State RegulationsTX specific✓ Verified · outline & fact-checked · Sep 2026Difficulty 2/5
A Texas HMO enrollee needs a covered specialty service, but no provider in the HMO's network can furnish it. What must the HMO do?
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Under 28 TAC 11.1611(b), an HMO that cannot furnish a covered, medically necessary service through its own network must pay for the service to be provided out of network under TIC 1271.055, at the same benefit level the enrollee would receive in network. Network limitations are the HMO's responsibility, not the enrollee's; a covered benefit does not disappear merely because no contracted provider is available. If the enrollee is turned away, the HMO's complaint and appeal process, and ultimately TDI, are available to enforce the benefit.
Why the other options are wrong
- B) Arranging care is the HMO's duty; TDI does not locate providers for members.
- C) A covered service stays covered; unavailability in the network shifts the cost to the HMO, not the enrollee.
- D) Requiring up-front payment by the enrollee would defeat the HMO's out-of-network claim obligations.
Memory hook
If the network cannot do it, the HMO pays to send you outside it.