State RegulationsTX specificDifficulty 1/5
When a Texas HMO cancels or refuses to renew an enrollee's evidence of coverage, what must it provide to the enrollee?
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Answer & full 3-part explanation (select an option above, or peek)
Why C is correct
Under TIC 843.208 and 28 TAC 11.506(3), an HMO must give the enrollee advance written notice before a cancellation or nonrenewal takes effect, stating the reason for the action and informing the enrollee of applicable rights such as continuation or conversion. Notice is what allows the enrollee to cure a curable problem, such as a missed payment, or to arrange replacement coverage. A termination that takes effect without the required notice is defective, and the enrollee may complain to TDI.
Why the other options are wrong
- A) Notice is mandatory and must be given in advance; it is not supplied only on request.
- B) The underwriting manual is an internal HMO document, not the notice owed to the enrollee.
- D) A certificate of creditable coverage does not substitute for the required advance notice of termination.
Memory hook
No secret terminations: notice first, and say why.