A Texas HMO prepares a revised enrollee certificate reflecting a change in covered services and gives copies to its producers to hand out during open enrollment. Under 28 TAC 11.501, when may that certificate be used?

Why C is correct

Under 28 TAC 11.501, an evidence of coverage or an amendment to an evidence of coverage may not be issued, delivered, or used in Texas unless it has been filed for review and has received the approval of the commissioner. The rule reaches the certificate itself and any amendment to it, and it attaches before issuance, delivery, or use rather than afterward. In practice, a producer who distributes a revised certificate that has not been approved exposes the HMO to a form-violation finding, and the enrollee's entitlement remains governed by the previously approved document.

Why the other options are wrong

• A) Internal corporate approval does not satisfy 28 TAC 11.501; the form must be filed for review and approved by the commissioner before use.
• B) The group contract holder's consent is irrelevant to the form-filing requirement, which is satisfied only by the commissioner's approval.
• D) 28 TAC 11.501 draws no distinction between benefit increases and reductions; every evidence of coverage and every amendment must be filed and approved.

Memory hook

File it, get it approved, then and only then issue it.