CHAPTER 1368. AVAILABILITY OF CHEMICAL DEPENDENCY COVERAGE
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1368. AVAILABILITY OF CHEMICAL DEPENDENCY COVERAGE
Sec. 1368.001. DEFINITIONS. In this chapter:
(1) "Chemical dependency" means the abuse of, a psychological or
physical dependence on, or an addiction to alcohol or a
controlled substance.
(2) "Chemical dependency treatment center" means a facility that
provides a program for the treatment of chemical dependency under
a written treatment plan approved and monitored by a physician
and that is:
(A) affiliated with a hospital under a contractual agreement
with an established system for patient referral;
(B) accredited as a chemical dependency treatment center by the
Joint Commission on Accreditation of Healthcare Organizations;
(C) licensed as a chemical dependency treatment program by the
Texas Commission on Alcohol and Drug Abuse; or
(D) licensed, certified, or approved as a chemical dependency
treatment program or center by another state agency.
(3) "Controlled substance" means an abusable volatile chemical,
as defined by Section 485.001, Health and Safety Code, or a
substance designated as a controlled substance under Chapter 481,
Health and Safety Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1368.002. APPLICABILITY OF CHAPTER. This chapter applies
only to a group health benefit plan that provides hospital and
medical coverage or services on an expense incurred, service, or
prepaid basis, including a group insurance policy or contract or
self-funded or self-insured plan or arrangement that is offered
in this state by:
(1) an insurer;
(2) a group hospital service corporation operating under Chapter
842;
(3) a health maintenance organization operating under Chapter
843; or
(4) an employer, trustee, or other self-funded or self-insured
plan or arrangement.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1368.003. EXCEPTION. This chapter does not apply to:
(1) an employer, trustee, or other self-funded or self-insured
plan or arrangement with 250 or fewer employees or members;
(2) an individual insurance policy;
(3) an individual evidence of coverage issued by a health
maintenance organization;
(4) a health insurance policy that provides only:
(A) cash indemnity for hospital or other confinement benefits;
(B) supplemental or limited benefit coverage;
(C) coverage for specified diseases or accidents;
(D) disability income coverage; or
(E) any combination of those benefits or coverages;
(5) a blanket insurance policy;
(6) a short-term travel insurance policy;
(7) an accident-only insurance policy;
(8) a limited or specified disease insurance policy;
(9) an individual conversion insurance policy or contract;
(10) a policy or contract designed for issuance to a person
eligible for Medicare coverage or other similar coverage under a
state or federal government plan; or
(11) an evidence of coverage provided by a health maintenance
organization if the plan holder is the subject of a collective
bargaining agreement that was in effect on January 1, 1982, and
that has not expired since that date.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1368.004. COVERAGE REQUIRED. (a) A group health benefit
plan shall provide coverage for the necessary care and treatment
of chemical dependency.
(b) Coverage required under this section may be provided:
(1) directly by the group health benefit plan issuer; or
(2) by another entity, including a single service health
maintenance organization, under contract with the group health
benefit plan issuer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1368.005. MINIMUM COVERAGE REQUIREMENTS. (a) Except as
provided by Subsection (b), coverage required under this chapter:
(1) may not be less favorable than coverage provided for
physical illness generally under the plan; and
(2) shall be subject to the same durational limits, dollar
limits, deductibles, and coinsurance factors that apply to
coverage provided for physical illness generally under the plan.
(b) A group health benefit plan may set dollar or durational
limits for coverage required under this chapter that are less
favorable than for coverage provided for physical illness
generally under the plan if those limits are sufficient to
provide appropriate care and treatment under the guidelines and
standards adopted under Section 1368.007. If guidelines and
standards adopted under Section 1368.007 are not in effect, the
dollar and durational limits may not be less favorable than for
physical illness generally.
(c) This section does not require payment of a usual, customary,
and reasonable rate for treatment of a covered individual if a
health maintenance organization or preferred provider
organization establishes a negotiated rate for the locality in
which the covered individual customarily receives care.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1368.006. LIMITATION ON COVERAGE. (a) In this section,
"treatment series" means a planned, structured, and organized
program to promote chemical-free status that:
(1) may include different facilities or modalities; and
(2) is completed when the covered individual:
(A) is, on medical advice, discharged from:
(i) inpatient detoxification;
(ii) inpatient rehabilitation or treatment;
(iii) partial hospitalization or intensive outpatient treatment;
or
(iv) a series of those levels of treatments without a lapse in
treatment; or
(B) fails to materially comply with the treatment program for a
period of 30 days.
(b) Notwithstanding Section 1368.005, coverage required under
this chapter is limited to a lifetime maximum of three separate
treatment series for each covered individual.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1368.007. TREATMENT STANDARDS. (a) Coverage provided
under this chapter for necessary care and treatment in a chemical
dependency treatment center must be provided as if the care and
treatment were provided in a hospital.
(b) The department by rule shall adopt standards formulated and
approved by the department and the Texas Commission on Alcohol
and Drug Abuse for use by insurers, other third-party
reimbursement sources, and chemical dependency treatment centers.
(c) Standards adopted under this section must provide for:
(1) reasonable control of costs necessary for inpatient and
outpatient treatment of chemical dependency, including guidelines
for treatment periods; and
(2) appropriate utilization review of treatment as well as
necessary extensions of treatment.
(d) Coverage required under this chapter is subject to the
standards adopted under this section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1368.008. USE OF ENDORSEMENT OR RIDER TO COMPLY WITH
CHAPTER. A group health benefit plan issuer that uses a policy
form approved by the commissioner before November 10, 1981, may
use an endorsement or rider to comply with this chapter if the
endorsement or rider is approved by the commissioner as complying
with this chapter and other provisions of this code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.