Law:Title 8. Health Insurance And Other Health Coverages. Subtitle E. Benefits Payable Under Health Coverages from Chapter 1377. Coverage For Certain Amino Acid-based Elemental Formulas (Texas)

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Subtitle E. Benefits Payable Under Health Coverages

Contents

Chapter 1377. Coverage For Certain Amino Acid-based Elemental Formulas

Subchapter A. General Provisions

Section 1377.001.  Definition.

In this chapter, "enrollee" means an individual entitled to coverage under a health benefit plan.

Added by Acts 2009, 81st Leg., R.S., Ch. 1129, Sec. 1, eff. September 1, 2009.



Section 1377.002.  Applicability Of Chapter.

(a) This chapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage provided by a health group cooperative under Subchapter B of that chapter, that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:

(1)  an insurance company;

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

(3)  a fraternal benefit society operating under Chapter 885;

(4)  a stipulated premium company operating under Chapter 884;

(5)  an exchange operating under Chapter 942;

(6)  a Lloyd's plan operating under Chapter 941;

(7)  a health maintenance organization operating under Chapter 843;

(8)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or

(9)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.

(b)  Notwithstanding any provision in Chapter 1551, 1575, 1579, or 1601 or any other law, this chapter applies to:

(1)  a basic coverage plan under Chapter 1551;

(2)  a basic plan under Chapter 1575;

(3)  a primary care coverage plan under Chapter 1579; and

(4)  basic coverage under Chapter 1601.

Added by Acts 2009, 81st Leg., R.S., Ch. 1129, Sec. 1, eff. September 1, 2009.



Section 1377.003.  Exception.

This chapter does not apply to:

(1)  a plan that provides coverage:

(A)  only for benefits for a specified disease or  for another limited benefit, other than a plan that provides benefits for a disease or disorder listed in Section 1377.051(a);

(B)  only for accidental death or dismemberment;

(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;

(D)  as a supplement to a liability insurance policy;

(E)  only for dental or vision care; or

(F)  only for indemnity for hospital confinement;

(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(3)  a workers' compensation insurance policy;

(4)  medical payment insurance coverage provided under an automobile insurance policy;

(5)  a credit insurance policy;

(6)  a limited benefit policy that does not provide coverage for physical examinations or wellness exams; or

(7)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1377.002.

Added by Acts 2009, 81st Leg., R.S., Ch. 1129, Sec. 1, eff. September 1, 2009.



Subchapter B. Coverage For Certain Amino Acid-based Elemental Formulas

Section 1377.051.  Required Coverage For Certain Amino Acid-based Elemental Formulas.

(a) A health benefit plan must provide coverage as provided by this chapter for amino acid-based elemental formulas, regardless of the formula delivery method, that are used for the diagnosis and treatment of:

(1)  immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins;

(2)  severe food protein-induced enterocolitis syndrome;

(3)  eosinophilic disorders, as evidenced by the results of a biopsy; and

(4)  impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.

(b)  Subject to Subsection (c), the coverage required under Subsection (a) is required if the treating physician has issued a written order stating that the amino acid-based elemental formula is medically necessary for the treatment of an enrollee who is diagnosed with a disease or disorder listed in Subsection (a). The coverage must include coverage of any medically necessary services associated with the administration of the formula.

(c)  A health benefit plan must provide the coverage described by Subsection (a) on a basis no less favorable than the basis on which prescription drugs and other medications and related services are covered by the plan, and to the same extent that the plan provides coverage for drugs that are available only on the orders of a physician.

Added by Acts 2009, 81st Leg., R.S., Ch. 1129, Sec. 1, eff. September 1, 2009.



Section 1377.052.  Utilization Review.

(a) A utilization review agent acting on behalf of a health benefit plan issuer may review a treating physician's determination of the medical necessity of the use of an amino acid-based elemental formula for the treatment of an enrollee who is diagnosed with a disease or disorder listed in Section 1377.051(a).

(b)  Utilization review under this section is subject to Chapter 4201.

Added by Acts 2009, 81st Leg., R.S., Ch. 1129, Sec. 1, eff. September 1, 2009.


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