Law:Title 8. Health Insurance And Other Health Coverages. Subtitle E. Benefits Payable Under Health Coverages from Chapter 1368. Availability Of Chemical Dependency Coverage (Texas)

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Subtitle E. Benefits Payable Under Health Coverages

Contents

Chapter 1368. Availability Of Chemical Dependency Coverage

Section  1368.001.  Definitions.

In this chapter:

(1)  "Chemical dependency" means the abuse of, a psychological or physical dependence on, or an addiction to alcohol or a controlled substance.

(2)  "Chemical dependency treatment center" means a facility that provides a program for the treatment of chemical dependency under a written treatment plan approved and monitored by a physician and that is:

(A)  affiliated with a hospital under a contractual agreement with an established system for patient referral;

(B)  accredited as a chemical dependency treatment center by the Joint Commission on Accreditation of Healthcare Organizations;

(C)  licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drug Abuse; or

(D)  licensed, certified, or approved as a chemical dependency treatment program or center by another state agency.

(3)  "Controlled substance" means an abusable volatile chemical, as defined by Section 485.001, Health and Safety Code, or a substance designated as a controlled substance under Chapter 481, Health and Safety Code.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1368.002.  Applicability Of Chapter.

This chapter applies only to a group health benefit plan that provides hospital and medical coverage or services on an expense incurred, service, or prepaid basis, including a group insurance policy or contract or self-funded or self-insured plan or arrangement that is offered in this state by:

(1)  an insurer;

(2)  a group hospital service corporation operating under Chapter 842;

(3)  a health maintenance organization operating under Chapter 843; or

(4)  an employer, trustee, or other self-funded or self-insured plan or arrangement.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1368.003.  Exception.

This chapter does not apply to:

(1)  an employer, trustee, or other self-funded or self-insured plan or arrangement with 250 or fewer employees or members;

(2)  an individual insurance policy;

(3)  an individual evidence of coverage issued by a health maintenance organization;

(4)  a health insurance policy that provides only:

(A)  cash indemnity for hospital or other confinement benefits;

(B)  supplemental or limited benefit coverage;

(C)  coverage for specified diseases or accidents;

(D)  disability income coverage; or

(E)  any combination of those benefits or coverages;

(5)  a blanket insurance policy;

(6)  a short-term travel insurance policy;

(7)  an accident-only insurance policy;

(8)  a limited or specified disease insurance policy;

(9)  an individual conversion insurance policy or contract;

(10)  a policy or contract designed for issuance to a person eligible for Medicare coverage or other similar coverage under a state or federal government plan; or

(11)  an evidence of coverage provided by a health maintenance organization if the plan holder is the subject of a collective bargaining agreement that was in effect on January 1, 1982, and that has not expired since that date.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1368.004.  Coverage Required.

(a) A group health benefit plan shall provide coverage for the necessary care and treatment of chemical dependency.

(b)  Coverage required under this section may be provided:

(1)  directly by the group health benefit plan issuer; or

(2)  by another entity, including a single service health maintenance organization, under contract with the group health benefit plan issuer.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1368.005.  Minimum Coverage Requirements.

(a) Except as provided by Subsection (b), coverage required under this chapter:

(1)  may not be less favorable than coverage provided for physical illness generally under the plan; and

(2)  shall be subject to the same durational limits, dollar limits, deductibles, and coinsurance factors that apply to coverage provided for physical illness generally under the plan.

(b)  A group health benefit plan may set dollar or durational limits for coverage required under this chapter that are less favorable than for coverage provided for physical illness generally under the plan if those limits are sufficient to provide appropriate care and treatment under the guidelines and standards adopted under Section 1368.007. If guidelines and standards adopted under Section 1368.007 are not in effect, the dollar and durational limits may not be less favorable than for physical illness generally.

(c)  This section does not require payment of a usual, customary, and reasonable rate for treatment of a covered individual if a health maintenance organization or preferred provider organization establishes a negotiated rate for the locality in which the covered individual customarily receives care.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1368.006.  Limitation On Coverage.

(a) In this section, "treatment series" means a planned, structured, and organized program to promote chemical-free status that:

(1)  may include different facilities or modalities; and

(2)  is completed when the covered individual:

(A)  is, on medical advice, discharged from:

(i)  inpatient detoxification;

(ii)  inpatient rehabilitation or treatment;

(iii)  partial hospitalization or intensive outpatient treatment; or

(iv)  a series of those levels of treatments without a lapse in treatment; or

(B)  fails to materially comply with the treatment program for a period of 30 days.

(b)  Notwithstanding Section 1368.005, coverage required under this chapter is limited to a lifetime maximum of three separate treatment series for each covered individual.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1368.007.  Treatment Standards.

(a) Coverage provided under this chapter for necessary care and treatment in a chemical dependency treatment center must be provided as if the care and treatment were provided in a hospital.

(b)  The department by rule shall adopt standards formulated and approved by the department and the Texas Commission on Alcohol and Drug Abuse for use by insurers, other third-party reimbursement sources, and chemical dependency treatment centers.

(c)  Standards adopted under this section must provide for:

(1)  reasonable control of costs necessary for inpatient and outpatient treatment of chemical dependency, including guidelines for treatment periods; and

(2)  appropriate utilization review of treatment as well as necessary extensions of treatment.

(d)  Coverage required under this chapter is subject to the standards adopted under this section.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1368.008.  Use Of Endorsement Or Rider To Comply With Chapter.

A group health benefit plan issuer that uses a policy form approved by the commissioner before November 10, 1981, may use an endorsement or rider to comply with this chapter if the endorsement or rider is approved by the commissioner as complying with this chapter and other provisions of this code.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.


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