based on an individualized treatment plan; or provided
by, or ordered and provided under, the direction of a licensed healthcare
practitioner.
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| Source Note: The provisions of this §21.3101 adopted to be effective August 26, 2002, 27 TexReg 7814; amended to be effective February 23, 2009, 34 TexReg 1247; amended to be effective June 7, 2015, 40 TexReg 3179 |
