SECTION 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.

Source Note: The provisions of this §11.2405 adopted to be effective August 1, 2017, 42 TexReg 2169