| (a) Required Coverage. Under Insurance Code Chapter
1352, a health benefit plan must include coverage for services specified
in §1352.003, including cognitive rehabilitation therapy, cognitive
communication therapy, neurocognitive therapy and rehabilitation,
neurobehavioral, neurophysiological, neuropsychological, and psychophysiological
testing and treatment, neurofeedback therapy, remediation, and postacute
transition services, community reintegration services, including outpatient
day treatment services, or other post-acute-care treatment services,
if such services are necessary as a result of and related to an acquired
brain injury.
(b) Medically Necessary and Appropriate.
(1) For purposes of Insurance Code §1352.003 and
this subchapter, the word "necessary" means "medically necessary."
(2) Under Insurance Code §1352.007(a), a health
benefit plan may not deny benefits for the coverage required under
Insurance Code Chapter 1352 based solely on the fact that the treatment
or services are provided at a facility other than a hospital. Medically
necessary treatment and services for an acquired brain injury must
be provided under the coverage required by Chapter 1352 at a facility
where appropriate services may be provided, including:
(A) a hospital regulated under the Health and Safety
Code Chapter 241, including an acute or postacute rehabilitation hospital;
and
(B) an assisted living facility regulated under the
Health and Safety Code Chapter 247.
(c) Maintenance, Prevention, and Reevaluation of Care.
(1) Treatment goals for services required by Insurance
Code Chapter 1352 may include the maintenance of functioning or the
prevention or slowing of further deterioration.
(2) Under Insurance Code §1352.003(e), 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 has incurred an acquired brain injury, been unresponsive
to treatment, and becomes responsive to treatment at a later date.
As provided in Insurance Code §1352.003(f), factors for determining
whether reasonable expenses related to periodic reevaluation of care
must be covered may include:
(A) cost;
(B) the time that has expired since the previous evaluation;
(C) any difference in the expertise of the physician
or practitioner performing the evaluation;
(D) changes in technology; and
(E) advances in medicine.
(d) Lifetime Dollar Amount or Number of Visit Limitations,
Deductibles, Copayments, and Coinsurance.
(1) A health benefit plan may not subject the coverage
required under Insurance Code Chapter 1352 to dollar amount or number
of visit limitations, deductibles, copayments, and coinsurance factors
that are more restrictive than dollar amount or number of visit limitations,
deductibles, copayments, and coinsurance factors applicable to other
medical conditions for which the health benefit plan provides coverage.
(2) A health benefit plan that includes annual or lifetime
limitations on coverage required under Insurance Code Chapter 1352
is prohibited from including any post-acute-care treatment for the
coverage in any annual or lifetime limitation on the number of days
of acute-care treatment covered under the plan.
(3) A health benefit plan may not limit the number
of days of covered postacute care, including any therapy, treatment,
or rehabilitation, testing, remediation, or other service described
in Insurance Code §1352.003(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, as provided in Insurance Code §1352.003(c-1)
and §1352.006.
(e) Other Coverage Limitations. The coverage for services
required under Insurance Code Chapter 1352 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.
(f) Permitted Coverage Exclusions. The types of limitations
or exclusions permitted under Insurance Code §1352.003(d) do
not include limitations or exclusions under a health benefit plan
that meet the definition of a therapy or service required under Insurance
Code Chapter 1352. 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 Insurance Code Chapter 1352.
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 (e) of this subsection, deny coverage
based on the prior authorization exclusion.
(g) Permitted Coverage Denials. A 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 (for example, acts
of war, participation in a riot, etc.).
(h) Inapplicability of Section to Small Employer Health
Benefit Plan. Under Insurance Code §1352.003(h) and §1352.007(b),
this section does not apply to a small employer health benefit plan.
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