A Houston employer buys group HMO coverage for its staff and the HMO delivers only the group contract to the employer. What does Texas law require regarding the coverage document for the employees and their covered dependents?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under TIC 1271.002, each enrollee is entitled to an evidence of coverage, and the HMO must issue that document to the enrollee; covered dependents who are entitled to services are enrollees as well. In a group setting the group contract governs the HMO's relationship with the employer, but the member's own benefits and obligations are stated in the evidence of coverage issued under the HMO's TDI-approved forms (28 TAC 11.501). An enrollee cannot be left to rely on the employer's copy alone, because the enrollee needs the document to know how to obtain care and to pursue a complaint.
Why the other options are wrong
- A) Covered dependents who are entitled to receive services are enrollees and are entitled to coverage documentation as well.
- C) Delivering the group contract to the employer does not discharge the HMO's obligation to give each enrollee the evidence of coverage.
- D) Enrollees receive the document as a matter of course; they are not required to request it from TDI.
Memory hook
The group contract goes to the boss; the evidence of coverage goes to the member.