A Texas HMO enrollee applies for coverage but does not select a primary care physician or provider at the time of application or enrollment. Under TIC 843.315, what may the HMO do?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under TIC 843.315, if an enrollee does not select a primary care physician or provider at the time of application or enrollment, the HMO may assign the enrollee to one. A primary care physician or provider assigned in that way must be located within the ZIP code nearest the enrollee's residence or place of employment, and the HMO must make the assignment in a manner that results in a fair and equal distribution of enrollees among the network's primary care physicians and providers. The location limit keeps a default assignment convenient for the enrollee rather than letting the HMO park unassigned enrollees wherever it prefers.
Why the other options are wrong
- A) The statute permits the HMO to assign a primary care physician or provider when none is selected, so it need not decline or delay the enrollment.
- C) A failure to select does not reduce coverage to specialty care only; the HMO may make the assignment and coverage continues in full.
- D) Location is not discretionary; the assigned physician or provider must be within the ZIP code nearest the enrollee's residence or place of employment.
Memory hook
No pick means the HMO assigns, nearest ZIP to home or work.