A Texas HMO enrollee insists on using a specialist who is not in the HMO's delivery network, even though the HMO has network providers available for the service and the care is not an emergency. Under 28 TAC 11.1611, what is the consequence of that voluntary choice?
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
Under 28 TAC 11.1611(b)(2)(C), when an enrollee voluntarily receives covered services from an out-of-network provider even though the services are available in network, the HMO must inform the enrollee that the provider is not in the network and that the enrollee may be responsible for payment to the provider. This is the mirror image of the protected situations: emergency care under TIC 1271.155 and facility-based physicians at network facilities under TIC 1271.157, where the enrollee did not choose to go out of network and cannot be balance billed. Voluntary out-of-network use is the case in which the balance-billing risk falls on the enrollee.
Why the other options are wrong
- A) The usual-and-customary payment duty applies when the HMO must arrange out-of-network care, not when the enrollee voluntarily bypasses an available network provider.
- B) Outright denial is not the automatic consequence; the point is that the enrollee, not the HMO, bears the payment risk created by the voluntary choice.
- D) A non-network provider who was never promised the network rate may bill for its services, and the voluntary choice leaves the balance-billing risk with the enrollee.
Memory hook
Voluntarily leave the network and the balance bill may follow; emergencies and facility-based care never carry it.