State RegulationsTX specificDifficulty 1/5
Under the Texas HMO statute, what is the term for the document that a health maintenance organization issues to an enrollee setting out the health care services to which the enrollee is entitled?
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
Under TIC 843.002, the document issued to a Texas HMO enrollee is the evidence of coverage, not an insurance policy. It sets out the health care services the HMO is obligated to provide or arrange, together with the enrollee's copayments, deductibles and any limitations. Because it is not a policy, provisions that speak to "policies" generally do not apply to it automatically, and the member's contract rights are found in the evidence of coverage itself.
Why the other options are wrong
- A) A certificate of insurance is an individual policy-market term; the HMO statute names the evidence of coverage as the member document.
- B) An HMO does not deliver a master policy; Chapter 843 uses the evidence of coverage and the group contract instead.
- D) A certificate of authority is the commissioner's license authorizing the HMO to operate in Texas; it is not issued to individual members.
Memory hook
HMO members carry an evidence of coverage, never a policy.