Under TIC 843.208, a Texas health maintenance organization may cancel or refuse to renew the coverage of an enrollee only for which of the following?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under TIC 843.208, a health maintenance organization may cancel or refuse to renew the coverage of an enrollee only for failure to pay the charges for the coverage, or for another reason prescribed by rules adopted by the commissioner. The statute is a closed list, so anything not on it — health status, claims experience, or the exercise of a complaint right — is not a lawful ground. A producer who tells a client that an HMO can drop coverage because the client became sick is misstating Texas law, and that statement is the kind of misrepresentation that creates a complaint against the agent.
Why the other options are wrong
- A) Health status is not one of the statutory grounds, and the commissioner's rules under 28 TAC 11.506(3) bar cancellation based on health status-related factors.
- C) Filing a complaint is a protected enrollee right under Chapter 843 and is not among the grounds permitted by TIC 843.208.
- D) Using covered services is the entire purpose of the coverage; claims experience is not a permitted ground for cancellation or nonrenewal.
Memory hook
Only two doors: nonpayment, or a reason the commissioner wrote into a rule.