HMO definitions and evidence of coverage

Correct answer: Arranges for or provides, on a prepaid basis, a health care plan, a limited health care service plan, or a single health care service plan to enrollees

Chapter 843 defines an HMO as a person who arranges for or provides, on a prepaid basis, a health care plan, a limited health care service plan, or a single health care service plan to enrollees. The prepaid, service-delivery character is exactly what brings an entity under the chapter.

Correct answer: Evidence of coverage

Chapter 843 defines evidence of coverage as the certificate, agreement, policy, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled. It performs the job a policy performs in the indemnity world.

Correct answer: Obtain a certificate of authority issued under Chapter 843

Chapter 843 requires an HMO to hold a certificate of authority issued under the chapter before it does business in this state. That authorization is a condition of operating, distinct from anything given to enrollees.

Correct answer: Services that an enrolled population might reasonably require to be maintained in good health

Chapter 843 defines basic health care services as the services an enrolled population might reasonably require to be maintained in good health. The definition is framed around maintaining health, not around a fixed emergency-only list.

Correct answer: Her evidence of coverage

The evidence of coverage is the document issued to the enrollee setting out the coverage to which she is entitled, and because an HMO delivers care through contracted providers inside a defined service area, that is where the geographic and network context of the coverage appears.

Correct answer: Single health care service plan

Section 843.002(26) defines a "single health care service plan" as a plan "under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of a single health care service," that "consists in part of providing or arranging for the single health care service on a prepaid basis through insurance or otherwise, as distinguished from indemnifying for the cost of that service," and "that does not include arranging for the provision of more than one health care need of a single specified nature." Section 843.002(25) in turn defines a "single health care service" as a service "that an enrolled population may reasonably need to be maintained in good health with respect to a particular health care need to prevent, alleviate, cure, or heal human illness or injury of a single specified nature." Prepaid vision-only care addresses one specified health care need and is arranged rather than indemnified, so it fits the single health care service plan definition.

Correct answer: The individual entitled to health care services receives an evidence of coverage describing that entitlement, even though the employer contracts with the HMO

Chapter 843 defines evidence of coverage as the document issued to an enrollee. In group situations the group holder contracts with the HMO, but the individual entitled to services still receives the document describing that entitlement.

Correct answer: Because part of what Entity Two does consists of arranging for or providing health care services rather than pure indemnification

The Chapter 843 definitions turn on the service-delivery character: a health care plan is one under which part of the plan consists of arranging for or providing services rather than pure indemnification. Both entities take prepayment, so prepayment alone does not distinguish them; the arranging or providing of care does.

Correct answer: A person who arranges for or provides, on a prepaid basis, a health care plan, a limited health care service plan, or a single health care service plan to enrollees

Chapter 843 defines an HMO by two features: it arranges for or provides health care, and it does so on a prepaid basis, through a health care plan, a limited health care service plan, or a single health care service plan offered to enrollees. That prepaid service-delivery character is what brings an entity under the chapter.

Correct answer: The certificate, agreement, policy, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled

Chapter 843 defines evidence of coverage as the certificate, agreement, policy, or contract issued to an enrollee that states the coverage to which the enrollee is entitled. It plays the role a policy plays in the indemnity world, but the chapter gives it its own name because the promise is one of services arranged through the plan.

Correct answer: The evidence of coverage, because Chapter 843 makes that the document issued to the enrollee stating the coverage to which she is entitled

The enrollee's benefits, and therefore the limits, exclusions, and conditions on those benefits, are set out in the evidence of coverage. Even though the employer contracts with the HMO in a group arrangement, the individual entitled to services receives the evidence of coverage describing that entitlement.

Correct answer: Services an enrolled population might reasonably require to be maintained in good health

Chapter 843 describes basic health care services as those services an enrolled population might reasonably require in order to be maintained in good health. The definition is framed around the needs of the enrolled population, not around a particular cost-sharing treatment or a single service.

Correct answer: Single health care service plan

Section 843.002(26) defines a "single health care service plan" as a plan "under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of a single health care service," that "consists in part of providing or arranging for the single health care service on a prepaid basis through insurance or otherwise, as distinguished from indemnifying for the cost of that service," and "that does not include arranging for the provision of more than one health care need of a single specified nature." Section 843.002(25) in turn defines a "single health care service" as a service "that an enrolled population may reasonably need to be maintained in good health with respect to a particular health care need to prevent, alleviate, cure, or heal human illness or injury of a single specified nature" and that is provided by persons licensed or authorized by the state. A prepaid chiropractic-only arrangement is exactly that. It is not a limited health care service plan, because Section 843.002(18) confines "limited health care services" to a closed list: "services for mental health, chemical dependency, or intellectual disability, or any combination of those services; or an organized long-term care service delivery system." Chiropractic care appears nowhere on that list.

