State RegulationsTX specificDifficulty 2/5
In Texas HMO law, the term "basic health care services" refers to which of the following?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under TIC 843.002, basic health care services are the core services that a health maintenance organization must provide or arrange for its enrollees, such as physician and hospital care, emergency care and the related services described in the statute and in the HMO's filed evidence of coverage. The term is a floor of required services, not a promise that anything a physician recommends will be paid for; services outside the filed benefit package remain uncovered.
Why the other options are wrong
- A) Basic health care services are the routine core benefits, not merely emergency care delivered outside the service area.
- C) Unauthorized out-of-network services are not the definition of basic health care services; they are a claim-handling question.
- D) A physician's recommendation does not create coverage; benefits are limited to what the evidence of coverage describes.
Memory hook
Basic health care services are the floor of benefits, not the ceiling of requests.