Tex. Ins. Code Section 1355.054
Conditions for Coverage

(a)

Benefits of coverage provided under this subchapter may be used only in a situation in which:

(1)

the covered individual has a serious mental illness that requires confinement of the individual in a hospital unless treatment is available through a residential treatment center for children and adolescents or a crisis stabilization unit; and

(2)

the covered individual’s mental illness:

(A)

substantially impairs the individual’s thought, perception of reality, emotional process, or judgment; or

(B)

as manifested by the individual’s recent disturbed behavior, grossly impairs the individual’s behavior.

(b)

The service for which benefits are to be paid from coverage provided under this subchapter must be:

(1)

based on an individual treatment plan for the covered individual; and

(2)

provided by a service provider licensed or operated by the appropriate state agency to provide those services.

(c)

Benefits under coverage provided under this subchapter are subject to the same benefit maximums, durational limitations, deductibles, and coinsurance factors that apply to inpatient psychiatric treatment under the coverage.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Source: Section 1355.054 — Conditions for Coverage, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1355.­htm#1355.­054 (accessed May 18, 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
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Accessed:
May 18, 2024

§ 1355.054’s source at texas​.gov