A Texas HMO is preparing a new evidence of coverage. Which of the following must the document contain?
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
Under TIC 1271.051 and 1271.052, the evidence of coverage is the contract or certificate that must state the covered health care services and the enrollee's obligations, including copayments, deductibles, coinsurance, and any exclusions or limitations. Under TIC 1271.053 and 1271.054, it must also explain how and where the enrollee obtains services and describe the HMO's complaint and appeal procedures, and 28 TAC 11.501 makes these disclosures part of the approved, filed evidence of coverage. Financial statements, agent compensation, and provider credentialing files are internal or filing materials, not required contents of the member document.
Why the other options are wrong
- A) Financial statements are filed with TDI for solvency review, not delivered to members as part of the evidence of coverage.
- B) Provider credentialing files are confidential HMO records; the evidence of coverage explains how to access the network, not each provider's file.
- D) Agent commission schedules are business records and need not be disclosed in the member's coverage document.
Memory hook
The evidence of coverage answers: what is covered, what it costs, where to get it.