Correct answer: A certificate of authority issued under the chapter

Chapter 843 conditions doing business as an HMO in Texas on holding a certificate of authority issued under the chapter. Remember the pairing: the organization holds the certificate of authority; the enrollee receives the evidence of coverage.

Correct answer: No, because the company only indemnifies and does not arrange for or provide health care services, which the chapter's definition requires

The Chapter 843 definitions require more than prepayment or payment of costs: part of the arrangement must consist of arranging for or providing health care services rather than pure indemnification. A company that only reimburses submitted bills lacks the service-delivery element and so does not meet the definition.

Correct answer: The service area

Chapter 843 defines service area as the geographic area within which the plan's health care services are available and accessible to enrollees. Because an HMO delivers care through contracted physicians and providers inside that area, the evidence of coverage is where an enrollee finds this geographic context.

Correct answer: Arranges for or provides, on a prepaid basis, a health care plan, a limited health care service plan, or a single health care service plan to enrollees

Chapter 843's definition of a health maintenance organization turns on two features: the arrangement or provision of care (not mere payment) and the prepaid basis on which it is done. The entity may offer a full health care plan, a limited health care service plan, or a single health care service plan, but in each case it arranges for or provides care to enrollees on a prepaid basis.

Correct answer: The evidence of coverage issued to her

Chapter 843 defines evidence of coverage as the certificate, agreement, policy, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled. It is the HMO analogue of an indemnity policy and is therefore the document that states benefits and, by extension, limits, exclusions, and conditions.

Correct answer: Basic health care services

Basic health care services is the Chapter 843 term for the services an enrolled population might reasonably require to be maintained in good health. It describes a broad maintenance-of-health package, in contrast with narrower categories such as a limited health care service or a single health care service plan.

Correct answer: The geographic area in which the plan's health care services are available and accessible to enrollees

Service area is a geographic concept: the area within which the plan's health care services are available and accessible to enrollees. Because an HMO delivers care through contracted physicians and providers, Chapter 843 defines service area alongside physician and provider to capture the network-and-geography context of coverage.

Correct answer: A certificate of authority issued under Chapter 843

Chapter 843 conditions doing business as an HMO in Texas on holding a certificate of authority issued under the chapter. The pairing to remember is that the certificate of authority is what the organization must hold to operate, while the evidence of coverage is what the enrollee receives to know what was purchased.

Correct answer: Single health care service plan

A single health care service plan is defined in Chapter 843 as a plan under which the organization undertakes to provide or arrange for a single health care service. An HMO's definition expressly includes offering such a plan on a prepaid basis, alongside health care plans and limited health care service plans.

Correct answer: Each individual enrollee entitled to health care services under the plan

Chapter 843 defines evidence of coverage as the certificate, agreement, policy, or contract issued to an enrollee. In group situations the employer or other group holder contracts with the HMO, but the individual who is entitled to services still receives the document describing that entitlement.

Correct answer: Because part of the arrangement must consist of arranging for or providing health care services, not pure indemnification

Chapter 843 pulls an entity in only when it arranges for or provides health care on a prepaid basis. In the definition of a health care plan, part of the plan must consist of arranging for or providing services rather than merely indemnifying the member after the fact. A pure cash-reimbursement product lacks that service-delivery element.

Correct answer: Arranges for or provides, on a prepaid basis, a health care plan, a limited health care service plan, or a single health care service plan to enrollees

Chapter 843 defines an HMO by two features: it arranges for or provides health care, and it does so on a prepaid basis, through a health care plan, a limited health care service plan, or a single health care service plan delivered to enrollees. That service-delivery, prepaid character is what brings an entity under the chapter.

Correct answer: A certificate of authority issued under the chapter

Chapter 843 conditions doing business as an HMO in Texas on holding a certificate of authority issued under the chapter. The useful pairing to memorize is that the certificate of authority is what the organization must hold to operate, while the evidence of coverage is what the enrollee receives.

Correct answer: The certificate, agreement, policy, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled

Chapter 843 defines evidence of coverage as the certificate, agreement, policy, or contract issued to an enrollee that states the coverage to which the enrollee is entitled. It performs the job a policy performs in the indemnity world, but the chapter gives it its own name because the promise is one of services arranged through the plan.

Correct answer: The services an enrolled population might reasonably require to be maintained in good health

Basic health care services are described in Chapter 843 as the services an enrolled population might reasonably require to be maintained in good health. That broad, health-maintenance framing distinguishes basic services from the narrower limited health care service category.

