Under Chapter 843 of the Texas Insurance Code, a health maintenance organization is best described as a person who:
Reimburses enrollees for medical bills after they are incurred, without arranging for any services
Sells indemnity major medical policies through independent agents anywhere in the state
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
Licenses physicians and hospitals to practice within a defined geographic area
Question 2 of 40
In Chapter 843 terminology, the certificate, agreement, policy, or contract issued to an enrollee that sets out the coverage to which the enrollee is entitled is called the:
Evidence of coverage
Certificate of authority
Health care plan
Service area agreement
Question 3 of 40
A new company intends to arrange prepaid health care services for enrollees in Dallas. Before it may do business as an HMO in Texas, it must first:
File a sample evidence of coverage with each enrollee's employer
Contract with at least one hospital in every county of the state
Register each participating physician as an agent of the organization
Obtain a certificate of authority issued under Chapter 843
Question 4 of 40
Chapter 843 uses the term "basic health care services" to mean:
Services that an enrolled population might reasonably require to be maintained in good health
Only emergency services furnished outside the service area
Dental, vision, and mental health services offered under a narrow plan
The single service an organization undertakes to provide under a single health care service plan
Question 5 of 40
An enrollee asks her producer where she can find out which geographic area her HMO's services are available and accessible in, and which providers deliver them. The producer should direct her to:
The HMO's certificate of authority on file with the state
Her employer's group application for coverage
Her evidence of coverage
The physician's own license and practice records
Question 6 of 40
A Texas company contracts with optometrists and ophthalmologists and, for a monthly prepaid fee, arranges eye examinations and corrective lenses for its members. It arranges no other care. Under Chapter 843's vocabulary, this arrangement is a:
Basic health care services plan
Blended contract
Limited health care service plan
Single health care service plan
Question 7 of 40
An employer contracts with an HMO to cover its workers. Which statement best reflects how Chapter 843 treats the evidence of coverage in this arrangement?
The employer holds the only document describing benefits, and workers receive nothing individually
The individual entitled to health care services receives an evidence of coverage describing that entitlement, even though the employer contracts with the HMO
The evidence of coverage is issued to the HMO's contracted physicians so they know what to deliver
The evidence of coverage replaces the HMO's certificate of authority for group business
Question 8 of 40
Two entities collect payments in advance from members. Entity One only cuts checks to reimburse members after they pay their own doctors. Entity Two contracts with clinics and arranges the care members receive. Why does Chapter 843's HMO framework reach Entity Two in a way it does not reach Entity One?
Because Entity Two collects payments in advance and Entity One does not
Because part of what Entity Two does consists of arranging for or providing health care services rather than pure indemnification
Because Entity Two issues an evidence of coverage and Entity One issues a policy, and the name of the document controls
Because Entity Two operates within a service area and any entity with a defined geography is an HMO
Question 9 of 40
Under Texas Insurance Code Chapter 843, which description best fits a "health maintenance organization"?
A licensed insurer that indemnifies members for medical expenses after the member pays a provider directly
A network of physicians and hospitals that contracts with employers to discount their billed charges
A third-party administrator that processes claims for a self-funded employer health plan
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
Question 10 of 40
In Chapter 843 terminology, "evidence of coverage" means:
The certificate, agreement, policy, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled
The authorization the Texas Department of Insurance issues permitting the HMO to do business in the state
The written contract between the HMO and each participating physician or provider
The enrollee's identification card showing the plan name and member number
Question 11 of 40
An employee covered under her employer's Texas HMO plan calls her producer and asks, "Where can I read exactly what benefits, limits, and exclusions apply to me?" What should the producer tell her, and why?
The HMO's certificate of authority, because it lists the benefits the HMO is authorized to sell
The master group contract only, because in a group HMO the employer is the only party entitled to coverage documents
The evidence of coverage, because Chapter 843 makes that the document issued to the enrollee stating the coverage to which she is entitled
The provider directory, because it identifies which services each contracted physician performs
Question 12 of 40
Chapter 843 uses the term "basic health care services" to mean:
Only emergency and urgent care furnished outside the HMO's service area
A single health care service the organization undertakes to provide or arrange
Services an enrolled population might reasonably require to be maintained in good health
Preventive services delivered at no cost sharing to the enrollee
Question 13 of 40
A Texas organization proposes a prepaid arrangement under which it contracts with chiropractors and arranges chiropractic care for members for that one specified health care need. It arranges no other care of any kind. Under Chapter 843's vocabulary, this arrangement is a:
Single health care service plan
Limited health care service plan
Health care plan providing basic health care services
Blended contract
Question 14 of 40
Before an entity may lawfully operate as a health maintenance organization in Texas, Chapter 843 requires that it hold:
An evidence of coverage filed with each enrollee's employer
A certificate of authority issued under the chapter
A resident general lines agent license
A single health care service plan endorsement from its contracted providers
Question 15 of 40
A company sells a prepaid membership under which members may see any licensed provider they choose; the company neither arranges nor provides care and simply reimburses part of whatever bill the member submits. Analyzing this against Chapter 843, is the company a health maintenance organization?
