CHAPTER 1355. BENEFITS FOR CERTAIN MENTAL DISORDERS
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1355. BENEFITS FOR CERTAIN MENTAL DISORDERS
SUBCHAPTER A. GROUP HEALTH BENEFIT PLAN COVERAGE
FOR CERTAIN SERIOUS MENTAL ILLNESSES AND OTHER DISORDERS
Sec. 1355.001. DEFINITIONS. In this subchapter:
(1) "Serious mental illness" means the following psychiatric
illnesses as defined by the American Psychiatric Association in
the Diagnostic and Statistical Manual (DSM):
(A) bipolar disorders (hypomanic, manic, depressive, and mixed);
(B) depression in childhood and adolescence;
(C) major depressive disorders (single episode or recurrent);
(D) obsessive-compulsive disorders;
(E) paranoid and other psychotic disorders;
(F) schizo-affective disorders (bipolar or depressive); and
(G) schizophrenia.
(2) "Small employer" has the meaning assigned by Section
1501.002.
(3) "Autism spectrum disorder" means a neurobiological disorder
that includes autism, Asperger's syndrome, or Pervasive
Developmental Disorder--Not Otherwise Specified.
(4) "Neurobiological disorder" means an illness of the nervous
system caused by genetic, metabolic, or other biological factors.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 7, eff. September 1, 2007.
Sec. 1355.002. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a group health benefit plan that
provides benefits for medical or surgical expenses incurred as a
result of a health condition, accident, or sickness, including:
(1) a group insurance policy, group insurance agreement, group
hospital service contract, or group evidence of coverage that is
offered by:
(A) an insurance company;
(B) a group hospital service corporation operating under Chapter
842;
(C) a fraternal benefit society operating under Chapter 885;
(D) a stipulated premium company operating under Chapter 884; or
(E) a health maintenance organization operating under Chapter
843; and
(2) to the extent permitted by the Employee Retirement Income
Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a plan
offered under:
(A) a multiple employer welfare arrangement as defined by
Section 3 of that Act; or
(B) another analogous benefit arrangement.
(b) Notwithstanding any provision in Chapter 1575 or 1579 or any
other law, Section 1355.015 applies to:
(1) a basic plan under Chapter 1575; and
(2) a primary care coverage plan under Chapter 1579.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1107, Sec. 1, eff. September 1, 2009.
Sec. 1355.003. EXCEPTION. (a) This subchapter does not apply
to coverage under:
(1) a blanket accident and health insurance policy, as described
by Chapter 1251;
(2) a short-term travel policy;
(3) an accident-only policy;
(4) a limited or specified-disease policy that does not provide
benefits for mental health care or similar services;
(5) except as provided by Subsection (b), a plan offered under
Chapter 1551 or Chapter 1601;
(6) a plan offered in accordance with Section 1355.151; or
(7) a Medicare supplement benefit plan, as defined by Section
1652.002.
(b) For the purposes of a plan described by Subsection (a)(5),
"serious mental illness" has the meaning assigned by Section
1355.001.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.004. REQUIRED COVERAGE FOR SERIOUS MENTAL ILLNESS.
(a) A group health benefit plan:
(1) must provide coverage, based on medical necessity, for not
less than the following treatments of serious mental illness in
each calendar year:
(A) 45 days of inpatient treatment; and
(B) 60 visits for outpatient treatment, including group and
individual outpatient treatment;
(2) may not include a lifetime limitation on the number of days
of inpatient treatment or the number of visits for outpatient
treatment covered under the plan; and
(3) must include the same amount limitations, deductibles,
copayments, and coinsurance factors for serious mental illness as
the plan includes for physical illness.
(b) A group health benefit plan issuer:
(1) may not count an outpatient visit for medication management
against the number of outpatient visits required to be covered
under Subsection (a)(1)(B); and
(2) must provide coverage for an outpatient visit described by
Subsection (a)(1)(B) under the same terms as the coverage the
issuer provides for an outpatient visit for the treatment of
physical illness.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.005. MANAGED CARE PLAN AUTHORIZED. A group health
benefit plan issuer may provide or offer coverage required by
Section 1355.004 through a managed care plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.006. COVERAGE FOR CERTAIN CONDITIONS RELATED TO
CONTROLLED SUBSTANCE OR MARIHUANA NOT REQUIRED. (a) In this
section, "controlled substance" and "marihuana" have the meanings
assigned by Section 481.002, Health and Safety Code.
