Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter W - COVERAGE FOR ACQUIRED BRAIN INJURY
Section 21.3103 - Coverage for Services

Universal Citation: 28 TX Admin Code § 21.3103

Current through Reg. 50, No. 13; March 28, 2025

(a) Required Coverage. Under 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, and postacute transition services, 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.

(b) Medically Necessary and Appropriate.

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

(2) Under Insurance Code § 1352.007(a), a health benefit plan may not deny benefits for the coverage required under Insurance Code Chapter 1352 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 where appropriate services may be provided, including:
(A) a hospital regulated under the Health and Safety Code Chapter 241, including an acute or postacute rehabilitation hospital; and

(B) an assisted living facility regulated under the Health and Safety Code Chapter 247.

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

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

(2) Under 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. As provided in Insurance Code § 1352.003(f), factors for determining whether reasonable expenses related to periodic reevaluation of care must be covered may include:
(A) cost;

(B) the time that has expired since the previous evaluation;

(C) any difference in the expertise of the physician or practitioner performing the evaluation;

(D) changes in technology; and

(E) advances in medicine.

(d) Lifetime Dollar Amount or Number of Visit Limitations, Deductibles, Copayments, and Coinsurance.

(1) A health benefit plan may not subject the coverage required under Insurance Code Chapter 1352 to dollar amount or number of visit limitations, deductibles, copayments, and coinsurance factors that are more restrictive than dollar amount or number of visit limitations, deductibles, copayments, and coinsurance factors applicable to other medical conditions for which the health benefit plan provides coverage.

(2) A health benefit plan that includes annual or lifetime limitations on coverage required under Insurance Code Chapter 1352 is prohibited from including any post-acute-care treatment for the coverage in any annual or lifetime limitation on the number of days of acute-care treatment covered under the plan.

(3) A health benefit plan may not limit the number of days of covered postacute care, including any therapy, treatment, or rehabilitation, testing, remediation, or other service described in Insurance Code § 1352.003(a) and (b), or the number of days of covered inpatient care to the extent that the treatment or care is determined to be medically necessary as a result of and related to an acquired brain injury, as provided in Insurance Code § 1352.003(c-1) and § 1352.006.

(e) Other Coverage Limitations. The coverage for services required under 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.

(f) Permitted Coverage Exclusions. The types of limitations or exclusions permitted under Insurance Code § 1352.003(d) do not include limitations or exclusions under a health benefit plan that meet the definition of a therapy or service required under 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, and coverage is required for it under 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 on the prior authorization exclusion.

(g) Permitted Coverage Denials. A health benefit plan may deny coverage or apply a limitation or exclusion in a health benefit plan for a service required under 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 coverage for other medical conditions under the health benefit plan is limited or excluded (for example, acts of war, participation in a riot, etc.).

(h) Inapplicability of Section to Small Employer Health Benefit Plan. Under Insurance Code § 1352.003(h) and § 1352.007(b), this section does not apply to a small employer health benefit plan.

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