1. (a) Required Coverage. Pursuant to the 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, post-acute transition services and 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.

2. (b) Medically Necessary and Appropriate.

   1. (1) For purposes of the Insurance Code §1352.003 and this subchapter, the word "necessary" means "medically necessary."

   2. (2) Pursuant to the Insurance Code §1352.007(a), a health benefit plan may not deny benefits for the coverage required under the Insurance Code Chapter 1352, relating to brain injury, 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 at which appropriate services may be provided, which may include:

      1. (A) a hospital regulated under the Health and Safety Code Chapter 241, including an acute or post-acute rehabilitation hospital; and
      2. (B) an assisted living facility regulated under the Health and Safety Code Chapter 247.

3. (c) Maintenance, Prevention, and Reevaluation of Care.

   1. (1) Treatment goals for services required by the Insurance Code Chapter 1352 may include the maintenance of functioning or the prevention of or slowing of further deterioration.

   2. (2) Pursuant to the 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. In accordance with the Insurance Code §1352.003(f), factors for determining whether reasonable expenses related to periodic reevaluation of care must be covered may include:

      1. (A) cost;
      2. (B) the time that has expired since the previous evaluation;
      3. (C) any difference in the expertise of the physician or practitioner performing the evaluation;
      4. (D) changes in technology; and
      5. (E) advances in medicine.

4. (d) Lifetime Payment Limitations, Deductibles, Copayments, and Coinsurance.

   1. (1) A health benefit plan is prohibited from subjecting the coverage required under the Insurance Code Chapter 1352 to payment limitations, deductibles, copayments, and coinsurance factors that are more restrictive than payment limitations, deductibles, copayments, and coinsurance factors applicable to other similar coverage provided under the health benefit plan.
   2. (2) A health benefit plan that includes lifetime limitations on coverage required under the Insurance Code Chapter 1352 is prohibited from including any post acute care treatment for such coverage in any lifetime limitation on the number of days of acute care treatment covered under the plan.
   3. (3) A health benefit plan must separately state in the plan any lifetime limitation imposed under the plan on days of post-acute care treatment for the coverage required under the Insurance Code Chapter 1352.
5. (e) Other Coverage Limitations. The coverage for services required under the 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.
6. (f) Permitted Coverage Exclusions. The types of limitations or exclusions permitted under the Insurance Code §1352.003(d) do not include limitations or exclusions under a health benefit plan which, in and of themselves, meet the definition of a therapy or service required under the 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 (relating to Definitions), and for which coverage is required under the 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 upon the prior authorization exclusion.
7. (g) Permitted Coverage Denials. A health benefit plan may deny coverage and/or apply a limitation or exclusion in a health benefit plan for a service required under the 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 other similar coverage under the health benefit plan is limited or excluded (e.g., acts of war, participation in a riot, etc.).
8. (h) Inapplicability of Section to Small Employer Health Benefit Plan. In accordance with the Insurance Code §1352.003(h) and §1352.007(b), this section does not apply to a small employer health benefit plan.

Source Note:The provisions of this §21.3103 adopted to be effective August 26, 2002, 27 TexReg 7814; amended to be effective February 23, 2009, 34 TexReg 1247.