A Texas HMO enrollee needs a covered, medically necessary service that no provider in the HMO's delivery network can furnish, so the care is arranged with an out-of-network provider. The provider bills the enrollee for the difference between its charge and the amount the HMO paid. Which statement is correct?
Select an option to reveal the answer and the full 3-part explanation — free, no signup.
Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
Under 28 TAC 11.1611(b), when a covered, medically necessary service is not available through the HMO's network, the HMO must pay for the out-of-network service under TIC 1271.055 at the same benefit level the enrollee would receive in network. Under 28 TAC 11.1611(d), the HMO pays the non-network provider at the usual and customary rate or at a rate agreed to between the HMO and the provider, and the enrollee's responsibility is limited to the applicable copayment, deductible, and coinsurance. The provider's remedy for a disputed amount is against the HMO, not by balance billing the member.
Why the other options are wrong
- A) The enrollee is not required to pay first and litigate; the excess is resolved between the provider and the HMO.
- B) An out-of-network provider is not automatically entitled to its full billed charge; the payment standard is the usual and customary or agreed rate.
- C) The absence of a contract with the HMO does not entitle the provider to collect the balance from an enrollee whose care the HMO was obliged to arrange.
Memory hook
Out-of-network disputes are settled between the HMO and the provider, never on the member's credit card.