A Texas HMO enrollee is taken by ambulance to the nearest hospital, which is not in the HMO's network, for emergency treatment. How is the claim handled?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
Under TIC 1271.155(a), an HMO must pay for emergency care furnished by a non-network provider at the usual and customary rate or at a rate agreed to by the HMO and the provider, and under TIC 1271.155(e) that duty applies whether or not the provider has a contractual arrangement with the HMO. Under TIC 1271.155(g), the provider may not collect from the enrollee anything beyond the applicable copayment, coinsurance, or deductible, so the enrollee pays no more than the cost sharing that would otherwise apply. 28 TAC 11.1611(a) administers these out-of-network emergency claims under Insurance Code Chapter 1271. Emergency care is not gated on prior authorization, and the network status of the facility does not defeat the claim; shifting the balance to the member would defeat the purpose of the emergency benefit.
Why the other options are wrong
- A) Emergency care cannot be denied merely because the treating facility is out of network.
- B) The HMO is not required to pay billed charges in full, and it may not shift the balance to the enrollee.
- C) Requiring the enrollee to pay up front and then seek reimbursement is not how out-of-network emergency claims are handled.
Memory hook
Emergencies get no gatekeeping and no in-network penalty.