28 TAC §21.3106 — what it says, and how the exam tests it

28 TAC §21.3106. (a) Required Coverage. Under Insurance Code §1352.0035(a), a small employer health benefit plan may not exclude coverage for cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and rehabilitation, neurobehavioral, neurophysiological, neuropsychological, or psychological testing or treatment, neurofeedback therapy, remediation, postacute transition services, or community reintegration services, if the services are medically necessary as a result of and related to an acquired brain injury. (b) Deductibles, Copayments, Coinsurance, and Lifetime Limitations. Under Insurance Code §1352.0035(b), small employer health benefit plan coverage of acquired brain injury may be subject to deductibles, copayments, coinsurance, or annual or maximum dollar amount or number of visit limits consistent with the deductibles, copayments, coinsurance, or annual or maximum dollar amount or number of visit limits applicable to other medical conditions for which coverage is provided under the small employer health benefit plan. (c) Maintenance and Prevention; Treatment Goals. Treatment goals for services required by Insurance Code §1352.0035 may include the maintenance of functioning or the prevention or slowing of further deterioration. (d) Other Coverage Limitations. The coverage for services required by Insurance Code §1352.0035 may be subject to limitations and exclusions that are generally applicable to other physical illnesses or injuries under the health benefit plan. These types of exclusions or limitations include, but are not limited to, limitations or exclusions for services that may be limited or excluded because they are solely educational in nature, experimental or investigational, not medically necessary, or services for which the enrollee failed to obtain proper preauthorization under the requirements of the health benefit plan. (e) Permitted Coverage Exclusions. The types of limitations or exclusions permitted under subsection (d) of this section do not include limitations or exclusions under a health benefit plan that meet the definition of a therapy or service required under subsection (a) of this section. For example, if a health benefit plan contains an exclusion for biofeedback therapy, the issuer may deny coverage for biofeedback therapy for any diagnosis except an acquired brain injury diagnosis because…