Under TIC 843.002, what is an "evidence of coverage" issued by a Texas health maintenance organization?
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Under TIC 843.002, an evidence of coverage is any certificate, agreement, or contract, including a blended contract, that is issued to an enrollee and states the coverage to which the enrollee is entitled. It is the document that defines the HMO's obligation to the covered person, and in a group plan the certificate issued to each subscriber is part of the evidence of coverage. Because the evidence of coverage is issued to the enrollee and states entitlement, a producer should never describe benefits from memory or from sales material; the evidence of coverage controls what the HMO owes.
Why the other options are wrong
- B) Advertising and sales material is not the contract; only the certificate, agreement, or contract issued to the enrollee states the coverage.
- C) Physician and provider contracts govern the HMO's relationship with its network; they are not issued to the enrollee and do not state the enrollee's coverage.
- D) The schedule of charges is a separate rate filing; it is not the document issued to an enrollee that states the coverage to which the enrollee is entitled.
Memory hook
The evidence of coverage is issued TO the enrollee and states what they get.