(b) This subchapter does not require a group health benefit plan
to provide coverage for the treatment of:
(1) addiction to a controlled substance or marihuana that is
used in violation of law; or
(2) mental illness that results from the use of a controlled
substance or marihuana in violation of law.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.007. SMALL EMPLOYER COVERAGE. An issuer of a group
health benefit plan to a small employer must offer the coverage
described by Section 1355.004 to the employer but is not required
to provide the coverage if the employer rejects the coverage.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.015. REQUIRED COVERAGE FOR CERTAIN CHILDREN. (a) At
a minimum, a health benefit plan must provide coverage as
provided by this section to an enrollee who is diagnosed with
autism spectrum disorder from the date of diagnosis until the
enrollee completes nine years of age. If an enrollee who is
being treated for autism spectrum disorder becomes 10 years of
age or older and continues to need treatment, this subsection
does not preclude coverage of treatment and services described by
Subsection (b).
(b) The health benefit plan must provide coverage under this
section to the enrollee for all generally recognized services
prescribed in relation to autism spectrum disorder by the
enrollee's primary care physician in the treatment plan
recommended by that physician. An individual providing treatment
prescribed under this subsection must be a health care
practitioner:
(1) who is licensed, certified, or registered by an appropriate
agency of this state;
(2) whose professional credential is recognized and accepted by
an appropriate agency of the United States; or
(3) who is certified as a provider under the TRICARE military
health system.
(c) For purposes of Subsection (b), "generally recognized
services" may include services such as:
(1) evaluation and assessment services;
(2) applied behavior analysis;
(3) behavior training and behavior management;
(4) speech therapy;
(5) occupational therapy;
(6) physical therapy; or
(7) medications or nutritional supplements used to address
symptoms of autism spectrum disorder.
(d) Coverage under Subsection (b) may be subject to annual
deductibles, copayments, and coinsurance that are consistent with
annual deductibles, copayments, and coinsurance required for
other coverage under the health benefit plan.
(e) Notwithstanding any other law, this section does not apply
to a standard health benefit plan provided under Chapter 1507.
Added by Acts 2007, 80th Leg., R.S., Ch.
877, Sec. 8, eff. September 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1107, Sec. 2, eff. September 1, 2009.
SUBCHAPTER B. ALTERNATIVE MENTAL HEALTH TREATMENT BENEFITS
Sec. 1355.051. DEFINITIONS. In this subchapter:
(1) "Crisis stabilization unit" means a 24-hour residential
program that provides, usually for a short term, intensive
supervision and highly structured activities to individuals who
demonstrate a moderate to severe acute psychiatric crisis.
(2) "Individual treatment plan" means a treatment plan with
specific attainable goals and objectives that are appropriate to:
(A) the patient; and
(B) the program's treatment modality.
(3) "Residential treatment center for children and adolescents"
means a child-care institution that:
(A) is accredited as a residential treatment center by:
(i) the Council on Accreditation;
(ii) the Joint Commission on Accreditation of Healthcare
Organizations; or
(iii) the American Association of Psychiatric Services for
Children; and
(B) provides residential care and treatment for emotionally
disturbed children and adolescents.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.052. APPLICABILITY OF SUBCHAPTER. This subchapter
applies to a group health benefit plan that is delivered or
issued for delivery in this state and that is:
(1) an accident and health insurance group policy;
(2) a group policy issued by a group hospital service
corporation operating under Chapter 842; or
(3) a group health care plan provided by a health maintenance
organization operating under Chapter 843.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.053. REQUIRED COVERAGE FOR CERTAIN ILLNESSES AND
DISORDERS. A group health benefit plan that provides coverage
for treatment of mental or emotional illness or disorder for a
covered individual when the individual is confined in a hospital
must also provide coverage for treatment in a residential
treatment center for children and adolescents or a crisis
stabilization unit that is at least as favorable as the coverage
the plan provides for treatment of mental or emotional illness or
disorder in a hospital.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.054. CONDITIONS FOR COVERAGE. (a) Benefits of
coverage provided under this subchapter may be used only in a
situation in which:
(1) the covered individual has a serious mental illness that
requires confinement of the individual in a hospital unless
treatment is available through a residential treatment center for
children and adolescents or a crisis stabilization unit; and
(2) the covered individual's mental illness:
(A) substantially impairs the individual's thought, perception
of reality, emotional process, or judgment; or
(B) as manifested by the individual's recent disturbed behavior,
grossly impairs the individual's behavior.
