In Texas, a health benefit plan must include coverage for treatment and services related to an acquired brain injury.
- Hospitalization is not required, and the services may be provided in a facility other than a hospital, such as a post-acute rehabilitation hospital or assisted living facility.
- Periodic re-evaluation is covered if the patient is initially unresponsive to treatment but becomes responsive at a later date.
- Separate lifetime limitations for acute and post-acute care are required so the benefit is available at both acute and post-acute stages.
- Pre-authorization and utilization review personnel must be trained to prevent inappropriate denial of coverage and to avoid confusion of medical benefits with mental health benefits.
- Physicians must conduct medical necessity reviews before a denial of services is issued.
- Requests for utilization review or appeals for an extension of coverage based on medical necessity require a response by phone within three business days.
Health insurance cannot exclude:
- Cognitive Rehabilitation Therapy - Services to address therapeutic cognitive activities, based on an assessment and understanding of the individual’s brain-behavioral deficits.
- Cognitive Communication Therapy - Services to address comprehension and expression, including understanding, reading, writing and verbal expression of information.
- Neurocognitive Therapy and Rehabilitation - Services to address informational processing and to facilitate the development of higher level cognitive abilities.
- Neurobehavioral Testing and Treatment - An evaluation of the history of neurological and psychiatric difficulty, current symptoms, current mental status and the patient’s history, including the identification of problem behavior and interventions that focus on behavior.
- Testing and Treatment - An evaluation of the functions of the nervous system and interventions that focus on the functions of the nervous system.
- Neurophysiological Testing and Treatment - Comprehensive tests to evaluate neurocognitive, behavioral and emotional strengths and weaknesses and interventions designed to improve or minimize deficits in behavioral and cognitive processes.
- Psychophysiological Testing and Treatment - An evaluation of the interrelationships between the nervous system and other bodily organs and behavior and interventions designed to alleviate or decrease abnormal physiological responses of the nervous system due to behavioral or emotional factors.
- Neurofeedback Therapy - Services that use operant conditioning learning procedure based on electroencephalography (EEG) parameters and which are designed to improve mental performance and behavior and stabilize mood.
- Remediation - The process of restoring or improving a specific function.
- Post-acute Transition Services - Services that facilitate the continuum of care through rehabilitation and community reintegration.
- Community Reintegration Services - Services that facilitate the continuum of care as an affected individual transitions into the community.
Small employer health benefit plans are not required to provide periodic re-evaluation, separate lifetime limitations for acute and post-acute care, or respond by phone within three days to requests for utilization review or appeals for an extension of coverage based on medical necessity.
Self-funded plans are not required to provide coverage for acquired brain injury.
There may be limits to health insurance coverage. A health benefit plan, other than a small employer health plan, must include the same payment limitations, deductibles, copayments and coinsurance factors for coverage required under this chapter as applicable to other similar coverage provided under the health benefit plan. Coverage under a small employer health benefit plan 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 small employer health benefit plan.
Source: Texas Insurance Code, Chapter 1352, and Texas Administrative Code, title 28, Chapter 21.
For more information please contact the Texas Department of Insurance at 1-800-252-3439.