Texas § IN.1351.007 - LIMITATIONS AND EXCLUSIONS ON COVERAGE PERMITTED

§ IN.1351.007. LIMITATIONS AND EXCLUSIONS ON COVERAGE PERMITTED

LIMITATIONS AND EXCLUSIONS ON COVERAGE PERMITTED. (a) A group health benefit plan may include: (1) a limitation on the number of visits for home health services for which benefits are payable, subject to Subsection (b); (2) an exclusion for home health services coverage for: (A) custodial care; (B) services provided by an individual who: (i) resides in the covered individual's home; or (ii) is a member of the covered individual's family; or (C) services provided to a covered individual who is eligible for Medicare coverage; (3) annual deductible and coinsurance provisions for home health services coverage that are not less favorable than the deductible or coinsurance provisions applicable to hospital services coverage under the plan; and (4) other coverage limitations or exclusions consistent with the remaining provisions of the plan. (b) A limitation under Subsection (a)(1) may not limit each individual covered under the plan to fewer than 60 visits in any calendar year or continuous 12-month period. (c) For purposes of this section, each of the following is considered to be one visit for home health services: (1) a visit by a representative of a home health agency; (2) four hours of home health aide service; and (3) if home health aide service extends beyond four hours, each additional four hours or portion of that four-hour period. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.