1. (a) Each limited service HMO evidence of coverage providing coverage for mental health/chemical dependency services and benefits shall cover, in accord with the limited service HMO's standards of medical necessity, court ordered mental health/chemical dependency treatment and may, if clearly disclosed, require the enrollee to have such treatment completed by a participating provider in the Health Maintenance Organization Delivery Network, as defined under Insurance Code §843.002, or as otherwise arranged by the limited service HMO.

2. (b) Each limited service HMO evidence of coverage providing coverage for mental health/chemical dependency services and benefits shall provide primary mental health/chemical dependency services and benefits, including:

   1. (1) For treatment of serious mental illness (as defined in Texas Insurance Code Article 3.51-14), up to 45 inpatient days per year, up to 60 outpatient visits per year, which include assessment/screening, treatment planning, and crisis services.
   2. (2) For treatment of non-serious mental illness, up to 30 inpatient days per year, up to 30 outpatient visits per year, which include assessment/screening, treatment planning, and crisis services.
   3. (3) Treatment of chemical dependency in accord with the levels of care and clinical criteria specified in §§3.8001, et seq. of this title (relating to Standards for Reasonable Cost Control and Utilization Review for Chemical Dependency Treatment Centers).
   4. (4) Any other services necessary and appropriate to treat mental health/chemical dependency or required by the Insurance Code, Health and Safety Code, and other applicable laws and regulations of this State.
3. (c) Each limited service HMO evidence of coverage providing coverage for mental health/chemical dependency services and benefits shall demonstrate the capacity to provide, and may provide, secondary intensive rehabilitative and community support services for mental illness/chemical dependency, including, but not limited to, case management, partial hospitalization, residential, acute day treatment, intensive outpatient, ACT teams, and habilitative/rehabilitative services for pervasive developmental disorders.

Source Note:The provisions of this §11.2405 adopted to be effective February 14, 1999, 24 TexReg 726; amended to be effective February 24, 2005, 30 TexReg 854.