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.