Under 28 TAC 11.501, which of the following is considered part of the evidence of coverage and must therefore be filed and individually approved before it is issued or used in Texas?
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Under 28 TAC 11.501, the following are always considered part of the evidence of coverage: the group agreement, the certificate issued to each group subscriber, conversion and individual agreements, applications for coverage, the group subscriber enrollment form, riders, endorsements, amendments, and letters of agreement, matrix filings, the schedule of benefits, and any other form attached to or made a part of the evidence of coverage. Each such form must be identified with a unique form number and individually approved by the commissioner before it is issued, delivered, or used in Texas. The practical consequence is that no rider or side letter can be slipped into an approved certificate without its own filing and approval.
Why the other options are wrong
- B) Audited financial statements are filed under the HMO's financial requirements; they are not part of the evidence of coverage form set.
- C) Credentialing policies govern which physicians and providers join the network and are not among the forms listed in 28 TAC 11.501 as part of the evidence of coverage.
- D) Internal claims-processing manuals are operational documents, not forms issued to an enrollee that state the coverage.
Memory hook
If it changes or schedules the enrollee's coverage, it is part of the evidence of coverage.