A Texas HMO enrollee is treated for an emergency at a hospital that is not in the HMO's delivery network. Under TIC 1271.155, how must the HMO handle the claim?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under TIC 1271.155(a), an HMO must reimburse a non-network provider for emergency care services at the usual and customary rate or at a rate agreed to by the HMO and the provider, and under TIC 1271.155(e) that duty applies whether or not the provider has a contractual arrangement with the HMO. Under TIC 1271.155(g), the provider may not collect from the enrollee anything beyond the applicable copayment, coinsurance, or deductible, so an emergency never becomes a balance bill. Emergency care is not gated on prior authorization. The transfer-cutoff language in option D reflects a former version of 28 TAC 11.1611 that was removed when the rule was amended effective March 30, 2025; the operative emergency-payment rule now sits in the Insurance Code itself.
Why the other options are wrong
- A) Preauthorization is not a condition of emergency coverage; the reimbursement duty arises from the emergency itself.
- C) Emergency care at a non-network facility is exactly the circumstance TIC 1271.155 addresses; it is not excluded from coverage.
- D) The former transfer-based cutoff no longer limits the HMO's obligation to pay for emergency care under the current rule.
Memory hook
Emergencies are paid at usual and customary, and the member only owes normal cost sharing.