Section 21.3106 - Small Employer Health Benefit Plans(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.).28 Tex. Admin. Code § 21.3106
The provisions of this §21.3106 adopted to be effective February 23, 2009, 34 TexReg 1247; Amended by Texas Register, Volume 40, Number 22, May 29, 2015, TexReg 3179, eff. 6/7/2015