Sec. 1355.015. REQUIRED COVERAGE FOR CERTAIN ENROLLEES. (a) At a minimum, a health benefit plan must provide coverage for screening a child for autism spectrum disorder at the ages of 18 and 24 months.
(a-1) At a minimum, a health benefit plan must provide coverage for treatment of autism spectrum disorder as provided by this section to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis, only if the diagnosis was in place prior to the child's 10th birthday.
(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:
(1) a health care practitioner:
(A) who is licensed, certified, or registered by an appropriate agency of this state;
(B) whose professional credential is recognized and accepted by an appropriate agency of the United States; or
(C) who is certified as a provider under the TRICARE military health system; or
(2) an individual acting under the supervision of a health care practitioner described by Subdivision (1).
(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.
(c-1) The health benefit plan is not required to provide coverage under Subsection (b) for benefits for an enrollee 10 years of age or older for applied behavior analysis in an amount that exceeds $36,000 per year.
(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.
(f) Subsection (a) does not apply to a qualified health plan defined by 45 C.F.R. Section 155.20 if a determination is made under 45 C.F.R. Section 155.170 that:
(1) this subchapter requires the qualified health plan to offer benefits in addition to the essential health benefits required under 42 U.S.C. Section 18022(b); and
(2) this state must make payments to defray the cost of the additional benefits mandated by this subchapter.
(g) To the extent that this section would otherwise require this state to make a payment under 42 U.S.C. Section 18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 C.F.R. Section 155.20, is not required to provide a benefit under this section that exceeds the specified essential health benefits required under 42 U.S.C. Section 18022(b).
Added by Acts 2007, 80th Leg., R.S., Ch. 877 (H.B. 1919), Sec. 8, eff. September 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 1107 (H.B. 451), Sec. 2, eff. September 1, 2009.
Acts 2013, 83rd Leg., R.S., Ch. 1070 (H.B. 3276), Sec. 1, eff. September 1, 2013.
Acts 2013, 83rd Leg., R.S., Ch. 1359 (S.B. 1484), Sec. 1, eff. September 1, 2013.
Acts 2013, 83rd Leg., R.S., Ch. 1359 (S.B. 1484), Sec. 2, eff. September 1, 2013.
Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 11.003(a), eff. September 1, 2015.
Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 11.003(b), eff. September 1, 2015.
Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(37), eff. September 1, 2015.
Last modified: September 28, 2016