A Texas HMO enrollee schedules non-emergency surgery with an out-of-network specialist without contacting the HMO first. What is the likely result?
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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), out-of-network benefits for non-emergency care are governed by the evidence of coverage and the HMO's network and authorization rules: when the service is available in network, an enrollee who voluntarily goes outside the network may be responsible for payment under 28 TAC 11.1611(b)(2)(C). Emergency care is the exception, because TIC 1271.155 requires emergency claims to be paid regardless of the provider's network status. An enrollee who obtains planned out-of-network services without authorization therefore risks a reduced or denied claim while remaining responsible for the applicable cost sharing, which is why members should verify network status and obtain authorization before scheduling non-urgent care.
Why the other options are wrong
- B) The specialist's qualifications do not replace the HMO's authorization requirement for non-emergency services.
- C) Out-of-network care is not automatically covered at full plan benefits; the evidence of coverage and its authorization rules apply.
- D) Cost sharing continues to apply, and the lack of authorization may reduce or eliminate the benefit.
Memory hook
Planned care out of network needs permission; emergencies never do.