(b) The service for which benefits are to be paid from coverage
provided under this subchapter must be:
(1) based on an individual treatment plan for the covered
individual; and
(2) provided by a service provider licensed or operated by the
appropriate state agency to provide those services.
(c) Benefits under coverage provided under this subchapter are
subject to the same benefit maximums, durational limitations,
deductibles, and coinsurance factors that apply to inpatient
psychiatric treatment under the coverage.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.055. DETERMINATIONS FOR TREATMENT IN A RESIDENTIAL
TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS. (a) Treatment in
a residential treatment center for children and adolescents must
be determined as if necessary care and treatment were inpatient
care and treatment in a hospital.
(b) For the purposes of determining policy benefits and benefit
maximums, each two days of treatment in a residential treatment
center for children and adolescents is the equivalent of one day
of treatment of mental or emotional illness or disorder in a
hospital or inpatient program.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.056. DETERMINATIONS FOR TREATMENT BY A CRISIS
STABILIZATION UNIT. (a) Treatment by a crisis stabilization
unit must be determined as if necessary care and treatment were
inpatient care and treatment in a hospital.
(b) For the purposes of determining plan benefits and benefit
maximums, each two days of treatment in a crisis stabilization
unit is the equivalent of one day of treatment of mental or
emotional illness or disorder in a hospital or inpatient program.
(c) Treatment provided to an individual by a crisis
stabilization unit licensed or certified by the Texas Department
of Mental Health and Mental Retardation shall be reimbursed.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.057. REVIEW AND ADJUSTMENT OF MINIMUM RATIOS OF
REIMBURSEMENT. (a) The commissioner shall monitor and review
the minimum ratios of reimbursement for alternative treatments
required by Sections 1355.055 and 1355.056.
(b) If the commissioner finds that the limits provided by this
subchapter are creating an artificial increase in the costs of
services, the commissioner by rule may adjust the ratios to the
extent necessary to prevent the artificial increase.
(c) Before the commissioner adjusts a ratio under Subsection
(b), the commissioner must give notice and hold a hearing to:
(1) consider information related to the adjustment; and
(2) determine whether the information justifies the adjustment.
(d) The department shall review the reimbursement ratios at
least every two years.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.058. ASSISTANCE OF THE TEXAS DEPARTMENT OF MENTAL
HEALTH AND MENTAL RETARDATION. (a) The Texas Department of
Mental Health and Mental Retardation shall assist the department
in carrying out the department's responsibilities under this
subchapter.
(b) The department and the Texas Department of Mental Health and
Mental Retardation by rule may adopt a memorandum of
understanding to carry out this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER C. PSYCHIATRIC DAY TREATMENT FACILITIES
Sec. 1355.101. DEFINITION. In this subchapter, "psychiatric day
treatment facility" means a mental health facility that:
(1) provides treatment for individuals suffering from acute
mental and nervous disorders in a structured psychiatric program
using individualized treatment plans with specific attainable
goals and objectives that are appropriate to the patient and the
program's treatment modality; and
(2) is clinically supervised by a doctor of medicine who is
certified in psychiatry by the American Board of Psychiatry and
Neurology.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.102. APPLICABILITY OF SUBCHAPTER. This subchapter
applies to a group policy of accident and health insurance
delivered or issued for delivery in this state, including a group
policy issued by a group hospital service corporation operating
under Chapter 842.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.103. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.
