Tex. Ins. Code Section 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.

Source: Section 1351.007 — Limitations and Exclusions on Coverage Permitted, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1351.­htm#1351.­007 (accessed Jun. 5, 2024).

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Accessed:
Jun. 5, 2024

§ 1351.007’s source at texas​.gov