Yes, because members pay in advance, and prepayment alone brings the arrangement within the chapter
Yes, because the company pays part of the cost of health care services for its members
No, because an HMO must be an organization that offers only basic health care services
No, because the company only indemnifies and does not arrange for or provide health care services, which the chapter's definition requires
Question 16 of 40
When an HMO's evidence of coverage describes the geographic area in which the plan's health care services are available and accessible to enrollees, it is describing the Chapter 843 concept of:
The enrollee's provider panel
The service area
The health care plan
The certificate of authority territory
Question 17 of 40
Under Texas Insurance Code Chapter 843, a health maintenance organization is defined as a person who does what?
Indemnifies enrollees in cash for medical costs they have already incurred, without arranging any care
Licenses and disciplines physicians who practice within a defined service area
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
Sells only dental and vision coverage on a statewide basis through independent agents
Question 18 of 40
An HMO enrollee calls her agent and asks, "Where exactly does it say what my plan covers and what it excludes?" Which document should the agent point her to?
The HMO's certificate of authority
The service area description filed with the state
The provider directory for her network
The evidence of coverage issued to her
Question 19 of 40
Chapter 843 uses a defined term for the services an enrolled population might reasonably require in order to be maintained in good health. Which term is it?
Limited health care service
Single health care service plan
Evidence of coverage
Basic health care services
Question 20 of 40
Chapter 843 defines "service area" as which of the following?
The list of hospitals and clinics the HMO owns outright
The period during which an eligible person may enroll in the plan
The geographic area in which the plan's health care services are available and accessible to enrollees
The maximum dollar amount of services an enrollee may receive in a plan year
Question 21 of 40
Before an entity may operate as a health maintenance organization in Texas, what must it obtain?
An evidence of coverage approved for each enrollee
A certificate of authority issued under Chapter 843
A separate producer license for every contracted physician
A single health care service plan filing for each county in its service area
Question 22 of 40
An organization undertakes to provide or arrange for one health care service only. Chapter 843 calls this arrangement a:
Single health care service plan
Basic health care services package
Evidence of coverage
Health care plan for indemnity purposes
Question 23 of 40
An employer contracts with an HMO to cover its workforce. Under Chapter 843, who receives the evidence of coverage?
Each individual enrollee entitled to health care services under the plan
Only the employer, as the group contract holder
Only the physicians and providers contracted to deliver the care
No one; in group cases the master contract replaces any enrollee document
Question 24 of 40
A company markets a product that pays cash to members for medical bills they have already paid but does not arrange for or provide any care. Why would this product, standing alone, fall outside Chapter 843's HMO definition?
Because the company charges its members a periodic premium
Because part of the arrangement must consist of arranging for or providing health care services, not pure indemnification
Because a company can never have enrollees unless it owns its own hospitals
Because Texas prohibits any form of indemnity health coverage
Question 25 of 40
Under Chapter 843 of the Texas Insurance Code, a health maintenance organization is defined as a person who does what?
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
Reimburses enrollees in cash for covered medical expenses after the enrollee pays the provider
Licenses physicians and hospitals to practice within a defined geographic region
Sells stop-loss and excess-of-loss coverage to self-funded employer health plans
Question 26 of 40
Before an HMO may do business in Texas, what must it hold under Chapter 843?
An evidence of coverage filed with each enrollee's employer
A single health care service plan endorsement
A certificate of authority issued under the chapter
A provider network accreditation certificate issued by its contracted physicians
Question 27 of 40
Which statement best describes an "evidence of coverage" as that term is used in Chapter 843?
The HMO's annual financial statement showing it can pay claims
The contract between the HMO and each contracted physician or provider
The state's written authorization allowing the HMO to enroll members
The certificate, agreement, policy, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled
Question 28 of 40
Chapter 843 uses the term "basic health care services." Which description matches that term?
