28 Tex. Admin. Code § 11.2405 - Minimum Standards - Mental Health and Chemical Dependency Services and Benefits
Each limited service HMO evidence of coverage providing coverage for mental health and chemical dependency services and benefits must:
(1) cover, in compliance with
the limited service HMO's standards of medical necessity, court-ordered mental
health and chemical dependency treatment and may, if clearly disclosed, require
the enrollee to have the treatment completed by a participating physician or
provider in the HMO delivery network, as defined in Insurance Code §
843.002 (concerning
Definitions), or as otherwise arranged by the limited service HMO;
(2) comply with Chapter 21, Subchapter P, of
this title (relating to Mental Health Parity)
(3) provide primary mental health and
chemical dependency services and benefits, including:
(A) for treatment of serious mental illness,
as defined in Insurance Code Chapter 1355, Subchapter A, (concerning Group
Health Benefit Plan Coverage for Certain Serious Mental Illnesses and Other
Disorders), up to 45 inpatient days per year and up to 60 outpatient visits per
year, which include assessment or screening, treatment planning, and crisis
services;
(B) for treatment of
nonserious mental illness, up to 30 inpatient days per year and up to 30
outpatient visits per year, which include screening and assessment, treatment
planning, and crisis services;
(C)
treatment of chemical dependency in compliance with the levels of care and
clinical criteria specified in Chapter 3, Subchapter HH, of this title
(relating to Standards for Reasonable Cost Control and Utilization Review for
Chemical Dependency Treatment Centers); and
(D) any other services necessary and
appropriate to treat mental health and chemical dependency services or required
by the Insurance Code, Health and Safety Code, and other applicable laws and
regulations of this state; and
(4) demonstrate the capacity to provide, and
may provide, secondary intensive rehabilitative, and community support services
for mental illness and chemical dependency, including, but not limited to, case
management, partial hospitalization, residential, acute day treatment,
intensive outpatient service, Assertive Community Treatment teams, and
habilitative or rehabilitative services for pervasive developmental
disorders.
Notes
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