Which statement best describes the authority of a licensed agent in the Texas HMO enrollment process?
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
Under 28 TAC 11.501 and 11.503, the evidence of coverage and its terms are filed with TDI and approved by the commissioner before they may be issued or used, so the terms of coverage, including the eligibility rules, come from the HMO's filed forms. The agent's role is to solicit and take the application, deliver required disclosures, and explain the coverage as filed; an agent cannot waive the HMO's eligibility requirements, set the effective date, or bind the HMO to cover an applicant the HMO has not accepted. Overstating an agent's authority in the sale of coverage misrepresents the terms of the coverage and can be a misrepresentation under TIC 541.052.
Why the other options are wrong
- A) Eligibility requirements are set by the HMO and approved by TDI; an agent has no power to waive them.
- B) The HMO accepts or declines applications; that decision is not the agent's to make.
- D) Only the filed evidence of coverage governs benefits; an agent may not alter it to make a sale.
Memory hook
Agents solicit and explain; only the HMO says yes.