Tex. Ins. Code Section 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 (Consumer Choice of Benefits Plans).

(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.

Source: Section 1355.015 — Required Coverage for Certain Enrollees, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1355.­htm#1355.­015 (accessed Jun. 5, 2024).

1355.001
Definitions
1355.002
Applicability of Subchapter
1355.003
Exception
1355.004
Required Coverage for Serious Mental Illness
1355.005
Managed Care Plan Authorized
1355.006
Coverage for Certain Conditions Related to Controlled Substance or Marihuana Not Required
1355.007
Small Employer Coverage
1355.015
Required Coverage for Certain Enrollees
1355.051
Definitions
1355.052
Applicability of Subchapter
1355.053
Required Coverage for Certain Illnesses and Disorders
1355.054
Conditions for Coverage
1355.055
Determinations for Treatment in a Residential Treatment Center for Children and Adolescents
1355.056
Determinations for Treatment by a Crisis Stabilization Unit
1355.057
Review and Adjustment of Minimum Ratios of Reimbursement
1355.058
Health and Human Services Commission Assistance
1355.101
Definition
1355.102
Applicability of Subchapter
1355.103
Applicability of General Provisions of Other Law
1355.104
Required Coverage for Treatment in Psychiatric Day Treatment Facility
1355.105
Determinations for Treatment in Psychiatric Day Treatment Facility
1355.106
Offer of Coverage Required
1355.151
Prohibition on Exclusion or Limitation of Certain Coverages
1355.201
Applicability of General Provisions of Other Law
1355.202
Prohibition of Exclusion of Mental Health or Intellectual Disability Benefits for Treatment by Tax-supported Institution
1355.251
Definitions
1355.252
Applicability of Subchapter
1355.253
Exceptions
1355.254
Coverage for Mental Health Conditions and Substance Use Disorders
1355.255
Compliance
1355.256
Definitions Under Plan
1355.257
Coordination with Other Law
1355.258
Rules
1355.2571
Parity Complaint Portal
1355.2572
Educational Materials and Parity Law Training

Accessed:
Jun. 5, 2024

§ 1355.015’s source at texas​.gov