Texas law · Section IV · Life, Accident and Health only
Texas statutes and rules pertinent to Health Maintenance Organizations (HMOs)
Texas rules for health maintenance organizations: definitions, the evidence of coverage, nonrenewal and cancellation, enrollment and out-of-network claims. It is the smallest section of the exam.
Questions on the exam
- Life, Accident and Health: 3 questions
- Life Agent: Not on this exam
Life, Accident and Health exam
What the official outline lists
- Definitions
- Evidence of coverage
- Nonrenewal/cancellation
- Enrollment
- Out of network claims
Practice questions
Choose your answer, then open “Show the answer” to see why each option is right or wrong and the exact source text.
1. Under TIC §1271.051, how does the required content of an HMO evidence of coverage that is a certificate differ from one that is a contract?
- A contract must contain a clear and complete statement; a certificate, a reasonably complete facsimile
- A certificate must contain a clear and complete statement; a contract, a reasonably complete facsimile
- Both must contain a clear and complete statement, but only the contract must be filed for approval
- A contract must contain a clear and complete statement; a certificate needs only a summary on request
Show the answer
Correct answer: A. A contract must contain a clear and complete statement; a certificate, a reasonably complete facsimile
According to TIC §1271.051, an evidence of coverage that is a contract must contain a clear and complete statement of the information required by Sections 1271.052, 1271.053, and 1271.054, while one that is a certificate must contain a reasonably complete facsimile of that information.
Why the other options are wrong
- B. This reverses TIC §1271.051: subsection (a) requires the clear and complete statement in a contract, and subsection (b) allows a reasonably complete facsimile in a certificate.
- C. TIC §1271.051(b) does not require a certificate to contain a clear and complete statement; it requires a reasonably complete facsimile of the required information.
- D. TIC §1271.051(b) requires a certificate to contain a reasonably complete facsimile of the required information; it does not reduce the requirement to a summary provided only on request.
(a) An evidence of coverage that is a contract must contain a clear and complete statement of the information required by Sections 1271.052, 1271.053, and 1271.054.
(b) An evidence of coverage that is a certificate must contain a reasonably complete facsimile of the information required by Sections 1271.052, 1271.053, and 1271.054.
2. An enrollee residing in Texas obtains coverage under a health care plan through an insurance policy issued by an insurer, rather than directly from the health maintenance organization. Under TIC §1271.002, who shall issue the evidence of coverage?
- The insurer that issued the insurance policy
- The health maintenance organization itself
- The employer that sponsors the group plan
- The Texas Department of Insurance
Show the answer
Correct answer: A. The insurer that issued the insurance policy
According to TIC §1271.002(c), if the enrollee obtains coverage under a health care plan through an insurance policy or a contract issued by a group hospital service corporation, the insurer or the group hospital service corporation shall issue the evidence of coverage.
Why the other options are wrong
- B. TIC §1271.002(b) makes the HMO the issuer only "except as provided by Subsection (c)"; when coverage is obtained through an insurance policy, subsection (c) assigns issuance to the insurer.
- C. TIC §1271.002 assigns issuance to the HMO, or under subsection (c) to the insurer or group hospital service corporation; it does not make the employer the issuer.
- D. TIC §1271.002 does not give the department the duty to issue the evidence of coverage; under subsection (c) the insurer issues it in this situation.
(b) The health maintenance organization shall issue the evidence of coverage, except as provided by Subsection (c).
(c) If the enrollee obtains coverage under a health care plan through an insurance policy or a contract issued by a group hospital service corporation, whether by option or otherwise, the insurer or the group hospital service corporation shall issue the evidence of coverage.
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Terms on this topic
- Evidence of coverage — Prueba de cobertura
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