Correct answer: Her evidence of coverage, which sets out the coverage, limits, exclusions, and conditions she is entitled to

The evidence of coverage is the document that states what the enrollee is entitled to receive, and therefore also the limits, exclusions, and conditions on those benefits. In an HMO, that document takes the place of the policy form a producer would cite in an indemnity plan.

Correct answer: The geographic area in which the plan's health care services are available and accessible to enrollees

Chapter 843 defines service area as the geographic area in which the health care services of the plan are available and accessible to enrollees. Because an HMO delivers care through contracted providers, the geographic scope of access is a defined term alongside physician and provider.

Correct answer: A single health care service plan

The compliance officer is half right and half wrong: dental truly is not a limited health care service, but that does not push the product outside Chapter 843. Section 843.002(25) defines a "single health care service" as a health care service "that an enrolled population may reasonably need to be maintained in good health with respect to a particular health care need to prevent, alleviate, cure, or heal human illness or injury of a single specified nature; and that is provided by one or more persons licensed or otherwise authorized by the state to provide that service." Section 843.002(26) then defines a "single health care service plan" as a plan "under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of a single health care service," that "consists in part of providing or arranging for the single health care service on a prepaid basis through insurance or otherwise, as distinguished from indemnifying for the cost of that service," and "that does not include arranging for the provision of more than one health care need of a single specified nature." A prepaid, dental-only arrangement delivered through contracted dentists matches that definition exactly.

Correct answer: The enrollee, because the enrollee is the individual entitled to health care services under the plan

Chapter 843 defines evidence of coverage as the document issued to an enrollee, and an enrollee is an individual entitled to health care services under a plan. Even where a group holder such as an employer contracts with the HMO, the individual entitled to services receives the document describing that entitlement.

Correct answer: Arranges for or provides, on a prepaid basis, a health care plan, a limited health care service plan, or a single health care service plan to enrollees

Chapter 843 defines an HMO as a person who arranges for or provides, on a prepaid basis, a health care plan, a limited health care service plan, or a single health care service plan to enrollees. The prepaid, service-delivery character is exactly what pulls an entity under the chapter.

Correct answer: Evidence of coverage

Chapter 843 defines evidence of coverage as the certificate, agreement, policy, or contract issued to an enrollee stating the coverage to which the enrollee is entitled. It fills the role a policy fills in the indemnity world.

Correct answer: The services an enrolled population might reasonably require to be maintained in good health

Chapter 843 describes basic health care services as those services an enrolled population might reasonably require to be maintained in good health. The definition is framed around maintaining health for the enrolled population, not around a setting or a narrow service line.

Correct answer: Her evidence of coverage, which defines her benefits and their limits, exclusions, and conditions

The evidence of coverage is the written statement of what the enrollee is entitled to receive, and by extension it is where the limits, exclusions, and conditions on those benefits appear. It is issued to the enrollee, so she holds it even in a group situation.

Correct answer: The geographic area in which the plan's health care services are available and accessible to enrollees

Service area is the geographic area in which the plan's health care services are available and accessible to enrollees. Chapter 843 defines it alongside physician and provider because an HMO delivers care through contracted practitioners inside that defined geography.

Correct answer: A certificate of authority issued under Chapter 843

Chapter 843 requires an HMO to hold a certificate of authority issued under the chapter before doing business in this state. The evidence of coverage is what the enrollee receives; the certificate of authority is what authorizes the organization itself.

Correct answer: A single health care service plan

Section 843.002(25) defines a "single health care service" as a health care service "that an enrolled population may reasonably need to be maintained in good health with respect to a particular health care need to prevent, alleviate, cure, or heal human illness or injury of a single specified nature" and "that is provided by one or more persons licensed or otherwise authorized by the state to provide that service." Section 843.002(26) then defines a "single health care service plan" as a plan "under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of a single health care service," "that consists in part of providing or arranging for the single health care service on a prepaid basis through insurance or otherwise, as distinguished from indemnifying for the cost of that service," and "that does not include arranging for the provision of more than one health care need of a single specified nature." Prepaid podiatric care and nothing else matches that definition exactly. It is not a limited health care service plan, because Section 843.002(18) makes "limited health care services" a closed list: services for mental health, chemical dependency, or intellectual disability, or any combination of those, or an organized long-term care service delivery system. Podiatry is not on that list.

Correct answer: Because a health care plan requires that part of the plan consist of arranging for or providing services rather than pure indemnification

Under Chapter 843, a health care plan is one under which a person undertakes to provide, arrange for, pay for, or reimburse part of the cost of health care services, where part of the plan consists of arranging for or providing the services rather than pure indemnification. The second entity arranges services through contracted physicians and providers; the first merely indemnifies.