Only the emergency services an HMO must cover outside its service area
The services an enrolled population might reasonably require to be maintained in good health
A narrow category of services such as dental, vision, or mental health services
The single service provided under a single health care service plan
Question 29 of 40
An HMO enrollee calls her producer and asks, "Where is it actually written that this benefit is limited the way you described?" What should the producer point her to?
Her evidence of coverage, which sets out the coverage, limits, exclusions, and conditions she is entitled to
The HMO's certificate of authority on file with the state
The employer's group application submitted to the HMO
The provider directory listing physicians in the service area
Question 30 of 40
A prospect asks why the HMO's materials keep referring to a "service area." Using the Chapter 843 definition, what does that term identify?
The list of hospitals that have agreed to accept the HMO's payment rates
The counties in which the HMO's producers are appointed to sell
The geographic area in which the plan's health care services are available and accessible to enrollees
The period during which an enrollee may use benefits before renewal
Question 31 of 40
A Texas company proposes a product under which members pay a flat monthly amount in advance and the company, through contracts with dentists, arranges cleanings, fillings, and extractions. It arranges no other care of any kind. The company's compliance officer argues that because dental care is absent from Chapter 843's list of limited health care services, the product does not fit any Chapter 843 plan category at all. Applying the chapter's definitions, how should the product be classified?
A limited health care service plan
A single health care service plan
A basic health care services plan
No Chapter 843 category; the arrangement falls outside the chapter
Question 32 of 40
An employer contracts with an HMO for coverage for its workforce. Under Chapter 843, who receives the evidence of coverage?
Only the employer, since the employer is the party to the contract with the HMO
Only the contracted physicians and providers who will deliver the services
The Texas Department of Insurance, which then distributes copies to covered workers
The enrollee, because the enrollee is the individual entitled to health care services under the plan
Question 33 of 40
Under Chapter 843 of the Texas Insurance Code, a health maintenance organization is defined as a person who does what?
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
Reimburses enrollees for covered medical expenses after they submit proof of loss
Sells only major medical indemnity coverage through independent agents in Texas
Underwrites disability income benefits for employer groups on a post-payment basis
Question 34 of 40
In Texas HMO terminology, what is the name of the certificate, agreement, policy, or contract issued to an enrollee that sets out the coverage to which the enrollee is entitled?
Certificate of authority
Provider participation agreement
Evidence of coverage
Service area declaration
Question 35 of 40
Chapter 843 uses the term "basic health care services." How is that category described?
Only those services delivered inside a hospital by a contracted physician
A single health care service the organization agrees to arrange for enrollees
Dental, vision, and mental health services offered separately from medical coverage
The services an enrolled population might reasonably require to be maintained in good health
Question 36 of 40
An HMO enrollee calls her producer and says a treatment was denied as excluded. She asks, "Where exactly does it say that?" What document should the producer point her to?
The HMO's certificate of authority filed with the state
The group contract signed by her employer, since only the employer is a party to it
Her evidence of coverage, which defines her benefits and their limits, exclusions, and conditions
The HMO's provider directory for her service area
Question 37 of 40
Chapter 843 defines "service area." What does that term identify?
The list of covered benefits an enrollee may receive under the plan
The categories of licensed practitioners and facilities the HMO may contract with
The period during which an eligible person may enroll in the plan
The geographic area in which the plan's health care services are available and accessible to enrollees
Question 38 of 40
Before a health maintenance organization may do business in Texas, what must it obtain?
An evidence of coverage approved for each enrollee
A certificate of authority issued under Chapter 843
A single health care service plan endorsement from its providers
A service area waiver from each county in which it markets
Question 39 of 40
A Texas entity contracts with podiatrists and, for a fixed amount paid in advance each month, arranges foot and ankle care for its members. It arranges no other care of any kind. Under Chapter 843's vocabulary, this arrangement is best classified as:
A single health care service plan
A limited health care service plan
A basic health care services plan
A blended contract
Question 40 of 40
Two entities each collect money from members and pay for care. Entity One only reimburses members in cash after they pay a provider of their choosing. Entity Two contracts with physicians and facilities in a defined area so members receive services from them. Why does the second entity fit Chapter 843's concept of a health care plan while the first does not?
Because Chapter 843 applies only to entities that pay claims within a defined geographic area
Because a health care plan requires that part of the plan consist of arranging for or providing services rather than pure indemnification
Because only the second entity issues an evidence of coverage, and issuing that document is what creates a health care plan
Because the first entity collects money from members and therefore cannot be prepaid