Sec. 1351.007. LIMITATIONS AND EXCLUSIONS ON COVERAGE PERMITTED. (a) A group health benefit plan may include:
(1) a limitation on the number of visits for home health services for which benefits are payable, subject to Subsection (b);
(2) an exclusion for home health services coverage for:
(A) custodial care;
(B) services provided by an individual who:
(i) resides in the covered individual's home; or
(ii) is a member of the covered individual's family; or
(C) services provided to a covered individual who is eligible for Medicare coverage;
(3) annual deductible and coinsurance provisions for home health services coverage that are not less favorable than the deductible or coinsurance provisions applicable to hospital services coverage under the plan; and
(4) other coverage limitations or exclusions consistent with the remaining provisions of the plan.
(b) A limitation under Subsection (a)(1) may not limit each individual covered under the plan to fewer than 60 visits in any calendar year or continuous 12-month period.
(c) For purposes of this section, each of the following is considered to be one visit for home health services:
(1) a visit by a representative of a home health agency;
(2) four hours of home health aide service; and
(3) if home health aide service extends beyond four hours, each additional four hours or portion of that four-hour period.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
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