2005 Texas Insurance Code CHAPTER 1352. BRAIN INJURY

INSURANCE CODE

CHAPTER 1352. BRAIN INJURY


	§ 1352.001. APPLICABILITY OF CHAPTER.  This chapter 
applies only to a health benefit plan, including a small employer 
health benefit plan written under Chapter 1501, 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)  a reciprocal 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.

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


	§ 1352.002. EXCEPTION.  This chapter does not apply to:                     
		(1)  a plan that provides coverage:                                           
			(A)  only for a specified disease or for another 
limited benefit other than an accident policy;
			(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)  for credit insurance;                                                   
			(F)  only for dental or vision care;                                         
			(G)  only for hospital expenses;  or                                         
			(H)  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), 
as amended;
		(3)  a workers' compensation insurance policy;                                
		(4)  medical payment insurance coverage provided under 
a motor vehicle insurance policy;  or
		(5)  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 1352.001.

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


	§ 1352.003. EXCLUSION OF COVERAGE PROHIBITED.  (a) A 
health benefit plan may not exclude coverage for cognitive 
rehabilitation therapy, cognitive communication therapy, 
neurocognitive therapy and rehabilitation, neurobehavioral, 
neurophysiological, neuropsychological, or psychophysiological 
testing or treatment, neurofeedback therapy, remediation, 
post-acute transition services, or community reintegration 
services necessary as a result of and related to an acquired brain 
injury.
	(b)  Coverage required under this chapter may be subject to 
deductibles, copayments, coinsurance, or annual or maximum payment 
limits that are consistent with the deductibles, copayments, 
coinsurance, or annual or maximum payment limits applicable to 
other similar coverage provided under the health benefit plan.
	(c)  The commissioner shall adopt rules as necessary to 
implement this section.

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


	§ 1352.004. TRAINING FOR CERTAIN PERSONNEL REQUIRED.  (a) 
In this section, "preauthorization" means the provision of a 
reliable representation to a physician or health care provider of 
whether a health benefit plan issuer will pay the physician or 
provider for proposed medical or health care services if the 
physician or provider provides those services to the patient for 
whom the services are proposed.  The term includes 
precertification, certification, recertification, or any other 
activity that involves providing a reliable representation by the 
issuer to a physician or health care provider.
	(b)  The commissioner by rule shall require a health benefit 
plan issuer to provide adequate training to personnel responsible 
for preauthorization of coverage or utilization review under the 
plan.  The purpose of the training is to prevent denial of coverage 
in violation of Section 1352.003 and to avoid confusion of medical 
benefits with mental health benefits.

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