A Texas HMO enrollee has surgery at a network hospital, but the anesthesiologist who treats the enrollee is not in the HMO's delivery network. Under TIC 1271.157, how must the HMO handle that claim?
Select an option to reveal the answer and the full 3-part explanation — free, no signup.
Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Under TIC 1271.157, when an enrollee receives care at a network facility from a facility-based physician who is not in the HMO's network, such as an anesthesiologist, radiologist, or pathologist the enrollee did not choose, the HMO must fully reimburse that physician at the usual and customary rate or at a rate agreed to by the HMO and the physician. Under TIC 1271.157(c), the physician may not collect from the enrollee anything beyond the applicable copayment, coinsurance, or deductible. The enrollee did not choose to go outside the network, so the cost of that absence of choice falls on the HMO rather than on the enrollee; TIC 1271.157(d) preserves an exception only for non-emergency care that the enrollee knowingly and voluntarily selects in writing after full written disclosure.
Why the other options are wrong
- B) Shifting the physician's entire charge to the enrollee is precisely the outcome TIC 1271.157 is written to prevent when the enrollee had no network choice.
- C) Absence of network choice is the trigger for the rule, not an exception to it; the HMO cannot deny merely because the facility-based physician is non-network.
- D) The mandate is full reimbursement at the usual and customary or agreed rate, not payment at the network rate with the balance shifted to the enrollee.
Memory hook
No network choice inside a network facility means the HMO pays usual and customary.