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RULE §21.3106 Small Employer Health Benefit Plans

Published: 2015

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(a) Required Coverage. Under Insurance Code §1352.0035(a),
a small employer health benefit plan may not exclude coverage for
cognitive rehabilitation therapy, cognitive communication therapy,
neurocognitive therapy and rehabilitation, neurobehavioral, neurophysiological,
neuropsychological, or psychological testing or treatment, neurofeedback
therapy, remediation, postacute transition services, or community
reintegration services, if the services are medically necessary as
a result of and related to an acquired brain injury.
(b) Deductibles, Copayments, Coinsurance, and Lifetime
Limitations. Under Insurance Code §1352.0035(b), small employer
health benefit plan coverage of acquired brain injury may be subject
to deductibles, copayments, coinsurance, or annual or maximum dollar
amount or number of visit limits consistent with the deductibles,
copayments, coinsurance, or annual or maximum dollar amount or number
of visit limits applicable to other medical conditions for which coverage
is provided under the small employer health benefit plan.
(c) Maintenance and Prevention; Treatment Goals. Treatment
goals for services required by Insurance Code §1352.0035 may
include the maintenance of functioning or the prevention or slowing
of further deterioration.
(d) Other Coverage Limitations. The coverage for services
required by Insurance Code §1352.0035 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.
(e) Permitted Coverage Exclusions. The types of limitations
or exclusions permitted under subsection (d) of this section do not
include limitations or exclusions under a health benefit plan that
meet the definition of a therapy or service required under subsection
(a) of this section. 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 subsection (a) of this section.
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 (d) of this subsection, deny coverage
based on the prior authorization exclusion.
(f) Permitted Coverage Denials. A small employer 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 (e.g.,
acts of war, participation in a riot, etc.).

Source Note: The provisions of this §21.3106 adopted to be effective February 23, 2009, 34 TexReg 1247; amended to be effective June 7, 2015, 40 TexReg 3179