The provisions of Chapter 1201, including provisions relating to
the applicability, purpose, and enforcement of that chapter,
construction of policies under that chapter, rulemaking under
that chapter, and definitions of terms applicable in that
chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.104. REQUIRED COVERAGE FOR TREATMENT IN PSYCHIATRIC
DAY TREATMENT FACILITY. (a) A group insurance policy that
provides coverage for treatment of mental or emotional illness or
disorder when an individual is confined in a hospital must also
provide coverage for treatment obtained under the direction and
continued medical supervision of a doctor of medicine or doctor
of osteopathy in a psychiatric day treatment facility that
provides organizational structure and individualized treatment
plans separate from an inpatient program.
(b) The psychiatric day treatment facility coverage required by
this section may not be less favorable than the hospital coverage
and must be subject to the same durational limits, deductibles,
and coinsurance factors.
(c) A group insurance policy subject to this section may require
that:
(1) the treatment obtained in a psychiatric day treatment
facility be provided by a facility that treats a patient for not
more than 8 hours in any 24-hour period;
(2) the attending physician certify that the treatment is in
lieu of hospitalization; and
(3) the psychiatric day treatment facility be accredited by the
Program for Psychiatric Facilities, or its successor, of the
Joint Commission on Accreditation of Healthcare Organizations.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.105. DETERMINATIONS FOR TREATMENT IN PSYCHIATRIC DAY
TREATMENT FACILITY. (a) Benefits provided under this subchapter
shall be determined as if necessary care and treatment in a
psychiatric day treatment facility were inpatient care and
treatment in a hospital.
(b) For the purpose of determining policy benefits and benefit
maximums, each full day of treatment in a psychiatric day
treatment facility is the equivalent of one-half of one day of
treatment of mental or emotional illness or disorder in a
hospital or inpatient program.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.106. OFFER OF COVERAGE REQUIRED; ALTERNATIVE BENEFITS.
(a) An insurer shall offer, and a policyholder is entitled to
reject, coverage under a group insurance policy for treatment of
mental or emotional illness or disorder when confined in a
hospital or in a psychiatric day treatment facility.
(b) A policyholder may select an alternative level of benefits
under the group insurance policy if the alternative level is
offered by or negotiated with the insurer.
(c) The alternative level of benefits must provide policy
benefits and benefit maximums for treatment in a psychiatric day
treatment facility equal to at least one-half of that provided
for treatment in a hospital, except that benefits for treatment
in a psychiatric day treatment facility may not exceed the usual
and customary charges of the facility.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER D. CERTAIN COVERAGES PROVIDED BY LOCAL GOVERNMENTS
Sec. 1355.151. PROHIBITION ON EXCLUSION OR LIMITATION OF CERTAIN
COVERAGES. (a) In this section, "serious mental illness" has
the meaning assigned by Section 1355.001.
(b) A political subdivision that provides group health insurance
coverage, health maintenance organization coverage, or
self-insured health care coverage to the political subdivision's
officers or employees may not contract for or provide coverage
that is less extensive for serious mental illness than the
coverage provided for any other physical illness.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER E. BENEFITS FOR TREATMENT BY TAX-SUPPORTED INSTITUTION
Sec. 1355.201. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.
The provisions of Chapter 1201, including provisions relating to
the applicability, purpose, and enforcement of that chapter,
construction of policies under that chapter, rulemaking under
that chapter, and definitions of terms applicable in that
chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1355.202. PROHIBITION OF EXCLUSION OF MENTAL HEALTH OR
MENTAL RETARDATION BENEFITS FOR TREATMENT BY TAX-SUPPORTED
INSTITUTION. (a) An individual or group accident and health
insurance policy delivered or issued for delivery to a person in
this state that provides coverage for mental illness or mental
retardation may not exclude benefits under that coverage for
support, maintenance, and treatment provided by a tax-supported
institution of this state, or by a community center for mental
health or mental retardation services, that regularly and
customarily charges patients who are not indigent for those
services.
(b) In determining whether a patient is not indigent, as
provided by Subchapter B, Chapter 552, Health and Safety Code, a
tax-supported institution of this state or a community center for
mental health or mental retardation services shall consider any
insurance policy or policies that provide coverage to the patient
for mental illness or mental retardation.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.